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A  MANUAL  OF  SURGERY 
jfor  StuDents  auD  practitioners 


ROSE  AND  CARLESS'S 

MANUAL  OF  SURGERY 

jTor  Stubente  ant)  practitionere 

NINTH    EDITION 


REVISED    BY 

ALBERT  CARLESS,  M.B.,  M.S.  Lond.,  F.R.C.S. 

Professor  of  Surgery  in,   and  Surgeon  to,    King's  College   Hospital,   London 

formerly  examiner  in   surgery  to  the  universities  of  london,  glasgow, 

Manchester,  Liverpool,  and  Leeds  ;  Consulting  Surgeon  to  the  King 

Edward's   Memorial   Hospital,    Ealing  ;   to   the   St.    John's 

Hospital,  Twickenham,  etc. 


NEW     YORK 
WILLIAM     WOOD     &     COMPANY 

MDCCCCXIV 


First  Edition,  May,  iSg8. 
Second  Edition,  September,  iSgg. 

Hungarian  Translation. 
Tliird  Edition,  September,  iqoo. 
Fourth  Edition,  September,  igot. 

Fifth  Edition,  August,  igo2.    Reprinted,  September,  1Q04. 
Sixth  Edition,  August,  1905.    Reprinted,  April,  igoy. 

Ameri  an  Edition,  August,  igos.    Reprinted,  November,  rgo6. 
Seventh  Edition.  September,  ,goS.    Reprinted,  May,  igw. 

American  Edition,  September,  igoS.    Reprinted.  July,  igic. 

Chinese  Translation. 
Eighth  Edition,  September,  igjj.    Refrinted,  April,  igij. 

American  Edition.  August,  igir.     Reprinted.  August.  ig,2. 

Arabic  Translation. 
Ninth  Edition,  October,  igi^. 

American  Edition,  October  igi^. 


LONDON 

BAILLlfeRE-,    TINDALL    AND  COX 

8,    HENRIETTA   STREET,    COVENT   GARDEN 


TO    THE    LATE 

LORD  LISTER,  ll.d.,  f.r.s.,  o.m., 

Late  President  of  the  Royal  Society, 

THE    FATHER    OF    ANTISEPTIC    SURGERY, 

THIS    WORK    WAS,    WITH    PERMISSION, 

IN    GRATEFUL   ACKNOWLEDGMENT    OF   THE    MANY    ADVANTAGES 

THEY    DERIVED 

WHILST    ASSOCIATED   WITH    HIM    IN    HIS    WORK 

AT    king's    COLLEGE    HOSPITAL. 


PREFACE  TO  THE  NINTH   EDITION 


The  triennium  which  has  elasped  since  the  issue  of  the  eighth 
edition  of  this  Manual  has  been  characterized,  not  by  the  discovery  of 
any  revolutionary  or  wonder-working  novelty,  but  by  the  steady 
elaboration  of  ideas  and  methods  which  had  already  been  introduced, 
and  required  time  for  their  investigation.  Salvarsan  and  radium 
in  particular  maybe  mentioned  as  subjects  to  the  consideration  of 
which  a  vast  amount  of  work  has  been  devoted.  Salvarsan  stands 
as  the  conqueror  of  the  worst  ill-effects  of  syphilis,  if  only  it  be 
employed  in  time;  radium  has  proved  itself  a  potent  agent  for  good 
in  many  cases,  but  the  magniloquent  prophets  who  hailed  it  as  the 
victor  of  cancer  have  not  yet  proved  their  claims.  Steady  progress 
is  being  made  in  all  the  varied  realms  of  research  which  are  touched 
on  in  this  work,  and  an  effort  has  been  made  to  incorporate  therein 
the  mast  important,  keeping  in  view  the  double  purpose  of  this 
manual — viz.,  to  instruct  students  and  to  help  practitioners. 
Room  has  been  found  for  a  new  chapter  on  modern  methods  of 
treatment  by  heat,  light,  electricity,  etc.,  and  for  other  fresh 
subjects.  Many  new  illustrations  have  been  added,  as  well  as  a 
few  more  coloured  plates,  and  this  without  adding  a  single  page  to 
the  book.  The  paper  on  which  it  is  printed  is  slightly  thinner  than 
previously,  so  as  to  keep  its  weight  within  the  requirements  of  the 
postal  authorities,  who  distribute  it  far  and  wide  overseas.  I  trust 
that  this  edition  may  prove  even  more  helpful  than  those  which 
have  preceded  it,  and  pray  that  when  the  tenth  edition  is  required 
the  sounds  of  war  and  strife,  which  boom  on  the  ear  as  these  lines 
are  penned,  may  long  have  ceased,  and  that  a  righteous  peace 
leading  to  a  happy  competition  of  race  with  race  in  the  effort  to 


viii  I'REFACE  TO  THi;  NINTH  IIDITION 

promote,  not  the  destruction,  but  the  welfare  of  mankind  of  all 
nationalities  may  have  been  established. 

1  have  to  thank  many  vvho  have  kindly  helped  me  in  preparing 
this  edition.  Dr.  Emery  has  again  answered  pathological  queries; 
Dr.  Knox  has  helped  me  with  radiographic  preparations;  Dr.  Silk 
has  kindly  revised  the  chapter  on  Anaesthetics.  Mr.  John  Everidge, 
Dr.  Thurston  Holland,  Dr.  Knevitt,  Dr.  Salmond,  Dr.  Mack,  and 
others  have  helped  with  photographs,  which  have  been  prepared 
for  press  by  the  artistic  skill  of  Dr.  Dupuy.  To  one  and  all  I  offer 
my  hearty  thanks,  as  also  to  Mr.  Eric  Gauntlett,  who  helped  me 
until  called  out  on  active  service.  Again  I  have  to  acknowledge 
the  kindly  courtesy  of  my  publishers,  who  have  cheerfully  assisted 
me  in  every  way  possible. 

ALBERT  CARLESS. 

6,   Upper  Wimpole  Street,  W., 
September,   191 4. 


PREFACE  TO  THE   FIRST  EDITION 


In  preparing  this  Manual  of  Surgery  for  the  profession,  we  have 
endeavoured  to  meet  what  we  think  is  at  the  present  time  a  genuine 
need.  The  many  large  and  valuable  text-books  and  works  of 
reference  already  in  existence  are  almost  more  than  the  ordinary 
student  can  master  during  the  time  at  his  disposal.  It  has  therefore 
been  our  aim  to  present  the  facts  of  surgical  science  in  a  concise 
and  succinct  form,  so  as  to  satisfy  the  needs  of  the  student,  even  of 
those  who  are  preparing  for  the  higher  examinations.  At  the  same 
time,  the  requirements  of  the  general  practitioner  have  not  been 
overlooked,  for  we  have  taken  care  to  discuss  in  detail  those  con- 
ditions which  are  most  likely  to  be  met  with  in  ordinary  practice. 
The  main  difficulty  has  been  to  compress  into  a  small  space  the 
ever-increasing  amount  of  material  available,  so  that  we  have  only 
been  able  to  sketch  in  outline  much  that  could  have  been  elaborately 
described  did  the  size  of  the  book  permit.  For  the  same  reason, 
historical  and  bibliographical  references  have  to  a  large  extent  been 
omitted,  whilst  diseases  of  special  regions — such  as  the  eye,  ear, 
and  female  genital  organs — are  also  practically  excluded,  except  in 
so  far  as  they  encroach  on  the  domains  of  general  surgery.  The 
progress  of  bacteriology  and  the  influence  of  antisepsis  have  so 
transformed  the  characters  and  extended  the  scope  of  surgical  work, 
that  many  of  the  traditions  and  theories  of  the  past  have  had  to  be 
discarded,  although  at  the  same  time  we  have  endeavoured  to 
preserve  and  respect  that  which  has  been  shown  to  be  good  and 
useful  in  the  laborious  researches  and  accumulated  experiences  of 
bygone  generations. 

In  conclusion,  our  best  thanks  are  due  to  Dr.  St.  Clair  Thomson, 
who  has  kindly  looked  through  the  proofs  of  the  sections  devoted  to 


X  PREFACE  TO   THE  FIRST  EDITION 

the  Nose  and  Ear;  to  Dr.  Silk,  who  has  fuhilled  a  similar  office  in 
reference  to  the  chapter  on  Anaesthetics;  to  Mr.  William  Turner  for 
preparing  the  Index;  and  to  Dr.  Arthur  (Griffiths,  late  of  the  Bristol 
General  Hospital,  who  has  drawn  several  of  the  pictures,  and  given 
other  valuable  assistance. 

Many  of  the  illustrations  have  been  specially  prepared  for  this 
work,  but  we  have  also  to  acknowledge  the  loan  of  blocks  from 
Messrs.  Veit  and  Co.,  of  Leipzig;  from  Messrs.  Cassell  and  Co., 
J.  and  A.  Churchill,  Longmans  and  Co.;  and  from  the  editors  of 
the  Lancet  for  the  loan  of  Fig.  287.  The  various  sources  from 
which  these  are  derived  are  acknowledged  throughout  the  book. 
Illustrations  of  instruments  are  mainly  derived  from  Messrs.  Down 
Brothers,  who  have  kindly  placed  them  at  our  disposal. 

W.  ROSE, 

17,  Harley  Street,  W. 

A.  CARLESS, 

10,  Welbeck  Street,  W. 

London, 

May  I,   1898. 


CONTENTS 

CHAPTER  ^'^'^^ 

I.    SURGICAL      BACTERIOLOGY  INFECTION  IMMUNITY       (BY 

DR.    W.     D'eSTE    emery)       -                   -                   -                   "                   "  ^ 
II.    INFLAMMATION               -                   -                   "                   "                   "                   "29 

III.  THE    USE    OF    HEAT,     LIGHT,     ELECTRICITY,    AND    RADIUM    IN 

SURGERY    -  -  -  -  -  -  -47 

IV.  EXAMINATION     OF     THE     BLOOD     IN     HEALTH     AND      DISEASE 

(by  dr.  w.  d'este  emery)          -             -             -             -  58 

v.  non-specific  pyogenic  infections            -             -             -  68 

vi.  ulceration               ----""  ^^^ 

vii.  gangrene     -----"'  ^0° 

viii.  specific  infective  diseases          -             -             "             "  129 

ix.   tumours  and  cysts             -----  ^94 

X.    WOUNDS            -------  239 

XI.  THE    GENERAL    TECHNIQUE    OF    OPERATIVE    SURGERY                   -  27I 

XII.  HEMORRHAGE                ------  282 

XIII.    INJURIES    AND     DISEASES     OF    ARTERIES ANEURISM LIGA- 
TURE   OF    ARTERIES                 -                   -                   "                   -                   "  299 

XIV.    SURGERY    OF    THE    VEINS         -----  34^ 

XV.    DISEASES    OF    THE    LYMPHATICS             -                   -                   -                   -  35^ 

XVI.    AFFECTIONS    OF    NERVES           -                   -                   -                   -                   "  37^ 

XVII.    SURGICAL   DISEASES    OF   THE   SKIN   AND    OF   THE  CUTANEOUS 

APPENDAGES               ------  399 

XVIII.    AFFECTIONS    OF    MUSCLES,    TENDONS,    AND    BURSiE    -                    -  4I4 

XIX.    DEFORMITIES                    ---"■"  432 

XX.    INJURIES    OF    BONES — -FRACTURES      -                   -                    -                    "  47^ 

XXI.    DISEASES    OF    BONE  ------  555 

XXII.  INJURIES    OF   JOINTS DISLOCATIONS                  ■                   "                   "  599 

XXIII.  DISEASES    OF    JOINTS  -  -  "  " 


627 


Xii  COi\ri£NTS 

CHAPTER  PAGE 

XXIV.  IXJURIES    OF    THE    SPINE                     -                  -                  .  .  584 

XXV.  DISEASES    OF    THE    SPINE                     -                  .                  _  .  yoo 

XXVI.  AFFECTIONS    OF    THE    SCALP    AND    CRANIUM              -  -  722 

XXVII.  AFFECTIONS    OF    THE    BRAIN    AND    ITS    MEMBRANES  -  744 

XXVIII.  AFFECTIONS    OF    THE    LIPS    AND    JAWS         -                   -  -  783 

XXIX.  AFFECTIONS    OF    THE    NOSE    AND    NASO-PHARYNX  -  814 

XXX.  AFFECTIONS  OF  THE  MOUTH,   THROAT,   AND  CESOPHAGUS  -  832 

XXXI.  AFFECTIONS    OF    THE    EAR                     ...  -  873 

XXXII.  SURGERY    OF    THE    NECK  .                   -                  .                  -  -  884 

XXXIII.  SURGERY    OF    THE    AIR- PASSAGES,     LUNGS,    AND    CHEST  -  9OO 

XXXIV.  DISEASES    OF    THE    BREAST                -                  .                  .  .  g^j 
XXXV.  ABDOMINAL    SURGERY         -                   .                   -                   -  .  g^g 

XXXVI.  HERNIA       --.-.-.  1084 

XXXVII.  INTESTINAL    OBSTRUCTION                  .                   -                   .  .  1124 

XXXVIII.  AFFECTIONS    OF    THE    RECTUM    AND    ANUS  -  "1144 

XXXIX.  SURGICAL   AFFECTIONS    OF    THE    KIDNEYS                    -  -  1 1 75 

XL.  SURGERY    OF    THE    BLADDER    AND    PROSTATE            -  -  I2I5 

XLI.  AFFECTIONS    OF    THE    URETHRA    AND    PENIS               -  -  I253 

XLII.  AFFECTIONS      OF      THE      TESTIS,       CORD,       SCROTUM,      AND 

SEMINAL    VESICLES            -                   -                   .                   .  .  1275 

XLIII.  SURGERY    OF    THE    FEMALE    GENITAL    ORGANS          -  -  1 299 

XLIV.  AMPUTATIONS           -----.  1324 

XLV.  ANESTHESIA             -.-_..  13^2 

INDEX         .--...  -  1357 


ri.ATE  I. 


fjo  I  —Staphylococci  in  pus.  Slaininij— Gram  and  dilute  carbol-fuchsm. 
Fi^  "2  —Streptococci  in  pus.  Staining-methylene  blue.  Fis;.  3.-Gonococci  in 
pus  Gram  and  carhol-fuchsin,  only  the  latter  of  which  has  stained.  Fig.  4.— Pneu- 
mococciin  sputum.  Methylene  blue.  Fig.  5.— Sarcinae.  from  a  culture.  Grams 
stain.     Fig.  6.  — Spirilla  (with  a  few  bacilli)  from  \incent  s  angina.      Carbol-fuchsin. 

[To  face  page  I. 


A    MANUAL   OF   SURGERY 

CHAPTER  I. 
BACTERIOLOGY— INFECTION— IMMUNITY. 

The  importance  to  the  surgeon  of  a  study  of  bacteriology  is  twofold. 
In  the  first  place,  many  surgical  diseases  (especially  those  of  an 
inflammatory  nature)  are  due  to  the  action  of  bacteria;  secondly, 
these  organisms  are  practically  ubiquitous,  and  in  the  absence  of 
suitable  precautions  will  infallibly  enter  any  external  wound,  whether 
accidental  or  intentional,  and  by  their  development  and  the  in- 
flammatory troubles  which  result  therefrom  delay  the  process 
of  healing,  or  even  give  rise  to  fatal  results.  Hence  every  surgeon 
must  have  a  general  knowledge  of  the  habits  and  distribution  of 
the  more  important  species  of  bacteria,  their  mode  of  life,  and  the 
mechanism  by  which  they  give  rise  to  morbid  processes  in  the  human 
body,  as  well  as  of  the  methods  used  in  their  investigation.  It 
was  only  by  means  of  such  knowledge  that  the  present  methods 
of  treating  wounds  were  evolved,  and  without  it  these  methods 
cannot  be  intelligently  applied  in  actual  practice.  Moreover,  the 
.diagnosis  of  disease  is  often  much  assisted  by  the  bacteriological 
examination  of  morbid  products,  and  information  of  the  highest 
importance  may  be  obtained  thereby. 

Bacteria  (schizomycetes,  or  fission  fungi)  form  a  very  important 
group  of  the  lower  plants.  Although  several  thousand  species  have 
been  described,  comparatively  few  are  of  importance  in  medicine  or 
surgery.  They  may  be  defined  as  minute  unicellular  plants,  which 
reproduce  themselves  bv  simple  fission,  or  in  some  forms  by  endo- 
genous spore-formation,  not  more  than  one  spore  being  formed  in 
each  cell.  They  are  devoid  of  organs  except  flagella,  and  contain 
no  chlorophyll.  Their  structure  is  extremely  simple,  consisting 
of  a  delicate  cell-wall  (composed  of  cellulose  or  an  allied  substance) 
which  encloses  a  mass  of  protoplasm,  in  which  there  may  be  one 
or  more  vacuoles  and  a  few  granules  of  unknown  nature.  External 
to  the  cell-wall  there  is  sometimes  a  gelatinous  capsule,  which  may 
serve  to  unite  the  bacterial  cell  looselv  with  its  neighbours.     When 


2  A   MANUAL  OF  SURGERY 

such  capsules  become  very  prominent,  large  numbers  of  bacteria 
may  become  embedded  in  a  gelatinous  mass,  known  as  a  zooglaa. 
Capsule-formation  is  of  some  importance  in  diagnosis;  the  pneumo- 
coccus,  for  example,  possesses  a  well-marked  capsule  when  it  occurs 
in  blood  or  morbid  exudates,  and  may  thereby  be  distinguished  from 
many  organisms  otherwise  resembling  it. 

Flagella  are  delicate  filamentous  extensions  of  the  protoplasm, 
which  occur  in  those  bacteria  which  are  possessed  of  spontaneous 
mobility.  They  are  sometimes  of  great  length,  but  are  always 
extremely  thin,  and  are  only  visible  after  the  use  of  complicated 
staining  processes.  Their  number  is  of  importance  in  diagnosis. 
The  tvphoid  bacillus,  for  example,  has  usually  from  twelve  to  twenty 
flagella  (Plate  III.,  Fig.  25),  whilst  the  closely-allied  Ij.  coli  has  from 
three  to  six.  It  should  be  remembered  that  bacteria  which  are 
devoid  of  flagella  often  exhibit  very  marked  Brownian  movement, 
which  the  uninitiated  might  mistake  for  spontaneous  motility. 

Reproduction  among  the  bacteria  is  extremely  simple,  nothing 
akin  to  sexual  processes  having  been  observed.  In  simple  fission 
the  cell  becomes  divided  by  a  thin  membrane  into  two  portions, 
which  develop  into  mature  organisms.  The  two  bacteria  thus 
produced  may  become  entirely  separated  from  one  another,  or  may 
remain  more  or  less  connected  by  means  of  the  capsules  described 
above,  thereby  becoming  united  into  groups,  which  are  more  or 
less  characteristic  of  the  species.  This  process  of  division  may 
take  place  with  great  rapidity,  so  that  a  suitable  m.aterial  which 
has  become  infected  with  one  or  two  bacteria  mav  contain  vast 
numbers  in  the  course  of  a  few  hours. 

Spore-formation  is  a  more  complicated  process,  and  is  found  only  in 
certain  of  the  rod-shaped  bacteria  or  bacilli.  Bacterial  spores  are 
round  or  oval  in  shape,  and  are  formed  within  the  bacterial  cell 
(endospores).  They  consist  of  a  thick  cell-wall  filled  with  proto- 
plasm, which  contains  less  water  than  the  mature  bacterium,  and 
has,  therefore,  a  highly  refractile  appearance  when  seen  under  the 
microscope.  The  shape  and  size  of  the  spores  have  much  diagnostic 
value;  thus,  the  bacillus  of  tetanus  has  an  almost  spherical  spore, 
which  is  distinctly  larger  than  the  diameter  of  the  rod  in  which  it 
is  formed,  whilst  the  spore  of  the  anthrax  bacillus  is  oval,  and  little 
or  no  broader  than  the  rod  itself.  The  position  of  the  spore  is  also 
of  importance.  The  spores  of  the  tetanus  "bacillus  are  at  the  extreme 
end  of  the  bacillus,  giving  it  the  appearance  of  a  drumstick,  whilst 
those  of  anthrax  are  central.  Spores  are  to  be  regarded  as  resting 
forms  adapted  to  maintain  the  life  of  the  species  under  adverse  con- 
ditions, and  in  this  respect  are  analogous  to  the  seeds  of  the  higher 
plants.  They  resist  dr\'ing  to  a  far  greater  extent  than  do  the 
bacteria  themselves.  Anthrax  spores  have  been  preserved  in  the 
laboratory  for  twenty  years  without  loss  of  viability  or  virulence, 
whilst  asporogenous  anthrax  dies  in  a  few  weeks  when  dried.  They 
are  also  very  resistant  to  heat.  Most  bacteria  (when  moist)  are 
killed  when  exposed  to  a  temperature  of  60'^  C.  for  half  an  hour. 


BACTERIOLOGY—INFECTION— IMMUNITY  3 

whereas  many  spores  are  not  killed  by  prolonged  boiling.  Lastly, 
they  are  very  difficult  to  kill  by  means  of  antiseptics.  Anthrax 
spores  can  be  killed  by  immersion  in  i  in  20  carbolic  lotion,  but  only 
after  several  days.  Of  the  bacilli  of  chief  interest  to  the  surgeon 
the  B.  tetani,  B.  anthracis,  B.  rvdemaiis  maligni  form  spores,  and  of 
these  only  the  B.  tetani  in  the  body,  whilst  those  of  glanders,  tubercle, 
diphtheria,  typhoid  fever,  leprosy,  influenza,  and  soft  sore  are 
asporogenous. 

The  Classification  of  the  bacteria  is  based,  in  the  first  instance,  on 
their  morphology,  but  owing  to  the  simplicity  of  the  shape  of  the 
organisms,  morphological  characteristics  have  to  be  supplemented  by 
physiological  and  cultural  properties  in  the  definition  of  the  separate 
species.     There  are  three  great  groups — the  cocci,  bacilli,  and  spirilla. 

I.  Cocci  are  organisms  which  are  spherical,  or  nearlj^  spherical. 
They  constitute  the  simplest  forms  of  bacteria,  since  but  few  species 
possess  flagella,  and  spore-formation  is  unknown,  (a)  Micrococci 
are  those  forms  in  which  there  is  no  definite  arrangement  into 
groups.  The  term  '  staphylococcus  ' — more  properly  the  name  of 
a  species,  the  Staphylococcus  pyogenes — is  applied  to  cocci  in  which 
the  individual  elements  are  arranged  in  clusters  resembling  bunches 
of  grapes  (Plate  L,  Fig.  i).  {h)  Diplococci  (Plate  L,  Fig.  4)  are 
forms  in  which  the  two  elements  arising  from  the  division  of  a 
single  coccus  remain  in  more  or  less  close  apposition,  so  that  they 
are  arranged  in  pairs,  (c)  Streptococci  (Plate  L,  Fig.  2)  are  arranged 
in  longer  or  shorter  chains,  like  a  necklace.  This  formation  is  due 
to  the  fact  that  the  successive  planes  of  division  in  which  the  cocci 
are  divided  lie  parallel  to  one  another,  (d)  In  a  few  cases  a  coccus 
divides  into  two,  which  are  again  divided  in  a  plane  at  right  angles 
to  the  first,  so  that  the  four  cocci  which  result  lie  at  the  corners  of 
a  square;  these  are  called  Tetracocci.  Lastly,  {e)  Sarcince  are  formed 
by  three  consecutive  divisions  in  the  three  planes  of  space,  so  that 
the  eight  cocci  which  are  formed  lie  at  the  corners  of  a  sphere 
(Plate  L,  Fig.  5),  and  the  group  resembles  a  bale  of  wool  tightly 
tied  in  three  directions.  These  cocci  often  divide  again,  and  lead 
to  the  formation  of  composite  masses. 

IL  Bacilli  (Plate  IIL,  p.  128)  are  bacteria  which  have  the  form  of 
straight  or  curved  rods,  the  long  diameter  of  the  cell  being  greatly 
larger  than  the  short  diameter.  Spore-formation  is  common  in 
this  group,  and  many  of  its  members  possess  flagella,  and  are  there- 
fore motile.  The  group  is  not  subdivided,  but  l^e  terms  strepto- 
hacillus  for  those  which  remain  adherent  in  chains,  and  leptothrix  for 
forms  which  produce  long  threads  before  breaking  up  into  short 
rods,  are  convenient. 

IIL  Spirilla  are  rods  which  are  uniformly  curved  in  the  three 
planes  of  space,  so  that  when  sufficiently  long  they  form  corkscrew- 
like spirals.  Short  forms  also  occur,  and  these  are  sometimes 
designated  vibrios,  the  term  '  spirilla  '  being  then  reserved  for  the 
long  spiral  forms.  The  spirilla  are  not  of  much  surgical  importance, 
the   only  well-known   pathogenic   varieties   being    the   F.    choleroi 


4  A   MANUAL  OP  SURGERY 

Asiaticcc  and  the  sj)irilluin  of  rclapsiiif,'  fever  (I'kite  I.,  Fig.  b),  wliicli 
latter,  how  e\i'r,  is  now  thought  to  be  a  protozoan. 

Conditions  of  Life. — l^acteria  resemble  other  jikints  devoid  of 
chloropliyll  in  being  unalile  to  form  proteid  from  simple  materials 
in  the  presence  of  sunlight,  and  have  to  be  supplied  with  ready- 
formed  organic  nitrogen  from  animal  or  vegetable  sources.  Re- 
garded from  this  standpoint,  they  may  be  divided  into  two  classes 
— the  parasites,  which  can  obtain  their  pabulum  only  from  the 
living  animal  (or  plant),  and  the  saprophytes,  which  are  unable  to 
do  so,  and  flourish  only  in  dead  materials.  The  leprosy  bacillus 
may  be  taken  as  an  example  of  a  strict  parasite,  since,  as  far  as  is 
known  at  present,  it  grows  only  in  the  living  tissues,  and  cannot 
be  cultiveited  outside  the  body.  The  term  facultative  saprophyte 
is  applied  to  those  organisms  which  prefer  a  parasitic  existence, 
but  which  will  grow  under  suitable  conditions  in  dead  materials. 
The  gonococcus  is  a  good  example;  it  multiplies  readily  enough  in 
the  living  mucous  membrane,  but  grows  only  feebly  on  dead 
culture  media.  Facultative  parasites,  on  the  other  hand,  are 
organisms  which  grow  best  in  dead  materials,  but  which  have  the 
power  of  adapting  themselves  to  a  parasitic  existence.  It  must 
be  understood  that  the  terms  '  parasitic  '  and  '  pathogenic  '  are 
not  quite  synonymous.  K  pathogenic  organism  is  one  that  has  the 
power  of  producing  disease,  and  it  may  do  so  without  entering  the 
living  tissues  at  all,  as  when  putrefactive  organisms  gain  access  to 
a  blood-clot  in  the  uterus  and  cause  toxaemia.  A  parasitic  organ- 
ism is  not  necessarily  pathogenic,  especially  in  the  lower  animals, 
since  these  frequently  harbour  blood-parasites  without  appearing 
to  suffer  therefrom  in  any  way. 

In  addition  to  combined  nitrogen,  all  bacteria  require  water, 
certain  salts,  and  a  suitable  temperature  for  their  growth.  The 
necessity  for  water  must  be  borne  in  mind  in  surgical  practice, 
and  every  attempt  must  be  made  (by  accurate  co-aptation  of  parts, 
drainage,  etc.)  to  prevent  the  accumulation  of  putrescible  material 
in  wounds  or  body-cavities.  This  is  well  seen  in  dealing  with  the 
peritoneum,  the  absorptive  power  of  which  is  one  of  the  chief 
natiiral  defences  against  peritonitis.  In  laboratory  experiments 
we  find  that  large  amounts  of  fluid  cultures  of  pathogenic  bacteria 
can  be  injected  into  the  peritoneal  cavity  of  animals  without  injury; 
the  fluid  is  rapidly  absorbed  and  bacterial  growth  ceases.  If, 
however,  the  peritoneum  is  injured  so  that  absorption  is  checked, 
the  bacteria  continue  to  grow,  and  fatal  peritonitis  results. 

The  requirements  of  different  bacteria  as  to  temperature  vary 
greatly.  The  majority  of  those  of  importance  in  human  pathology 
grow  best  at  or  about  the  body  temperature  (37°  C),  but  man}' 
forms,  especially  those  which  are  commonly  met  with  as  saprophytes 
outside  the  body  (such  as  Staphylococcus  pyogenes  and  B.  coli),  grow 
well  at  18°  C,  or  even  lower.  Other  forms  flourish  best  at  lower  or 
higher  temperatures  than  these,  but  they  are  not  of  pathological 
importance.     Lower  temperatures  inhibit  growth,  but  do  not  kill 


BACTERIOLOC,  Y— INFECTION— I MMUN  IT  Y  5 

tlie   bacteria    unless    applit'd    for    loni;    periods.     The    destruction 
of  bacteria  and  spores  bv  lieat  has  been  already  mentioned. 

I  i'dit  is  injurious  to  almost  all  bacteria.  This  is  especially  the 
case  with  B.  litberciilosis,  which  in  vitro  is  killed  after  a  very  short 
exposure  to  sunlight  and  more  slowlv  bv  diffused  daylight.  The 
action  seems  to  depend  on  the  formation  of  peroxide  of  hydrogen 

in  the  culture  medium.  r     .t.  •    j       1 

Manv  pathogenic  organisms  require  free  oxygen  for  their  develop- 
ment and  are^  spoken  of  as  aerobes.  A  few,  such  as  the  tetanus 
bacillus  will  grow  onlv  in  the  complete  absence  of  oxygen,  ceasing 
to  develop  though  still  remaining  alive,  when  that  gas  is  admitted; 
such  organisms  are  called  anaerobes.  Bacteria  which  grow  best  m 
air  but  which  will  also  grow  in  its  absence,  are  called  facultative 
anaerobes,  and  those  which  grow  best  under  anaerobic  conditions 
but  are  capable  of  some  growth  in  presence  of  oxygen,  are  called 
facultative  aerobes.  It  must  be  pointed  out  that  the  conditions 
in  the  living  bodv  are  pecuhar,  in  that  both  strict  aerobes  and  stnct 
anaerobes  are  capable  of  growth.  Further,  a  strict  anaerobe  may 
grow  in  a  fluid  freely  exposed  to  air  in  the  presence  of  other  organisms 
which  have  a  great  affinitv  for  oxvgen  and  rapidly  absorb  it.  in 
this  way  tetanus  baciUi  may  flourish  in  superficial  wounds  it  other 
bacteria  are  present. 

In  their  <^rowth  bacteria  give  off  metabolic  products  which  are 
often  of  great  importance.  The  chief  of  these  are  (i)  acids,  such  as 
lacric,  acetic,  but\Tic,  etc.;  (2)  alkalies;  (3)  gases,  such  as  sul- 
phuretted hvdrogen,  marsh  gas,  etc. ;  (4)  pigments,  such  as  the 
green  colouring  matter  produced  bv  B.  pyocyaneus  and  seen  m  the 
so-called  blue  pus;  (5)  aromatic  substances,  such  as  mdol,  phenol, 
and  tvrosin;  (6)  alcohol  and  other  similar  bodies;  (7)  ferments— 
e  o  diastase,  invertase,  and  a  ferment  allied  to  rennm.  A  more 
ir^portant  enz\Tne  is  one  resembling  trvpsin  and  having  the  power 
of  peptonizing  proteid  material.  It  is  produced  by  one  of  the 
commonest  pvogenic  organisms  {Staphylococcus  Pyogenes),  and 
plavs  some  part  in  the  destruction  of  the  tissues  m  suppuration. 
Its  "presence  or  absence  is  ascertained  by  cultivating  the  organism 
on  gelatin  or  coagulated  blood-serum,  either  of  which  is  digested 
or  '^liquefied  '  if  the  enz\Tne  is  produced.  (8)  Certain  crystalhzable 
organic  substances  of  definite  chemical  composition,  alhed  to  the 
ve-etable  alkaloids,  and  spoken  of  as  ptomains.  They  have  some 
poisonous  properties,  and  were  once  thought  to  be  of  great  impor- 
tance in  the  production  of  disease.  {9)  The  true  Toxins  have  never 
been  isolated  in  a  state  of  puritv,  but  appear  to  be  allied  m  chemical 
composition  to  the  albumoses,  and  have  some  features  m  common 
mth  the  enz\Tnes.  Thev  are  intenselv  poisonous  when  injected  into 
the  blood  or  tissues,  though  innocuous  (m  most  cases)  \vhen  taken 
bv  the  mouth.  Thev  are  verv  unstable  substances,  being  readily 
destroyed  bv  heat,  peptic  digestion,  etc.,  and  when  kept  m  a  state 
of  solution  graduallv  become  inert.  .  ^        . 

Toxins  are  di\dded  into  two  distinct  classes :  {a)  Certain  organisms. 


6  A   MANUAL  OF  SURGERY 

of  whicli  the  most  important  arc  the  bacilH  of  tetanus  and  diph- 
tlicria,  produce  soluble  exiraccUiilar  toxins  which  accumulate  in 
the  fluid  in  which  they  are  grown,  {b)  In  the  case  of  many  other 
organisms,  the  specific  poison  appears  to  remain  locked  up  in  the 
bodies  of  the  bacteria,  and  is  only  given  off  under  conditions  which 
we  are  unable  to  reproduce  experimentally;  they  are  known  as 
intracellular  toxins.  For  example,  the  soluble  products  secreted 
by  the  tubercle  bacillus  have  but  little  toxic  action,  whereas  the 
washed  bodies  of  the  bacilli  themselves  are  extremely  poisonous. 

The  pathological  effects  of  these  toxins  are  highly  diverse,  but  in 
nearly  all  cases  they  include  the  production  of  fever.  Some  are 
selective  in  their  action,  affecting  onh'  a  certain  class  of  cell — e.g., 
the  cells  of  the  central  nervous  svstem  in  the  case  of  tetanus.  Others, 
such  as  those  of  the  pyogenic  bacteria,  affect  any  tissues  they  may 
happen  to  reach.  Under  natural  conditions  the  results  vary  with 
the  amount  of  toxin  present  in  the  body,  and  with  the  susceptibility 
of  the  animal  and  of  the  tissues  in  question.  Thus  a  very  powerful 
toxin  may  immediately  destroy  the  vitality  of  a  part  en  masse, 
whilst  one  that  is  somewhat  less  intense  in  its  action  may  kill  the 
tissues  after  causing  an  acute  inflammation.  A  similar  but  still 
slower  process  leads  to  caseation;  in  this  fatty  degeneration  has 
time  to  supervene  in  the  affected  tissues  before  their  death.  In 
another  group  of  cases  the  inflammation  may  terminate  in  a  slower 
but  progressive  molecular  death  of  the  tissues,  leading  to  suppura- 
tion. Finally,  if  a  very  feeble  toxin  acts  for  prolonged  periods  it 
may  serve  as  a  stimulant  to  growth  and  determine  proliferation  of 
the  fibrous  tissues,  etc.,  without  the  development  of  any  external 
signs  of  inflammation. 

Distribution. — Bacteria  are  very  mdely  distributed  in  nature. 
Their  presence  in  the  air  varies  greatly  with  circumstances.  They 
are  absent  from  the  air  of  mountain-tops  or  mid-ocean,  and  present 
in  vast  numbers  in  towns.  They  are  not  given  off  from  the  surface 
of  liquids  containing  them,  and  only  remain  in  suspension  in  the  air 
when  adherent  to  particles  of  dust  or  moisture.  They  are  more 
plentiful  in  dry  weather  than  in  wet,  and  more  abundant  in  occupied 
houses  than  in  the  open  air.  When  the  atmosphere  of  an  enclosed 
space  is  kept  at  rest,  the  dust  gradually  sinks  to  the  bottom  and 
the  air  becomes  absolutely  sterile.  It  has  been  found  that  the 
air  of  schoolrooms  contains  far  fewer  bacteria  when  the  scholars 
are  sitting  quietly  than  when  they  are  allowed  to  move  about — 
a  fact  which  should  be  borne  in  mind  by  spectators  at  a  surgical 
operation.  Expired  air  is  sterile,  but  in  speaking  and  coughing 
minute  particles  of  fluid  are  ejected,  and  are  usually  charged  with 
an  abundance  of  bacteria,  wliich  are  frequently  pathogenic,  and 
may  constitute  a  source  of  danger  in  operations.  The  bacterial 
contents  of  water  also  vary  greatly.  That  suitable  for  a  public 
water-supplv  should  contain  but  few  bacteria,  and  pathogenic  forms 
should  be  absent.  Where  this  is  known  to  be  the  case,  the  water 
mav  be  used  in  an  emergency  to  cleanse  wounds,  though  even  then 


BACTERIOLOGY— INFECTION— IMMUNITY  7 

it  is  desirable  to  sterilize  it ;  but  as  a  rule  water  from  natural  sources 
contains  so  many  injurious  bacteria  that  a  preliminary  steriliza- 
tion is  absolutely  necessary  before  its  use  for  surgical  purposes. 
Earth  contains  vast  numbers  of  bacteria,  and  pathogenic  varieties 
are  freciuently  present. 

The  human  skin  teems  with  bacteria,  like  anything  else  which  is 
exposed  to  dust  and  dirt.  The  majority  of  these  organisms  are 
present  simply  by  accident,  and  are  readily  removed  by  washing. 
A  few,  however,  are  normal  inhabitants  of  the  skin,  and  are  very 
difficult  to  destroy,  as  they  penetrate  deeply.  Bacteria  are  also 
present  in  the  alimentary  canal  from  the  mouth  to  the  anus,  the 
external  auditory  meatus,  the  inferior  meatus  of  the  nose,  the  con- 
junctiva, the  anterior  portion  of  the  male  urethra,  and  the  vulva. 
The  superior  meatus  of  the  nose,  the  deeper  portions  of  the  urethra, 
and  the  upper  part  of  the  vagina  in  a  virgin  are  in  general  sterile, 
as  are  also  the  healthy  gall-bladder,  together  with  the  bihary  and 
pancreatic  ducts.  The  blood  and  deeper  tissues  of  a  healthy 
animal  are  usually  free  from  germs,  but  careful  observations  have 
shown  that  the  escape  of  small  numbers  of  bacteria  from  the 
alimentary  canal  into  the  blood  and  lymph  is  a  common,  perhaps 
constant,  occurrence.  Under  conditions  of  health  these  bacteria 
do  not  find  suitable  conditions  for  continued  growth  in  the  body, 
and  are  soon  destroyed  in  the  blood;  but  when  the  general  vitality 
of  the  body  is  lowered  they  may  persist,  and,  finding  a  suitable 
foothold  in  an  area  of  low  vitality,  may  develop  and  give  rise  to 
pathological  effects.  This  is  probably  the  explanation  of  the 
suppuration  that  sometimes  occurs  in  deep  lesions,  such  as  the 
subcutaneous  rupture  of  a  muscle  or  ligament,  and  it  is  termed 
aitto-infection  (p.  72). 

Methods  of  Observation — (i)  Microscopical  Exajnination. — This 
may  be  carried  out  on  morbid  material  taken  direct  from  the  body, 
or  on  cultures  of  organisms  derived  therefrom.  A  high  magnifying 
power  (yV-inch  oil  immersion)  and  a  suitable  substage  condenser 
are  necessary.  The  material  may  be  stained  or  unstained.  Un- 
stained specimens  are  usually  examined  in  a  '  hanging-drop ' 
preparation,  and  this  enables  the  observer  to  recognise  the  shape, 
size,  and  arrangement  of  the  bacteria  present,  the  presence  or 
absence  of  spores,  and  also  whether  the  organism  is  motile.  This 
method  of  examination  is  of  the  highest  importance  in  dealing  with 
cultures,  and  should  never  be  omitted.  For  morbid  exudates, 
pus,  etc.,  it  is  often  unnecessary,  and  chief  rehance  is  placed  on 
stained  specimens.  To  this  end  a  thin  film  of  the  material  is  spread  on 
a  clean  shde  or  cover-glass,  allowed  to  dry,  and  fixed  by  being  passed 
two  or  three  times  through  the  flame.  This  film  is  then  submitted 
to  the  staining  process,  of  which  there  are  three  chief  varieties: 

{a)  Simple  stains,  such  as  carbol-fuchsin,  carbol-thionin,  methy- 
lene blue,  etc.,  affect  all  bacteria,  as  well  as  the  cells,  nuclei,  etc., 
of  the  morbid  material.  They  enable  the  presence  of  the  bacteria 
to  be  recognised,  and  their  shape,  size,  etc.,  to  be  determined. 


8  A   MANUAL  OF  SURGERY 

{}))  Grani's  Method. — Tlie  film  is  imnuTsed  for  three  to  five  minutes 
in  a  stain  consistinj^'  of  lo  parts  of  a  saturated  alcoholic  solution  of 
f^entian  violet  diluted  with  90  parts  of  i  in  20  carbolic  acid  in  water. 
It  is  then  treated  for  two  or  three  minutes  with  a  watery  solution 
of  iodine  in  iodide  of  potassium  (iodine  i,  KI  2,  water  300),  and 
finally  washed  in  alcohol  until  no  more  colour  is  dissolved  out. 
Some  bacteria  remain  stained  when  treated  in  this  way,  whilst 
others  are  completely  decolorized. 

The  following  remain  stained,  and  are  termed  Gram-positive  : 
Staphylococci,  Streptococcus  pyogenes,  the  pneumococcus,  the 
Micrococcus  tefragenus,  the  bacilli  of  tetanus,  anthrax,  tubercle, 
lepros^^  diphtheria,  and  the  streptothrices  causing  actinomycosis. 

The  following  lose  their  stain  and  are  Gram-uegative  :  The  gono- 
coccus,  the  meningococcus,  the  Micrococcus  Melitensis,  the  B.  coli, 
the  bacilli  of  glanders,  typhoid  fever,  influenza,  and  soft  sore,  the 
B.  pyocyaneus,  the  vibrio  of  cholera,  the  spirillum  of  relapsing  fever, 
and  the  spirochfete  of  svphilis. 

{c)  The  Ziehl-Nielsen  Method. — The  film  is  stained  by  means  of  a 
powerful  stain,  usually  carbol-fuchsin,  which  is  either  heated  or 
allowed  to  act  for  several  hours.  It  is  then  immersed  in  20  to 
25  per  cent,  sulphuric  acid  for  five  or  ten  minutes.  This  removes 
the  stain  from  all  cells,  etc.,  and  from  the  majority  of  bacteria.  A 
few,  however,  retain  it,  and  these  are  called  acid-fast.  Films  may 
also  be  stained  in  the  same  way  and  subsequently  decolorized  in 
alcohol,  and  organisms  which  retain  the  stain  are  called  alcohol-fast. 
Of  the  organisms  which  are  of  importance  in  human  pathologv, 
the  bacilli  of  tubercle  and  leprosy  and  a  bacillus  frequently  found  in 
smegma  are  acid-fast,  and  the  two  former  are  also  alcohol-fast. 
Certain  streptothrices  are  also  acid-fast. 

_  (2)  It  is  usually  necessary  to  supplement  microscopical  examina- 
tion by  cultural  methods  in  which  a  suitable  culture  medium  is 
inoculated  with  the  material  to  be  examined  and  kept  in  an  incu- 
bator at  a  proper  temperature.  These  culture  media  are  very 
numerous,  but  broth,  gelatin,  sohdified  blood-serum,  and  agar- 
agar  suffice  for  most  purposes.  Broth  is  chiefly  used  for  making 
vaccines,  and  for  observations  on  the  chemical  products  of  bacteria. 
Solid  culture  media  are  more  generally  useful,  since  many  organisms 
form  characteristic  growths  or  colonies  on  the  surface  or  in  the  depth 
of  the  medium.  Nutrient  gelatin  is  especially  valuable,  since  it 
is  liquefied  by  some  bacteria,  whilst  others  have  no  such  action :  un- 
fortunately, it  melts  at  the  temperature  necessary  for  the  growth  of 
many  pathogenic  bacteria,  and  when  this  is  the  case  observations  on 
the  formation  of  a  peptonizing  ferment  have  to  be  carried  out  by  cul- 
tures on  blood-serum  coagulated  by  heat.  Agar-agar  is  not  rnelted 
at  the  temperature  of  the  body,  and  is  not  liquefied  by  any  organism. 

For  full  details  of  this  method  of  examination  a  work  on  bacteri- 
ology must  be  consulted. 

(3)  The  inoculation  of  living  animals  is  also  frequently  necessary, 
in  order  to  prove  that  an  organism  which  has  been  isolated  in  cases 


BACTERIOLOGY— INFECTION— IMMUNITY  g 

of  a  given  disease  is  actually  the  cause  of  that  disease.  In  the 
early  days  of  bacteriology,  when  the  bacterial  origin  of  disease  was 
hotly  contested,  Koch  formulated  the  following  postulates,  and 
when  these  are  fulfilled,  we  may  consider  the  cause  of  the  disease  as 
proved  to  demonstration: 

(a)  The  organism  (which  must  be  one  that  can  be  definitely 
recognised  from  all  others)  must  be  present  in  the  body  in  every 
case  of  the  disease. 

{b)  It  must  be  possible  to  cultivate  it  for  many  generations  apart 
from  the  bodv,  thereb\'  getting  rid  of  every  trace  of  the  original 
substance  taken  from  the  first  case  of  the  disease. 

[c)  The  inoculation  of  a  suitable  animal  must  be  followed  by  the 
appearance  of  the  specific  disease. 

(d)  The  organism  must  be  found  in  the  animal  thus  infected. 
^^'■e  do  not  now  demand  so  rigid  a  proof  of  the  pathogenic  effects 

of  bacteria.  Thus,  although  the  B.  leprce  is  universally  admitted 
to  be  the  cause  of  leprosy,  it  has  never  been  cultivated,  so  that 
with  it  only  the  first  of  Koch's  postulates  holds.  Other  tests, 
such  as  the  presence  of  specific  agglutinins  in  the  blood  of  cases  of 
the  disease,  are  now  applicable. 

Inoculation  experiments  are  frequently  employed  in  the  practical 
diagnosis  of  various  clinical  conditions.  Thus,  in  examining 
the  morbid  products  (urine,  pus,  etc.)  of  tuberculous  affections, 
the  B.  tuberculosis  is  often  present  in  such  scanty  numbers  that 
staining  and  cultural  methods  prove  ineffective.  The  subcutaneous 
or  intraperitoneal  inoculation  of  a  guinea-pig  is  an  extremely 
delicate  test,  and  will  infallibly  lead  to  the  development  of 
tuberculosis  if  living  bacilli  are  present.  The  chief  drawback  is 
the  fact  that  it  takes  two  or  three  weeks  for  the  disease  to  develop. 

Inoculations  of  pure  cultures  are  also  often  resorted  to  where 
the  organism  present  has  so  close  a  resemblance  to  a  non-pathogenic 
form  that  its  recognition  is  a  matter  of  uncertainty.  Thus,  several 
harmless  organisms  have  a  close  resemblance  to  the  anthrax 
bacillus,  and  the  latter  can  only  be  distinguished  by  causing  anthrax 
when  injected  into  the  lower  animals.  A  refinement  on  this 
method,  which  is  applicable  in  some  cases,  consists  in  injecting  a 
normal  animal  and  also  an  animal  immunised  against  the  organism 
suspected  to  be  present  in  the  culture.  Ihus,  the  tetanus  bacillus 
in  pus  is  usually  mixed  with  many  other  bacteria,  so  that  it  is 
excessively  difficult  to  isolate.  A  broth  culture  is  inoculated  with 
the  pus  in  question,  and  incubated  in  the  absence  of  air,  since  the 
tetanus  bacillus  is  an  anaerobe.  It  is  then  di\'ided  into  two  parts, 
of  which  one  is  injected  into  a  normal  animal  and  the  other  into 
one  which  has  received  a  dose  of  antitetanic  serum.  If  the 
former  dies  and  the  latter  remains  alive,  the  presence  of  the 
tetanus  bacillus  in  the  culture  is  certain. 

A  few  micro-organisms  other  than  bacteria  require  brief  mention, 
but  most  of  them  are  of  little  surgical  importance. 


lo  A   MANUAL  OF  SURGERY 

1.  The  yeasts  or  hlastomycetes  are  devoid  of  chlorophyll,  and 
multiply  by  budding,  or  endogenous  spore-formation.  They  cause 
many  forms  of  fermentation — e.g.,  the  alcoholic  fermentation  in 
solutions  of  grape-sugar;  they  occasionally  gain  access  to  the 
urinary  bladder  in  diabetes,  and,  by  leading  to  the  production  of 
irritative  products  of  fermentation,  give  rise  to  cystitis.  The  only 
important  disease  now  attributed  to  the  veast-fungi  is  blastomycetic 
dermatitis,  which  is  characterized  bv  multiple  chronic  lesions, 
resembling  verrucous  tuberculides. 

2.  The  hyphomycetes,  or  filamentous  fungi,  are  characteiizcd  by  the 
presence  of  a  mycelial  network  of  long  fibres,  and  have  a  method 
of  sporulation  which  is  more  complicated  than  that  seen  in  the 
bacteria  or  yeasts.  The  following  are  the  more  important  of  their 
pathological  effects: 

Thrush,  due  to  Oidiiim  albicans,  an  organism  sometimes  included 
in  the  blastomycetes,  and  called  Saccharomyces  or  Monilia  albicans. 

Ringworm,  which  may  be  caused  by  Microsporon  Audouini  (the 
small-spored  fungus),  or  the  Trichophyton  or  large-spored  fungus, 
of  which  there  are  several  varieties.  Of  these  the  former  is  more 
common  in  London  and  Paris,  but  is  rare  in  most  parts  of  the 
Continent. 

Favus,  caused  b}^  the  Achorion  Schdnleinii. 

pityriasis  rubra,  due  to  the  Microsporon  furfur. 

Keratomycosis,  or  parasitic  ulcer  of  the  cornea,  is  due  to  fungi  of 
the  aspergillus  type,  and  similar  organisms  may  also  affect  the  lungs 
(pneumomycosis)  or  the  external  auditory  meatus  (otomycosis). 

The  group  streptothrix  rray  be  regarded  as  the  lowest  of  the 
hyphomycetes,  and  its  members  possess  many  similarities  to  the 
bacteria.  They  are  of  importance,  since  their  pathogenic  members 
give  rise  to  the  group  of  diseases  known  as  '  actinomycosis.'  The 
streptothrices  form  long  filamentous  hypha,  which  are  narrower 
than  those  of  the  higher  fungi,  and  which  differ  from  the  leptothrical 
filaments  sometimes  exhibited  by  some  bacilli  in  that  they  show 
true  branching.  Thev  form  chain-spores,  the  protoplasm  of  the 
mycelial  threads  collecting  in  small  masses  separated  by  spaces  in 
which  the  sheath  is  empty.  These  appear  to  be  true  spores,  since 
they  resist  a  temperature  higher  than  that  which  kills  the  mycelium 
itself.  The  streptothrices  are  widely  distributed,  and  many  forms 
are  known,  of  which  but  a  few  are  pathogenic. 

It  is  worthy  of  notice  that  the  tubercle  bacillus  (as  well  as  other 
organisms  usually  classified  as  bacteria)  sometimes  grows  into  long 
branching  filaments.  Hence  some  regard  it  as  belonging  to  the 
streptothrices,  and  term  it  '  tuberculomyces.' 

3.  The  protozoa,  or  unicellular  animals,  are  a  group  of  consider- 
able importance,  since  syphilis  and  not  a  few  tropical  affections  are 
due  to  members  of  this  family.  The  life-history  of  many  of  them 
is  not  known  in  its  entirety,  but  it  has  been  traced  out  in  some. 
Malaria  and  the  amcebic  "form  of  dysentery,  together  with  the 
tropical   abscess  of  the  liver  associated  therewith,    are  protozoal 


BACTERIOLOGY— INFECTION— IMMUNITY  ii 

in  origin.  Trypanosomcs  are  also  of  animal  nature,  and  by  their 
development  in  the  bod^^give  rise  to  sleeping  sickness  and  numerous 
other  tropical  diseases  in  man  and  lower  animals. 

Infection. 

Infection  may  be  defined  as  the  access  of  living,  virulent,  patho- 
genic bacteria  to  a  region  whence  their  toxins  may  act  on  the 
tissues  of  the  body.  Certain  points  in  this  definition  require  ex- 
planation: (i)  It  is  interesting  to  notice  that  dead  bacteria,  especi- 
ally dead  tubercle  bacilli,  may  cause  pathogenic  effects  quite 
similar  to  those  of  the  living  ones.  This,  however,  can  scarcely 
be  spoken  of  as  infection,  since  one  of  the  fundamental  ideas  of 
that  process  is  that  it  can  be  transmitted  from  one  sufferer  to 
another  indefinitely.  (2)  The  question  of  vimlence  is  one  of  the 
greatest  importance,  since  differing  strains  of  the  same  organism 
may  vary  much  in  the  degree  of  \arulence,  as  may  also  the  same 
strain  under  varying  conditions.  Thus,  rabbits  are  often  but  little 
affected  by  the  injection  of  large  amounts  of  a  pure  culture  of  the 
Streptococcus  pyogenes,  and  yet  it  is  possible  so  to  exalt  the  virulence 
of  the  same  culture  that  an  extremely  small  dose  (possibly  a  single 
coccus)  may  produce  death.  This  exaltation  of  virulence  is  usually 
accomplished  by  '  passage  '  through  a  series  of  animals,  each  in 
turn  being  inoculated  from  the  last ;  the  disease  appears  more  rapidly 
and  runs  its  course  more  acutely  in  each  instance  up  to  a  certain 
point  of  maximum  intensity,  which  persists.  Probably  something 
of  the  sort  occurs  under  natural  conditions,  for  an  organism  taken 
directly  from  a  patient  is  usually  much  more  virulent  than  one  that 
has  been  cultivated  in  the  laboratory.  Thus,  a  slight  post-mortem 
wound  infected  from  a  case  of  streptococcic  peritonitis  is  usually 
very  severe,  indicating  a  very  high  degree  of  virulence  in  the 
organism.  In  general,  we  know  little  or  nothing  of  the  causes 
which  lead  to  increase  of  virulence  under  natural  conditions,  and 
especially  so  as  regards  epidemic  outbreaks  of  disease. 

Cultures  of  an  organism  of  diminished  virulence  are  said  to  be 
attenuated.  The  artificial  attenuation  of  pathogenic  bacteria  is 
a  subject  of  great  importance  in  connection  with  the  production  of 
immunity,  and  it  may  be  laid  down  as  a  general  rule  that  the  cultiva- 
tion of  an  organism  under  shghtly  disadvantageous  conditions 
tends  to  diminish  its  virulence,  and  vice  versa.  For  example,  the 
anthrax  bacillus  grows  best  at  37°  C,  or  thereabouts,  and  retairis 
its  virulence  for  long  periods  at  this  temperature,  but  if  it  is  culti- 
vated at  42°  C.  it  becomes  attenuated.  Cultures  thus  treated  con- 
stitute Pasteur's  vaccine  against  anthrax;  when  injected  into  animals 
they  cause  transient  ill-effects,  but  the  animal  becomes  immune  to 
the  disease. 

(3)  The  organism  must  be  pathogenic,  if  infection  is  to  occur,  arid 
by  this  we  mean  capable  of  producing  disease  in  the  animal  in 
question.     Thus,  the  inoculation  of  the  gonococcus  into  the  urethra 


12  A    MANUAL  OF  SUUGF.RY 

of  animals  leads  to  no  results,  and  infection  does  not  take  place. 
Hence  two  factors  must  be  present :  the  organism  must  be  virulent, 
and  the  host  susceptible. 

(4)  Lastly,  an  essential  feature  of  infection  is  that  the  toxins  of 
the  organism  must  act  on  the  tissues  of  the  host.  Thus,  it  is  quite 
possible,  and  not  uncommon,  for  streptococci  to  be  present  in  the 
outer  layers  of  the  skin,  and  the  B.  diphtherice  in  the  mouth,  etc., 
and  yet  for  no  harmful  effects  to  arise,  since  either  the  organisms 
do  not  form  toxins,  or  else  these  toxins  do  not  reach  the  tissues. 
This  is  not  infection,  although  in  such  cases  any  slight  lesion  or  any 
condition  leading  to  local  or  general  lowering  of  resistance  may 
bring  it  about. 

The  terms  specific  and  non-specific  as  applied  to  infectious  diseases 
also  require  explanation.  A  specific  disease  is  defined  as  one  which 
is  produced  by  a  single  cause — i.e.,  a  particular  species  of  micro- 
organism, and  by  no  other.  Thus,  tetanus  is  a  well-marked  patho- 
logical entity,  always  due  to  the  B.  tetani,  and  may  be  taken  as  the 
type  of  a  specific  infection.  Suppuration,  on  the  other  hand,  is 
caused  by  many  different  species  of  bacteria,  and  is  therefore 
termed  '  non-specific'  The  boundaries  of  these  divisions  are 
constantly  changing  with  the  advancement  of  pathological  research. 
The  common  process  is  for  diseases  which  are  apparently  homo- 
geneous to  be  split  up  into  specific  groups,  each  due  to  its  own 
organism.  Thus,  ringworm  is  now  known  to  be  due  to  several 
different  forms  of  fungus,  and  combined  clinical  and  pathological 
research  have  shown  that  the  conditions  due  to  one  variety  differ 
in  minute  points  from  those  due  to  another.  Again,  actinomycosis 
was  formerly  thought  to  be  a  specific  disease  due  to  a  single 
organism,  but  it  has  now  been  shown  that  many  organisms 
may  produce  it.  The  reverse  process  is  sometimes  seen,  several 
apparently  different  diseases  being  united  together  on  the  discovery 
of  their  cause.  For  example,  malignant  pustule  and  wool-sorter's 
disease  are  apparently  quite  distinct  maladies;  vet  since  it  has  been 
found  that  thev  are  both  caused  by  the  F>.  anthracis  they  can  now 
be  included  as  manifestations  of  one  specific  disease. 

Local  Infective  Processes  are  those  caused  at  the  site  of  inoculation 
by  the  growth  and  development  of  the  microbes.  After  a  period 
of  incubation — which  varies  with  different  organisms,  and  during 
which  we  may  imagine  that  thev  are  struggling  wdth  the  germicidal 
action  of  the  tissues,  and  establishing  their  foothold  in  the  body — 
the  bacteria  begin  to  grow  and  multiply,  and  bv  the  deleterious 
products  of  their  activity  cause  irritation  of  the  tissues  and  various 
degrees  of  inflammation. 

These  inflammatory  foci  mav  remain  limited,  or  diffusion  may 
occur  by  the  bacteria  spreading  with  more  or  less  rapidity  by  con- 
tinuity of  tissue  or  along  lymph  channels;  or  the  organisms  may  be 
widely  disseminated  through  the  body  by  the  bloodvessels  in  the 
shape  of  emboli.  A  certain  amount  of  constitutional  disturbance 
may  accompany  these  manifestations,  due  to  the  absorption  of  the 


BACTERIOLOGY— INFECTION—IMMUNITY  13 

toxins  produced  locally,  whilst  in  some  diseases  the  general  toxic 
symptoms  (or  toxaemia)  associated  with  some  local  mischief  may  be 
extremely  severe,  as  in  tetanus  and  diphtheria.  Hence  local  in- 
fective processes  ma}'  be  classed  in  two  divisions:  {a)  those  in  which 
there  is  but  little  or  no  general  toxaemia,  such  as  a  soft  chancre, 
a  tuberculous  abscess,  or  a  mild  attack  of  gonorrhoea;  and  (b)  those 
in  which  the  toxsemic  condition  is  well  marked,  as  in  erysipelas, 
tetanus,  diphtheria,  etc.,  the  character  of  the  symptoms  varying 
necessarily  with  the  different  toxins. 

Many  of  the  organisms  which  are  the  causes  of  local  infection 
may  also  develop  generally  in  the  system,  and  produce  grave  con- 
stitutional affections. 

General  Infective  Processes  are  those  in  which  the  organisms 
develop  and  multiply  in  the  blood-stream,  so  that  inoculation  of  a 
sound  person  \\'ith  the  blood  would  almost  certainly  transmit  the 
disease  if  a  sufficient  dose  were  introduced.  Many  of  the  bacteria 
producing  local  infection  give  rise  to  these  general  diseases,  and, 
indeed,  in  surgery  we  rarely  see  the  latter  wdthout  some  local 
condition  being  present  to  explain  its  origin.  Septicsemia,  pya-mia, 
acute  tuberculosis,  the  second  stage  of  syphihs,  anthracaemia,  and 
probably  the  exanthemata,  are  illustrations  of  general  infection 
(see  Chapters  V.  and  VIII.). 

Immunity. 

Under  ordinary  circumstances  every  living  animal  is  constantly 
exposed  to  possible  sources  of  infection.  Bacteria  are  present  in 
the  air  Vv'e  breathe,  in  our  food,  drink,  etc.,  as  well  as  on  our  skins 
and  in  our  alimentary  canals.  It  is  obvious,  therefore,  that  there 
is  some  potent  natural  means  of  resisting  the  attack  of  these 
organisms,  and  that  it  is  only  when  these  means  break  down  or 
are  insufficient  that  infection  occurs.  This  power  of  resisting  the 
invasion  of  micro-organisms  is  termed  immunity,  and  it  is  the  exact 
opposite  of  susceptibility.  Further,  the  process  of  natural  cure 
of  any  infective  disease  is  brought  about  by  the  production  of  such 
a  degree  of  immunit}^  (whether  local  or  general)  as  shall  suffice  to 
destroy  the  causative  bacteria.  It  is  therefore  obvious  that  the 
study  of  immunity  is  of  the  greatest  importance  in  connection  \\dth 
the  prevention  and  cure  of  disease,  and  the  more  so  since  the  most 
potent  artificial  methods  of  accompHshing  these  ends  are  those  which 
imitate,  or  stimulate,  or  give  free  play  to,  these  natural  processes. 

Natural  Immunity  is  that  which  is  inherent  in  the  constitution  of 
the  animal  when  born,  and  not  due  to  any  event  taking  place  in  its 
hfe  history.  Thus  the  lower  animals  are  all  naturally  immune  to 
gonorrhoea  and  many  other  diseases  which  affect  man,  whereas  man 
is  naturally  immune  to  many  diseases  of  the  lower  animals.  In 
most  cases  natural  immunity  is  general  throughout  all  the  members 
of  the  species,  but  this  is  not  alwa^/s  the  case;  thus,  some  children 
are  absolutely  immune  to  vaccinia,  though  the  vast  majorit}-  are 


M  A   MANUAL  OF  SURGERY 

susceptible.  Hence  racial  and  natural  immunity  are  not  quite 
identical. 

It  must  be  clearly  understood  that  there  is  no  absolute  standard 
of  immunity,  since  the  reaction  of  the  tissues  varies  from  time  to 
time  between  the  highest  degree  of  susceptibility  and  the  highest 
degree  of  immunity.  Thus,  if  several  animals  are  inoculated  with 
equal  doses  of  the  same  bacterial  culture,  one  may  show  no  ill- 
effects;  another  may  exliibit  a  slight  amount  of  inflammation  at 
the  site  of  inoculation;  a  third  may  acquire  a  spreading  inflamma- 
tion, which  may  progress  to  suppuration  or  gangrene;  whilst  a 
fourth  may  develop  a  fatal  general  infection.  Further,  an  animal 
may  be  highly  immune  to  an  organism  of  ordinary  virulence,  but 
at  the  same  time  highly  susceptible  to  the  same  organism  when  its 
virulence  is  exalted. 

Again,  the  immunity  or  susceptibility  of  any  animal  to  a  given 
bacterium  is  greatly  influenced  by  external  and  internal  conditions. 
A  study  of  these  conditions  is  of  fundamental  importance  in  the 
prevention  of  disease.  It  may  be  regarded  as  certain  that  man 
possesses  a  verv  considerable  degree  of  immunity  to  nearly  all  bacteria 
(including  even  the  tubercle  bacillus),  and  it  is  only  when  this 
immunity  becomes  lowered  by  general  or  local  causes  which  depreciate 
the  vitalitv  that  infection  occurs. 

Of  the  general  causes  which  predispose  to  infection,  cold  and  wet, 
especially  if  combined,  are  perhaps  the  most  potent,  but  the 
method  in  which  they  act  is  still  uncertain.  Starvation  and  mal- 
nutrition are  also  important,  and  even  in  slight  degrees  have  a  very 
decided  effect  on  immunity.  Thus,  it  lias  long  been  recognised  that 
post-mortem  wounds  received  when  fasting  are  more  dangerous 
than  those  received  when  digestion  is  in  progress.  In  this  case  the 
immunity  may  perhaps  be  correlated  with  the  increased  number 
of  leucocytes  in  the  blood  during  digestion,  but  it  does  not  appear 
to  be  a  constant  fact  that  a  large  number  of  leucocytes  always 
implies  a  high  grade  of  resistance,  and  vice-versa.  Age  is  an  impor- 
tant factor,  children  being,  as  a  rule,  much  more  susceptible  than 
adults.  Immunity  is  greatly  reduced  by  hcemorrhage ,  and  by 
certain  poisons,  particularly  alcohol.  Protracted  exposure  to  a 
vitiated  atmosphere  is  a  very  potent  factor  in  the  production  of 
susceptibility  to  the  tubercle  bacillus.  Prolonged  ancesthesia  lowers 
the  general  resistance  of  the  body,  as  also  certain  diseases,  notably 
Bright's  disease  and  diabetes. 

The  local  causes  include  injury,  especially  bruises,  contusions, 
burns,  and  the  irritation  due  to  chemical  substances.  This  latter 
condition  is  often  used  in  the  laboratory  to  exalt  the  virulence  of 
certain  bacteria.  Thus,  pyogenic  cocci  are  often  without  effect 
on  rabbits,  even  in  tolerably  large  doses;  but  if  injected  together 
with  some  dilute  lactic  acid,  the  toxins  of  other  bacteria  (such  as 
B.  prodigiosus),  or  other  soluble  irritant,  they  arc  frequently 
enabled  to  develop  and  produce  pathological  results.  Consider- 
able surgical  importance  is  attached  to  this  observation,  since  it 


BA  C  TERIOLOG  Y~INFEC  TION—IMM  UNIT  Y  1 5 

must  not  be  forgotten  that  nearly  all  antiseptics  are  irritant,  and 
if  applied  in  too  concentrated  a  state  or  for  too  long  may  lower 
the  local  resistance,  and  render  the  wound  more  liable  to  be  infected 
by  any  organism  that  may  at  the  time  or  subsequently  gain  acci- 
dental entrance.  The  local  application  of  cold  or  hot  liquids  has 
a  similar  action,  and  hence  all  fluids  used  to  wash  out  wounds  or 
body  cavities  should  be  used  exactly  at  blood  heat,  unless  the 
direct  effect  of  the  heat  or  cold  is  required.  Lastly,  a  defective  supply 
of  fresh  blood,  due  to  disease  in  the  bloodvessels,  or  stagnation 
of  venous  blood  due  to  tight  bandaging,  pressure,  etc.,  also  renders 
a  part  less  resistant  to  infection. 

Acquired  Immunity  is  of  two  lands — active  and  passive. 

Active  immunity  results  from  a  previous  attack  of  the  disease, 
either  natural  or  due  to  artificial  inoculation,  so  that  the  individual 
is  freed  from  the  risk  of  contracting  it  again.  S\^philis  and  the 
exanthemata  are  good  illustrations  of  diseases  conferring  an  active 
immunity,  which,  however,  is  not  always  absolute,  since  well- 
confimied  examples  of  second  attacks,  even  of  syphilis,  have  been 
recorded.  On  the  other  hand,  it  is  doubtful  whether  tuberculosis 
and  the  pvogenic  diseases  are  capable  of  producing  immunity. 

The  following  are  the  most  important  artificial  methods  of  bestow- 
ing active  immunity:  (i)  Inoculation  of  the  disease  as  it  occurs  in 
nature.  This  is  of  course  a  dangerous  method,  since  the  attack  is 
almost  as  severe  as  one  acquired  in  the  normal  way.  It  was  for- 
merly practised  as  a  preventive  of  small-pox  before  the  introduc- 
tion of  vaccination.  (2)  Inoculation  with  the  virus  of  the  disease 
or  its  causal  micro-organism  in  an  attenuated  condition.  Vaccina- 
tion is  the  best  example  of  this  process;  the  Ij^roph  employed  is  a 
culture  of  the  small-pox  organism  (the  exact  nature  of  which  is  at 
present  not  definitely  known)  in  a  state  of  diminished  virulence. 
Pasteur  also  applied  the  same  method  in  the  prevention  of  hydro- 
phobia (p.  140)  and  of  anthrax  in  cattle,  the  '  vaccine  '  in  the 
latter  case  being  a  living  culture  of  anthrax  bacilli  attenuated  by 
being  cultivated  at  a  temperature  of  42°  C.  (3)  Injection  of  dead 
cultures  of  bacteria  is  used  in  the  preventive  inoculation  against 
plague  (Haffkine)  and  against  typhoid  fever  (Wright).  The  cul- 
tures are  killed  by  heat,  and  small  doses  injected  subcutaneously. 
The  result  is  a  local  inflammatory  reaction  of  varpng  severity, 
together  with  general  s\'mptoms,  such  as  fever  and  malaise.  When 
these  have  passed  off,  the  patient  has  acquired  some  immunity 
to  the  disease,  so  that  he  is  now  able  to  withstand  the  injection  of 
a  larger  dose  or  even  of  a  li\ang  culture,  by  which  means  the 
immunity  is  greatly  increased.  Koch's  tuberculin  (TR)  is  of  a 
similar  nature;  it  consists  of  an  emulsion  of  finelv  comminuted 
tubercle  bacilli  which  have  been  killed  by  a  process  of  grinding. 
This  method  has  now  been  extended  to  the  cure  of  man}^  other 
infective  conditions.  (4)  Injection  of  the  extracellular  toxins  of 
the  causative  organism  is  not  used  in  man,  but  it  is  of  the  utmost 
value  in  immunizing   the  lower   animals   for  the   preparation  of 


i6  A   MANUAL  OF  SURGERY 

curative  sera,  especially  antidiphtheritic  and  antitetanic.  The 
horse  is  chosen  for  this  purpose,  since  it  is  easy  to  liandle,  and  yields 
a  large  amount  of  serum  at  each  bleeding.  The  principle  of  the 
method  is  simple.  A  small  quantity  of  the  toxin  (which  has  been 
filtered  to  remove  living  bacteria)  is  injected  subcutaneously. 
It  causes  local  inflammation,  fever,  and  malaise:  but  when  these 
have  quite  subsided,  another  and  slightly  larger  amount  of  toxin 
can  be  tolerated.  In  this  way  the  dose  is  gradually  increased,  until 
the  animal  is  so  resistant  that  the  injection  of  enormous  doses  of 
most  powerful  toxin  will  produce  but  slight  and  transient  ill-effects. 
In  actual  practice  this  method  is  usually  modified,  the  earlier  stages 
being  considerabh'  shortened  by  the  injection  of  a  mixture  of  toxin 
and  antitoxin,  or  by  the  use  of  peculiar  forms  of  toxin  of  diminished 
activity. 

It  will  be  noticed  that  in  all  these  methods  the  animal  which 
subsequently  becomes  immune  combats  with  and  overcomes  the 
organism  or  its  toxin,  and  is  always  rendered  more  or  less  ill  (in 
some  cases  very  slightly)  by  the  process.  For  this  reason  it  is 
teiTned  an  active  immunity — i.e.,  it  is  acquired  by  the  animal's 
own  active  combat  with  and  victory  over  the  disease. 

Passive  immunity  is  that  which  is  conferred  on  an  animal  without 
effort  on  its  part  by  the  injection  of  serum  from  an  animal  that  has 
alreadv  acquired  an  active  immunity  against  the  disease  in  question. 
For  example,  if  some  of  the  serum  from  a  horse  which  has  been 
actively  immunized  against  tetanus  is  injected  into  a  second  horse 
(or  other  animal),  the  latter  will  also  become  immune  to  the  tetanus 
bacillus  or  to  its  toxin.  The  second  animal  is  not  rendered  ill  by 
the  injection,  and  is  merely  the  passive  recipient  of  protective  sub- 
stances which  have  been  elaborated  by  the  first.  The  fact  that  the 
injection  of  these  sera  into  man  sometimes  causes  transient  ill-effects, 
such  as  fever,  joint-pains,  rashes,  etc.,  in  no  way  modifies  the  truth 
of  this  statement :  the  phenomena  in  question  do  not  always  occur, 
and  may  be  due  to  other  causes  (p.  28). 

Passive  immunity  cannot  be  bestowed  by  the  injection  of  serum 
from  an  animal  w^hich  is  naturally  immune:  most  of  the  lower 
animals,  for  example,  are  naturally  immune  to  syphilis,  but  their 
serum  has  no  protective  or  curative  action  in  man.  The  diseases 
in  which  the  serum  has  the  greatest  practical  value  for  protection 
or  cure  are  those  in  which  the  specific  micro-organisms  produce 
extracellular  toxins,  especially  diphtheria  and  tetanus. 

Active  and  passive  immunity  also  differ  in  other  respects. 
Passive  immunity  is  produced  immediately  the  serum  is  injected, 
whereas  active  immunity  is  only  developed  slowly  after  the  in- 
jection of  the  toxin,  or  of  the  hving  or  dead  culture;  in  general,  a 
week  at  least  must  elapse  before  the  full  degree  of  immunity  is 
produced.  Again,  passive  immunity  lasts  a  comparatively  short 
time,  unless,  of  course,  the  dose  of  the  immunizing  serum  is  repeated. 
In  the  case  of  a  prophylactic  injection  of  antidiphtheritic  serum  in 
man,  the  duration  of  the  immunity  is  about  a  couple  of    months. 


BACTERIOLOG  Y— INFECTION— IMM  UNITY  1 7 

Active  immunity  is  usually  much  more  lasting,  though  its  duration 
varies  greatly  in  different  cases.  In  most  cases  of  syphilis  and 
small-pox  it  is  permanent,  second  attacks  being  extremely  rare, 
whereas  in  pneumt)nia  and  erysipelas  it  is  of  very  short  duration. 

When  we  turn  to  the  theories  which  have  been  promulgated  to 
explain  the  facts  briefly  outlined  above,  it  must  be  borne  in  mind 
that  there  are  two  groups  of  phenomena  which  require  elucidation: 
the  immunity  to  the  bacteria  and  the  immunity  to  their  toxins. 
Thus,  if  a  culture  of  living  diphtheria  bacilli  is  injected  together 
with  their  toxin  into  a  susceptible  animal,  the  bacilli  will  continue 
to  grow  in  its  tissues,  and  the  toxin  will  exert  its  poisonous  effects, 
both  local  and  remote.  If  the  same  culture  is  injected  into  an 
immune  animal  (whether  the  immunity  is  natural,  active,  or 
passive),  the  bacteria  will  be  killed  and  the  toxin  will  have  no 
action.     This  bacterial  immunity  must  first  be  discussed. 

Omitting  theories  which  are  merely  of  historical  interest,  we  come 
first  to  the  humoral  theory,  which  asserts  that  the  destruction  of  the 
bacteria  is  due  to  certain  substances  which  are  present  in  the 
blood,  lymph,  etc.,  and  which  are  designated  alexins.  The  ex- 
perimental foundation  for  this  theory  consists  in  the  fact  that  fresh 
blood,  and  more  especially  fresh  blood-serum,  has  very  consider- 
able bactericidal  action.  This  action  is  destroyed  if  the  serum  is 
exposed  to  heat  (about  60°  C.  for  half  an  hour),  and  disappears 
spontaneously  after  a  day  or  so;  when  the  alexins  have  been 
destroyed  by  either  process,  the  serum  becomes  an  excellent  culture 
medium  for  most  bacteria. 

MetchJiikoff's  theory  of  phagocytosis  (the  cellular  theory)  was  at 
first  in  strong  opposition  to  the  humoral  theory,  but  subsequent 
researches  have  brought  the  two  closer  together.  Starting  from 
the  fact  that  unicellular  protozoa  (such  as  the  amoeba)  ingest, 
digest,  and  assimilate  the  bacteria  found  in  water,  Metchnikoff 
was  led  to  examine  the  action  of  the  leucocytes,  or  wandering  cells 
of  the  higher  animals,  which  in  their  morphology  so  strongly 
resemble  the  lower  protozoa,  and  found  in  them  a  similar  power 
of  engulfing  and  digesting  living  micro-organisms.  This  process 
he  termed  -phagocytosis.  A  striking  example  occurs  in  Daphnia 
(the  fresh-water  flea),  an  animal  which  is  so  transparent  that  the 
whole  phenomenon  can  be  followed  under  the  microscope  during 
life.  It  is  affected  with  a  disease  due  to  the  growth  in  its  tissues 
of  a.  fungus  known  as  Monospora.  The  spores  of  this  parasite  are 
taken  in  with  the  food,  and  penetrate  from  the  alimentar}-  canal 
into  the  body  cavity ;  when  unchecked,  they  continue  to  grow  until 
the  whole  animal  is  filled  with  growth.  If,  however,  but  few  spores 
gain  access,  the  defensive  mechanism  comes  into  play,  and  the 
spores  are  surrounded  and  engulfed  by  the  leucocytes,  submitted 
to  a  process  of  digestion,  and  finally  destroyed.  It  is  ob\aous  that 
Daphnia  is  partially  immune  to  Monospora,  and  that  the  immunity 
depends  on  the  phagocytic  activity  of  its  leucoc\i:es.  Metchnikoff 
had  no  difficulty  in  finding  many  examples  of  the  same  process  in 


1 8  A   MANUAL  OF  SURGERY 

man  and  tlie  liiglier  animals.  If,  for  instance,  a  culture  of  a  non- 
pathogenic organism  is  injected  into  the  peritoneal  cavity  oi  an 
animal,  and  ])ortions  of  the  peritoneal  fluid  are  examined  from 
time  to  time,  the  bacteria  will  be  seen  first  lying  free;  then  engulfed 
in  the  protoplasm  of  the  leucocytes,  but  retaining  their  normal 
appearance  and  staining  reactions;  then  less  distinct  and  refractile 
than  before,  indicating  that  they  have  undergone  partial  digestion, 
and  in  this  state  they  stain  badly.  Similar  appearances  may  also 
be  seen  in  sections  of  tuberculous  tissue,  especially  those  that  are 
healing,  though  here  the  phagocytic  cells  are  not  leucocytes,  but 
endothelioid  or  giant  cells. 

The  leucocytes  are  attracted  to  the  region  of  the  bacteria  owing 
to  the  fact  that  the  latter  give  off  soluble  substances  for  which  the 
leucocytes  have  an  affinity,  so  that  they  move  into  the  region  in 
which  these  substances  exist  in  a  high  state  of  concentration.  This 
process  is  known  as  chemotaxis,  and  it  is  one  which  is  widely  dis- 
trilnited  throughout  the  lower  members  of  the  animal  and  vegetable 
kingdoms.  If,  for  instance,  a  capillary-tube  filled  with  meat-extract 
is  placed  in  a  watery  emulsion  of  typhoid  bacilli,  the  latter  will  be 
attracted  by  chemotaxis  and  enter  the  tube.  Similar  phenomena 
are  seen  in  the  formation  of  an  abscess:  the  pyogenic  bacteria  give 
off  substances  which  attract  the  leucocytes,  so  that  they  soon 
become  surrovmded  by  a  zone  of  these  cells,  and  at  the  same  time 
some  of  these  substances  gain  access  to  the  blood  and  attract  the 
leucocytes  from  the  bone-marrow,  giving  rise  to  a  general  leuco- 
cytosis. 

Metchnikoff  found  that  in  cases  where  phagocytosis  was  active 
recover}^  usually  took  place,  and  that  when  it  failed  the  bacteria 
continued  to  grow  and  death  occurred;  from  this  he  argued  that 
immunity  depends  entirely  on  the  leucocytes.  He  further  noted 
that  in  animals  with  acquired  immunity  the  leucocytes  had  gained 
the  power  of  ingesting  the  bacteria,  although  previously  unable 
to  do  so;  hence  he  explained  acquired  immunity  as  being  due  to 
the  education  which  the  leucocytes  had  gained  during  the  previous 
attack.  The  opponents  of  the  theory  urged  tliat  only  dead,  or  at 
least  non-virulent,  bacteria  were  taken  up  by  the  cells,  but  Metch- 
nikoff's  great  technical  skill  enabled  him  to  isolate  bacilli  that  had 
been  actuall}^  ingested  by  leucocytes  and  prove  them  to  be  living 
and  virulent. 

The  theory  of  phagocytosis  was  never  generally  accepted  in  its 
original  form,  and  it  was  soon  found  not  to  apply  in  certain  cases. 
Thus,  it  is  possible  to  enclose  active  bacteria  in  a  collodion  sac, 
which  will  allow  the  transudation  of  body  fluids,  but  will  prevent  the 
passage  of  leucocytes ;  if  such  a  contrivance  is  placed  in  the  peritoneal 
cavity  of  an  immune  animal,  the  bacteria  are  often  killed.  Further 
research  also  showed  that  even  when  bacteria  are  ultimately 
destroyed  by  phagocytic  activity  they  may  lose  their  definite  out- 
line,|refractility,  etc.,  and  give  other  indications  of  being  injured 
whilst  still  free  and  extracellular.     The  fact  that  this  extracellular 


BACTERIOLOG  Y— INFECTION— IMMUNITY  ig 

injury  or  destruction  usually  occurs  when  the  bacteria  are  sur- 
rounded by  leucocytes  led  to  the  theory  that  the  alexins  are  formed 
from  or  secreted  bv  the  leucocj'tes.  This  is  the  celliilo-humoral 
theory,  and  it  may  be  regarded  as  a  compromise  between  the  two 
views  enunciated  above.  It  agrees  with  the  humoral  theory  in 
regarding  the  destruction  of  the  invading  bacteria  as  due  wholly 
or  partlv  to  soluble  substances  present  in  the  bodv  fluids;  and  with 
the  cellular  theory  in  attributing  to  the  leucocytes  the  paramount 
role  in  the  defences  of  the  body,  but  differs  from  it  in  allotting  to 
them  a  double  action,  partly  chemical  and  partly  phagocytic. 

Many  facts  go  to  prove  that  there  is  much  truth  in  this  com- 
promise, but  it  is  not  a  complete  explanation.  Thus,  Behring's 
investigations  on  the  subject  of  passive  immunity,  especially  in  con- 
nection with  diphtheria,  introduced  a  new  element  and  opened  up 
a  fresh  field  of  research.  It  was  found  possible  to  cure  the  disease 
by  a  suitable  serum  or  antitoxin  which  has  no  bactericidal  effect 
whatever,  so  that  its  activity  cannot  be  attributed  to  alexins  or 
other  bactericidal  substances. 

Metchnikoff  explained  its  practical  value  by  attributing  to  it  the 
power  of  stimulating  the  leucocyi:es  to  more  vigorous  phagocytic 
action;  but  this  view  can  no  longer  be  sustained,  though,  as  we 
shall  see,  it  has  a  substratum  of  truth.  Further  researches  showed 
that  the  action  of  the  antitoxin  is  an  extremely  simple  one.  It  unites 
with  its  specific  toxin,  and  forms  a  compound  which  is  devoid  of 
toxic  properties.  It  is  unnecessary  to  give  the  full  evidence  on 
which  this  statement  is  based,  but  one  single  proof  mav  be  men- 
tioned. Several  bacteria — amongst  others  the  tetanus  bacillus — - 
produce  toxins  which  have  the  power  of  dissoKing  red  blood  cor- 
puscles (haemolysis) ;  hence  these  substances  are  called  the  bac- 
terial hemolysins.  Experiments  on  haemolysis  can  be  carried 
out  in  vitro,  and  it  is  thus  possible  to  avoid  all  complications  arising 
from  phagocytosis  or  the  action  of  the  living  tissues.  Now  it  is 
found  that  tetanus  antitoxin  will  prevent  the  hffimol}i:ic  action  of 
the  haemolysin  of  the  tetanus  bacillus  in  the  test-tube  as  well  as  in 
the  body.  Here,  therefore,  there  must  be  merel\^  a  simple  process 
of  chemical  neutralization,  which  may  be  compared  with  the  action 
of  an  alkali  on  an  acid. 

The  discovery  of  the  antitoxins  for  diphtheria  and  tetanus  led 
to  numerous  attempts  to  form  similar  substances  for  other  poisons. 
It  was  found  impossible  to  produce  antitoxins  for  the  alkaloids, 
mineral  poisons,  etc.  iVntitoxins  were,  however,  prepared  for 
snake- venom,  eel-serum,  abrin,  ricin,  etc.,  and  for  some  other 
bacterial  toxins.  These  poisons  have  these  factors  in  common: 
they  are  all  formed  in  living  organisms,  whether  animal  or  vege- 
table, and  they  are  all  proteids  or  closely- allied  substances. 

The  method  of  action  of  the  antitoxins  throws  a  certain  amount  of 
light  on  the  mechanism  of  some  forms  of  immunity.  It  has  no 
bearing  on  natural  immunity,  for  the  blood  of  an  animal  which  is 
naturally  immune,  say,  to  tetanus,  does  not  contain  tetanus  anti- 


20  A   MANUAL  OF  SURGERY 

toxin;  but  in  recovery  from  tetanus  the  antitoxin  appears  in  the 
blood.  When  this  happens,  any  fresh  toxin  that  the  bacilU  form 
will  be  immediately  neutralized,  and  the  latter  will  thereby  be 
deprived  of  their  power  to  injure  the  cells  of  the  animal,  and  can 
be  dealt  with  by  phagocytosis  or  other  means.  In  the  production 
of  passive  immunity  similar  phenomena  take  place;  the  antitoxin 
artificially  mjccted  in  the  blood  combines  with  the  toxin  and  shields 
the  cells  from  its  action. 

But  this  still  leaves  the  method  of  formation  of  these  antitoxins  unexplained. 
Several  theories  have  been  advanced  to  account  for  this  phenomenon,  but  the 
only  one  of  importance  is  Ehrlich's  side-chain  theory.  It  is  somewhat  com- 
plicated, but  the  brUliant  way  in  which  it  accounts  for  the  chief  facts,  and 
its  profound  inlluence  on  modern  ideas  of  pathology,  justify  a  brief  outline 
of  its  more  important  features. 

A  toxin  possesses  two  properties,  that  of  poisoning  a  cell  and  that  of  com- 
bining with  antitoxin,  and  Ehrlich  proves  that  these  two  functions  reside  in 
different  portions  of  the  molecule.  To  the  part  that  unites  with  antitoxin  he 
gives  the  name  '  haptophore,"  whilst  the  toxic  portion  is  termed  the  '  toxophore.' 

Ehrlich  next  assumes  that  a  molecule  of  living  protoplasm  may  be  con- 
sidered as  consisting  of  two  parts.  One  discharges  the  function  of  the  cell  of 
which  it  forms  part,  whilst  the  other  subserves  the  nutrition  of  the  former 
more  highly  differentiated  portion,  and  has  the  power  of  uniting  with  mole- 
cules of  proteid  dissolved  in  the  blood  or  lymph,  and  then  building  them  up 
into  living  protoplasm.  This  function  is  suppo.sed  to  be  accomplished  by 
side-chains,  or  specialized  portions  of  the  cell,  which  unite  with  the  molecules 
of  food  proteid.  It  is  assumed  that  these  latter  contain  a  haptophore  group 
similar  to  that  of  a  molecule  of  toxin,  but  no  toxophore  group ;  so  that  the  first 
step  in  the  nutrition  of  the  cell  consists  in  the  union  of  a  side-chain  with  the 
haptophore  group  of  a  molecule  of  proteid,  a  process  which  Ehrlich  compares 
with  the  seizure  of  particles  of  food  by  the  tentacles  of  a  sea-anemone.  Further, 
tliere  are  many  varieties  of  proteids  in  the  blood,  and  the  molecules  of  each 
of  these  must  have  their  own  peculiar  haptophore  groups.  Each  haptophore 
group  must  '  fit  '  a  side-chain  (like  a  key  fitting  a  lock),  or  it  will  be  useless  for 
nutrition. 

In  applying  this  view  to  the  action  of  a  toxin,  it  must  be  remembered  that 
the  toxins  are  proteids  or  similar  substances.  If  we  inject  a  solution,  e.g., 
of  tetanus  toxin  into  an  animal,  it  may  happen  that  the  side-chains  carried 
by  the  animal's  cells  do  not  possess  haptophore  groups  which  '  fit  '  those  of 
the  toxin;  in  this  case  no  poisoning  can  occur,  as  the  to.xin  cannot  unite  with 
the  cells.  If  the  cells  do  po.ssess  such  side-chains,  they  will  unite  with  the 
haptophore  of  the  toxin,  just  as  if  these  side-chains  had  seized  a  nutritious 
molecule.  The  toxophore  radicle  is  thus  brought  into  action,  since  it  is 
united  to  the  cell  by  means  of  the  haptophore  group  and  side-chain.  Pre- 
sumably it  exerts  an  injurious  influence  similar  to  that  of  an  enzyme,  and  the 
integrity  of  the  functionating  part  of  the  protoplasmic  molecule  is  thereby 
destroyed.  In  other  words,  the  first  step  in  the  into.xication  of  a  cell  by  a 
true  toxin  is  exactly  the  same  as  the  first  step  in  cell-nutrition. 

Suppose,  now,  that  a  certain  number  of  the  side-chains  are  fixed  to  molecules 
of  toxin,  and  that  the  living  molecule  is  injured,  but  not  fatally.  The  side- 
chains  are  necessary  for  the  nutrition  of  the  cell,  and  those  that  are  rendered 
useless  must  be  regenerated,  just  as  a  hydra  replaces  a  lost  tentacle.  If  a 
second  dose  of  toxin  is  given  this  process  is  repeated;  and  if  we  continue  to 
administer  toxin  in  suitable  (non-lethal)  doses,  we  may  gradually  '  train  '  the 
cell  to  produce  side-chains  more  and  more  rapidly.  But  it  often  happens  that 
the  reaction  of  a  living  tissue  is  much  greater  than  the  stimulus  demands  ;  e.g., 
the  formation  of  callus  is  disproportionate  to  the  amount  of  bone  to  be  replaced. 
Jhis  may  be  presumed  also  to  happen  in  the  production  of  antitoxins.  The  cell 
produces  more  side-chains  than  it  has  any  necessity  for — more,  indeed,  than  can 


JJA  CTJiRJOLOG  Y— INFECTION— 1  MM  UNIT  Y  21 

remain  united  with  it,  and  the  super/luous  ones  detach  themselves  from  the  cell 
and  float  off  in  the  blood.  They  still  retain  their  power  of  uniting  with  the 
huptophore  group  of  a  toxin  molecule,  thereby  rendering  the  toxin  inert,  and  thus 
they  constitute  antitoxin. 

It  is  impossible  to  discuss  here  the  evidence  that  has  been  brought  forward 
in  support  of  this  theory,  but  one  remarkable  point  may  be  noticed.  For  a 
cell  to  be  poisoned  by  a  given  toxin,  it  is  necessary  that  it  should  contain 
side-chains  which  '  ht  '  the  haptophore  group  of  that  toxin.  But  antitoxin 
consists  of  such  side-chains,  so  that  it  follows  that  any  cell  which  can  be 
poisoned  by  a  toxin  may  be  made  to  produce  an  antitoxin  to  it.  There  is 
evidence  that  this  is  the  case  in  tetanus,  the  toxin  of  which  (tetano-spasmin) 
acts  only  on  the  cells  of  the  central  nervous  system.  It  was  found  by  Wasser- 
mann  that  an  emulsion  of  the  gray  matter  of  the  brain  has  the  power  of 
neutralizing  tetanus  toxin  just  as  antitoxin  has,  but  that  this  power  is  lacking 
from  emulsions  of  other  tissues.  Thus  the  cells  of  the  central  nervous  system 
are  the  only  ones  which  have  side-chains  that  can  unite  with  the  tetanus  toxin. 

Again,  it  would  not  be  surprising  if  some  of  these  side-chains  were  to  break 
off  and  pass  into  the  blood  under  natural  conditions.  This  actually  happens, 
for  traces  of  antitoxins  (and  other  '  antibodies  ')  frequently  occur  in  normal 
blood. 

Ordinary  chemical  poisons  do  not  give  rise  to  the  formation  of  antitoxins, 
since  they  do  not  unite  especially  with  the  side-chains  as  if  they  were  nourish- 
ing proteids,  but  form  chemical  combinations  with  all  parts  of  the  molecule 
indiscriminately. 

It  was  soon  found  that  substances  allied  to  antitoxin  might  be  obtained  by 
the  injection  of  proteid  substances  other  than  toxins  into  living  animals. 
These  are  known  as  antibodies,  the  term  being  used  to  include  precipitins, 
agglutinins,  cytolysins,  bacteriolysins,  etc. 

Precipitins  are  substances  formed  by  the  injection  of  proteid  solutions,  and 
have  the  property  of  forming  a  precipitate  when  mixed  with  a  solution  of 
the  same  proteid  as  was  injected.  Thus,  if  a  solution  of  egg  albumen  is  in- 
jected into  a  rabbit,  the  serum  of  this  animal  (after  a  week  or  so)  will  give  a 
flocculent  precipitate  with  egg  albumen,  but  not  with  other  proteids.  The 
precipitins  are  not  known  to  have  any  bearing  on  the  question  of  immunity, 
except  in  that  they  form  an  example  of  the  general  law  that  if  any  foreign 
proteid  is  injected  into  a  living  animal  it  gives  rise  to  the  production  of  an 
antibody. 

Agglutinins  are  formed  by  the  injection  of  bacteria,  red  blood  corpuscles, 
cells,  etc.,  and  they  have  the  power  of  causing  the  cells  injected  to  collect  into 
clumps.  A  special  case  of  great  importance  is  in  typhoid  fever,  where  the 
agglutinin  is  formed  early  in  the  disease  and  is  of  diagnostic  value  [Widal's 
reaction).  In  most  infections  this  is  not  the  case;  thus  in  pneumonia  the 
serum  rarely  shows  any  power  to  agglutinate  the  pneumococcus  before  con- 
valescence is  established.  They  are,  however,  of  value  in  that  they  often 
enable  the  bacteriologist  to  prove  the  causal  relationship  of  an  organism  and 
the  disease  it  is  supposed  to  produce.  Thus  in  the  investigation  of  the  path- 
ology of  dysentery  various  organisms  are  isolated  from  the  stools,  and  if  one 
of  these  is  found  to-be  clumped  powerfully  by  the  patient's  own  serum,  it 
affords  strong  proof  that  it  is  really  the  infective  agent.  The  agglutinins  are 
also  useful  as  proving  the  identity  of  an  organism  which  has  been  isolated 
in  culture.  For  example,  if  a  culture  of  an  organism  resembling  the  tjnphoid 
bacillus  had  been  isolated  from  the  stools  in  a  case  of  suspected  typhoid  fever 
(or  from  drinking-water,  etc.),  the  first  test  applied  to  establish  its  nature 
would  be  to  see  if  it  clumped  with  the  serum  of  an  animal  which  had  been 
injected  with  a  known  culture  of  typhoid  bacilli.  Agglutinins  are  not  known 
to  play  any  part  in  the  production  of  immunity,  and  their  presence  in  the 
blood  does  not  necessarily  indicate  that  the  animal  is  immune,  though  this 
is  usually  the  case. 

The  next  group  of  antibodies — cytolysins  (including  the  bacterio- 
lysins, hcBmolysins,  etc.) — are  of  great  importance  in  the  doctrine 


2  2  A    MANUAL  OF  SURGERY 

of  immunity,  and  are  much  more  complex  in  their  structure  and 
action  than  the  preceding.  The  earliest  indication  of  their  existence 
was  obtained  by  Pfeiffer,  who  immunized  guinea-pigs  to  the  cholera 
vibrio,  and  when  the  immunity  was  fully  established  injected  a 
culture  of  that  organism  into  the  peritoneal  cavity.  Some  of  the 
peritoneal  fluid  was  withdrawn  from  time  to  time,  and  the  organisms 
therein  examined  microscopically.  They  were  found  to  undergo 
remarkable  changes,  losing  their  shape,  becoming  spherical,  and 
finally  undergoing  complete  solution;  the  whole  process  often  takes 
half  an  hour  or  so.  This  is  called  Pfeiffcr's  reaction,  and  is  specific 
— i.e.,  the  peritoneal  fiuid  of  an  animal  vaccinated  against  cholera 
has  no  effect  on  the  typhoid  bacillus  or  any  organism  other  than  the 
cholera  vibrio  or  its  congeners.  Further  research  showed  that  the 
reaction  can  be  obtained  in  vitro,  provided  that  the  peritoneal  fluid 
is  perfectly  fresh;  if,  however,  the  fluid  is  kept  a  day  or  two,  it  loses 
this  power,  but  regains  it  if  mixed  with  perfectly  fresh  serum,  whether 
tliis  be  taken  from  a  normal  or  from  an  immunized  animal.    Thus: 

Fresh  normal  blood  serum.+ cholera  vibrios  =  no  reaction. 

Fresh  serum  (or  peritoneal  fluid)  from  immunized  animal+ cholera   vibrios 

=  solution. 
Stale  serum  from  immunized  animal+ cholera  vibrios  =no  reaction. 
Stale   serum   from   immunized    animal+ fresh   scrum   from   normal   animal 

+  cholera  vibrios  =solution. 

It  is  obvious  from  this  that  tivo  substances  are  necessary  for  the 
solution  of  the  organisms  in  the  tissues  of  an  immunized  animal. 
One  occurs  only  in  the  fluids  of  the  immunized  animal,  not  in  a 
normal  one,  and  is  an  antibody  similar  to  the  agglutinins,  but  more 
complex;  it  has  received  many  names,  and  is  usually  known  as 
amboceptor,  or  substance  sensibilatrice.  The  other  occurs  in  normal 
blood,  as  well  as  in  the  blood  of  the  immune  animal,  and  is  very 
fragile,  rapidly  disappearing  when  the  fluid  is  kept ;  it  is  also  readily 
destroyed  by  heat.  It  is  probably  the  same  as  the  alexin  referred  to 
above  in  connection  with  the  humoral  theory  of  immunity,  but 
German  writers  usually  term  it  the  complement. 

Further  research  on  the  antibodies  of  this  group  has  been  greatly  facili- 
tated by  Bordet's  discovery  of  the  production  of  ha?molysins  by  the  injection 
of  blood  from  one  animal  into  another  of  a  different  species.  Thus,  rabbit's 
serum  is  without  effect  on  the  red  corpuscles  of  a  horse;  but  if  the  rabbit  is 
injected  with  a  horse's  red  corpuscles,  its  serum  acquires  the  power  of  dis- 
solving or  haemolyzing  them.  These  haemolysins  apparently  act  in  exactly 
the  same  way  as  do  the  bacteriolysins  in  Pfeiffer's  reaction,  and  are  much 
more  convenient  for  experimental  purposes.  Further,  it  appears  that  the 
reaction  is  a  general  one,  and  that  cytolysins  can  be  prepared  for  sperma- 
tozoa, liver  and  kidney  cells,  cells  of  the  central  nervous  system,  etc.,  and  that 
in  each  case  the  reaction  depends  on  a  stable  antibody  or  amboceptor  and  a 
labile  ingredient  of  normal  blood,  the  complement  or  alexin. 

In  applying  these  facts  to  the  production  of  acquired  immunity — 
e.g.,  to  the  immunization  of  an  animal  by  injections  of  small  doses 
of  cholera  vibrios — it  must  be  noted  that  the  organism  at  first 
continues  to  grow  in  the  tissues;  the  only  known  force  capable  of 
opposing  it  at  this  stage  is  the  action  of  the  phagocytes,  for  the 


BACTERIOLOG  Y~-INFECTION~IMMUNITY  23 

alexins  or  complements  are  unable  to  act,  since  they  cannot  imite 
directly  with  the  bacteria,  and  there  is  no  amboceptor.  After  a  time 
the  cells  of  the  host  begin  to  form  antibodies  to  the  proteids  of  the 
bacterial  protoplasm.  Some  of  these  may  be  antitoxins,  which  pre- 
vent the  further  intoxication  of  the  animal;  others  are  agglutinins, 
which  are  without  known  value  to  the  host ;  lastly,  there  are  ambo- 
ceptors which  link  the  alexin  or  complement  of  the  blood  to  the 
bacteria,  and  bring  about  the  solution  of  the  latter.  The  animal  is 
now  immune,  and  when  any  further  invasion  with  cholera  vibrios 
takes  place  the  apparatus  of  amboceptor  and  complement  is  ready 
for  the  defence  of  the  animal.  Further,  the  serum  of  the  animal 
contains  amboceptor,  and  when  injected  into  a  second  animal  this 
acquires  passive  immunity,  provided  that  a  suitable  alexin  is  also 
present.  This  is  one  of  the  practical  difficulties  which  prevent  the 
successful  application  of  the  bacteriolytic  sera  in  medicine.  The 
alexin  presen'.  in  the  serum  of  the  immunized  animal  soon  disappears, 
and  although  an  amboc  ^ptor  which  is  formed  in  the  blood  of  one 
animal  is  alwa^-s  capable  of  being  '  activated  '  by  the  complement  of 
the  same  animal,  it  cannot  necessarily  be  activated  by  the  comple- 
ment of  other  animals.  This  question  is  one  which  is  extremely 
complex,  and  is  at  present  not  thoroughly  investigated,  though  we 
can  hardlv  hope  for  any  further  advance  in  serotherapy  until  it  has 
been  elucidated. 

The  role  of  the  leucocvtes  now  acquires  fresh  interest.  We  have 
alreadv  seen  reason  to  believe  that  alexin  is  derived  from  these  cells, 
and  some  hold  that  they  are  also  the  main  source  of  the  production 
of  amboceptor  and  the  other  antibodies.  The  study  of  these  latter 
substances  has  afforded  a  further  insight  into  the  function  of  phago- 
cytosis. It  was  found  (by  Mennes)  that  leucocytes  from  a  normal 
animal  had  no  power  of  ingesting  virulent  pneumococci,  but  that 
they  acquired  this  power  when  mixed  with  the  serum  of  an  animal 
which  had  been  immunized  to  pneumococci.  It  is  thus  evident 
that  immune  sera  have  the  power  of-  aiding  the  action  of  the  leuco- 
cytes, presumably  in  virtue  of  containing  an  antibody  which  unites 
with  the  bacteria  and  renders  them  vulnerable.  The  antibodies 
which  act  in  this  wa}'  might  be  antitoxins,  amboceptors,  etc.,  but 
it  is  possible  that  they  may  be  fundamental^  different.  Sir 
Almroth  Wright,  who  has  done  much  in  elucidating  this  field  of 
work,  terms  them  opsonins  (from  opsono,  I  cook,  or  prepare  for  food), 
and  holds  that  the  amount  which  is  present  in  the  blood  determines 
the  degree  of  immunity  to  various  infections.  That  they  act 
directlv  on  the  bacteria  maj^  be  proved  thus:  Bacteria  are  mixed 
with  fresh  serum,  and  the  latter  removed  by  centrifugalization,  and 
the  organisms  freed  from  all  traces  of  serum  by  repeated  washings 
with  normal  sahne  sohition.  Bacteria  thus  treated  are  taken  up  by 
the  leucocytes  as  readilv  as  if  the  serum  were  still  present,  from 
which  we  infer  that  they  have  retained  some  element  of  the  serum 
which  has  sensitized  or  prepared  them  for  phagocytosis.  It  is,  of 
course,  possible  that  the  serum  may  also  act  directly  on  the  leu- 


24 


A   MANUAL  01-  SURGERY 


cocytes,  stimulating  them  to  greater  activity,  but  there  is  no  proof 
of  this. 

These  substances  have  recently  been  the  subject  of  much  in- 
vestigation, both  from  the  clinical  and  scientific  aspects.  There  is, 
of  course,  no  method  by  which  the  amount  present  in  a  given 
sample  of  serum  can  be  estimated  quantitatively,  but  Wright  has 
devised  a  process  by  which  the  quantity  in  two  specimens  can  be 
compared.  Thus  it  is  possible  to  count  the  number  of  individual 
bacteria  of  any  particular  type  which  can  be  ingested  by  washed 
healthy  leucocytes  when  mixed  with  a  patient's  serum,  and  the 
number  ingested  bv  similar  leucocytes  mixed  with  the  serum  of  a 
known  healthy  individual,  the  two  mixtures  being  kept  at  the  body 
temperature  for  the  same  period  of  time.  The  ratio  between  these 
two  numbers  is  termed  the  opsonic  index.  The  test  is  carried  out 
by  preparing  two  mixtures  in  separate  long  capillary  pipettes.     The 

first  contains  equal  parts  of 
washed  corpuscles,  bacterial 
emulsion,  and  the  patient's 
serum ;  the  second,  equal  parts 
of  washed  corpuscles,  bacterial 
emulsion,  and  the  healthy 
serum.  The  contents  of  each 
pipette  must  be  well  mixed. 
The  two  pipettes  are  then  in- 
cubated for  fifteen  minutes  at 
body  temperature.  Films  are 
prepared  from  each  mixture, 
suitably  stained,  and  examined 
microscopically;  the  leucocytes 
will  be  found  to  have  ingested 
a  certain  number  of  the  bac- 
teria (Fig.  7).  A  careful  count 
is  now  made  of  the  number 
in  50  or  100  leucoyctes  in 
each  preparation,  and  the  ratio 
between  the  totals  determined.  Thus,  if  in  the  preparation  cor.t  lin- 
ing the  normal  serum  there  were  240  organisms  {e.g.,  tubercle  bacilh) 
in  100  leucocytes,  and  in  the  other  only  120,  the  opsonic  index 
would  be  ^§=  0-5,  showing  that  the  patient's  serum  contained  much 
less  of  the  opsonin  to  the  tubercle  bacillus  than  did  that  of  the 
healthy  person.  In  practice  the  process  is  a  difficult  one,  and  many 
precautions  are  necessary  if  accurate  results  are  to  be  obtained. 

Opsonins  are  delicate  substances,  which  chsappear  on  keeping, 
and  are  readily  destroyed  at  moderate  temperatures  (60"  C.  or  less), 
closely  resembhng  the  alexins  in  this  and  some  other  respects. 
They  appear  to  be  specific  (though  this  is  disputed).  A  patient 
may  have  a  high  opsonic  index  to  one  organism  and  a  low  one  to 
another. 

Healthy  persons   approximate  closely  to  one   another  in   their 


Fig.  7. — Phagocytosis  of  Tubercle 
Bacilli  in  Opsonin  Preparation. 
(Emery.) 


ILI CTERIOLOG  Y— INFECTION— IMM  UNIT  Y 


25 


opsonic  indices.  In  the  case  of  the  tuliercle  bacillus  it  is  rare  to 
find  a  non-tuberculous  patient  with  an  index  above  i-2  or  below  o-8, 
and  in  a  doubtful  case  a  figure  decidedly  above  or  below  these  limits 
is  very  suggestive  of  tubercle.  The  diagnostic  value  of  this  test, 
however,  is  diminished  by  the  fact  that  many  tuberculous  patients 
have  normal  indices.  As  a  general  rule,  in  cases  of  acute  diseases, 
it  is  found  that  the  index  is  below  normal,  and  that  as  recovery 
occurs  it  rises  to  or  above  the  healthy  level.  This  rise  may  be 
sudden,  as  in  most  cases  of  pneumonia,  or  gradual,  as  is  usually  the 
case  in  furunculosis.  It  is  not  uncommon  to  see  patients  in  whom 
the  disease  is  progressing  though  the  index  is  high,  and  this  is 
especially  the  case  in  tubercle. 


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Fig.  8.- 


-Chart  of  Opsonic  Index  in  a  Case  of  Injection  of  a 
Staphylococcic  Vaccine. 


It  is  too  early  to  form  a  definite  opinion  of  the  importance  of  the 
opsonins  in  immunity.  There  can  be  no  doubt  that  they  play  some 
part,  but  they  are  not  the  sole  agents;  and  their  importance  has 
certainly  been  exaggerated  by  man}^  authorities.  In  some  respects 
their  discovery  has  rendered  the  phenomena  of  immunity  still  more 
difficult  of  comprehension. 

Wright  has  put  the  study  of  the  opsonic  index  to  practical  use 
in  the  regulation  of  the  dosage  of  his  vaccines  (Fig.  8).  After  each 
injection  there  is  a  rapid  fall  in  the  opsonic  level  (the  negative 
phase),  followed  by  a  rise,  the  index  usually  going  well  above 
normal  (the  positive  phase).  The  improvement  is  supposed  to 
coincide  with  and  be  due  to  the  increased  amount  of  opsonin  in  the 
blood,  and  when  this  begins  to  diminish,  a  fresh  injection  is  given. 
A  second  injection  should  not  be  given  during  the  negative  phase, 
since  if  this  is  done  the  index  falls  still  further,  and  it  is  held  that 
danger  (of  dissemination  or  rapid  spread  of  the  disease)  might  arise. 


26  A   MANUAL  OF  SURGERY 

Wright  therefore  controls  his  injections  by  ])erioclical  examinations 
of  tlie  opsonic  index,  determining  the  dose  which  gives  the  maximum 
rise,  and  giving  a  fresh  injection  as  soon  as  the  effect  begins  to  wear  off. 

The  experience  of  the  past  few  years  has,  however,  shown  that  the 
frequent  and  laborious  estimations  of  the  opsonic  index  are  really 
unnecessary,  and  the  majority  of  practitioners  dispense  with  them 
in  the  more  simple  cases,  relying  for  the  recognition  of  the  good  or 
bad  effects  upon  the  clinical  results — e.g.,  diminution  of  fever,  dis- 
charge, or  pain,  commencing  healing  of  the  wound,  etc.  Where 
this  fails,  opsonic  control  should  be  resorted  to,  as  also  when  dealing 
with  internal  infective  processes,  especially  if  acute  and  dangerous, 
and  particularly  in  septicaemia  and  basic  meningitis. 

The  practical  applications  of  these  researches  and  theories  of 
immunity  are  twofold — diagnostic  and  therapeutic.  The  chief 
examples  of  their  diagnostic  application  are  the  agglutination  reac- 
tion, as  used  in  Widal's  test  (p.  21)  in  the  diagnosis  of  typhoid  fever 
and  to  a  less  extent  in  other  diseases,  Wassermann's  reaction  in 
syphilis  (p.  153),  and  the  employment  of  the  opsonic  index. 

The  therapeutic  applications  are  more  important,  though  there  is 
still  much  to  be  done  before  their  practical  use  is  fully  understood. 
The  substances  employed  in  artificial  immunization,  and  in  the 
curative  treatment  of  disease,  fall  under  three  main  headings: 

I.  Vaccines,  using  the  temi  more  especially  in  reference  to  the 
emulsions  of  dead  bacteria  referred  to  on  p.  15.  As  used  curatively, 
they  are  prepared  as  follows:  The  organism  is  obtained  in  a  pure 
condition  from  the  patient  to  be  treated,  and  a  voung  culture  is 
emulsified  with  sterile  normal  saline  solution,  and  sterilized  by  being 
heated  in  a  sealed  test-tube  to  a  suitable  temperature — e.g.,  60°  C. 
for  half  an  hour.  The  number  of  bacteria  per  cubic  centimetre  is 
then  ascertained  (there  are  several  methods  by  which  this  can  be 
done),  and  the  emulsion  diluted  with  a  sterile  0-25  per  cent,  solution 
of  lysol  or  carbolic  acid  in  normal  saline  solution.  1  he  degree  of 
dilution  has,  of  course,  to  be  determined  by  the  strength  of  the 
original  emulsion,  and  by  the  number  of  bacteria  which  it  is  desired 
to  administer  in  each  dose.  This  varies  greatly  with  different 
organisms;  thus  staphylococci  and  gonococci  are  usually  tolerated 
in  large  doses  (500,000,000  or  more),  whereas  B.  coli  in  large  doses 
causes  severe  local  and  general  symptoms,  and  the  number  given 
should  be  much  smaller.  As  a  rule,  too,  the  patient  acquires  some 
degree  of  tolerance,  and  the  dose  may  often  be  slightly  increased  as 
the  treatment  progresses. 

It  is  always  advisable,  where  practicable,  to  prepare  the  vaccine 
for  each  patient  from  the  organism  which  is  attacking  him  (auto- 
genous vaccine),  since  there  are  minute  differences  between  the 
various  strains  of  bacteria,  and  a  ready-made  vaccine  may  not  prove 
efficacious  against  an  infection  with,  apparently,  the  same  species. 
This  is  less  important  in  the  case  of  the  staphylococci,  more  so  in 
dealing  with  the  streptococci  and  B.  coli.  As,  however,  the  vaccine 
takes  a  few  days  to  prepare  (having  to  be  tested  for  sterilit}),  it  is 


BACTERIOLOG  Y~INFECTION~IM MUNITY  27 

often  a  good  plan  to  commence  the  treatment  with  a  small  dose  of  a 
stock  vaccine. 

At  present  the  use  of  vaccines  must  not  he  looked  upon  as  replacing 
surgical  t-eotmenf,  but  as  an  adjunct  thereto.  Abscesses  must 
be  opened  and  drained,  dead  bone  removed  from  the  bottom  of 
a  sinus,  etc.,  just  as  before,  but  the  use  of  a  suitable  vaccine  mav 
often  greatly  aid  the  process  of  healing  and  shorten  the  conval- 
escence. In  cases  which  are  not  amenable  to  surgical  treatment,  or 
in  which  the  surgeon  desires  to  wait  for  a  time  before  operating,  this 
treatment  should  be  tried  whenever  possible.  Boils,  however,  may 
often  be  aborted  in  a  most  striking  manner  bv  an  injection  of 
250,000,000  to  500,000,000  staphylococci. 

2.  Antitoxic  Sera  are  the  antitoxins  to  tetanus,  diphtheria,  and 
possibly,  to  some  extent,  dvsenterv.  These,  as  has  already  been 
explained,  contain  substances  which  neutralize  the  extracellular 
toxins  of  the  organisms  in  question :  the  problem  of  preparing  potent 
antitoxins  for  the  intracellular  toxins  has  not  yet  been  solved.  The 
main  point  to  notice  in  the  use  of  antitoxic  sera  is  that  they  will 
render  the  toxins  inert,  pro\'ided  that  they  are  brought  in  contact 
therewith  before  the  latter  have  combined  with  and  injured  the 
living  cells;  hence  the  importance  of  their  early  administration. 
Time  may  also  be  saved  by  intravenous  injection,  since  it  has  been 
found  that  diphtheria  antitoxin  is  not  fully  absorbed  from  the  sub- 
cutaneous tissues  for  twenty-four  hours  or  more.  The  process  is 
simple.  The  serum  is  warmed  to  body-heat  and  sucked  into  an  all- 
glass  syringe  (carefully  sterilized).  The  skin  over  a  large  vein  of 
the  forearm  is  prepared  as  for  an  operation,  and  the  vein  itself 
rendered  prominent  bv  obstructing  the  circulation  bv  gentle  pressure 
with  the  finger.  All  air  is  removed  from  the  syringe  and  needle, 
and  the  latter  introduced  obliquely  at  the  side  of,  and  about  |  inch 
from,  the  distended  vein.  It  is  pushed  gently  in  until  the  vein  is 
entered,  when  the  blood  will  rise  into  the  syringe.  As  soon  as  this 
happens,  the  finger  which  is  obstructing  the  vein  is  removed,  the 
piston  pushed  gently  down,  and  the  antitoxin  forced  slowly  into  the 
circulation.  There  is  less  object  in  administering  the  serum  bv  this 
method  in  tetanus  than  in  other  cases ;  but  even  here  the  first  dose 
may  be  given  in  this  way  with  advantage. 

3.  Other  Sera. — These  act  bactericidally  (from  containing  ambo- 
ceptor), or  perhaps  facilitate  phagoc\i:osis.  They  are  not,  as  a  rule, 
so  potent  curatively  as  are  the  antitoxic  sera,  but,  wiiere  these  and 
the  vaccines  are  not  available,  mmst  be  given  a  trial.  The  sera  most 
important  in  surgical  practice  are : 

{a)  Anti-stre ptococcic  Serum. — This  is  prepared  by  immunizing 
horses  with  living  cultures  of  Streptococcus  pyogenes.  This  organism 
is  found  to  present  marked  differences  in  cultures  from  various 
sources :  and  since  it  is  held  that  a  serum  prepared  against  one  variety 
is  useless  against  another,  polyvalent  sera  are  prepared  by  treating 
horses  with  cultures  from  manv  sources,  and  should  always  be  used 
if  possible.     If  no  noticeable  benefit  follows  shortly  after  the  first 


28  A   MANUAL  OF  SURGERY 

dose,  it  is  advisable  that  the  second  should  be  from  a  different 
laboratory,  as  one  serum  may  be  efficacious  in  one  case  and  another 
in  a  different  one.  If  there  is  marked  improvement,  especially  a  fall 
in  the  temperature,  the  serum  should  not  be  changed.  A  transient 
rise  of  temperaturi;  (due,  possil)ly,  to  solution  of  the  streptococci 
and  liberation  of  their  toxins)  is  not  necessarily  a  bad  sign,  and 
is  often  followed  by  marked  improvement.  The  dose  may  be  lo  to 
20  c.c,  or  even  more. 

(b)  Anti-anthrax  Sera,  of  which  the  best  known  in  this  country  is 
that  prepared  by  Sclavo.  This  has  given  excellent  results  in  the 
treatment  of  localized  anthiax  (malignant  pustule),  and  the  improve- 
ment is  often  manifested  within  twenty-four  hours. 

(c)  Anti-pneumococcic  Serum  (Pane's  or  Romer's)  may  be  tried  in 
severe  pneumococcal  infections,  more  especially  in  septicaemia  and 
peritonitis,  and  in  some  cases  seems  to  act  well.  Good  results  have 
also  been  obtained  in  pneumococcal  ulceration  of  the  cornea  (ulcus 
serpens). 

There  are  numerous  other  sera,  which  do  not  call  for  notice. 
Serum  Disease. — It  sometimes  happens,  especially  if  the  patient 
has  received  large  doses  of  antitoxin,  that  a  remarkable  series 
of  phenomena  take  place  after  an  incubation  period  of  eight  to 
twelve  days  or  more.  The  chief  are  fever;  a  skin  rash  (urticarial, 
scarlatiniform,  or  morbilliform),  usually  accompanied  by  severe 
itching;  enlargement  of  the  lymph-glands,  corresponding  to  the  site 
of  infection ;  pains  in  the  joints,  especially  the  metacarpo-phalangeal, 
wrist,  and  knee;  and  leucocytosis.  Though  unpleasant,  the  symp- 
toms are  not  dangerous,  and  recovery  usually  occurs  in  a  few  days. 
Calcium  lactate,  in  15-grain  doses  at  the  time  of  the  injection  and 
for  a  day  or  two  subsequently,  diminishes  the  frequency  with  which 
the  disease  develops,  and  constitutes  the  best  treatment  for  it  when 
developed. 

Anaphylaxis  is  a  condition  of  supersensitiveness  to  certain 
proteid  substances,  such  as  serum,  egg  albumen,  bacterial  toxins, 
etc.,  set  up  in  the  body  by  their  injection.  It  may  follow  one  in- 
jection, or  may  require  several  in  order  to  determine  its  occurrence. 
Thus,  if  a  subtoxic  dose  of  horse  serum  is  injected  into  an  animal, 
and  a  second  subtoxic  injection  be  made  after  a  suitable  interval, 
the  second  injection  may  be  followed  by  marked  toxic  or  even  fatal 
symptoms.  About  eight  to  twelve  days  is  usually  the  minimum 
necessary  to  establish  anaphylaxis,  and  the  condition  may  persist 
indefinitely.  Thus,  a  patient  with  sarcoma  of  the  ileum  had  been 
treated  repeatedly  and  wth  much  benefit  by  injections  of  Coley's 
fluid.  After  a  somewhat  prolonged  interval  he  was  again  submitted 
to  an  injection  of  half  a  minim  of  the  fluid.  The  result  was  a  febrile 
attack  of  great  intensity  lasting  for  over  a  week,  with  a  temperature 
of  104°  F.,  which  only  gradually  siibsided  to  the  normal.  Nothing 
definite  is  known  of  the  cause  of  this  phenomenon,  and  the  treatment 
is  merely  symptomatic. 


CHAPTER  II. 

INFLAMMATION. 

'  Inflammation  is  the  succession  of  changes  which  occur  in  a  Hving 
tissue  when  it  is  injured,  providing  the  injury  is  not  of  such  a  degree 
as  at  once  to  destroy  its  structure  and  vitaHty.'  Such  was  the 
definition  given  in  1870  by  Burdon  Sanderson,  and  it  is  sufficiently 
accurate  if  we  reahze  that  the  exciting  injury  usually  involves  the 
admission  of  a  soluble  chemical  irritant,  and  in  most  cases  of  a 
bacterial  toxin ;  we  must  also  exclude  from  the  process  of  inflamma- 
tion the  later  stages  of  repair.  Formerly  inflammation  was  looked 
on  by  pathologists  as  always  of  a  destructive  and  harmful  nature; 
but  at  the  present  time  bacteriological  research  has  demonstrated 
that,  if  it  can  be  suitably  controlled,  it  is  rather  of  a  protective  or 
conservative  character,  being  Nature's  means  of  limiting  the  advance 
of  noxious  micro-organisms,  and  of  finally  eliminating  them  from 
the  system.  Occasionally,  however,  the  tissue  reaction  called  into 
existence  by  bacterial  invasion  is  so  severe  as  to  increase,  rather 
than  diminish,  the  risks  of  the  patient,  who  may,  moreover,  be 
destroyed  by  absorbing  virulent  toxic  bodies  produced  by  the 
bacteria. 

The  causes  of  inflammation  are  varied  and  numerous.  Most 
frequently  it  is  due  to  the  admission  of  bacteria,  and  we  have  already 
alluded  (p.  14)  to  the  conditions,  local  and  general,  which  pre- 
dispose an  individual  to  such  invasion,  and  render  him  more  liable 
to  an  inflammatory  attack.  Apart  from  bacteria,  inflammation  may 
be  lighted  up  by  (a)  mechanical  lesions,  such  as  blows,  sprains, 
tension,  pressure,  etc. ;  (b)  burns  or  scalds ;  (c)  toxic  bodies,  such  as 
acids,  alkalies,  or  vegetable  and  animal  poisons;  and  (d)  the  electric 
current,  either  in  the  form  of  lightning,  or  as  applied  by  the  surgeon 
or  through  the  agency  of  strong  currents  as  employed  for  purposes 
of  traction  or  illumination.  It  is  but  fair  to  state  that  not  a  few 
authorities  look  on  the  tissue  reaction  caused  by  these  non-bacterial 
irritants  as  distinct  from  inflammation,  limiting  the  latter  term  to 
conditions  resulting  from  bacterial  invasion.  The  phenomena, 
however,  are  identical  up  to  a  certain  point,  and  we  see  no  advan- 
tage in  the  suggested  dissociation. 

29 


30  A   MANUAL  OF  SURGERY 

The  actual  phenomena  of  inflammation  are  ju'iiiaps  best  studied  in 
the  web  of  a  frog's  foot.  If  this  is  spread  out  and  examined  under 
the  microscope,  the  following  evidences  of  normal  physiological 
activity  may  be  seen :  {a)  the  flow  of  blood  through  the  vessels  (Fig.  9), 
as  indicated  b\'  the  movement  of  the  corpuscles — the  red  ones,  each 
separate  from  the  other,  flowing  in  the  central  or  axial  current;  the 
leucocytes  occasionally  seen  amongst  the  red,  or  here  and  there  one 
may  be  noticed  rolhng  lazily  along  in  the  inert  corpuscle-free  peri- 
pheral portion  of  the  tube:  {b)  the  constant  rhythmical  changes  in 
calibre  of  the  arterioles  independent  of  the  heart's  action,  and 
influencing  in  a  marked  degree  the  flow  through  the  capillaries: 
and  (f)  the  changes  which  occur  in  the  pigment-cells,  and  are  mainly 
due  to  the  influence  of  light,  the  cells  contracting  or  expanding  as 
the  light  is  increased  or  diminished. 

I.  The  Vascular  Changes  in  acute  inflammation.  If  a  crystal 
of  common  salt,  or  some  such  irritant,  is  applied  to  the  web,  a 
momentary  contraction  may  perhaps  be  noticed  in  the  arterioles 
of  the  part,  but  this  is  only  apparent  in  inflammations  produced 
artificially,  and  is  of  no  known  significance.  It  is  followed  by 
a  condition  of  Hypersemia  of  the  inflamed  area,  as  manifested  b}' 
a  rapid  and  lasting  dilatation  of  the  vessels,  accompanied  by  an 
increase  in  the  rapidity  of  the  blood-flow  {acceleration) ;  it  is  probably 
brought  about  by  some  change  in  the  local  vasomotor  mechanism 
present  in  the  smaller  arterioles.  This  increased  rapidity  of  the 
flow  lasts  for  a  while,  and  then  the  current  gradually  becomes  slower 
and  slower  {retardation),  as  if  an  ever-growing  obstruction  existed 
to  the  passage  of  the  blood;  next  a  period  of  oscillation  will  be 
noticed,  the  crowded  corpuscles  swaying  forwards  and  backwards, 
and  finally  a  condition  of  stasis  or  still-stand  is  arrived  at,  which 
may  or  may  not  end  in  actual  thrombosis  or  intravascular  coagula- 
tion. During  this  period  the  relations  normall}-  existing  between 
the  vessel  walls  and  the  varied  constituents  of  the  blood  have  obvi- 
ously become  modified,  as  a  result  of  invisible  changes  m  the  former, 
and  not  of  any  alteration  in  the  blood.  Thus,  almost  as  soon  as 
dilatation  occurs,  the  leucocytes  collect  along  the  walls  in  the  peri- 
axial inert  layer,  seeming,  as  it  were,  to  fall  out  of  rank;  this  process 
first  commences  in  the  veins,  but  can  be  observed  in  all  the  vessels. 
The  red  corpuscles  also,  which  formerly  had  flowed  along  separately, 
now  tend  to  adhere  to  the  vessel  walls  and  to  each  other,  running  into 
rouleaux. 

The  second  factor  in  the  vascular  changes,  Exudation,  becomes 
evident  at  a  very  early  stage.  Every  element  of  the  blood  partici- 
pates in  this  process.  It  has  been  already  mentioned  that  the 
leucocytes  collect  in  the  peri-axial  layer,  a  phenomenon  due  partly  to 
an  alteration  in  the  vessel  wall,  whereby  it  is  rendered  more  '  sticky,' 
and  partly  to  chemotaxis  (p.  18).  The  next  change  consists  in  the 
passage  of  the  leucocytes  through  the  vessel  walls,  especially  those 
of  the  smaller  veins  and  less  often  of  the  capillaries.  The  process 
is  a  strictly  vital  one,  brought  about  by  amoeboid  movement ;  a  small 


INFLAMMATION 


31 


arm  or  outgrowth  of  the  leucocyte  {pseudopodium)  is  inserted  between 
the  endothehal  cells  lining  the  vessel,  whose  cohesion  has  been 
probably  interfered  with  by  the  inflammatory  process.  Into  this 
arm  the  protoplasm  of  the  leucocyte  flows,  still  further  separating 
the  endothelial  elements,  and  thus  the  cell  passes  through  the  wall 
into  the  surrounding  connective  tissues  (Fig.  10).  The  migration  of 
the  leucocytes  only  lasts  as  long  as  the  blood  in  the  vessel  is  actually 
circulating;  as  soon  as  thrombosis  occurs,  migration  ceases.  When 
the  white  corpuscle  has  escaped  into  the  perivascular  tissues,  it  may 
undergo  various  changes.  In  the  first  place,  it  may  die  and  be 
at  once  disintegrated,  setting  free  fibrin  ferment,  and  thus  assist  in 
the  production  of  the  inflammatory  coagulum  to  be  shortly  de- 
scribed; or,  again,  it  may  find  its  way  back  into  the  circulation 


Fig.  9.  Fig.  10. 

Semi-diagrammatic  Representation  of  the  Vascular  Phenomena  of 
Inflammation  (after  Thoma). 

On  the  left  is  a  normal  vessel  with  its  peripheral  la5'^er  free  from  corpuscles, 
and  its  axial  stream  so  rapid  that  the  individual  corpuscles  cannot  be 
seen.  On  the  right  is  a  similar  vessel  in  a  state  of  inflammation;  the 
blood-current  has  been  retarded  so  that  the  individual  corpuscles  are 
visible;  the  leucocytes  occupy  the  periphery  of  the  vessel,  and  are  in 
process  of  migration,  whilst  sundry  red  corpuscles  can  also  be  seen  in 
the  surrounding  tissues. 

through,  the  lymphatics,  or  be  transformed  into  a  pus  corpuscle ; 
moreover,  prior  either  to  disintegration  or  transformation  into  a  pus 
corpuscle,  it  may  attack  and  assist  in  removing  any  dead  tissue 
which  exists  in  the  neighbourhood  of  the  inflammatory  focus,  whilst 
a  phagocytic  or  microbe- destroying  function  is  also  subserved.  In 
fact,  the  leucocytes  may  be  looked  on  as  the  scavengers  of  the  body, 
or  as  advanced  guards,  which,  at  the  onset  of  mischief,  are  thrown 
out  from  the  vessels  as  Nature's  first  line  of  defence  against  the 
invading  forces,  their  chief  duty  being  to  remove  all  damaged  and 
noxious  material,  and  then,  having  limited  the  spread  of  the  destruc- 
tive process,  they  in  turn  give  place  to  larger  and  more  useful 


32  A   MANUAL  OF  SURGERY 

cells  (fibroblastic)  which  are  the  active  agents  in  the  process  of 
repair. 

The  red  corpuscles  pass  through  the  walls  of  the  capillaries  by 
a  process  of  diapedesis,  the  result  of  simple  mechanical  pressure; 
this  usually  occurs  only  in  acute  attacks.  When  once  external  to 
the  vessels,  they  are  broken  up  and  tlu-ir  colouring  matter  diffused 
through  the  tissues,  whence,  as  a  rule,  it  is  completely  reabsorbed. 

The  liquor  sanguinis  is  also  extravasated.  This  is  merely  an 
exaggeration  of  a  normal  process,  but  to  such  an  extent  that 
although  for  a  time  the  lymphatics  of  an  inflamed  region  do  in- 
creased work,  yet  the  transudation  is  soon  greater  than  they  can 
deal  with.  If  the  fluid  escapes  into  the  tissues,  it  undergoes  coagu- 
lation by  meeting  the  necessary  coagulating  media  developed  from 
the  breaking-down  leucocytes;  inflammatory  lymph  forms  locally, 
whilst  the  serum  collects  in  the  meshes  of  the  tissues,  constituting  an 
inflnmmatorv  form  of  oedema;  if  there  is  a  sufficient  breach  of 
surface,  the  serum  drains  away.  If  the  exudation  takes  place  from 
a  serous  surface — e.g.,  pleura,  peritoneum,  synovial  membrane,  etc. 
— the  fluid  distends  the  cavity;  it  is  at  first  spontaneously  coagulable 
{i.e.,  consists  of  plasma) ;  if  coagulation  occurs,  the  clot  or  lymph 
eitlier  forms  an  adherent  plastic  mass  on  the  surface  or  floats  free 
in  the  fluid. 

Looked  at,  therefore,  simply  from  a  vascular  point  of  view. 

Inflammation^  Hypercemia  +  Exudation. 

Each  of  the  elements  in  the  inflammatory  reaction  is  of  benefit 
to  the  patient  in  combating  a  colony  of  bacteria,  which  together 
with  their  toxins  have  gained  access  to  the  tissues.  The  accelera- 
tion of  the  blood-flow  serves  in  the  first  place  to  dilute  and  to 
remove  the  toxin;  if  the  amount  present  is  small,  the  rapid  flow 
of  blood  may  serve  to  remove  it  completely,  and  then  the  process 
begins  and  terminates  in  hyper?emia.  Further,  the  increased  supply 
of  blood  must  serve  to  keep  the  nutrition  of  the  tissues  at  its  highest 
level,  so  that  if  possible  they  may  be  preserved  alive  in  spite  of  the 
action  of  the  toxin.  Lastly,  if  the  blood  contains  antitoxins,  or 
other  antibodies,  or  alexins  (complements),  which  inhibit  the  action 
of  the  toxins  or  destroy  the  bacteria,  these  will  be  brought  in  large 
amounts  to  the  region  where  they  are  required.  The  excessive 
transudation  of  the  plasma  may  be  regarded  as  an  additional  means 
of  fulfilling  these  desiderata.  The  value  of  the  retardation  and 
stasis  of  the  blood  is  less  obvious,  although  it  probably  assists  the 
emigration  of  the  leucocytes,  which  might  otherwise  find  difficulties 
in  attaching  themselves  to  the  walls  when  floating  freely  in  a  rapid 
blood-stream.  The  role  of  the  leucocytes  has  been  already  con- 
sidered. 

II.  The  Tissue  Changes  in  inflammation  cannot  be  so  easily  ob- 
served as  the  vascular,  but  are  of  great  ini]-)()rtance. 

The  reaction  of  the  tissues  in  acute  bacterial  inflammations  aj)- 
pears  to  depend  entirely  on  the  irritative  power  of  the  toxins,  or 


INFLAMMATION  33 

rather  on  the  relation  of  this  power  to  the  resistance  of  the  patient's 
tissues.  It  may  be  laid  down  as  a  general  rule  that  any  irritant,  if 
weak  enough  {e.g.,  when  very  diluted),  acts  as  a  stimulant  to  the 
growth  of  cells;  on  the  other  hand,  if  sufftciently  powerful,  it  will 
cause  some  variety  of  necrosis  or  death  of  the  tissues.  Uncom- 
plicated examples  of  tissue-overgrowth  in  acute  inflammation  are 
not  often  seen  in  man,  since  the  slighter  lesions  are  rarely  examined 
microscopically.  The  process  is  best  observed  in  the  early  stages 
of  acute  inflammation  of  serous  membranes  in  animals,  where  the 
endothelium  may  be  seen  several  cells  thick,  whilst  its  nuclei  show 
active  mitosis,  pro\ang  that  cell-proliferation  was  in  progress.  An 
examination  of  the  outer  zone  of  a  mass  of  granulation  tissue  (where 
the  toxins  are  present  only  in  small  amount)  will  often  show  similar 
appearances. 

In  most  cases,  however,  the  toxins  are  more  active,  and  death  of 
the  tissue  results.  This  is  often  brought  about  by  what  is  termed 
coagitlation-iiecrosis.  In  this  condition  the  tissues  and  cells  become 
soaked  in  the  coagulable  plasma  which  exudes  from  the  vessels,  and 
the  activity  of  the  toxins  causes  coagulation  and  death  of  the  whole 
mass.  The  result  is  that  all  structure  disappears  from  the  area 
involved :  the  nuclei  cease  to  stain  with  hematoxylin  or  other  basic 
d3'es,  and  all  the  tissues  stain  uniformly  with  acid  stains,  such  as 
eosin.  The  further  history  of  the  lesion  depends  on  the  nature  of 
the  causative  organisms.  If  these  are  of  a  pyogenic  nature,  the 
necrotic  mass  will  become  (or  has  already  become)  infiltrated  with 
polynuclear  leucoc\i:es,  some  of  which  are  killed  by  the  toxins,  and 
suppuration  follows  (see  p.  74).  When  the  organism  is  not  of  this 
nature,  the  polynuclear  leucocytes  make  their  appearance  in  but 
moderate  numbers,  and  the  inflamed  area  becomes  infiltrated  with 
'  small  round  cells,'  which  appear  to  be  identical  with  hmiphocytes. 
It  is  as  yet  uncertain  whether  these  are  formed  locally  or  whether 
they  are  attracted  from  the  blood.  It  seems,  however,  tolerabty 
clear  that  they  undergo  a  local  increase  by  direct  division  in  the 
inflamed  area.  If  the  bacteria  are  killed  and  the  process  stops  at  this 
stage,  the  phenomena  of  repair  supervene  (Chapter  X.),  and  the 
inflamed  part  is  replaced  by  a  mass  of  fibro-cicatricial  or  scar  tissue. 

In  non-bacterial  inflanimations  of  superficial  parts  the  amount  of 
effusion  between  the  individual  cells  may  be  so  excessive  as  to 
separate  and  disintegrate  them,  and  thus  colliqtiative-necrosis  ma}'  be 
induced,  as  occurs  in  the  formation  of  blisters  after  a  burn. 

In  chronic  inflammations,  on  the  other  hand,  active  cell-prolifera- 
tion is  a  most  important  element  in  the  process,  resulting  in  sclerosis 
and  induration  of  the  parts.  This,,  however,  mainly  affects  the 
interstitial  tissues,  and  thereby  the  true  structure  of  the  organ  may 
be  impaired. 

III.  The  Terminations  of  inflammation  will  therefore  vary  con- 
siderably, and  more  especially  with  the  cause  of  the  trouble,  whether 
bacterial  or  not,  with  the  intensity  and  duration  of  its  action,  and 
finally  with  the  powers  of  resistance  possessed  by  the  individual. 

3 


34  A    MANUAL  OF  SURGERY 

In  bacterial  inflammations  (i)  it  is  unusual  for  the  tissues  so  to 
assei  t  tliemselves  as  to  permit  of  the  occurrence  of  resolution,  or  the 
reappearance  of  tlie  s/atiis  quo  ante  ;  it  is,  however,  seen  occasionally. 
(2)  More  frequently  local  destruction  of  tissue  results,  and,  according 
to  the  nature  of  the  bacteria  and  the  tissues  involved,  this  may  be 
followed  by  {a)  repair,  the  necrotic  tissue  disappearing  and  scar  tissue 
taking  its  place;  {h)  suppiiralion,  in  which  the  affected  tissues  and 
the  exudate  are  liquefied  and  transformed  into  pus;  evacuation  of 
the  abscess  thereby  formed  gives  exit  to  the  bacteria,  the  exudate, 
and  the  necrotic  tissue,  and  repair  is  finally  brought  about  by  cica- 
trization ;  (c)  ulceration,  when  the  necrotic  or  suppurative  process 
affects  the  surface;  or  {d)  extensive  necrosis  or  gangrene,  when  the 
toxic  effects  of  the  bacteria  are  able  to  break  down  the  tissue  re- 
sistance to  such  an  extent  that  the  bacteria  can  diffuse  them- 
selves widely  through  the  part.  In  this  connection  it  is  interesting 
to  note  that  the  more  highly  organized  and  important  organs  are 
always  more  vulnerable  than  the  simpler  forms  of  connective  tissue, 
and  this  in  spite  of  the  fact  that  the  former  are  usually  better 
supplied  with  blood.  Thus,  the  growing  end  of  the  diaphysis  in  a 
child  is  a  most  delicately  organized  region,  and  hence  is  peculiarly 
liable  to  serious  destructive  inflammation  from  bacterial  agents, 
which  would  do  little  harm  if  developing  under  similar  circumstances 
in  the  subcutaneous  connective  tissues. 

When  the  inflammatory  attack  is  due  to  mechanical  or  other  non- 
bacterial causes,  there  is  frequently  much  effusion  of  fluid,  and  at 
first  but  little  cellular  exudation,  whilst  the  process  is  distinctly 
limited  and  has  no  tendency  to  spread.  The  most  common  termina- 
tions are:  (a)  Resolution,  complete  and  absolute,  which  is  seen  not 
uncommonly;  {h)  the  formation  of  fibro-cicatricial  tissue,  as  seen  in 
the  organization  of  lymph  into  adhesions;  (c)  sometimes  the  in- 
flamm.atory  process  becomes  chronic,  and  is  then  characterized  by 
sclerosis  or  fibroid  thickening  of  the  part,  or  by  persistent  effusion 
into  a  serous  cavity. 

Resolution,  or  the  restoration  of  the  part  to  its  natural  condition 
and  function,  can  only  occur  when  the  injury  has  not  been  so  severe 
as  to  destroy  the  vitality  of  the  affected  tissues.  'Ihe  phenomena 
are  merely  those  of  inflammation  in  a  retrograde  order — viz.,  an 
oscillatory  movement  first  manifests  itself  amongst  the  corpuscles, 
and  then  the  blood-stream  is  gradually  restored,  slowly  at  first,  and 
more  and  more  rapidly  afterwards.  The  adhesiveness  of  the 
corpuscles  disappears  by  degrees,  but  it  is  some  time  before  the 
peripheral  inert  layer  can  be  seen.  The  (-xuded  leucocytes  find 
their  way  back  into  the  circulation  either  through  the  vessel  walls, 
or  to  a  greater  extent  via  the  lymphatics,  or  else  they  are  disinte- 
grated in  the  tissues  and  absorbed.  The  fluid  exudate  is  removed  by 
the  lymphatics.  For  some  time  after  an  acute  attack  the  vessels  of 
the  part,  especially  the  veins,  are  dilated  from  simple  loss  of  tone, 
but  this  also  gradually  disappears. 


IN  FLA  MM  A  TION  35 

Clinical  Signs  of  Inflammation. 

The  Local  Phenomena  may  be  described  under  the  four  headings 
suggested  by  Celsus  (about  a.d.  50),  viz.,  heat,  redness,  swelhng,  and 
pain,  with  the  addition  of  a  fifth,  viz.,  impairment  of  function. 

Heat. — An  inflamed  part  feels  hot  to  the  touch,  and  the  tempera- 
ture, if  taken  by  a  surface  thermometer,  is  definitely  raised  above 
that  of  the  surrounding  skin.  This  is  due  to  the  increased  amount 
of  blood  flowing  through  it,  for  the  temperature  of  an  inflamed  area 
is  never  higher  than  that  of  the  blood  at  the  centre  of  the  circulation, 
i.e.,  in  the  heart.  The  cause  of  the  increased  temperature  of  the 
blood  is  noted  elsewhere  (p.  37). 

Redness  is  due  to  the  h^-perjemic  condition  of  the  inflamed  part. 
In  the  early  active  h37pergemia  the  colour  is  a  bright  rosy-red,  fading 
quicklv  on  pressure,  and  returning  with  equal  rapidity.  During  the 
period  of  retardation  the  redness  is  more  dusky,  since  the  blood  is 
longer  in  passing  through  the  capillaries,  and  so  loses  more  of  its 
oxygen;  the  colour  does  not  disappear  or  return  so  rapidly,  and  a 
slight  3'ellowish  tinge  often  remains  from  extravasated  haemoglobin. 
When  stasis  is  reached,  and  a  fortiori  when  thrombosis,  pressure  does 
not  remove  the  red  colour,  and,  should  such  a  state  persist  for  long, 
permanent  pigmentation  may  remain. 

When  the  tissue  inflamed  is  non- vascular — e.g.,  the  cornea  or  arti- 
cular cartilage — redness  is  of  course  absent  until  the  part  becomes 
penneated  by  newly-formed  vessels.  In  the  case  of  the  cornea, 
however,  a  zone  of  deep  pink  injection  is  seen  in  the  ciliary  region. 
A  similar  absence  of  redness  is  observed  in  an  inflamed  iris,  owing  to 
the  excess  of  pigment  hiding  the  dilated  vessels;  if,  however,  the 
inflammation  is  very  prolonged,  the  pigment  may  be  absorbed,  and 
the  iris  becomes  obviously  red. 

Swelling  arises  from  the  same  two  causes,  viz.,  hyperaemia  of,  and 
exudation  into,  the  part.  Necessarily  the  amount  of  tumefaction 
depends  upon  the  acuteness  of  the  disturbance  and  the  distensibility 
of  the  tissue,  and  in  measure  varies  inversely  with  the  amount  of 
pain.  "Where  the  inflamed  area  is  covered  by  a  thick  and  firm 
fascia,  not  only  is  the  tensive  pain  very  considerable,  but  the  chief 
swelling  may  occur  away  from  the  inflamed  area,  e.g.,  over  the  back 
of  the  hand  in  a  palmar  abscess;  where  the  inflammatory  products 
escape  into  lax  tissues,  the  subjective  phenomena  are  diminished, 
although  the  swelling  ma}'  be  very  great.  Similar  illustrations  of 
the  occurrence  of  oedema  at  a  distance  are  to  be  seen  in  inflamma- 
tions of  the  sole  of  the  foot,  and  in  the  swelling  of  the  eyelids  when 
the  scalp  is  inflamed.  Swelling  due  to  inflammation,  though 
diminishing  after  death,  does  not  entirely  disappear. 

Pain  results  from  the  mechanical  irritation  of  the  peripheral  nerve 
terminals,  both  by  the  increased  arterial  tension  and  by  the  pressure 
of  the  exudate,  so  that  it  is  much  greater  if,  from  the  density  of 
fascial  or  fibrous  investments,  swelling  cannot  readily  occur,  e.g., 
in  the  palm  of  the  hand,  or  in  the  eye  or  testicle.     Possibly  the 


3G  A   MANUAL  OF  SriRGHRY 

exudate  may  have  some  direct  chemical  action  on  the  nerve  ter- 
minals, especially  when  destructive  changes  arc  taking  place,  or  if 
the\'  are  insufficiently  nourished  with  healthy  blood. 

A  marked  feature  of  inflammatory  pain  is  that  it  is  always  aggra- 
vated by  pressure,  whether  intrinsic — i.e.,  by  increasing  the  blood- 
pressure,  as  by  hanging  down  an  inflamed  hand — or  extrinsic,  from 
outside  agencies,  such  as  mechanical  or  digital  pressure,  the  pain 
then  being  known  as  tenderness. 

The  pain  of  suppuration  is  throbbing  in  character;  of  an  inflamed 
jnucous  membrane,  scalding,  burning,  or  gritty;  of  an  inflamed  serous 
membrane,  stabbing;  of  inflamed  hone,  aching  or  boring,  and  often 
worse  at  night;  of  an  inflamed  testicle,  sickening.  When  the  organs 
of  special  sense  are  inflamed,  there  may  be  little  real  pain,  but  much 
exaggeration  of  the  special  sense,  e.g.,  flashes  of  light  in  retinitis  and 
noises  in  the  ears  in  otitis  interna. 

The  pain  is  not  limited  only  to  the  inflamed  part,  but  is  sometimes 
experienced  in  distant  regions,  either  through  a  similarity  of  nerve- 
supply  or  from  the  fact  that  a  sensory  stimulus  is  always  referred,  by 
a  patient  to  the  end  of  the  affected  nerve.  For  example,  in  hip 
disease  the  chief  pain  is  often  felt  in  the  knee,  because  both  joints 
derive  their  nervous  supply  from  similar  sources.  In  renal  calculus 
or  colic,  pain  is  referred  along  the  course  of  the  genito-crural  nerve 
into  the  groin  and  front  of  the  thigh,  and  is  often  accompanied  in 
the  male  by  retraction  of  the  testicle  on  the  side  affected.  In  spinal 
caries  pain  is  frequently  experienced  in  the  terminal  branches  of  the 
nerves  issuing  from  the  part  affected,  e.g.,  the  '  girdle  '  pain  in  dorsal 
disease,  and  the  so-called  '  belly-ache  '  when  the  dorsi-lumbar  region 
is  affected.  Occasionally  a  s\'mpathetic  pain  is  experienced  on  the 
opposite  side  of  the  body,  especially  when  a  bilateral  organ  such  as 
the  kidney  is  involved. 

Impairment  or  Loss  of  Function  is  due  sometimes  to  the  mechanical 
difftculty  of  using  a  swollen  organ,  sometimes  to  the  pain  elicited  by 
such  attempts,  but  often  to  the  paralyzing  effect  of  the  inflammatory 
process,  and  this  in  infective  lesions  results  from  the  direct  influence 
of  the  toxins  on  the  protoplasm  of  the  cells  affected.  Thus,  an 
inflamed  eye  is  from  various  causes  of  little  use  for  vision;  a  muscle, 
when  inflamed,  is  naturally  kept  at  rest;  glandular  organs,  e.g.,  the 
liver  and  kidneys,  have  their  functions,  if  not  lost,  at  least  much 
diminished;  and  many  similar  illustrations  might  be  added. 

Constitutional  Symptoms  are  constantlj^  present  in  inflammatory 
conditions,  and  vary  greatly  in  their  severity  with  the  cause.  In 
non-bacterial  cases  there  is  usualh^  some  shght  fever  which  does  not 
last  long;  but  when  bacteria  are  present,  the  absorption  of  toxins 
may  cause  general  symptoms  varying  in  degree  from  a  mild  febrile 
reaction  to  a  grave  toxsemia  which  causes  death.  It  is,  however, 
astonishing  to  note  how  much  disturbance  a  small  bead  of  pus 
under  tension  may  sometimes  produce. 

It  is  only  necessary  at  this  place  to  deal  very  briefly  with  the 
subject  of  Fever  or  pyrexia.     The  general  characteristics  of  the 


IN  FLA  MM  A  TION  37 

lcl)iiU'  state  consist  in  a  greater  or  less  elevation  of  temperature, 
acconipanicd  l)y  a  corresponding  acceleration  of  the  rate  of  the  heart- 
beat and  of  the  respirations.  If  it  continues,  the  patient  becomes 
thin  and  emaciated,  and  loses  muscular  power.  The  mouth  is  dry 
and  the  tongue  furred;  and  in  the  later  stages  the  lips  and  teeth  are 
usually  covered  with  sordes  (or  accumulations  consisting  of  inspis- 
sated mucus  and  food  debris).  The  appetite  is  impaired,  digestion 
is  imperfect,  and  the  bowels  constipated;  the  motions  are  often  very 
offensive.  The  urine  is  scanty  and  high-coloured,  and  owing  to 
the  excessive  tissue  change  contains  an  unusual  amount  of  urea 
and  urates.  The  excess  of  urea  is  demonstrated  clinically  by  adding 
an  equal  part  of  cold  nitric  acid  in  a  test-tube  to  some  urine,  when 
crystals  of  nitrate  of  urea  will  form  on  the  top  of  the  fluid,  giving 
rise  to  a  mass  somewhat  resembling  sugar-candy  in  appearance. 
The  skin  of  a  febrile  patient  is  often  dry. 

Causes  of  Fever. — The  temperature  of  the  body,  it  is  well  known,  is  con- 
trolled by  a  principal  heat-governing  centre  in  the  corpus  striatum,  assisted 
possibly  by  accessory  centres  in  the  cord,  and  is  maintained  by  the  establish- 
ment of  equilibrium  between  the  amount  of  heat  lost  from  the  skin,  by  the 
breath,  and  in  other  directions,  and  the  amount  of  heat  produced  by  the  tissue 
metabolism  occurring  in  the  viscera  generally,  and  especially  in  the  volun- 
tary muscles.  Pyrexia  is  necessarily  due  to  one  of  two  causes,  viz.,  a  de- 
creased loss  of  heat,  or  an  increased  production.  The  former  is  a  scarcely 
tenable  proposition  when  we  look  at  the  patient's  condition,  and  hence  we  are 
driven  to  conclude  that  fever  is  due  to  increased  activity  in  the  heat-forming 
tissues,  especially  the  muscles,  a  fact  which  explains  the  rapid  emaciation 
and  loss  of  strength  under  such  circumstances,  and  the  presence  of  a  large 
amount  of  extractives  in  the  urine.  In  all  probability  this  increased  activity 
is  due  to  the  excitation  of  the  heat-producing  centres  by  some  pyrogenous 
body  developed  in  connection  with  the  local  inflammatory  process.  Experi- 
ments have  shown  that  fibrin  ferment,  various  products  of  the  breaking  down 
of  tissues,  and  many  of  the  toxins  produced  by  the  action  of  micro-organisms 
possess  such  a  power. 

In  regard  to  the  symptoms  of  fever,  it  may  be  stated  briefly  that  they  are 
in  large  part  due  to  the  effect  produced  by  the  increased  temperature  or  the 
toxic  products  circulating  in  the  blood  upon  the  constituent  cells  of  glandular 
and  other  organs.  The  phenomena  in  question  are  termed  by  different 
pathologists  '  acute  or  cloudy  swelling,'  '  granular  degeneration,'  '  albuminous 
infiltration,'  etc.,  and  are  characterized  by  the  organs  becoming  soft,  friable, 
and  more  or  less  swollen.  The  secreting  cells  of  glands  are  increased  in  size, 
and  the  protoplasm  becomes  markedly  granular,  so  that  the  nucleus  can  only 
be  distinguished  with  difficulty.  The  granules  are  albuminous  in  character, 
clearing  up  completely  on  the  addition  of  acetic  acid.  A  similar  change  is 
also  evident  in  the  fibres  of  the  cardiac  muscle,  which  lose  their  striation  and 
become  granular,  a  condition  which  must  considerably  interfere  with  their 
contractility.  The  effect  produced  upon  the  glands  of  the  digestive  system 
explains  many  of  the  febrile  manifestations.  The  salivary  and  buccal  glands 
are  unable  to  excrete  the  normal  amount  of  saliva,  and  hence  the  mouth  be- 
comes dry,  whilst  gastric  digestion  is  interfered  with  in  a  similar  way. 

The  intensity  and  character  of  the  fever  vary  with  the  preceding  condition 
of  the  patient,  and  also  with  the  nature  and  duration  of  the  disease.  In 
young  healthy  adults  of  sound  constitution,  the  fever  associated  with  an  acute 
inflammation  is  usually  of  an  active  type,  pyrexia  and  its  accompanying 
phenomena,  including  a  noisy  delirium,  being  well  marked  {sthenic  inflam- 
matory fever).  In  debilitated  subjects,  as  also  towards  the  close  of  a  long 
period  of  pyrexia  {e.g.,  in  the  third  week  of  enteric  fever),  and  in  grave  infec- 
tions such  as  erysipelas  and  septicaemia,  exhaustion  and  collapse  manifest 


38  A   MANUAL  OF  SURGERY 

themselves  {asthenic  fever,  or  the  typlioitl  slate).  The  pyrexia  is  not  neces- 
sarily high,  and  the  patient  often  passes  into  a  condition  of  low  muttering 
delirium,  picking  at  the  bedclothes,  passing  his  excreta  into  the  bed,  and  more 
or  less  unconscious. 

Varieties  of  Inflammation. — Many  different  tenns  are  used  t<^  indi- 
cate the  manifestations  of  the  inflammatory  process  in  the  body,  and 
to  some  of  these  we  must  now  direct  attention. 

A? Catarrhal  inflammation  is  one  affecting  mucous  membranes, 
whicli  in  tlie  early  stages  become  dry,  vividly  red,  and  the  seat  of 
a  burning  or  scalding  pain,  whilst  in  the  later  stages  there  is  free 
secretion  of  mucus,  muco-pus,  or  pus.  At  first  the  mucigenous 
function  of  the  hyper^emic  membrane  is  abrogated,  and  any  extra- 
vascular  exudation  passes  into  its  substance,  causing  it  to  become 
swollen.  Proliferation  of  the  epithelium  soon  follows,  resulting  in 
an  increased  formation  of  mucus;  as  the  membrane  becomes  more 
and  more  infiltrated  with  leucocytes,  these  are  added  to  the  dis- 
charge, which  is  thus  transformed  into  muco-pus,  or  even  pus. 
Small  ulcers  may  develop  from  the  loss  of  superficial  epithelium, 
but  tliis  is  an  exception  rather  than  the  rule.  Microscopic  examina- 
tion of  the  discharge  reveals  pus  cells,  leucocytes,  and  epithelial 
elements  in  various  conditions,  some  containing  globules  of  mucin, 
and  some  of  the  normal  type.  This  form  of  inflammation  is  caused 
by  bacteria,  or  by  the  action  of  local  irritants,  or  by  what  is  known 
as  '  taking  cold.' 

A  Croupous  or  plastic  inflammatic^n  is  one  characterized  by  the 
formation  of  a  firm  false-membrane,  due  to  the  coagulation  of  the 
plasma  exuded  from  the  vessels,  the  resulting  fibrin  being  deposited 
on  the  surface.  When  involving  a  serous  surface,  such  as  the  pleura, 
peritoneum,  or  synovial  membrane,  it  gives  rise  to  a  layer  of  plastic 
Ivmph,  which  may  (jrganize  into  adhesions;  it  is  also  seen  in  the 
alveoli  of  the  lungs  in  lobar  pneumonia.  On  mucous  membranes, 
such  as  the  conjunctiva  or  that  of  the  pharynx,  it  occasionally 
forms  white,  flaky  masses,  which  can  be  readily  detached,  leaving 
an  injected  surface  below,  with  merely  one  or  more  oozing  points, 
and  no  loss  of  substance. 

A  Diphtheritic  inflammation  is,  properly  speaking,  one  that  is 
due  to  the  action  of  the  diphtheria  bacillus  on  a  free  surface  (p.  ijj). 
'I  he  term  is,  however,  often  applied  to  inflammatory  processes  due 
to  other  causes,  but  resulting  in  a  '  false-membrane  '  of  similar  nature. 
This  differs  from  the  false-membrane  of  croupous  inflammation  in 
that  it  is  formed,  in  part  at  least,  by  necrosed  tissues,  and  not  simply 
by  fibrin  deposited  on  the  surface.  Hence  it  is  more  difficult  to 
'  peel  off,'  and  when  this  is  done  a  raw  bleeding  surface  is  left. 

The  term  Phlegmonous  is  now  but  rarely  employed.  It  was 
formerly  applied  to  any  inflammation  of  the  subcutaneous  connective 
tissues  where  the  local  phenomena  tend  to  spread,  and  there  is  a 
well-marked  brawnv  inflammatory  swelling  or  phlegmon. 

Parenchymatous  and  Interstitial  are  terms  which  indicate  that  in 
an  inflamed  organ  or  gland  the  process  is  mainly  limited,  either  to 


INFLAMMATION  39 

the  actual  and  active  substance  of  the  organ,  or  to  the  supporting 
fibrous  tissue. 

The  term  Metastasis  was  formerly  employed  to  indicate  a  sudden 
transference  of  an  inflammatory  attack  from  one  place  to  another 
without  apparent  cause.  Increased  knowledge  of  pathology  has 
explained  awav  nearly  all  the  formerly-described  illustrations  of 
metastasis,  and,  indeed,  the  use  of  this  term  is  now  almost  limited  to 
the  inflammation  of  testis,  ovary,  or  breast  which  follows  mumps. 
It  is  often  incorrectly  applied  to  the  secondarv  abscesses  of  pyaemia 
and  to  the  secondary  deposits  of  mahgnant  disease,  both  of  which 
are  of  embolic  origin. 

Treatment  of  Acute  Inflammation. 

It  is  only  possible  here  to  deal  with  the  general  principles  which 
guide  us  in  the  treatment  of  inflammatory  affections  ;  the 
application  of  these  to  different  parts  of  the  body  will  be  considered 
later. 

1.  The  Local  Treatment  of  Non-bacterial  Inflammation. — i.  Remove 
the  exciting  cause,  if  exddent,  and  any  contributory  causes  when 
feasible.  This  is  not  a  difficult  matter  when  the  lesion  is  a  gross 
one  and  the  exciting  cause  tangible,  e.g.,  a  foreign  body  imbedded 
in  the  conjunctiva  or  cornea,  or  the  use  of  a  chemical  irritant  such 
as  formalin  in  an  occupation  eczema.  In  the  majority  of  cases, 
however,  the  exciting  cause  has  ceased  to  act,  as  in  the  case  of  blows, 
sprains,  burns,  etc.,  and  all  one  can  do  is  to  protect  the  part  from 
further  irritation  or  bacterial  infection,  to  relieve  tension,  and  then 
to  assist  the  tissues  towards  healthy  repair. 

2.  Keep  the  inflamed  part  at  rest.  Wherever  inflammation  exists, 
both  physical  and  physiological  rest  should  be  secured  as  far  as 
possible.  Thus,  an  inflamed  joint  is  immobihzed;  an  inflamed 
mamma  needs  both  support  and  the  fixation  of  the  arm,  whilst  if 
in  a  condition  of  physiological  acti\'ity  this  must  be  checked;  an 
inflamed  cornea  needs  the  application  of  a  pad  and  bandage  to 
prevent  the  friction  of  the  eyelid;  an  inflamed  retina  is  put  to  rest 
by  exclusion  of  the  light. 

3.  Reduce  the  local  blood-pressure  and  h\^er£emia,  and  thereby 
reUeve  tension  by  diminishing  both  exudation  and  pain.  It  may 
be  pointed  out  here  that,  although  both  hyperemia  and  exudation 
are  beneficial,  yet  they  are  ahnost  always  present  in  excess,  and  it 
becomes  needful  to  keep  them  under  control.  Elevation  of  an 
inflamed  limb  may  secure  this  end,  and  is  usually  required  in  in- 
flammatorv  conditions  of  the  leg,  for  it  is  well  known  that  emptpng 
the  veins  by  gra\ity  leads  to  reflex  contraction  of  the  arteries. 
This  principle  must  not  be  carried  to  excess,  or  serious  interference 
with  the  vitality  of  the  limb  may  result.  The  rule  adopted  is  to 
raise  the  affected  part  to  such  an  extent  as  to  assist  the  venous 
return  without  interfering  with  the  arterial  supply.  Local  blood- 
letting by   punctures,    scarification,    and   wet    or    dry   cupping,   is 


4"  A   MANUAL  Oh'  SURGEUY 

useful  in  suitable  cases,  and  sometimes  gives  iinuucliate  relief  to 
pain. 

Cold  wisely  utilized  is  of  the  greatest  service  in  reducing  hyper- 
aemia  by  causing  contraction  of  the  arterioles.  It  should  only  be 
used  in  the  early  stages,  as  it  depresses  the  vitality  of  the  part,  and 
so,  if  much  congestion  is  present,  may  do  more  harm  than  good. 
Again,  it  should  be  used  with  the  greatest  care  in  old  people,  from 
fear  of  causing  necrosis  of  the  skin.  There  are  various  methods 
of  applying  it,  as  by  means  of  an  ice-bag;  or  by  irrigation  from  a 
vessel  suspended  over  the  part,  containing  iced  water  or  lotion,  from 
which  strips  of  lint  descend  to  envelop  the  inflamed  area;  or  a  piece 
of  lint  wrung  out  of  evaporating  lotion  may  be  placed  directly  on 
the  part ;  or,  better  still,  the  iced  water  may  be  run  through  a  coil 
of  leaden  pipes  (known  as  Leiter's  tubes),  fitted  carefullv  to  the 
inflamed  region. 

Heat,  especiall}'  when  combined  with  moisture,  is  very  largely 
used  in  treating  inflammatory  affections,  and  acts  in  a  diametrically 
opposite  way  to  cold  by  relaxing  the  vessels  and  tissues,  thus 
reducing  the  tension  and  pain;  it  also  favours  the  activity  and 
vitality  of  the  part  by  increasing  the  vascular  supply  and  facilitating 
lymphatic  absorption.  For  subcutaneous  lesions,  rubber  hot-water 
bottles,  fomentations,  medicated  or  not  with  opium  or  belladonna,  or 
spongiopiline  wrung  out  of  hot  water,  poultices,  or  simply  dry 
heated  cotton-wool,  may  be  employed.  Other  methods  of  employ- 
ing dry  heat  are  suggested  in  Chaptci-  III.,  but  are  more  applicable 
to  the  chronic  varieties  of  inflammation. 

II.  The  Local  Treatment  of  Inflammation  of  Bacterial  Origin. — This 
is  a  somewhat  different  problem  in  that  its  object  is  to  destroy 
bacteria,  to  eliminate  their  toxins,  and  to  attain  this  end  with  as 
little  destruction  of  tissue  as  possible.  The  chief  difficulty  lies  in 
the  stagnation  present  in  the  bloodvessels  and  Ivmphatics  of  the 
inflamed  part,  so  that  no  fresh  blood  is  circulating  through  it.  At 
the  same  time  the  toxins  formed  by  the  bacteria  have  the  opportunity 
of  acting  on  the  tissues,  and  are  absorbed  into  the  blood,  thereby 
1  eading  to  its  deterioration.  The  means  at  our  disposal  of  combating 
a  bacterial  inflammation  are:  [a)  The  antitoxic  and  bactericidal 
properties  of  the  blood,  which  can  be  influenced  beneficially  by  anti- 
sera,  vaccines,  drugs,  and  diet;  and  {b)  external  applications  and 
procedures,  directed  towards  the  removal  of  stagnant  blood  and 
exudate,  and  to  the  provision  of  a  sufficient  supply  of  fresh  blood 
which  shall  assist  the  tissues  in  the  direction  of  repair.  The  actual 
methods  are  as  follows: 

1.  Remove  the  cause  if  possible,  as,  for  instance,  an  infected 
foreign  body,  or  a  buried  stitch  at  the  bottom  of  a  sinus.  In  a  few 
cases  it  may  be  possible  totally  to  excise  a  local  focus — e.g.,  a 
malignant  pustule;  whilst  in  others,  such  as  a  carbuncle,  one  can 
scrape  away  the  inflltrated  and  sloughy  tissue  with  a  sharp  spoon. 

2.  Keep  the  inflamed  part  at  rest  a.%  far  as  possible,  not  only  for 
physical  and  physiological  reasons,  but  also  to  prevent  mechanical 


IN  FLA  MM  A  TION  4 1 

dissemination  of  the  infective  virns.     This  may  be  effected  by  con- 
lining  the  patient  to  bed,  or  by  the  use  of  sphnts  or  sUngs. 

3.  ^Unload  the  stagnant  vessels,  both  veins  and  lymphatics,  by 
elevation,  hot  applications,  which  soften  and  relax  the  tissues,  or 
local  blood-letting.  Scarification  is  of  great  value  in  the  slighter 
cases;  but  when  stasis  has  occurred,  free  incisions  are  often  indi- 
cated in  order  to  relieve  tension,  and  also  to  allow  of  the  escape  of 
bacteria  and  their  toxins. 

4.  Promote  the  removal  of  the  exudate  by  the  insertion  of  rubber 
drainage-tubes  into  deep  inflamed  cavities,  such. as  abscesses  or 
sinuses,  or  by  packing  an  open  wound  wdth  gauze  and  covering  it 
with  a  fomentation  or  a  hydrophile  dressing,  encouraging  thereby 
capillarv  drainage.  In  other  cases  immersion  of  the  inflamed  area 
in  a  bath  at  a  temperature  of  99^  to  105°  F.,  either  of  sterihzed  salt 
solution,  or  of  some  mild  antiseptic,  such  as  boric  acid,  may  be  of 
great  value  in  diluting  and  washing  away  toxins  and  cleansing  the 
part ;  but  it  must  not  be  used  to  excess,  or  repair  may  be  hindered 
by  the  tissues  becoming  waterlogged. 

'5.  Increase  the  supply  of  healthy  blood  to  the  part  by  the  applica- 
tion of  heat,  as  by  poultices  when  the  skin  is  unbroken,  or  boric  acid 
fomentations  if  there  is  a  wound,  or  by  emplopng  one  of  the  methods 
of  artificial  hypersemia  suggested  by  Professor  Bier. 

Artificial  or  induced  hypercemia  as  a  means  of  treatment  for 
inflammation  is  based  on  the  assumption  that  the  hypersemia  and 
accompanving  leucoc3'tosis  present  in  all  its  forms  are  useful  rather 
than  harmful  if  they'^can  be  suitably  controlled;  but  in  acute  cases 
the  hyperemia  is  usually  excessive,  and  therefore  harmful  by  pre- 
venting the  access  of  fresh  healthy  blood  to  the  part.  Bier's  treat- 
ment requires  the  relief  of  this  natural  harmful  congestion  by 
elevation,  etc.,  and  subsequently  replaces  it  by  a  controlled  hyper- 
semia, the  parts  being  flooded  from  time  to  time  with  fresh  blood, 
which  can  by  its  contained  antibodies  assist  in  destroying  bacteria 
and  bringing  about  a  cure. 

Induced  hypersemia  is  of  two  tj-pes,  active  and  passive.  The 
active  varietv  consists  in  determining  an  increased  flow  of  blood  to 
the  part  bv  vaso-dilation,  and  is  arterial  in  origin.  It  is  best  accom- 
phshed  bv  heat,  either  by  fomentations,  or  immersion  in  hot  water, 
or  by  one  of  the  diverse  methods  of  applying  hot  air  now  available. 
This  plan  is  not  so  generally  beneficial  in  acute  cases  as  passive 
h\^erffimia,  but  mav  be  useful  in  the  later  stages  by  hastening  the 
absorption  of  inflammatory  exudates,  thereby  completing  the  cure. 

Passive  hypercEmia  is  venous  in  origin,  and  may  be  induced  by 
the  application  of  a  constricting  bandage  on  the  proximal  side  of  the 
inflamed  area,  or  by  the  use  of  Klapp's  suction  balls.  The  constrict- 
ing bandage  is  of  elastic  material,  and  Martin's  rubber  bandage  may 
be  suitablv  utilized.  It  is  applied  with  sufficient  firmness  to  obstruct 
the  venous  return  without  interfering  Ndth  the  arterial  supply,  and 
if  this  is  satisfactorily  effected,  the  limb  becomes  reddish-blue, 
swollen,  and  oedematous,  but  without  pain;  if  it  becomes  cold,  or 


42 


A   MANUAL  OF  SURGERY 


the  patient  comphiins  of  the  pain  beinj^'  increased,  the  bandage  has 
been  apphed  too  tightly.  When  the  correct  degree  of  tension  has 
been  reached,  the  hmb  is  comfortalik",  and  the  l)andage  may  be 
retained  in  position  for  twenty  or  more  hours  at  a  stretcli,  being  re- 
moved each  day  for  two  or  three  hours  in  order  to  reheve  the  oedema 
and  empty  the  hmb  of  the  accumukited  and  more  or  less  stagnant 
blood.  This  method  of  treatment  is  maintained  until  the  inflamma- 
tion diminishes,  and  then  the  length  of  the  daily  application  of  the 
bandage  is  gradually  reduced. 

Klapp's  suction  halls  (Fig.  ii)  are  employed  in  cases  where  a 
rubber  bandage  cannot  be  applied — t.'.r,'.,  for  an  abscess  or  carbuncle 
on  the  trunk  or  back  of  the  neck,  for  an  inflamed  breast,  or  for  a 
septic  finger.  A  suitably-shaped  bell-glass  (similar  in  type  to  the 
wet  or  dry  cup  of  olden  days),  the  edge  of  which  is  greased  or 
moistened,  is  htteci  over  the  inflamed  part,  and  the  air  within 
rarefied  by  a  rubber  suction-pump.     Blood  is  thereby  drawn  into 


Fig.   II. — Klapp's  Suction  Ball. 
Suitable  for  small  superficial  infections,  e.g.,  boils  or  carbuncles. 

the  tissues,  which  swell  up  into  the  cup;  and  if  there  is  an  open 
wound,  as  in  a  boil  or  carbuncle,  discharge  and  sloughs  are  sucked 
out  therefrom.  The  application  is  maintained  for  hve  or  ten  minutes 
two  or  three  times  a  day. 

6.  Prevent  the  access  of  fresh  or  a  mixed  infection  to  an  open 
wound  b\'  suitable  dressings  and  antiseptics. 

III.  General  Treatment  of  Inflammation. — This  varies  considerably 
with  the  condition  of  the  patient  and  the  severity  of  the  attack. 

In  robust  patients  where  the  blood-pressure  is  high,  the  pulse 
large  and  full,  and  the  local  signs,  pain,  etc.,  well  marked,  it  may  be 
advisable  to  lower  the  arterial  tension  by  means  of  such  drugs  as 
antimony,  aconite,  ipecacuanha,  acetate  of  ammonia,  colchicum, 
etc.,  whilst  means  are  also  taken  to  determine  free  activity  of  the 
skin,  kidney,  and  bowels,  whereby  toxins  and  other  irritating  sub- 
stances may  be  eliminated  from  the  body,  and  the  blood  thereby 
purified.  In  a  few  cases — viz.,  acute  pneumonia  or  meningitis — it 
may  even  be  desirable  to  resort  in  the  early  stages  to  venesection, 
but  only  in  powerful,  full-blooded  adults,  and  never  to  such  an 


IN  FLA  MM  A  TION  43 

extent  as  uiululy  to  lower  their  resistance.  Subsequently  the 
administration  of  a  suitable  supply  of  simple,  easily-digested  food  is 
required,  the  exact  nature  of  which  depends  on  the  temperature  and 
the  condition  of  the  digestive  organs,  as  indicated  by  the  tongue. 

When  the  patient  is  weakly  and  feeble,  and  especially  when  his 
strength  has  been  gradually  sapped  by  persistent  fever  and  toxaemia, 
general  treatment  is  mainly  a  matter  of  feeding,  and  depends  as 
much  on  the  care  and  devotion  of  the  nurse  as  on  the  skill  of  the 
doctor.  Stimulants  may  be  required  in  these  cases,  and,  of  course, 
the  functions  of  the  bowels  and  kidneys  must  be  suitably  attended 
to,  though  without  depressing  the  patient's  strength. 

It  is  probable  that  moderate  pyrexia  is  useful  rather  than  harmful 
in  infective  diseases,  in  that  it  encourages  the  formation  of  anti- 
bodies. Hyperpyrexia,  however,  is  harmful,  in  that  it  paralyzes  the 
tissues  and  checks  the  production  of  these  substances.  It  is  un- 
necessary, therefore,  to  employ  antipyretic  measures  except  when 
the  temperature  runs  high,  and  the  chief  reliance  should  then  be 
placed  on  drugs  such  as  quinine  or  aspirin,  or  on  tepid  sponging. 

Chronic  Inflammation. 

The  Causes  are  similar  in  character  to  those  producing  the  acute 
mischief,  but  slighter  and  more  prolonged  in  their  action.  The  most 
striking  point  in  the  aetiology  is  the  large  part  played  by  diathetic 
conditions  or  constitutional  predispositions.  Most  of  the  manifesta- 
tions met  with  in  surgical  practice  are  due  to  syphilis,  tubercle, 
gout,  or  rheumatism,  and  one  should  never  treat  chronic  cases  with- 
out carefully  inquiring  as  to  the  possible  existence  of  some  such 
taint. 

The  Phenomena  are  essentially  the  same  as  those  of  the  acute 
process,  though  the  manifestations  are  somewhat  different. 

1.  The  hyperemia  is  less  in  degree,  but  longer  in  duration,  owing  to 
the  causative  irritant  being  frequently  of  little  activity.  The  local 
manifestations,  therefore,  are  less  obvious;  pain  is  not  so  great  and 
mainly  of  an  aching  character,  whilst  there  is  less  heat,  the  redness 
is  more  dusky,  and  the  tissues  often  become  pigmented.  Consider- 
able loss  of  tone  in  the  vessels,  especially  the  veins,  results  from  their 
prolonged  distension,  and  thus  there  is  greater  difficulty  in  restoring 
them  to  a  normal  state. 

2.  The  corpuscles  do  not  adhere  together  or  run  into  rouleaux  to 
the  same  extent  as  in  acute  inflammation,  and  migration,  though 
it  exists,  is  on  a  limited  scale.  The  exudation  is  more  fluid  in 
character,  containing  comparatively  little  albumen  or  fibrin ;  in  fact, 
in  some  chronic  inflammations  of  serous  membranes  the  cavities  are 
distended  with  fluid  of  a  much  lower  specific  gravity  than  that  of 
blood  serum. 

3.  The  greatest  difference  between  the  acute  and  chronic  pro- 
cesses lies  in  the  reaction  of  the  tissues.  In  acute  inflammation,  in- 
creased proliferation  of  the  tissues  is  rarely  a  marked  feature,  since 


44  A   MANUAL  OF  SURGERY 

tlic  toxin  lias  usually  sulticirnt  power  to  dcstnjy  tla-ir  \italit\'.  In 
clu-onic  inrtamniations  tliis  is  not  the  case,  at  least  not  until  tin-  later 
stages  of  lesions  like  those  of  tuberculosis  or  syphilis. 

An  area  which  in  is  a  state  of  chronic  inflammation  is  infiltrated 
with  round  cells  which  are  derived  from  various  sources,  (a)  In 
certain  tissues  cell-proliferation  is  well  marked,  especially  in  the 
endothelial  cells  of  the  vessels  and  lymph-clefts,  or  the  secreting 
cells  of  the  breast,  whilst  in  other  parts  {e.g.,  the  central  nervous 
system)  the  cells  never  undergo  proliferation.  {/;)  In  most  cases, 
however,  these  round  cells  are  lymphocytes,  and  are  often  found 
grouped  in  large  numbers  round  the  smaller  vessels;  in  the  chronic 
granulomata  this  is  very  characteristic,  large  areas  composed 
entirely  of  Ixniphocytes  being  met  with,  (c)  Another  cell  which  is 
often  found  in  these  lesions,  and  has  recently  attracted  much 
attention,  is  the  plasma-cell.  It  is  much  larger  than  a  lymphocyte, 
and  usually  of  an  oval  shape;  the  nucleus  is  about  as  large  as  that 
of  a  lymphoc\d:e,  is  usually  divided  into  five  or  six  segments,  and  is 
placed  excentrically  in  the  cell.  The  protoplasm  has  peculiar 
staining  affinities.  These  cells  sometimes  occur  in  chronic  inflam- 
mator}'  lesions  in  great  numbers,  scarcely  another  type  being  seen 
in  areas  of  considerable  size;  but  usually  they  are  mixed  with 
lymphocytes. 

From  whatever  source  they  are  derived,  these  newlv-formed  cells 
usually  develop  into  fibrous  tissue,  but  sometimes  produce  struc- 
tures more  or  less  resembling  normal  tissue.  Organization  is  there- 
fore a  marked  feature  of  chronic  inflammation.  The  actual  Results 
vary  according  to  the  part  of  the  body  aftccted,  and  also  with  the 
predisposing  diathetic  state.  In  simple  chronic  inflammation,  not 
due  to  tubercle  or  syphilis,  the  part  becomes  infiltrated  and  en- 
larged, and  if  this  persists,  fibrosis  or  sclerosis  follows.  Thus,  a  bone 
is  thickened  and  condensed  in  chronic  osteitis  (osleo-sclerosis),  whilst 
in  chronic  periostitis  a  new  subperiosteal  formation  of  bone  occurs. 
Glands  become  enlarged  and  indurated,  mainly  bv  hyperplasia  of 
the  connective  tissue,  whilst  if  the  skin  is  involved  it  either  becomes 
hypertrophied  and  thickened,  or  entirely  loses  its  characteristic 
structure,  being  converted  into  granulation  or  fibro-cicatricial  tissue, 
with  or  without  an  intervening  ulcerative  stage.  True  suppuration 
rarely  occurs,  although  certain  organisms  of  low  virulence  occa- 
sionally lead  to  its  development. 

Constitutional  symptoms  are  but  little  evident,  beyond  those 
dependent  on  the  diathetic  condition  to  which  the  local  phenomena 
are  due,  or  to  septic  changes  dc\-eloped  secondarily. 

The  Treatment  of  chronic  inflammation  is  usually  more  prolonged 
and  difficult  than  that  of  acute  cases,  because  of  the  constitutional 
dyscrasia  which  exists  so  frequently  behind  it. 

I.  The  cause  must  be  removed  whenever  practicable.  Dead  or 
diseased  bone  must  be  removed,  and  tuberculous  material  got  rid 
of  by  the  knife  or  sharp  spoon,  whilst  it  is  often  desiraljle  to  supple- 
ment this  by  swabbing  the  parts  over  with  hquelied  carbolic  acid. 


IN  FLA  MM  A  TION  45 

A  chronic  abscess  increases  the  action  of  the  original  irritant  through 
tlic  tension  engendered  by  its  presence,  and  hence  it  should  be  dealt 
with  as  early  as  possible. 

2.  Keep  the  part  at  rest.  This  is  just  as  much  an  essential  as  in  the 
treatment  of  acute  inflammation.  Joints  should  be  immobilized; 
the  spine  must  have  the  weight  taken  from  it  by  suitable  appliances, 
or,  better  still,  by  maintaining  the  recumbent  position;  secretory 
glands  are  not  actively  exercised,  and  the  organs  of  sense  are 
protected  from  irritation. 

3.  Counter-irritation  is  one  of  the  most  useful  forms  of  treatment 
for  chronic  inflammatory  conditions.  It  is  applied  in  many  different 
ways,  according  to  the  character  of  the  disease  and  the  part  involved. 
T\v\xs,  friction  with  the  hand,  or  with  stimulating  embrocations,  pro- 
duces a  hyperaemic  condition  of  the  skin,  and  promotes  local  activity 
in  the  superficial  parts  which  may  react  beneficially  on  deeper 
structures.  Scott's  dressing  may  be  similarly  employed;  it  consists 
in  wrapping  up  the  part  {e.g.,  a  joint)  in  strips  of  lint  covered  with 
ung.  hydrarg.  co.  (containing  over  10  per  cent,  of  camphor),  and 
then  encircling  it  fimily  with  soap  plaster,  spread  preferably  on 
chamois  leather.  Iodine  paint  is  another  useful  application,  whilst 
blisters  are  most  valuable  in  suitable  cases;  they  are  produced  by 
apphdng  a  cantharides  plaster,  or  by  painting  the  affected  area  with 
liquor  epispasticus  or  a  collodion  blistering  fluid.  The  moxa,  a 
wound  produced  by  burning  a  spirituous  solution  of  saltpetre  on  the 
skin;  the  issue,  the  maintenance  of  a  raw  surface,  however  pro- 
duced, by  the  constant  presence  of  some  irritant,  such  as  the  inser- 
tion of  a  bead,  or  the  use  of  savin  ointment  as  a  dressing;  and  the 
seton,  a  double  thread  knotted  at  each  end,  passed  for  some  distance 
under  the  skin,  and  drawn  from  end  to  end  daily — all  these  are  but 
little  used  now,  although  they  might  be  occasionally  employed  with 
advantage.  The  actual  cautery  is  the  most  severe  form  of  counter- 
irritant,  and  is  especially  useful  in  some  varieties  of  chronic  inflam- 
mation of  bones  and  joints.  The  exact  modus  operandi  of  counter- 
irritation  is  a  little  difficult  to  understand,  but  it  seems  likely  that 
in  some  cases  they  act  by  determining  hypersemia  of  the  part,  and 
in  others  through  some  influence  on  tlie  nervous  supply. 

4.  Pressure  is  an  important  element  in  the  treatment  of  chronic 
inflammatory  disorders,  and  probably  acts  by  bracing  up  vessels 
which  have  become  relaxed  and  atonic  from  the  prolonged  distension 
to  which  they  have  been  subjected.  It  also  favours  the  absorption 
of  inflammatory  exudations.  Firm  bandaging,  and  especially  the 
use  of  an  elastic  support,  are  the  usual  methods  of  application. 

5.  Artificial  Jiypercemia  (Bier's  treatment)  is  also  of  value  in 
chronic  inflammation,  and  perhaps  finds  most  useful  expression  in 
the  form  of  hot-air  baths,  or  various  electrical  methods  noted  else- 
where (Chapter  III.),  or  in  the  direction  of  massage  and  remedial 
exercises. 

Massage  is  also  a  valuable  means  of  treatment  of  manj-  chronic 
inflammatory  affections  and  other  lesions.     In  its  simplest  variety 


46  A   MANUAL  OF  SURGERY 

it  consists  in  rubbing  with  some  embrocation  or  liniment,  and  the 
stimulating  effect  of  the  latter  may  be  of  some  value  in  determining 
hyperaemia  of  the  part.  In  its  more  elaborate  forms  it  constitutes 
an  art  which  is  of  the  greatest  value,  and  concerning  which  lengthy 
text-books  have  been  written.  It  must  suffice  here  to  point  out  that 
the  chief  varieties  of  movement  are  known  as  effleurage,  petrissage, 
and  tapotement.  Effleurage  consists  in  plain  up  and  down  rubbing 
of  the  limb  with  the  flat  of  the  hand,  the  up  stroke  being  always 
firmer  than  the  down,  so  as  to  assist  in  the  return  of  the  blood  and 
lymph  from  the  part.  In  this  way  the  circulation  is  quickened,  and 
the  vital  activities  of  the  tissues  are  increased.  The  skin  should  be 
lubricated  with  oil,  vasehne,  or  some  stimulating  embrocation,  and 
the  rubbing,  at  first  light,  so  as  only  to  affect  the  skin  and  sub- 
cutaneous tissues,  should  gradually  become  firmer,  so  as  to  influence 
the  deep  structures.  Petrissage  consists  in  kneading  the  muscles  or 
other  tissues  between  the  finger-tips  and  the  palm  of  the  hand;  this 
necessarily  should  be  done  across  the  muscle  fibres,  working  from 
below  upwards,  and  is  especially  valuable  in  hastening  the  absorp- 
tion of  exudations.  In  Tapotement  a  series  of  blows  perpendicular 
to  the  surface  is  rapidly  delivered  by  the  ulnar  side  of  the  open  or 
clenched  hand;  the  circulation  in  the  parts  thus  struck  is  much 
quickened,  and  when  skilfully  done  no  pain  should  be  caused. 

As  a  modification  of  the  last  proceeding,  Vihro-massage  has  been 
recently  introduced,  in  which  rapidly  repeated  blows  of  the  affected 
region  give  rise  to  a  vibratory  effect,  which  is  often  of  the  greatest 
value.  Hand  vibrateurs  are  sold,  and  may  be  used  witli  advantage ; 
but  the  best  results  follow  from  the  employment  of  vibrateurs  worked 
by  electricity.  Rheumatic  inflammation  of  joints  and  fasciae,  such 
as  occurs  in  lumbago,  some  forms  of  sciatica,  and  other  neuralgic 
conditions,  are  often  much  benefited  by  this  procedure. 

6.  General  or  constitutional  treatment  must  be  adopted  to  meet 
the  specific  diatheses  which  are  commonly  associated  with  chronic 
inflammation,  e.g.,  mercury  or  iodide  of  potash  in  syphilis. 

7.  Finally,  if  the  condition  is  bacterial  in  origin,  and  the  organism 
can  be  isolated,  a  vaccine  may  be  prepared  and  treatment  carried 
out  on  the  lines  laid  down  on  p.  26.  Ordinary  surgical  methods 
should,  however,  not  be  neglected. 


CHAPTER  III. 

THE  USE  OF  HEAT,  LIGHT,  ELECTRICITY,  AND  RADIUM,  IN 

SURGERY. 

Within  recent  years  there  has  been  so  large  a  development  in  the 
application  of  various  physical  agencies  in  the  realm  of  medicine 
that  it  seems  desirable  to  discuss  their  powers  and  applications  in 
one  chapter,  and  we  propose  in  this  to  discuss  the  use  of  heat,  light, 
electricity,  and  radio-activity. 

Heat  (Therrao-Therapy). 

Apart  from  its  value  as  a  sterihzing  agent,  heat  is  of  use 
in  treatment  on  account  of  the  active  arterial  hyperemia  it  pro- 
duces, whereby  the  part  to  which  it  is  applied  is  bathed  with  fresh 
blood  containing  defensive  agents,  such  as  leucocytes,  opsonins, 
antitoxins,  and  other  antibodies,  by  means  of  which  the  activities 
of  harmful  bacteria  and  their  toxins  are  neutralized.  Moreover, 
when  applied  to  a  part  which  is  infiltrated  and  brawny,  it  assists 
in  the  restoration  of  a  healthy  circulation,  as  already  mentioned 
(p.  40),  by  softening  and  relaxing  the  tissues. 

Heat  is  employed  in  two  chief  forms — viz.,  as  moist  or  dry  heat — 
and  either  may  be  utilized  as  a  general  or  a  local  apphcation. 

I.  Moist  Heat  is  utilized  locally  in  the  form  of  the  fomentation 
or  poultice  (p.  40),  in  order  to  assist  an  inflamed  part  to  healthy 
repair.  It  matters  little  as  to  the  material  employed  when  the  skin 
is  unbroken,  so  long  as  it  retains  the  heat,  and,  with  this  object  in 
view,  a  linseed  poultice  is  often  preferable  to  a  fomentation.  When, 
however,  there  is  an  open  wound,  the  fomentation  or  poultice  must 
be  aseptic  at  least,  if  not  antiseptic,  in  character.  The  horacic  fomen- 
tation is  useful  in  these  cases,  consisting  of  boracic  acid  lint  wrung 
out  of  boiling  water,  or  a  carholized  poultice  may  be  employed.  This 
latter  consists  of  linseed-meal  mixed  with  boiling  lotion  (i  in  40),  and 
applied,  not  directly  to  the  wound,  but  over  a  few  layers  of  cyanide 
gauze.  A  hint  is  given  elsewhere  (p.  84)  as  to  the  dangers  [of  using 
carbolic  acid  in  chronic  infective  cases  with  amyloid  changes  in  the 
kidneys.    Occasionally  it  is  desirable  to  add  a  counter-irritating  effect 

47 


48  A    MANUAL  OF  SURGERY 

to  the  poultice,  so  as  to  inflncnce  unckTlyinf^^  inllaininatory  con- 
ditions— e.g.,  l)ronchitis,  etc. — and  then  a  suitalde  projjortion  of 
mustard  may  be  added  to  the  hnseed. 

Generally,  moist  heat  is  employed  in  the  form  of  a  hot  hath,  and, 
apart  from  its  cleansing  purposes,  this  is  most  valuable  in  many- 
conditions  and  for  varying  purposes — e.g.,  to  act  as  a  sedative  in 
cases  of  slight  shock  and  general  bruising  of  the  body  after  accidents; 
to  assist  in  the  painless  removal  of  extensive  dressings  which  might 
stick  to  raw  surfaces,  such  as  burns,  especially  in  children;  to  dilute 
toxins  and  help  in  their  removal  from  the  body,  as  in  extensive 
infected  wounds.  The  hot  bath  is  also  used  in  various  schemes  of 
hydro-therapy  in  order  to  act  upon  many  foci  of  chronic  inflam- 
matory trouble  ;  e.g.,  in  general  muscular  rheumatism  and  libro- 
sitis,  the  heat  of  the  bath  helps  to  relax  and  loosen  the  parts,  and 
therebv  to  restore  them  to  a  healthy  function.  Plain  water  may  be 
utilized  for  this  purpose,  or  hot  mud  or  peat  baths.  Active 
chemical  substances,  such  as  alkaline  carbonates,  sulphur,  etc., 
naturally  present  in  the  water,  or  artificially  added  to  it,  are  readily 
absorbed  through  the  skin,  and  influence  the  patient  considerably; 
natural  mineral  waters  are  probably  more  active  than  those  arti- 
ficially prepared. 

2.  Dry  Heat  may  also  be  made  to  serve  as  a  therapeutic  agent, 
generally  or  locally,  but  in  most  instances  introduces  a  new 
element — viz.,  diaphoresis  as  well  as  superficial  hyperaemia.  It  is 
especially  valuable  in  chronic  cases,  and,  of  course,  higher  tempera- 
tures can  be  borne  without  discomfort  than  in  the  preceding  variety. 

Generally,  various  methods  of  hot  air  or  vapour  baths  are  avail- 
able. Turkish  baths  consist  in  the  exposure  of  the  unclothed  body 
to  dry  heat  at  varying  temperatures  (up  to  250°  F.  or  more)  for 
twenty  or  thirty  minutes;  by  this  means  an  abundant  perspiration 
is  induced,  and  thereby  toxins  are  eliminated.  It  is  followed  by 
massage,  douching,  and  rest  for  an  hour  or  so,  to  allow  the  surface 
of  the  body  to  cool.  A  Russian  bath  is  very  similar,  but  the  air  is 
full  of  the  vapour  of  steam,  and  therefore  cannot  range  so  high ; 
perspiration  is  induced  more  rapidly,  and  the  bath  is  of  shorter 
duration.  In  both  of  these  agents  the  object  is  to  induce  the  rapid 
elimination  of  toxins  and  other  poisons,  and  at  the  same  time 
to  assist  in  maintaining  the  free  mobility  and  function  of  the  various 
parts  of  the  body  by  massage.  Either  may  be  employed  advan- 
tageously as  a  routine  preventive  of  gout  or  rheumatism,  especially 
by  those  who  are  unable  to  secure  suitable  exercise;  or  they  may  be 
utilized  as  a  means  of  cure. 

In  patients  who  are  incapable  of  leaving  their  beds  or  homes — 
e.g.,  in  cases  of  uraemia,  or  of  very  bad  chronic  rheumatism — hot-air 
baths  may  be  given  by  covering  the  patient  with  a  large  cradle 
over  which  is  placed  a  blanket  or  two,  and  under  it,  in  such  a  way 
as  not  to  endanger  him,  a  lighted  spirit-lamp  or  a  suital^le  number  of 
electric  lights  of  sufficient  power.  Occasionally,  however,  wet 
packs  have  to  be  relied  on  in  such  cases. 


THE   USE  OF  HEAT.  LIGHT,  ELECTRICITY.  AND  RADIUM 


49 


Locally,  there  are  many  metliuds  of  applying  dry  heat  to  a  part, 
of  which  the  following  are  the  chief: 

1.  Hot-air  baths,  such  as  the  Shefheld-Tallerman  apparatus,  etc., 
consist  essentially  of  a  box  or  chamber  with  walls  composed  of  felt 
or  asbestos,  and  arranged  so  that  the  contained  air  can  be  heated  to 
a  required  temperature  by  an  oil  or  gas  burner.  The  affected  limb 
is  introduced  into  the  chamber  through  a  window  with  a  closely- 
htting  curtain,  and  carefully  suspended  to  prevent  the  skin  touching 
the  hot  walls,  thereby  avoiding  burns.  Recently  air  baths  heated 
by  electric  currents  passing  through  metallic  resistances  have  also 
been  used. 

2.  Radiant-heat  baths  have  electric  incandescent  lamps  as  their 
heating  agents.  The  therapeutic  value  of  these  baths  depends 
not  only  on  the  hot  air  evolved,  but  also,  and  probably  mainly, 
on  certain  light  rays  which  have  no  heating  power.  A  bath  con- 
sists of  a  cabinet  containing  a  number  of  lamps,  which  may  have 
various- coloured  globes,  so  that,  by  absorbing  rays  corresponding 
to  certain  portions  of  the  spectrum,  the  quality  of  the  hght  may  be 
varied.  They  may  be  used  for  the  whole  body  or  for  individual 
limbs. 

3.  Diathermy,  or  thermo-penetration,  is  somewhat  akin  to  the 
high-frequency  current,  but  has  a  sustained  instead  of  an  inter- 
rupted oscillation.  A  current  of  high  potential  is  passed  through 
the  affected  part,  which  offers  some  resistance  to  its  passage,  and 
thereby  its  temperature  is  raised  several  degrees.  The  action  of 
this  agent,  therefore,  differs  from  hot-air  baths,  etc.,  in  that  the 
internal  temperature  of  the  body  is  raised  rather  than  that  of  the 
external  air,  and  hence  the  therapeutic  results  are  increased. 

Applications.  —  Hot-air  and  radiant-heat  baths  are  chiefly  em- 
ployed to  promote  the  absorption  of  chronic  inflammatory  exudates, 
and  for  such  conditions  as  chronic  arthritis,  adhesions,  neuralgia, 
lumbago,  and  sciatica.  They  are  also  used  to  aid  elimination  by 
determining  diaphoresis  in  general  toxic  conditions,  such  as  gout, 
Bright's  disease,  and  obesity.  Diathermy  is  useful  for  chronic 
inflammation,  osteo-arthritis,  rheumatic  and  gouty  librositis,  etc. 

Heat  is  also  of  great  value  in  preventing  or  counteracting  shock. 
The  importance  of  keeping  a  patient  warm  during  a  lengthy  opera- 
tion is  emphasized  again  and  again,  and  to  this  end  operating-rooms 
are  now  maintained  at  a  high  temperature  (70°  to  80°  F.),  and  the 
patient  is  carefully  clothed.  This  is  a  much  better  method  to 
employ  than  to  heat  the  table  on  which  he  Hes,  a  procedure  which 
has  before  now  resulted  in  serious  burns  to  the  back  or  buttocks. 
To  combat  the  shock  which  follows  operations  or  serious  injuries, 
such  as  bad  burns,  especially  in  children,  when  the  patient's  tem- 
perature often  falls  as  low  as  95°  or  96°  F.,  it  is  important  to  surround 
the  body  with  air  at  a  higher  temperature;  and  this  can  be  effected 
by  covering  him  with  a  cradle  over  which  a  blanket  is  placed, 
merely  leaving  the  head  uncovered,  and  within  which  is  placed 
an  electric  lamp  of  50  or  100  candle-power,  so  that  it  cannot  touch 

4 


50  A   MANUAL  01-  SURGERY 

or  be  touched  by  the  i);itieiit's  hiiibs.     The  result  of  this  liut-air 
bath  is  often  most  valuable. 

Cauteries  are  employed  in  three  forms: 

1.  The  actual  cautery,  which  consists  of  solid  irons  of  various 
shapes,  and  these  are  lieated  in  a  suitable  tlame  to  a  temperature 
depending  on  the  use  for  which  the}^  are  required. 

3.  The  galvano  -  cautery  consists  in  a  loop  of  platinum  wire 
mounted  on  an  insulated  liandle,  and  connected  with  the  ter- 
minals of  a  battery  of  sufficient  strength.  The  handle  is  fitted  with 
a  key,  so  that  the  current  may  be  opened  or  closed  at  will.  During 
the  passage  of  a  sufficiently  strong  current  (5  to  6  amperes  for 
small  loops)  the  platinum  becomes  red  or  white  hot. 

3.  Paquelin's  thermo-cautcry  depends  on  the  principle  that,  when 
the  vapour  of  benzoline  is  driven  over  heated  platinum,  its  com- 
bustion generates  sufficient  heat  to  maintain  or  increase  the  tem- 
perature of  the  platinum.  By  means  of  a  rubber  bellows,  air  is 
driven  over  the  surface  of  benzoline  contained  in  a  bottle,  and 
then,  saturated  with  its  vapour,  through  a  hollow  handle  into  a 
platinum  point.  The  platinum  point  is  previously  heated  to  a 
dull  redness  in  a  spirit  ffame,  and  on  pumping  the  mixture  through 
the  apparatus  it  can  be  kept  at  a  red  or  white  heat. 

Applications. — i.  .4s  a  counter-irritant,  when  the  skin  over  an 
affected  part,  usually  a  joint  or  the  spine,  is  seared  lightly. 

2.  As  a  hcemosfatic  or  bloodless  knife.  By  this  means  vascular 
tissues  can  be  divided  without  loss  of  blood,  and  at  the  same  time 
the  tissues  involved  are  kept  or  rendered  aseptic.  Thus,  polypi 
or  piles  can  be  removed  in  a  bloodless  fashion,  and  the  stimip  is 
left  sterile.  It  is  also  employed  to  divide  the  intestine  between 
clamps  without  soiling  the  peritoneum.  It  is  well  to  remember 
that  a  dull  red  heat  is  the  most  efficacious,  since  thereby  the  vessels 
are  seared  and  effectively  closed:  a  cautery  at  white  heat  cuts 
almost  as  cleanly  as  a  knife.  The  possibility  of  secondary  haemor- 
rhage when  the  slough  separates  must  not,  however,  be  forgotten. 

Light. 

Light  as  a  curative  agent,  apart  from  its  thermal  effects,  is 
chiefly  employed  in  the  form  of  (i)  the  arc  light,  (2)  Finsen  and 
mercury  vapour  lamps,  and  (3)  sun-baths. 

I.  The  projection  of  the  light  from  an  arc  lamp  by  means  of  a 
suitable  concave  mirror  may  be  employed  as  a  general  bath,  or 
locally  to  diseased  areas.  The  heat  evolved  by  the  lamp  can  be 
projected  to  some  depth  beneath  the  surface,  and  care  must  be 
taken  not  to  burn  the  patient  by  focussing  the  rays  on  the  skin. 
This  method  differs  from  radiant  heat  in  that  its  light  contains 
abundantly  the  chemical  rays  of  the  violet  end  of  the  spectrum, 
whilst  that  of  incandescent  lamps  contains  mainly  the  heat  rays 
of  the  red  end.  This  method  is  utilized  for  conditions  similar  to 
those  for  which  radiant  heat  is  employed,  but  more  especially  in 


THE  USE  OF  HEAT,  LICHl'.  ELECTRICITY,   AND  RADIUM     51 

cases  where  a  localized  application  is  required — e.g.,  in  lumbago, 
rheumatic  torticollis,  etc. 

2.  The  Finsen  and  mercury  vapour  lamps  arc  methods  of  ex- 
posing small  areas  of  disease  to  large  doses  of  light  containing  an 
abundance  of  chemically  active  rays.  A  Finsen  lamp  consists  of 
a  powerful  arc,  the  rays  of  which  are  collected  and  focussed  by 
quartz  lenses  on  a  small  area  of  skin,  which  is  cooled  and  rendered 
auccmic  by  a  quartz  compressor,  through  which  a  stream  of  cold 
water  flows.  Compression  aids  the  penetration  of  the  rays  by 
rendering  the  part  bloodless,  the  blood  having  the  power  of  absorb- 
ing the  violet  rays.  The  mercury  vapour  (Cooper  Hewitt)  lamp 
consists  of  a  glass  tube  exhausted  of  air,  and  containing  mercury 
and  mercury  vapour.  The  passage  of  a  suitable  current  through 
this  produces  a  light  rich  in  ultra-violet  rays.  These  lamps  are 
chiefly  used  in  the  treatment  of  lupus,  although  better  results  are 
often  obtained  bj^  the  X  rays. 

3.  Sun-baths  need  no  special  comment,  but  there  is  no  question 
as  to  their  value  in  cases  of  anaemia  and  malnutrition,  especially 
since  they  involve  exposure  of  the  body  to  an  abundance  of  fresh  air. 

Electricity. 

Electricity,  apart  from  its  thermogenic  power,  has  many  im- 
portant applications  in  the  domains  both  of  diagnosis  and 
treatment. 

I.  As  a  Diagnostic  Agent. 

(i)  By  means  of  the  faradic  and  galvanic  currents  the  electrical 
response  of  muscles  and  nerves  can  be  investigated,  and  valuable 
information  obtained  as  to  the  condition  of  the  nervous  and  mus- 
cular sj^stems. 

A  muscle  with  a  normal  nerve-supply  contracts  under  stimula- 
tion from  both  the  faradic  and  galvanic  currents  in  sufficient 
strength,  the  contraction  being  most  readily  obtained  when  the 
electrode  is  applied  over  a  definite  skin  area,  varying  for  every 
muscle,  and  called  the  '  motor  point.'  With  the  galvanic  current 
the  contraction  obtained,  when  the  current  is  closed,  is  greater  than 
that  produced  when  the  current  is  opened.  Again,  the  contraction 
elicited  when  the  electrode  applied  to  the  muscle  is  attached  to 
the  kathode  of  the  battery  is  greater  than  that  resulting  when  the 
anodal  electrode  is  used.  This  fact  is  expressed  in  the  formula 
— K.C.C.>A.C.C. 

In  the  muscular  degeneration  which  follows  nerve  injuries, 
neuritis,  anterior  polio-myelitis,  etc.,  these  reactions  are  modified, 
and  constitute  the  reaction  of  degeneration  (R.D.).  The  response 
of  the  muscle  and  nerve  to  the  faradic  current  quickly  disappears, 
and  with  the  galvanic  current  the  anodal  closure  contraction  be- 
comes greater  than  the  kathodal  (A.C.C.  >K.C.C.).  A  greater 
strength  of  current  will  be  required  than  in  the  sound  side  of  the 
body,  and  the  response  will  be  sluggish,  and  not  brisk.    As  long  as 


52  A   MANUAL  01'  SURGERY 

the  R.D.  persists,  however,  the  j)()ssil)ility  of  repair  in  tlii'  muscle 
remains,  should  the  centres  and  conducting  apparatus  be  restored. 
This  persistence  of  the  R.U.  may  exist  h)r  years.  When  once  the 
K.D.  is  lost,  all  hope  of  repair  is  gone.  In  spastic  conditions  the 
electrical  irritability  of  muscles  and  nerves  is  often  increased. 

(2)  Radiography. — When  a  current  from  the  secondary  circuit 
of  an  induction  coil  is  passed  between  two  suitable  metal  elec- 
trodes'Jn  a  vacuum  tube  of  a  high  degree  of  exhaustion  (Crookes 
tube),  a  stream  of  rays,  called  '  kathodal  'or  '  /3  rays,'  which 
consist  of  negatively  charged  electrons,  is  generated  from  the 
kathode.  If  the  kathode  is  concave,  and  the  rays  are  thereby  made 
to  converge  to  a  focus  on  a  third  electrode  called  the  '  target,'  or 
'  antikathode,'  from  their  impact  thereon  results  a  production 
of  rays  of  a  very  special  character,  known  as  the  '  X  rays  of 
Rontgen.'  X  rays  have  the  power  of  penetrating  most  opaque 
bodies  in  varying  degrees,  and  in  general  terms  substances  are 
opaque  to  X  rays  in  proportion  to  the  atomic  weights  of  their  con- 
stituent elements.  X  rays  also  have  the  power  of  acting  upon 
sensitive  silver  salts  in  the  same  way  as  light,  so  that  if  a  structure, 
such  as  a  limb,  be  interposed  between  the  source  of  the  rays  and  a 
sensitive  photographic  plate,  the  rays  will  readily  penetrate  the 
softer  parts;  but  their  passage  will  be  hindered  by  the  more  resistant 
structures,  such  as  bones,  which  will  thereby  throw  a  shadow  on 
the  plate.  Radiographs  or  skiagraphs  are  the  shadow-pictures 
produced  in  this  manner.  The  greater  the  vacuum  in  the  tube, 
the  greater  will  be  the  strength  of  current  needed  to  traverse  it, 
and  the  greater  the  penetrating  power  of  the  X  rays  produced. 
These  are  known  as  '  hard  tubes.'  Soft  tubes  are  those  in  which 
less  strength  of  current  is  required  to  produce  the  rays,  which  have 
a  less  penetrating  effect,  and  therefore  are  more  useful  in  per- 
mitting a  greater  differentiation  of  shadow. 

Barium  platino-cyanide  and  certain  uranium  salts  are  rendered 
fluorescent  by  the  passage  of  X  rays,  so  that,  if  a  screen  covered 
with  one  of  these  substances  is  held  distal  to  the  limb  or  part  to  be 
examined,  a  shadow  similar  to  a  radiograph  is  produced,  and  can 
be  seen.  The  radiographic  screen  is  of  great  value  in  many  con- 
ditions as  a  means  of  rapid  diagnosis,  and  sometimes  gives  better 
results  than  the  radiograph,  especially  when  absolute  immobility 
cannot  be  obtained.  Thus  the  movements  of  the  heart,  of  the 
diaphragm,  the  pulsations  of  an  aortic  aneurism,  etc.,  can  be 
better  examined  by  the  screen  than  by  taking  a  radiograph.  As  an 
illustration  of  this  may  be  mentioned  a  case  where  a  silver  probe 
had  slipped  down  through  a  tracheotomy  wound  into  a  bronchus. 
An  attempt  to  photograph  it  failed  completely,  but  on  examina- 
tion with  the  screen  the  probe  was  seen  lying  transversely  in  the 
left  bronchus,  moving  up  and  down  at  each  beat  of  the  heart. 

Great  care  is  necesseiry  in  the  interpretation  of  radiographic 
pictures,  as,  the  rays  being  divergent,  some  distortion  of  the  re- 
sulting shadows  occurs,  according  to  the  distance  of  the  object  from 


THE   USE  OE  HEAT,  LIGHT.   ELECTRTCTTY.  AND  RADIUM    53 

the  source,  and  tlie  exact  an,e;le  at  which  the  rays  impinge  upon 
it.  To  avoid  this  deception,  stereoscopic  photographs,  or  views 
in  two  directions  at  right  angles  to  one  another,  are  necessary. 
Moreover,  the  results  vary  much,  according  to  whether  the  radio- 
graph is  taken  from  before  or  behind.  Thus,  if  a  shoulder  be 
radiographed  from  behind,  with  the  plate  in  front,  the  details  of 
the  coracoid  process  and  of  the  head  of  the  humerus  will  be  most 
clearly  defined;  whereas  if  the  plate  is  posterior,  and  the  picture 
is  taken  from  the  front,  the  acromion  and  spine  of  the  scapula  are 
most  sharply  represented.  In  practice  the  outlines  of  bones  are 
clearly  seen;  cartilage  and  callus  are  more  transparent;  muscles 
and  tendons  are  sometimes  visible  if  a  very  soft  tube  is  employed. 
Calculi  vary  according  to  their  composition,  oxalates  being  most- 
opaque  and  uric  acid  stones  most  transparent.  Gallstones  are 
very  seldom  impervious.  By  the  use  of  soft  tubes  the  outlines  of 
viscera,  such  as  the  liver  and  kidneys,  may  often  be  obtained. 

3.  As  a  Therapeutic  Agent  electricity  is  employed  in  many  ways : 

(i)  The  galvanic  and  faradic  currents  are  employed,  both  generally 
and  locally,  for  their  stimulating  action.  Under  the  former  head- 
ing one  would  include  the  use  of  the  electric  hath,  in  which  a  patient 
lies  in  water  to  which  a  small  addition  of  salt  is  made,  and 
through  which  a  galvanic  current  is  passed.  The  effect  of  this  is 
to  increase  the  superficial  circulation  and  produce  cutaneous 
hyperasmia.  It  is  often  useful  in  diffuse  rheumatic  and  gouty 
fibrositis,  as  also  in  conditions  in  which  the  general  muscular  and 
nervous  tone  of  the  bodj^  has  been  lowered.  It  is  of  considerable 
value  in  the  treatment  of  conditions  depending  on  arterial  spasm, 
such  as  Raynaud's  disease.  Care  must  be  taken  only  to  increase 
or  decrease  the  strength  of  the  current  gradually,  otherwise  the 
patient  may  experience  an  unpleasant  shock. 

Locally  the  galvanic  and  faradic  currents  find  their  chief  em- 
plo3niient  in  cases  of  muscular  paralysis,  in  order  to  prevent  de- 
generation of  muscles  where  the  nervous  control  has  been  lost,  as  by 
division  of  motor  nerves,  and  also  to  maintain  the  conductivity  of 
the  nerves  where  this  has  been  impaired.  The  faradic  current  is 
probably  more  useful  in  this  direction  than  the  galvanic. 

(2)  Electrolysis  is  used  chiefly  for  the  destruction  of  superfluous 
hairs,  moles,  etc.,  the  removal  of  naevi,  and  the  coagulation  of  blood 
in  aneurisms.  The  passage  of  a  current  of  sufficient  strength 
between  metallic  poles  actually  inserted  into  the  tissues  sets  up  an 
electrolytic  action,  and  coagulation  of  the  blood  or  local  destruc- 
tion of  hair  folHcles,  etc.,  results.  The  clot  formation  is  most 
marked  at  the  positive  pole ;  hence  it  is  often  unnecessary  actually 
to  insert  the  negative  needle  into  the  tissues,  but  to  use  an  ordinary 
flat  pad,  moistened  with  salt  solution  and  apphed  to  the  skin 
away  from  the  part  to  be  treated.  The  use  of  the  negative  pole 
is  more  likely  to  produce  scarring,  since  a  caustic  alkaline  com- 
pound is  formed  around  it,  and  this  may  lead  to  sloughing  of  the 
tissues;  the  quality  of  the  clot  produced,  moreover,  is  loose  and 


.54  A    MANUAL  01-   .S f ^ AY; /;/.' V 

spongy.  In  larf^c  n.x-vi,  etc.,  sevcriil  needles  attached  to  tiie  ])ositivc 
pole  are  used  with  advantat^e,  and  should  be  made  of  ])latinum  or 
steel,  insulated  by  shellac  or  sealinf^-wax  up  to  the  point  of  entry 
through  the  skin,  in  order  to  protect  it  from  the  electric  current; 
ineffective  insulation  results  in  destruction  of  the  skin.  The 
strength  of  the  current  employed  varies  according  to  whether  both 
poles  are  introduced,  or  only  the  positive.  Under  the  latter  cir- 
cumstances a  current  equal  to  about  25  to  75  milliamperes  should 
be  applied  for  ten  to  fifteen  minutes,  care  being  taken  to  increase 
its  strength  gradually  to  the  maximum,  and  similarly  to  decrease 
it.  An  anesthetic  is  needed,  and  the  immediate  effect  should  be 
to  make  the  mass  feel  hard  and  firm  by  the  coagulation  of  the 
blood.  Organization  of  the  thrombus  leads  to  obliteration  of  the 
vascular  spaces  and  the  disappearance  of  the  tumour.  Two  or 
more  sittings  are  usually  necessary  before  the  growth  is  effectively 
treated.  Oif  course,  some  scarring  is  almost  always  left,  and 
hence  it  is  wise  not  to  do  too  much  at  one  sitting,  and  to  make  the 
intervals  sufficiently  long  to  allow  of  effective  cicatrization. 

(3)  Static  electricity  generated  by  a  machine  such  as  Wimshurst's 
or  Holtz's  is  used  as  a  bath  or  brush  discharge  in  the  treatment  of 
neurasthenia,  general  or  nervous  debihty,  neuralgia,  and  in  certain 
chronic  skin  diseases,  such  as  psoriasis,  lupus,  etc.  It  is  of  use 
rather  as  a  general  tonic  than  as  having  any  specific  effect.  The 
high-frequency  current  is  an  induced  current  set  up  in  a  secondary 
circuit  by  a  modified  induction  coil,  in  which  Leyden  jars  take  the 
place  of  a  voltaic  cell.  It  is  said  to  increase  metabolism  and  heat 
production,  and  is  recommended  for  constitutional  diseases,  such 
as  gout,  diabetes,  and  rheumatism,  etc. 

(4)  Ionic  medication,  or  cataphoresis,  consists  in  the  introduction 
of  drugs  directly  into  the  tissues  of  the  bodv  by  means  of  an  electric 
current.  It  is  based  on  the  principle  that  the  passage  of  a  current 
through  a  solution  of  a  salt  is  accompanied  by  movement  of  the 
constituent  ions — i.e.,  of  the  atoms  or  molecules  which  are  elec- 
trically charged.  The  positively  charged  ions  (kations),  which 
include  those  of  all  metals,  alkalies,  and  alkaloids,  are  attracted  to 
the  negative  pole,  while  the  negatively  charged  ions  (anions),  such 
as  those  of  chlorine,  iodine,  the  acids,  and  hydroxyl,  are  attracted 
to  the  positive  pole.  If  the  human  body  is  interposed  in  the 
current,  instead  of  a  solution  of  salt  in  a  vessel,  and  lint  pads,  soaked 
in  a  solution  of  the  salt  or  drug,  are  placed  between  the  skin  and  the 
electrodes,  kations  at  the  positive  pole  and  anions  at  the  negative 
pole  will  enter  the  tissues  and  be  disseminated  in  them  for  a  variable 
distance,  probably  from  i  to  10  millimetres.  The  pads  should  be 
thick  and  of  large  area,  and  the  strength  of  current  2  to  3  milli- 
amperes per  square  centimetre  of  area  of  the  pads. 

This  method  is  chiefly  used  in  the  treatment  of  chronic  inflamma- 
tion of  joints  and  other  tissues,  but  good  results  have  also 
been  obtained  in  chronic  ulcers,  rodent  ulcers,  lupus,  warts,  etc. 
Zinc,   copper,    magnesium,   iodides,  and  salicylates,  are  the  drugs 


////■;   //,S7:   OF  Iffi.l  r,   I.IGHT,   ELECTRICITY,  AND  RADIUM     55 

tiiicfly  used;  but  qniniuc,  cocaine,  and  adrenalin,  have  also  been 
employed. 

(5)  X  rays  are  used  therapeutically  in  the  treatment  of  cancer, 
rodent  ulcer,  and  certain  skin  conditions,  such  as  ringworm,  to 
produce  epilation;  keloid  scars;  and  also  in  general  conchtions,  such 
as  exophthalmic  goitre,  lymphadenoma,  the  leukaemias,  etc.  The 
effects  will  be  noted  under  the  ensuing  section,  deahng  with 
radium. 

Radium  and  Radio-Therapy. 

Radium,  discovered  by  Madame  Curie  in  i8g8,  is  a  constituent 
of  pitch-blende.  It  is  mainly  sold  in  the  form  of  radium  bromide, 
a  hard,  yellowish,  crystalhne  substance,  and  is  the  chief  of  a  group 
of  elements  which  have  a  radio-active  property — that  is  to  say, 
they  can  influence  a  photographic  plate  through  an  opaque  layer 
of  black  paper.  Radium  emits  three  types  of  rays,  named  «,  13, 
and  7,  of  which  the  7  rays  are  the  most  penetrative  and  of  the 
greatest  therapeutic  value. 

For  application,  the  salts  of  radium  are  contained  in  hermetically 
sealed  tubes  of  glass,  aluminium,  silver,  lead,  or  platinum,  each  tube 
containing  from  5  to  100  milligrammes,  or  are  spread  on  flat  metal 
plates  in  definite  amounts  per  square  centimetre  of  surface.  These 
are  covered  by  lead,  aluminium,  or  silver  filters  of  variable  thick- 
ness, in  order  to  exclude  the  a  and  (3  rays,  so  that  the  y  rays  may  be 
alone  utilized.  It  is  also  possible  to  charge  water  and  other  fluids 
with  emanations  (probably  gas  given  off  from  the  radium)  which 
render  them  radio-active,  and  enable  them  to  exercise  to  a  limited 
degree  similar  powers.  It  is  possible  that  the  therapeutic  value 
of  certain  mineral  waters — e.g.,  Bath — is  in  part  dependent  on  the 
possession  of  radio-active  properties. 

Radium  may  be  applied  directly  to  lesions  of  the  skin  or  mucous 
membranes,  or  it  may  be  possible  to  influence  deeper  growths 
through  healthy  integument  or  mucous  membrane ;  but  in  the  latter 
instance  it  is  better,  if  possible,  to  implant  the  radium  for  a  time 
into  the  midst  of  the  growth.  In  particular,  it  is  of  value  to  expose 
to  the  influences  of  the  radium  any  cavity  from  which  a  surgeon 
is  doubtful  as  to  the  complete  removal  of  a  malignant  growth. 

It  is  impossible  at  present  to  write  dogmatically  on  the  power  of 
radium  or  to  discuss  its  method  of  action;  but  certain  facts  are 
agreed  on:  (i)  That  it  has  a  power  of  influencing  the  cells  of  living 
tissues  is  undoubted.  If  a  series  of  suitable  growing  plants  be 
exposed  to  radium  at  various  distances,  it  will  be  found  that  it  is 
possible  to  kill  some  that  are  close  to  it  by  exposures  which  stimu- 
late others  to  richer  and  fuller  development,  whilst  at  intermediate 
distances  growth  is  hindered.  (2)  This  influence  lies  particularly 
in  the  direction  of  checking  the  growth  of  actively  multiplying 
cells,  and  perhaps  of  aiding  the  development  of  the  m.ore  stable 
elements.  Hence  the  actual  growing  cells  of  a  cancer  or  sarcoma 
are  likely  to  be  affected  destructively  by  exposure  to  radium. 


56  A    MANUAL  OF  SIJ RCIIRY 

whereas  the  connective  tissues  of  tlie  part  may  by  suitable  dosage 
ho.  stimulated  to  reparative  activity.  {^)  The  (luestion  of  dosage 
and  length  of  exposure  is  therefore  of  tiie  gravest  importance, 
jind  it  is  also  one  on  which  opinions  differ  considerably.  Probably 
it  will  be  wise  at  present  to  work  with  moderate  doses,  and  not  to 
employ  them  for  too  long  a  time.  (4)  What  has  been  written  con- 
cerning radium  is  similarly  true  as  regards  X  rays;  but,  of  course, 
the  great  distinction  between  the  two  procedures  is  the  ready 
applicability  of  radium  to  the  surface  and  into  the  substance  of 
tumours,  whereas  X  rays  can  only  be  applied  from  a  distance. 

The  results  of  radium  and  X-ray  treatment  vary  considerably, 
and  at  present,  out  of  the  mass  of  evidence  accumulating  on  every 
hand,  it  is  only  possible  to  draw  certain  broad  conclusions : 

1.  Superficial  growths  of  various  kinds  are  effectively  and 
satisfactorily  influenced  by  this  means.  Warts,  ncevi,  keloidal 
growths,  and  similar  non-malignant  developments,  are  often  cured 
by  one  exposure  or  application;  laryngeal  warts  are  similarly 
affected.  Rodent  ulcer  is  readily  cured  by  either  radium  or  X  rays, 
and  there  is  really  nothing  to  choose  between  the  two.  It  is  un- 
usual for  operative  measures  to  be  required  except  when  the  disease 
has  spread  deeply  and  affected  bone  or  cartilage.  In  these  cases 
it  is  probable  that  repeated  exposures  to  radium  or  X  rays  have 
depressed  the  vitality  of  the  parts  to  such  an  extent  as  to  influence 
the  result  even  of  operative  treatment.  Cutaneous  epithelioma 
may  be  affected  beneficially,  but  the  results  are  not  so  good  as  in 
rodent  ulcer,  and  it  is  quite  probable  that  excision  should  be 
undertaken  in  the  first  place  where  possible,  and  radium  treatment 
be  employed  subsequently.  Cancer  of  mucous  membranes  is,  on 
the  whole,  less  favourable  to  treat  than  that  of  the  skin. 

2.  Cancer  of  deeper  organs  is  variously  influenced  by  radio- 
therapy. There  is  as  yet  no  justification  for  replacing  operative 
treatment  of  cancer  of  the  breast  by  this  means.  It  is,  of  course, 
desirable  to  follow  operation  by  radio-therapy,  in  the  hope  of  de- 
stroying any  living  cells  that  may  remain.  Inoperable  recurrences 
may  also  be  cured  by  this  means;  and  even  large,  hopeless  growths 
involving  the  whole  breast  may  be  improved  by  burying  radium 
in  its  substance  for  twenty-four  to  forty-eight  hours,  introducing 
it  at  intervals  into  different  parts  of  the  organ.  Pain  is  usually 
reheved  thereby,  ulceration  may  be  healed,  and  discharge 
diminished. 

Cancer  of  the  mouth,  tongue,  and  jaws,  may  be  improved  locally 
to  some  extent,  but  recurrence  in  the  glands  and  death  are  only 
too  hkely  to  end  the  chapter.  If  the  glands  have  been  effectively 
removed,  local  recurrences  may  be  hopefully  attacked.  In  the 
(Esophagus,  a  cancerous  stricture  may  be  o[)ened  up  by  introducing 
into  it  a  tube  of  radium;  but,  although  the  power  of  deglutition 
may  be  thereby  restored  or  retained  for  a  longer  time  than  other- 
wise, a  cure  is  not  in  the  least  likely.  Cancer  of  the  stomach  or 
intestine  can  rarely  be  treated  by  radium,  as  destruction  of  the 


THE  USE  OF  HEAT,  LIGHT,  ELECTRICITY,  AND  RADIUM    57 

growth  may  involve  serious  consequences,  such  as  perforation  of 
the  bowel,  thrombosis  of  important  vessels,  or  grave  haemorrhage. 
Some  cases  of  rectal  carcinoma  may  be  treated  thereby ;  but  perma- 
nent improvement  can  scarcely  be  expected,  although  some  relief 
of  pain  may  be  experienced.  Similar  remarks  apply  to  cancer  of 
the  bladder.  Uterine  carcinoma  is  undoubtedly  influenced  most 
beneficially  by  radium;  haemorrhage  is  arrested;  the  discharge  is 
diminished  and  rendered  inoffensive ;  ulceration  is  healed  and  pain 
relieved.  Often  the  peri-uterine  thickening  and  infiltration  are 
absorbed  to  such  an  extent  as  to  render  operable  a  case  previously 
considered  hopeless.  Naturally,  the  ultimate  prognosis  depends 
on  the  extent  of  glandular  involvement,  and  hence,  where  prac- 
ticable, operation  is  still  desirable. 

3.  Sarcomata  are  amenable  to  radio-therapy  to  an  even  greater 
extent  than  cancers.  It  is  desirable  to  implant  the  radium  into 
their  substance,  and  cessation  of  growth  often  follows.  Periosteal 
or  round-celled  sarcomata  of  the  long  bones  may  be  thus  treated, 
and  thereby  amputation  avoided ;  but,  of.  course,  the  ultimate  prog- 
nosis depends  on  whether  or  not  secondary  deposits  have  occurred 
in  the  viscera.  Myeloma  of  bones  can  also  be  treated  by  this 
means,  with  or  without  erasion  of  the  growth,  and  thereby  in  early 
cases  amputation  or  excision  of  an  important  bone  may  be 
avoided. 

4.  Many  other  growths  are  capable  of  being  influenced  by  radio- 
therapy— e.g.,  lymphadenoma,  tuberculous  lymphadenitis,  etc. 
These  will  be  alluded  to  elsewhere. 

It  is  important  to  remember  that  prolonged  exposure  to  X  rays 
produces  erythematous  burns  which  frequently  lead  to  dermatitis, 
with  chronic  ulceration  of  the  skin.  In  some  cases  this  progresses 
and  takes  on  a  malignant  type  (X-ray  cancer) ;  this  has  been  seen 
most  frequently  on  the  fingers  and  hands  of  the  early  workers  in 
X  rays,  before  the  necessity  of  strict  protection  of  the  operator  was 
realized. 


CHAPTER  IV. 

EXAMINATION  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE. 

Although  an  examination  of  the  condition  of  the  blood  is  frequently 
of  great  importance  to  the  surgeon,  a  mere  outline  of  the  chief  facts 
is  all  that  can  here  be  attempted. 

The  red  blood  corpuscles  average  about  5,000,000  to  the  cubic 
millimetre  in  men  and  about  4,500,000  in  women,  and  are  readily 
counted  by  means  of  the  Thoma-Zeiss  h?emocytometer  or  other 
similar  instrument.  The  chief  surgical  value  of  such  investigations 
arises  in  connection  with  haemorrhage,  for  they  enable  us  to  deter- 
mine the  amount  of  blood  lost  at  a  surgical  operation  or  as  the  result 
of  a  wound,  and  to  trace  the  process  of  recovery.  It  is  usually 
advisable  to  supplement  the  counting  of  the  corpuscles  by  estimating 
the  amount  of  haemoglobin  present  by  means  of  Haldane's  or  some 
other  h?emoglobinometer,  the  resvilt  being  expressed  as  a  percentage 
of  the  normal  amount.  Thus,  blood  containing  half  the  amount 
that  should  exist  in  a  given  bulk  in  a  normal  man  is  said  to  contain 
50  per  cent,  of  haemoglobin.  It  is  also  convenient  to  calculate  the 
'  corpuscular  richness  '  or  '  colour-index,'  which  is  done  by  di\iding 
the  percentage  of  haemoglobin  by  the  number  of  corpuscles  expressed 
as  a  percentage  of  the  normal.  For  example,  under  normal  con- 
ditions the  haemoglobin  is  100  per  cent.,  and  there  are  5,000,000 
corpuscles  per  cubic  millimetre,  so  that  the  colour  -  index  is 
i^^=i.  If  the  corpuscles  have  fallen  to  3,000,000  (60  per  cent,  of 
the  normal),  whilst  the  haemoglobin  has  fallen  to  30  per  cent., 
the  colour-index  is  f^=o-5;  that  is  to  say,  each  red  corpuscle 
contains  only  half  as  much  haemoglobin  as  it  should  do.  In  general 
a  high  colour-index  is  indicative  of  pernicious  anaemia,  and  one 
which  is  greatly  reduced  of  chlorosis,  though  in  cases  of  severe 
secondary  anaemia  of  long  standing  a  similar  reduction  may  be 
present. 

If  the  blood  is  examined  immediately  after  a  patient  has  suffered 
from  a  severe  hcemorrhage,  it  w\\\  naturally  be  found  to  be  normal 
in  composition;  part  has  been  lost,  but  the  quality  of  the  remainder 
has  not  altered.  After  a  short  time  the  volume  of  blood  is  restored 
to  normal  by  means  of  fluid  derived  from  the  tissues.     In  this  stage 

58 


liXAMINATION  OF  THE  BLOOD  IN  HF.ALTH  AND  DISEASE     59 

the  blood  is  more  diluted  than  normal,  the  red  corpuscles  and 
hjemof^dobin  being  alike  reduced,  so  that  the  colour-index  remains  i. 
There  is  also  in  most  cases  a  temporary  increase  in  the  number  of 
leucocytes.  The  process  of  absorption  of  fluid  from  the  tissues  is 
imitated  artificially  in  the  infusion  of  saline  solutions  in  collapse  or 
after  severe  hemorrhage,  and  it  is  found  that  this  process  has  a 
beneficial  effect  in  accelerating  the  subsequent  regeneration  of  the 
blood  as  well  as  in  raising  the  blood-pressure  and  removing  the 
urgent  symptoms. 

In  the  subsequent  process  of  recovery  the  red  corpuscles  increase 
more  rapidly  than  the  haemoglobin,  so  that  the  colour-index  falls 
somewhat.  The  length  of  time  necessary  for  full  regeneration  of 
the  blood  varies  greatly,  the  process  being  more  rapid  in  men  than 
women,  and  in  young  adults  than  in  the  old  or  young.  Approxi- 
mately I  per  cent,  of  haemoglobin  is  regenerated  per  diem;  thus  the 
blood  becomes  normal  in  about  twenty  days  after  the  loss  of  20  per 
cent,  of  haemoglobin  if  the  patient  is  kept  under  favourable 
conditions. 

It  is  not  possible  to  lay  down  any  definite  rule  as  to  the  amount 
of  haemorrhage  which  is  necessarily  fatal.  Other  things  being  equal, 
a  patient  will  survive  a  much  greater  loss  of  blood  if  it  takes  place 
gradually  than  if  it  takes  place  quickly.  In  the  latter  case  a 
reduction  of  the  haemoglobin  to  50  per  cent,  will  probably  be  fatal, 
whereas  in  the  former  it  may  fall  to  20  per  cent.,  or  lower,  and 
recovery  still  take  place.  Women  tolerate  loss  of  blood  better  than 
men,  and  men  tolerate  it  better  than  children. 

Anaemic  patients  are  usually  bad  subjects  for  operations,  but  it  is 
not  possible  to  formulate  any  rule  for  the  guidance  of  the  surgeon 
as  to  the  degree  of  anaemia  which  should  make  him  unwilling  to 
operate. 

It  is  important  to  notice  that  a  high  degree  of  anaemia  occurs  in 
acute  spreading  inflammation,  septic  fever,  septicaemia,  etc.,  and. 
this  fact  is  occasionally  of  diagnostic  value.  The  diminution  of  the 
corpuscles  and  haemoglobin  usually  occurs  rapidly,  sometimes  with 
a  rapidity  only  second  to  that  which  occurs  after  severe  haemorrhage, 
and  gives  rise  to  a  severe  form  of  secondary  anaemia.  The  colour- 
index  is  usually  low,  the  haemoglobin  being  destroyed  more  rapidly 
than  the  corpuscles. 

The  examination  of  the  leucocytes  is  often  of  the  greatest  im- 
portance. It  comprises  an  enumeration  of  the  total  number  per 
cubic  millimetre,  and  a  differential  count  of  the  relative  number 
of  the  various  kinds.  The  former  examination  is  carried  out  by  a 
method  similar  to  that  used  in  counting  the  red  corpuscles,  and, 
as  it  takes  but  a  few  minutes  and  requires  but  little  practice,  should 
be  learnt  by  all  surgeons.  The  differential  count  is  made  on  thin 
films  of  blood,  which  are  dried  and  stained  by  a  double  or  triple  stain, 
Jenner's  stain  being  the  simplest  and  most  useful. 

Jenner's  stain  consists  of  a  solution  of  eosinate  of  methylene  blue 
in  methyl  alcohol.     To  use  it  the  blood  film  is  allowed  to  dry  spon- 


6o  A    M ANIMAL  Ol-   SnUGRRY 

taneously  and  is  tlifn  flooded  witli  the  stain,  \\Iii(  li  is  allowed  to  act 
for  about  two  minutes.  It  is  then  poured  off,  and  the  liim  is  rinsed 
in  distilled  water  for  a  few  seconds,  drained,  allowed  to  dry 
spontaneously,  and  mounted  in  Canada  balsam.  This  is  then 
examined  under  a  ,1  inch  lens,  each  leucocyte  seen  being  noted  down, 
until  400  or  more  have  been  counted.  The  results  are  reduced  to 
percentages. 

In  health  the  blood  contains  from  4,000  to  10,000  leucocytes  per 
cubic  millimetre,  five  different  forms  of  cell  being  present — the 
polynuclear  leucocyte,  the  eosinophile  leucocyte,  the  mast-cell,  the 
lymphoc\i;e,  and  the  hyaline  cell.  Of  these,  the  first  three  contain 
definite  granules  in  their  protoplasm,  the  others  do  not.  Tn  the 
following  description  we  assume  that  the  film  has  been  stained  by 
Jenner's  method.  If  other  staining  processes  are  used,  the  colours 
of  the  various  structures  will  naturally  be  somew^hat  different. 

1.  The  polynuclear  or  polymorphonuclear  leucocyte  (Fig.  12,  c)  is 
rather  larger  than  a  red  corpuscle.  It  is  characterized  by  having  a 
twisted  or  indented  nucleus,  which  in  badly  prepared  specimens  may 
appear  to  be  multiple,  although  with  proper  preparation  and  the  use 
of  high  powers  of  the  microscope  the  connecting  filaments  between 
the  various  parts  can  always  be  made  out.  It  contains  in  its  proto- 
plasm numerous  very  minute  granules  which  have  an  affinity  for  acid 
stains,  and  hence  are  coloured  pink  by  the  eosin  in  Jenner's  stain. 
In  specimens  which  have  not  been  well  stained  these  granules 
may  not  be  visible,  but  the  cell  can  always  be  identified  by  its 
nucleus.  ^ 

The  polynuclear  leucocytes  are  the  chief  phagocytic  cells  of  the 
blood,  being  actively  amoeboid  and  endowed  wnth  the  power  of 
ingesting  bacteria  or  other  small  objects.  Thev  are  formed,  mainly 
or  entirely,  in  the  bone-marrow,  and  constitute  in  health  from  65  to 
75  per  cent,  of  all  the  leucocytes. 

2.  The  eosinophile  leucocytes  (Fig.  12,  d)  are  about  as  large  as  the 
foregoing,  and  have  a  bilobed  or  polymorphous  nucleus.  They  have 
also  granules  which  stain  with  eosin,  but  these  are  much  larger  and 
more  defined  than  those  of  the  polynuclears. 

The  eosinophils  form  2  to  4  per  cent,  of  the  leucocytes  of  normal 
blood.  They  are  probably  formed  partly  in  the  bone-marrow  and 
partly  in  other  connective  tissues.  They  are  feebly  mobile,  and 
their  functions  are  not  definitely  known. 

3.  The  mast-cells  (Fig.  12,  e)  have  lobed  nuclei  and  granules  which 
stain  with  methylene  blue,  though  usually  metachromatically,  taking 
a  purplish  colour.  They  are  present  in  very  small  proportions 
(about  I  per  cent.)  in  normal  blocid,  and  their  functions  are  unknown. 
They  are  connective-tissue  cells,  and  are  often  present  in  considerable 
numbers  in  inflamed  tissues. 

4.  The  lymphocvtes  (Fig.  12,  a)  are  devoid  of  granules,  and  their 
nuclei  are  not  polymorphous.  They  vary  in  size,  but  the  majority 
are  rather  smaller  than  the  red  corpuscles.  Fach  lymphocyte  has  a 
single  circular  nucleus  which  is  situated  centrally;   this  is  sur- 


liX.lMlNAriON  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE     6i 

rounck'tl  l)y  ;i  narrow  /.one  ol  j)n)t()i)lasin,  whirli  in  suitably  stained 
specimens  takes  the  nietlulene  blue  more  deeply  than  does  the 
nucleus  itself. 

Lymphocytes  constitute  20  to  25  per  cent,  of  the  leucocytes  of 
health.  In  children  the  proportion  may  be  much  higher,  the  poly- 
nuclears  being  correspondingly  reduced.  They  arc  formed  in  the 
lymphatic  glands,  spleen,  Peyer's  patches,  and  lymph-adenoid 
tissue  generally.  They  are  probably  identical  with  the  '  small  round 
cell  '  wliich  is  so  characteristic  of  non-suppurative  inflammatory  foci, 
and  in  these  lesions  we  have  reason  to  believe  that  they  can  be  pro- 
duced locally  in  any  part  of  the  body,  probably  by  a  process  of 
budding  from  the  endothelial  cells. 

5.  The  large  hyaline  or  large  mononuclear  cells  (Fig.  12,  h)  vary  in 
size,  but  as  a  rule  are  decidedly  larger  than  the  red  corpuscles.  They 
have  a  single  circular,  oval,  or  kidney-shaped  nucleus,  which  is 
smaller  relatively  to  the  cell  than  the  nucleus  of  the  lymphocyte. 


Fig.  12. — Corpuscular  Elements  of  Normal  Blood.     (Emery.) 

a,  Lymphocyte;  b,  hyaline  or  large  mononuclear  cell;  c,  polynuclear  leucocyte; 
d,  eosinophile  cell;  e,  mast-cell ;  j/",  red  corpuscle,  to  show  the  relative  sizes 
of  the  other  cells. 


The  protoplasm  stains  faintly  with  methylene  blue.  It  is  devoid  of 
granules,  but  often  shows  bluish  points,  which  are  really  nodal 
thickenings  of  the  reticulum.  These  cells  form  2  to  4  per  cent,  of 
the  leucocytes  of  normal  blood,  and  have  considerable  powers  of 
phagocytosis.  Their  origin  and  relation  to  the  lymphocytes  is  not 
definitely  known,  but  there  is  some  reason  for  regarding  them  as 
endothelial  cells  which  have  been  detached  from  the  walls  of  the 
vessels. 

An  increase  of  the  total  leucocytes  present  in  the  blood  is  termed 
leucocytosis.  Under  most  circumstances  this  increase  is  mainly  due 
to  an  increase  in  the  number  of  polynuclears  present;  special  terms 
are  used  for  an  increase  of  other  forms  of  leucocytes.  An  increase 
in  the  eosinophiles  is  called  eosinophilia,  and  an  increase  in  the 
lymphoc3^tes  is  called  lymphocytosis.  A  diminution  of  the  leucocytes 
is  termed  leucopenia. 


62  A   MANUAL  OF  SURGERY 

Leucocytosis  occurs  under  physiological  conditions  during  diges- 
tion, during  pregnancy,  and  in  tlie  new-l»orn  infant.  This  has  to 
be  remembered  in  interpreting  leucocyte  counts  in  disease.  The 
former  factor  is  of  especial  importance,  and  if  possible  the  blood 
should  be  collected  whilst  the  patient  is  fasting. 

Pathological  leucocytosis  occurs  in  many  conditions,  the  most 
important  being  the  infective  diseases,  and  in  these  the  highest 
counts  are  met  with  in  pneumonia  and  in  suppuration.  The  latter 
is  of  special  importance  to  the  surgeon,  as  the  presence  of  a  high 
leucocytosis  may  be  regarded  as  the  most  definite  single  sign  of  the 
presence  of  pus.  It  is  especially  valuable  in  appendicitis,  where  the 
other  evidences  of  suppuration  are  often  equivocal.  When  no  pus 
is  present,  the  blood  shows  slight  leucocytosis,  the  number  not 
usuallv  exceeding  15,000  per  cubic  millimetre.  When  pus  is  present 
the  number  is  much  greater,  being  usually  not  less  than  18,000,  and 
it  mav  rise  as  high  as  50,000,  or  even  higher.  For  practical  purposes 
a  count  of  20,000  leucocytes  per  cubic  millimetre  may  be  taken  as  an 
almost  certain  proof  of  suppuration,  presuming,  of  course,  that  the 
other  causes  of  lecocytosis  can  be  excluded.  Figures  between 
15,000  and  20,000  are  not  sufficiently  definite  to  be  of  much  value, 
and  where  they  are  obtained  it  is  advisable  to  repeat  the  examina- 
tion in  twenty-four  hours.  If  suppuration  is  taking  place,  the 
count  will  almost  certainly  rise,  wliilst  if  it  remains  at  the  same 
level,  or  shows  a  decline,  the  presence  of  pus  is  unlikely.  The  height 
of  the  leucocytosis  gives  no  indication  of  the  size  of  the  abscess  or  of 
the  rapidity  of  its  spread. 

The  opening  of  the  abscess  is  usually  followed  by  a  fall  in  the 
number  of  leucocvtes,  and  this  is  so  rapid  as  to  be  quite  definite  in 
the  course  of  twelve  hours.  When  it  does  not  take  place,  the 
probabihty  is  that  a  second  abscess  is  present,  which  was  overlooked 
at  the  time  of  the  operation. 

The  absence  of  leucocytosis  is  presumptive  evidence  that  sup- 
puration has  not  occurred,  but  several  facts  have  to  be  considered  in 
applying  this  rule  in  actual  practice: 

I.  The  cause  of  the  leucocytosis  is  the  passage  of  the  bacterial 
products  from  the  inflammatory  focus  to  the  blood-stream,  where 
they  exert  a  positively  chemotactic  action,  attracting  the  leucocytes 
from  the  bone-marrow,  whilst  at  the  same  time  they  stimulate  the 
latter  to  an  increased  production  of  leucocytes.  As  long  as  the 
abscess  remains  unopened  and  is  spreading,  these  substances  gain 
access  to  the  blood-stream  with  ease,  for  it  is  the  only  path  available 
to  them.  But  when  the  abscess  is  opened  so  that  the  pus  laden  with 
bacterial  toxins  can  drain  away,  the  leucocytosis  falls,  even  although 
the  abscess  may  burrow  for  a  time.  An  example  of  this  was  seen  in 
a  patient  suffering  from  appendicitis,  in  whom  there  were  very  doubt- 
ful chnical  indications  of  pus,  and  who  showed  a  leucocytosis  of 
38,000;  this  was  regarded  as  definite  proof  of  the  existence  of 
an  abscess.  A  few  hours  after  the  count  was  made  the  patient 
suffered  from  diarrhoea,  and  pus  was  found  in  the  stools.     A  second 


EXAMIXATJUX  OF  THE  BLOOD  IN  HEALTH  AXD  DISEASE    63 

CDUut  was  made  forty-eight  hours  after  the  llrst,  and  the  leucocytes 
were  found  to  ha\'e  fallen  to  13,500,  3'et  at  the  operation  a  large 
abscess  cavity  with  extensive  ramihcations  was  found.  If  the 
patient  had  been  admitted  to  the  hospital  after  the  rupture  of  the 
abscess  into  the  intestine,  the  leucocyte  count  would  have  led  to 
an  erroneous  conclusion.  For  a  similar  reason — viz.,  the  non- 
absorption  of  toxins  into  the  blood — there  is  but  slight  leucocytosis 
in  suppurative  inflammation  of  the  mucous  membranes. 

2.  When  the  pyogenic  bacteria  have  been  killed,  the  toxins  are 
soon  carried  away  in  the  blood-stream  and  eliminated  from  the 
body,  and  when  this  has  happened  the  leucocj^tosis  falls,  although 
there  is  still  a  collection  of  pus  in  the  tissues.  In  other  words,  a 
high  leucocytosis  is  to  be  regarded  as  a  proof  of  the  process  of  sup- 
puration rather  than  as  a  proof  of  the  presence  of  pus.  For  example, 
such  sterile  collections  of  unabsorbed  pus  often  occur  in  cases  of  pyo- 
salpinx  of  some  standing,  and  are  unaccompanied  by  leucocytosis, 
although  acute  suppuration  in  the  Fallopian  tubes  causes  the  usual 
reaction. 

3.  When  the  organisms  are  ver}'  virulent  and  the  patient  of  feeble 
constitution,  so  that  the  infection  rapidly  spreads,  there  is  occasion- 
ally a  failure  of  leucoc3.tosis  or  even  a  leucopenia.  This  is  notably 
the  case  in  severe  cases  of  diffuse  septic  peritonitis.  The  general 
(as  well  as  the  local)  leucocytosis  must  be  regarded  as  a  conservative 
and  defensive  reaction,  whatever  views  are  held  as  to  the  nature  of 
immunity.  Its  presence  indicates  that  the  patient  has  sufficient 
resisting  powers  to  combat  the  infection,  or  at  least  to  localize  it 
for  a  time ;  its  absence  in  a  case  where  there  is  suppuration  renders 
the  prognosis  unusually  bad. 

4.  Leucocytosis  does  not  occur  in  cases  of  chronic  or  cold  abscess. 
The  products  formed  by  the  bacteria  which  produce  these  lesions 
have  no  positive  chemotactic  action  on  the  polynuclear  leucocytes. 
The  cells  found  in  the  local  lesions  are  mostly  lymphocytes.  Hence, 
even  when  the  toxins  of  these  organisms  enter  the  blood,  they  fail 
to  attract  the  polynuclear  leucoc3'tes  from  the  marrow.  We  might 
reasonably  expect  that  an  increase  in  the  lymphocytes  would  occur; 
but  these  cells  are  not  actively  motile  like  the  polynuclears,  and  are 
not  so  readily  subser\dent  to  chemotactic  influences. 

Another  method  sometimes  used  in  the  diagnosis  of  suppuration 
is  based  on  the  appearance  of  granules  of  glycogen  (or  an  allied 
substance)  in  the  protoplasm  of  the  leucocytes  in  septic  diseases. 
Dry  blood-films  are  mounted  in  a  recently  prepared  solution  of 
iodine  i,  iodide  of  potassium  3,  water  100,  which  has  been  saturated 
with  powdered  gum  acacia.  This  stains  the  granules  deep  brown. 
This  test  is  not  as  useful  as  the  foregoing. 

The  relations  of  some  of  the  other  infective  diseases  to  the 
leucocytes  may  be  briefly  epitomized.  In  pneumonia,  erysipelas, 
diphtheria,  scarlet  fever,  plague,  and  whooping-cough  there  is  a  high 
leucocytosis,  the  number  rarely  falhng  below  20,000.  In  rheumatic 
fever  (uncomplicated),  syphilis,  and  gonorrhoea  there  is  usually  a 


64  A   MANUAL  OF  SURGERY 

slight  rise,  and  in  tuberculosis,  typhoid  fever,  influenza,  measles,  and 
malaria  there  is  usually  no  excess,  and  often  a  diminution,  in  the 
number  of  leucocytes  (ieucopenia). 

Pathological  leucocytosis  also  occurs  after  severe  luemorrliage, 
and  in  all  cachectic  conditions,  especially  in  that  due  to  malignant 
disease.  In  these  cases  it  is  almost  always  due  to  a  local  inflamma- 
tion excited  by  the  new  growth,  and  is  rarely  of  diagnostic  value. 
In  carcinoma  of  the  stomach  there  is  usually  an  absence  of  digestion- 
leucocytosis,  and  this  fact  may  assist  in  the  diagnosis.  The  leuco- 
cytes are  counted  whilst  the  patient  is  fasting,  and  two  or  three 
times  (at  intervals  of  an  hour)  after  a  meal,  which  should  include 
some  meat.  If  the  count  does  not  rise  considerably  (2,000  per  cubic 
millimetre  or  more),  it  affords  strong  presumptive  evidence  of  the 
presence  of  mahgnant  disease  of  the  stomach,  but,  like  all  laboratory 
tests,  must  be  considered  in  conjunction  with  the  clinical  phenomena. 

Lymphocytosis,  or  an  increase  of  the  lymphocytes,  may  be 
absolute  or  relative.  A  relative  increase  {i.e.,  such  that  the  per- 
centage of  these  cells  rises  above  25,  although  the  total  number  of 
leucocytes  of  all  sorts  does  not  exceed  the  normal)  occurs  in  typhoid 
fever,  tuberculosis,  and  malaria.  A  great  excess  of  leucocytes 
(150,000  or  more  per  cubic  millimetre),  the  great  majority  being 
lymphocytes,  occurs  only  in  lymphatic  leucocythsemia,  and  con- 
stitutes an  important  means  of  diagnosis  between  this  condition 
and  Hodgkin's  disease,  in  which  the  leucocytes  are  normal  or  but 
slightly  increased.  Children's  blood  contains  an  excess  of  lympho- 
cytes, reaching  60  per  cent.,  and  in  inflammatory  diseases  of  children 
the  increase  in  the  total  leucocytes  may  be  due  partly  to  an  excess 
of  lymphocytes,  and  not  only  of  the  polynuclears,  as  in  the  adult. 
This  is  especially  the  case  if  the  lymph-glands  are  involved  in  the 
inflammatorv  process. 

Eosinophilia,  i.e.,  a  relative  increase  of  the  eosinophiles,  occurs  in 
several  conditions:  (i)  In  infection  with  animal  parasites,  especially 
in  trichinosis,  where  the  proportion  may  be  60  per  cent,  or  more. 
They  are  sometimes  increased  in  hydatid  disease;  in  doubtful  cases 
this  fact  has  some  diagnostic  value,  but  a  count  in  which  there  is 
no  increase  is  of  little  importance.  (2)  In  some  skin  diseases, 
especially  when  a  large  area  of  skin  is  involved.  (3)  In  asthma. 
(4)  In  gonorrhoea,  and  a  few  other  diseases. 

A  brief  account  of  the  blood  conditions  in  those  diseases  which 
are  especially  connected  with  the  blood-forming  organs  may  be  of 
some  value: 

I,  In  pernicious  ancemia  the  corpuscles  are  greatly  reduced  in 
numbers,  whilst  the  haimoglobin  is  reduced,  but  to  a  lesser  extent, 
the  colour-index  being  greater  than  i.  The  red  corpuscles  are  often 
distorted  in  shape  (poikilocytosis),  and  large  (megalocytes)  or  small 
(microcytes)  forms  occur.  Large  nucleated  red  corpuscles  (megalo- 
blasts)  are  usually  present,  and  are  almost  diagnostic  of  the  disease. 
The  leucocytes  are  usually  normal  or  subnormal  in  number,  and 
there  is  a  relative  increase  of  lymphocytes. 


EXAMINATION  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE     65 

2.  In  chlorosis  the  haemoglobin  is  reduced  to  a  greater  extent  than 
the  corpuscles,  the  colour-index  being  less  than  i.  There  may  be 
some  microcytes,  but  the  red  corpuscles  are  usually  normal  in  shape 
and  size,  though  of  pale  colour.     The  leucocytes  are  usually  normal. 

3.  In  spleno-medullary  leiicocyihcemia  there  is  an  enormous  increase 
in  the  leucocytes;  the  number  is  usually  not  less  than  100,000  per 
cubic  milhmelre,  and  may  rise  to  1,000,000  or  even  more.  Of  these 
a  large  proportion  are  myelocytes,  cells  which  do  not  occur  in  normal 
blood.  They  var}'  in  size,  but  are  usually  large,  and  may  be  very 
large;  they  have  a  single  nucleus,  which  stains  badly  and  is  circular, 
oval,  or  indented,  and  often  excentrically  placed;  they  contain 
granules  similar  to  those  of  the  polynuclear  leucocj^tes.  The 
eosinopliile  cells  are  greatly  increased  in  absolute  numbers,  though 
their  proportion  relativelv  to  the  other  cells  may  be  normal.  Eosino- 
phile  myeloc\-tes  also  occur;  they  are  similar  in  all  respects  to  the 
myelocvtes,  except  that  their  granules  are  large,  resembhng  those 
of"  the  eosinophiles  of  normal  blood.  The  polynuclears  are  present 
in  vast  numbers,  but  their  relative  proportion  is  less  o\\ing  to  the 
number  of  the  mvelocytes.  The  lymphocytes  are  scanty,  but  the 
mast-cells  are  often  abnormally  plentiful.  Nucleated  red  corpuscles 
occur. 

4.  Lymphatic  lencocythcBmia  can  be  distinguished  from  Hodgkin's 
disease  (lymphadenoma)  only  by  an  examination  of  the  blood.  In 
the  former  disease  there  is  a  vast  number  of  leucocj'tes,  the  great 
majority  (90  per  cent,  or  more)  of  which  are  Ijmiphocj^es.  In  the 
early  stages  of  Hodgkin's  disease  the  blood  is  absolutely  normal, 
whilst  later  there  is  marked  anaemia.  The  leucoc3i;es  are  not 
usually  increased  in  numbers,  and  there  may  be  leucopenia;  there 
is  often  a  slight  relative  increase  in  the  l^-mphocjtes.  In  some  cases 
there  is  leucoc\i;osis.  Hodgkin's  disease  cannot  be  differentiated 
from  tuberculosis  of  the  Ij-mphatic  glands  by  a  blood  count  alone. 

The  examination  of  the  blood  for  parasites  (including  bacteria)  is 
often  necessary.  It  may  be  carried  out  by  microscopic  examinations 
of  fresh  blood  or  blood- films,  or  by  cultures;  the  method  to  be 
selected  must  depend  upon  the  organism  sought. 

The  diagnosis  of  malaria  may  be  made  by  an  examination  of  a  wet 
fihn  of  fresh  blood  made  by  taking  a  small  drop  of  the  blood  on  a 
perfectly  clean  cover-glass,  and  placing  the  latter,  drop  downwards, 
on  a  perfectly  clean  shde;  or  films  may  be  prepared  in  the  ordinary 
way  and  stained  bv  carbol-thionin,  haematoxylin  and  eosin,  Jenner's 
stain,  or  bv  other  methods.  For  a  description  of  the  organisms  and 
their  Hfe-history  the  reader  is  referred  to  special  treatises. 

Relapsing  fever  is  due  to  a  corkscrew-like  organism  (the  Spirillum 
Ohermeyeri),\v]Ac]x  is  about  two  or  three  times  as  long  as  the  diameter 
of  a  red  corpuscle.  They  may  be  demonstrated  by  the  method  used 
for  the  malaria  parasite,  and  in  fresh  specimens  are  as  a  rule  actively 
motile. 

The  diagnosis  oi  filariasis  is  best  made  by  examining  \\ith  a  low- 
power  lens  thick  layers  of  fresh  blood  taken  at  night,  if  F.  noctiirna 

5 


66 


A   MANUAL  OF  SURGERY 


is  suspected;  in  the  daytime,  in  the  case  of  F.  diiirna  ;  and  at  any 
time  if  F.  perstans  is  sought. 

Where  bacteria  are  sought  for  in  the  blood,  cultural  methods  are 
almost  always  necessary,  for  their  numbers  are  usually  so  small  that 
the  chance  of  finding  even  a  single  specimen  in  a  stained  blood-film 
is  remote.  The  blood  must  be  drawn  directly  from  a  vein  with  a 
sterilized  hypodermic  needle  and  syringe  (or  better  with  a  hypo- 
dermic needle  mounted  on  a  short  length  of  glass  tul^ing  and  the 
whole  sterihzed  by  heat),  and  full  precautions  must  be  taken  in 
sterilizing  the  skin.  At  least  3  or  4  c.c.  should  be  taken  and 
inoculated  directly  into  broth  or  melted  agar,  which  is  incubated 
and  examined  at  the  end  of  twenty-four  and  forty-eight  hours.  It 
is  worse  than  useless  to  attempt  to  make  a  bacteriological  examina- 
tion of  blood  obtained  from  a  skin  puncture,  however  carefully  the 
skin  may  have  been  sterilized. 

In  septicaemia,  pyaemia,  ulcerative  endocarditis,  and  other  diseases 
due  to  the  pyogenic  bacteria,  the  organisms  may  or  may  not  be 
found  in  the  blood.  A  positive  result  is  most  hkely  to  be  obtained 
in  severe  cases,  especially  when  the  blood  is  collected  during  a  rigor; 
it  is  of  evil  omen,  although  such  cases  are  by  no  means  necessarily 
fatal.  Cultures  in  wliich  staphylococci  are  the  only  organisms  to 
develop  must  be  interpreted  with  caution,  as  being  possibl}^  due  to 
accidental  contamination.  A  negative  result  is  usually  of  httle 
value  in  diagnosis,  as  organisms  may  be  absent  from  the  blood  for 
long  periods  in  cases  of  chronic  septicaemia. 

It  is  sometimes  necessary  to  examine  the  blood  for  bacteria  in  the 
diagnosis  of  typhoid  fever,  especially  when  the  infection  is  not  due  to 
the  ordinary  typhoid  bacillus,  but  to  one  of  its  congeners  (the  para- 
typhoid bacillus,  etc.).  In  general,  the  diagnosis  is  made  by  means 
of  VVidal's  reaction. 

Typical  Blood-Counts. 

It  must  be  understood  that  the  series  of  blood-counts  here 
appended  are  to  be  looked  on  merely  as  typical  illustrations;  in  any 
particular  instance  considerable  differences  from  the  figures  given 
may  be  manifested. 


Normal  Blood — 

Red  corpuscles 

Haemoglobin 
Colour-index 


Morphology  of 
red    corpuscles  ^ 


5,120,000     per 

c.mm. 
100  per  cent. 

I  (nearly). 
^No  abnormal 
forms  seen . 
Corpuscles 
uniform  in 
size,  and  stain 
only  with  the 
acid  stain 
(eosin). 


Normal  Blood — continued  : 

Leucocytes  -     7,000  per  c.mm. 

Polynuclears   -  72*0  per  cent. 
Lymphocytes  -  22-8 
Eosinophiles    -     2*4 
Large  hyalines      2*4 
Mast-cells         -     0-4 

No  other  forms  of  leucocytes  seen. 

Secondary    Aneemia    from    repeated 
slight  hcemorrhages — 
Red  corpuscles    -     4,200,000     per 

c.mm. 
Haemoglobin        -     72^00  per  cent. 
Colour-index        -  '85 


EXAMINATION  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE     67 


Secondary  kasdvai^— continued  : 

f Corpuscles 


Lymphatic  Leucocythsemia- 


Morphology  of 
red  corpuscles 


stain  a  little 
faintly ;  no 
nucleated 
forms  seen. 

(N.ll.  —  In  severer  cases  of  secondary  ana;mia, 
and  especially  in  cases  of  profound  anremia  after 
a  single  large  haemorrhage  in  a  previously  healthy 
person,  normohlasts  may  be  seen,  and  are  a  good 
sign.) 

Malignant  Disease  with  cachexia — 


Red  corpuscles 

Haemoglobin 
Colour-index 


Morphology  of 
red  corpuscles 


Leucocytes 

Polynuclears  - 
Lymphocytes  - 
Large  hyalines 
Eosinophiles  - 
Mast-cells 

Morphology  of 
leucocytes 


3,200,000      per 

c.mm. 
48*00  per  cent. 

•75 

'  The  corpuscles 
stain  some- 
what faintly ; 
normoblasts 
are  present, 
but  in  scanty 
numbers. 

12,000  per  c.mm. 
82-4  per  cent. 
14-8 


•4 
Nothing        ab- 
normal seen. 


Suppuration  (acute  appendix  abscess) — 


Red  corpuscles 


per 


4,500,000 
c.mm. 
85-00  per  cent 
•95 


Haemoglobin 
Colour-index 
Morphology  of 

red  corpuscles     Normal. 
Leucocytes  -   23,oooperc.mm. 

Polynuclears    -     86'2  per  cent. 

Lymphocytes  -     ii'6         ,, 

Eosinophiles    -        i*o         ,, 

Large  hyalines         i'2 
No  abnormal  forms  seen.     Some  of  the  poly- 
nuclears show  '  glycogenic  '  degeneration. 

Tubercle  (not  complicated  with  sec- 
ondary infections) — 


Red  corpuscles    - 

Haemoglobin 

Colour-index 

Morphology  of 
red  corpuscles 

Leucocytes 

Polynuclears  - 
Lymphocytes  - 
Large  hyalines 
Eosinophiles    - 

Morphology  of 
leucocytes    - 


4,112,000     per 

c.mm. 
76'0  per  cent. 

•9 

Normal. 
4,200  perc.mm. 
64'2  per  cent. 

32-8         „ 

2-8 

•2 

Normal. 


Red  corpuscles 

Haemoglobin 
Colour-index 


Morphology 


Leucocytes 

Poljmuclears    - 
Lymphocytes 

(nearly    all 

small) 
Eosinophiles    - 
Myelocytes 


per 


2,000,000 

c.mm. 
36*0  per  cent. 

•7 
'  The  corpuscles 
stain     some- 
what faintly; 
normoblasts 
are    present, 
but  in  scanty 
numbers. 
I  12,000     per 
c.mm. 
8-2  per  cent. 


gi-2 


(N.B. — In  lymphatic  leucocythamia  there  is 
not  necessarily  a  great  total  increase  in  the  num- 
ber of  the  leucocytes,  but  the  relative  increase  in 
the  lymphocytes  is  usually  very  marked.) 

Leucocythaemia  (spleno-medullary) — 


Red  corpuscles    - 

Haemoglobin 
Colour-index 


Morphology  of 
red  corpuscles 


Leucocytes 


3,200,000  per 
c.mm. 

52-0  per  cent. 
•8 

Normoblasts 
present  in 
rather  large 
numbers 
(about  one  in 
every  two 
fields  of  a 
-^-inch  lens) . 

456,000  per 
c.mm. 


Myelocytes  and 
cells  inter- 
mediate be- 
tween them 
and  polynu- 
clears 

Polynuclears    - 

Eosinophiles 
and  eosino- 
phile  myelo- 
cytes   - 

Mast-cells  and 
mast-  cell 
myelocytes  - 

Lymphocytes 
and  large 
hyalines 

Many  of  the  polyiuiclear  leucocj'tes  show  signs 
of  degeneration,  having  faintly  stained  nuclei  and 
few  granules  ;  some  are  difficult  to  distinguish 
from  myelocytes.  Some  of  the  myelocytes 
are  also  deficient  in  granules,  and  almost  indis- 
tinguishable from  large  hyaline  leucocytes. 


42'0  per  cent. 
39-0 


7-6 


3-0 


CHAPTER  V. 

NON-SPECIFIC*  PYOGENIC  INFECTIONS. 

In  this  chapter  \vc  propose  to  deal  with  a  series  of  affections  asso- 
ciated with  or  aUied  to  suppuration,  and  due  to  non-specific  bacteria. 
These  organisms,  usually  termed  pyogenic,  cause  an  inflammatory 
reaction  in  the  tissues,  which  sooner  or  later  is  associated  with 
liquefaction  of  both  tissue  and  exudate,  the  liquefied  material  being 
known  as  pus,  and  the  process  which  leads  to  its  formation  as  sup- 
puration. Any  localized  collection  of  pus  in  the  tissues  is  known  as 
an  abscess,  and  this,  according  to  its  course,  may  be  acute  or  chronic, 
the  latter  being  uncommon.  Sometimes  the  infection  involves  the 
cellular  tissue  of  a  part  in  a  more  or  less  diffuse  manner,  the  pus 
burrowing  widely ;  this  condition  is  termed  cellulitis.  Constitutional 
phenomena  are  associated  with  these  local  manifestations,  and  may 
be  of  two  types:  (a)  When  toxic  products  alone  are  absorbed,  re- 
sulting in  toxceniia  or  some  modification  of  the  same;  and  {h)  when 
the  bacteria  invade  the  blood-stream  and  become  disseminated  to 
distant  parts,  thereby  giving  rise  to  either  septicamia  or  pycemia. 
Each  of  these  various  conditions  must  be  dealt  with  separately, 
but  one  must  first  describe  in  some  httle  detail  the  organisms  com- 
mon to  the  whole  group. 

Bacteriology.^ — The  following  are  the  more  important  pyogenic 
bacteria  : 

I.  The  Staphylococcus  pyogenes  (Plate  T,  Fig.  i)  is  perhaps  the 
most  common  organism  of  acute  localized  suppuration,  especially  in 
connection  with  the  skin  and  subcutaneous  tissues.  It  is  a  coccus 
of  medium  size  which  occurs  in  the  pus  in  characteristic  clusters, 
which  have  been  compared  to  bunches  of  grapes.  It  stains  by 
Gram's  method,  and  liquefies  gelatin  or  solidified  blood-serum,  as  it 
produces  a  powerful  peptonizing  enzyme,  and  is  readily  cultivated 
on  almost  all  media;  it  grows  best  when  an  abundant  supply  of 
oxygen  is  present. 

Cultures  on  sohd  media  develop  rapidly,  and  the  colonies  spread, 
the  surface  being  soon  covered  by  a  imiform  thickish  film  of  growth. 
This  may  be  orange-yellow,  lemon-yellow,  or  white  in  colour,  and 
three  organisms — Staphylococcus  pyogenes  aureus,  ciireus,  and  albus, 

*■  For  the  significance  of  the  term  non-specific,  see  p.  12. 
68 


NON-SPECIFIC  PYOGENIC  INFECTIONS  69 

respectively — have  been  recognised.  Under  certain  circumstances, 
however,  the  one  may  change  into  the  other,  and  there  is  httle 
doubt  that  the  three  really  constitute  one  species. 

Staphylococci  are  very  widely  distributed,  being  common  in  air, 
dust,  etc.  They  are  frequently  found  in  or  on  the  human  skin, 
though  apparently  not  normal  inhabitants  of  that  structure.  Sup- 
purative inflammations  of  the  skin  and  subcutaneous  tissue  are 
due  to  staphylococci  in  the  vast  majority  of  cases;  and  when  the 
inflammation  is  caused  by  other  organisms  in  the  first  instance,  a 
secondary  infection  with  staphylococci  almost  always  takes  place 
later.  Impetigo  contagiosa,  a  disease  due  primarily''  to  streptococci, 
may  be  taken  as  an  example  of  this,  and  the  vesicles  of  small-pox  or 
vaccinia  another,  for  in  each  case  a  secondary  staphylococcic  in- 
vasion takes  place.  The  chief  skin  lesions  due  to  staphylococci  are 
abscesses,  boils,  carbuncles,  pustular  acne,  etc.  In  some  cases 
diffuse  spreading  cellulitis  depends  on  the  same  cause,  but  this  is 
unusual.  Deep-seated  suppuration,  such  as  osteomyelitis,  peri- 
tonitis, empyema,  etc.,  may  also  be  due  to  staphylococci;  in  fact, 
they  may  cause  suppuration  in  any  part  of  the  body.  Lastly, 
staphylococcic  septicaemia,  pyaemia,  and  ulcerative  endocarditis 
occur,  but  are  less  common  than  the  forms  due  to  streptococci, 
and  the  prognosis  appears  to  be  slightly  less  grave. 

Most  cases  of  suppuration  occurring  after  operations  in  which  the 
antiseptic  or  aseptic  precautions  have  been  inadequate  are  due  to 
staphylococci,  either  alone  or  in  admixture  with  other  organisms. 

2.  The  Streptococcus  pyogenes  is  an  organism  in  which  the  individual 
cocci  are  arranged  in  longer  or  shorter  chains  (Plate  I.,  Fig.  2).  It 
stains  with  Gram,  and  does  not  grow  very  easily  on  artificial  culture 
media.  A  temperature  approximating  to  that  of  the  body  is  desir- 
able, and  hence  it  does  not  grow  well  on  gelatin.  The  colonies  are 
small  and  translucent,  and  do  not  tend  to  spread  or  become  con- 
fluent. It  forms  no  peptonizing  enzyme,  and  hence  does  not  liquefy 
solidified  blood-serum.     The  cultures  readily  die  out. 

On  comparing  cultures  of  Streptococcus  pyogenes  from  different 
sources,  slight  differences  may  be  noted,  e.g.,  in  the  length  of  the 
chains,  the  size  of  the  cocci,  the  appearance  of  the  colonies,  etc.  It 
is  as  yet  uncertain  whether  these  are  sufficient  to  differentiate  several 
species,  or  whether  they  merely  indicate  unimportant  (and  perhaps 
not  permanent)  varieties  of  a  single  species. 

The  Streptococcus  pyogenes  is,  on  the  whole,  a  more  virulent 
organism  than  the  staphylococcus,  and  tends  to  produce  an  acute 
spreading  inflammation  rather  than  a  localized  abscess,  although  the 
latter  lesion  is  quite  commonly  due  to  it.  Erysipelas  is  (in  most 
cases)  caused  by  a  streptococcus  which  has  been  held  to  be  a  distinct 
species,  although  the  differences  are  so  unimportant  that  the  two  are 
generally  considered  identical.  Cellulitis,  too,  is  usually  due  to  the 
Streptococcus  pyogenes.  The  organism  plays  its  most  important  role, 
however,  in  connection  with  septicaemia  and  pyaemia,  whether 
puerperal  or  not,  and  is  the  usual  cause  of  ulcerative  endocarditis, 


70  A   MANUAL  OF  SURGERY 

3.  Tlie  Pneiiinococciis  (Plate  I.,  ¥\^.  4),  geiurully  })r('S(.'nt  in  lobar 
pneiinionia,  is  a  diplococciis,  the  individual  cocci  liaving  usually  a 
triangular  or  lancet  shape,  with  the  bases  facing  one  another.  When 
it  occurs  in  pus  or  other  animal  fluids,  it  is  surrounded  by  a  clear 
capsule.  In  cultures  it  closely  resembles  the  Streptococcus  pyogenes. 
It  is  chiefly  of  importance  in  suppuration  connected  with  the  lungs, 
especially  empyema.  It  occurs  almost  constantly  in  all  inflam- 
matory lesions  of  the  lung,  whatever  their  origin,  as  a  secondary 
infection;  thus,  in  the  walls  of  a  tuberculous  cavity  suppuration  is 
nearly  always  due  to  pneumococci  alone  or  in  conjunction  with 
other  organisms.  It  is  a  common  cause  of  middle-ear  disease,  and 
of  its  cranial  or  intracranial  compUcations.  Pneumococci  also  cause 
arthritis,  which  may  or  may  not  result  in  suppuration ;  the  arthritis 
usually  follows  an  attack  of  pneumonia,  but  this  is  not  necessarily 
the  case.  Peritonitis  is  also  due  to  this  organism  in  3'oung  children, 
and  may  be  primary  or  secondary  to  some  pulmonary  lesion.  The 
pneumococcus  frequently  enters  the  blood  and  causes  septicemia, 
with  or  without  ulcerative  endocarditis. 

4.  The  B.  coli  communis  (Plate  III.,  Fig.  30)  occurs  in  great 
numbers  in  the  contents  of  the  healthy  intestine.  It  is  a  short 
motile  bacillus  which  does  not  form  spores,  and  is  not  stained  by 
Gram's  method.  It  grows  best  in  presence  of  oxygen,  but  is  a 
facultative  anaerobe;  no  peptonizing  enzyme  is  produced,  so  that 
gelatin  is  not  liquefied,  but  an  abundance  of  foul  gas  is  developed. 
The  B.  coli  is  one  of  the  most  important  putrefactive  organisms,  and 
it  breaks  down  proteids,  forming  indol  and  allied  bodies,  and  gases 
with  faecal  odour.  It  is  closely  allied  to  the  tvphoid  bacillus,  and  is 
distinguished  therefrom  by  its  action  on  various  sugars;  thus,  the 
typhoid  bacillus  produces  acid,  but  no  gas,  when  grown  in  broth 
containing  glucose,  whereas  the  B.  coli  produces  both  acid  and  gas. 
These  two  bacteria  are  members  of  a  large  and  important  group  of 
micro-organisms  which  have  a  close  morphological  resemblance  to 
one  another,  bvit  differ  in  their  chemical  activities. 

Under  normal  conditions  the  bacilli  of  this  species,  which  occur  in 
the  intestinal  contents,  are  not  very  virulent,  but  when  any  patho- 
logical condition  arises  in  the  gut — e.g.,  strangulation,  ulceration, 
perforation,  etc. — their  virulence  appears  to  be  increased,  and  an 
active  invasion  of  the  tissues  may  follow.  It  is  thus  a  common  cause 
of  appendicitis,  acute  peritonitis,  etc.,  and  pus  due  to  its  action  has 
usually  a  fascal  odour.  It  can  also  ascend  the  bile-ducts,  and  give 
rise  to  cholecystitis  and  cholangitis.  Lastly,  the  B.  coli  is  one  of  the 
commonest  causes  of  cystitis.  It  has,  however,  no  power  to  render 
the  urine  alkaline;  this  is  due  to  the  presence  of  a  micrococcus, 
formerly  known  as  M.  itrece,  but  now  believed  to  be  identical  with 
M.  epidermidis  albits,  an  organism  of  constant  occurrence  in  the  skin. 

5.  The  typhoid  bacillus  (Plate  III.,  Fig.  25)  sometimes  causes 
abscesses,  especially  in  connection  with  the  bones  or  joints,  after  an 
attack  of  typhoid  fever.  In  some  cases  the  organism  may  lie  latent 
for  years  before  suppuration  occurs.     It  has  also  been  proved  that 


NON-SPECIFIC  PYOGENIC  INFECTIONS  71 

some  persons  continue  to  give  off  these  bacilli  in  the  urine  or  faeces 
for  many  years  after  an  attack  of  typhoid  fever;  in  the  latter 
instance  the  gall-bladder  has  sometimes  been  the  infected  focus. 
These  '  typhoid  carriers,'  as  they  are  termed,  may  at  any  time 
initiate  an  epidemic  of  the  disease,  which  may  thus  appear  to  arise 
without  reason. 

6.  The  B.  pyocyaneus  is  a  comparatively  rare  cause  of  suppura- 
tion. The  pus  produced  by  it  turns  bluish-green  when  exposed  to 
the  atmosphere.     It  sometimes  gives  rise  to  a  general  infection. 

7.  The  Gonococciis  (see  p.  142). 

8.  The  M.  tetragenus,  an  organism  in  which  the  individual  cocci 
occur  in  tetrads,  is  rarely  met  with. 

Many  cases  of  suppuration  are  due  to  a  mixed  infection  with  two 
or  more  of  the  species  of  bacteria  enumerated  above.  In  other 
instances  an  abscess  formed  by  the  action  of  one  of  the  pyogenic 
bacteria  may  be  subsequently  inoculated  with  simple  saprophytes 
that  have  the  power  of  growing  in  dead  pus,  but  cannot  invade  the 
living  tissues.  This  accident  is  very  likely  to  occur  in  a  large 
abscess  when  the  drainage  is  insufhcient  and  the  dressings  are  not 
performed  with  sufficient  care.  It  should  be  studiously  avoided, 
for  lesions  due  to  a  mixed  infection  heal  with  difficulty;  the  tissues 
appear  more  easily  to  acquire  immunity  to  a  single  organism  than 
to  two  or  more  at  the  same  time.  The  fact  that  a  wound  is  already 
infected  is  no  reason  for  neglecting  to  treat  it  with  the  fullest  anti- 
septic precautions. 

I.  Acute  Abscess. 

etiology. — (a)  It  may  be  taken  as  established  that  suppuration 
as  met  with  in  surgical  practice  is  always  due  to  the  action  of  bacteria. 
It  is  true  that  in  the  laboratory  it  is  possible  to  obtain  aseptic  sup- 
puration in  animals  by  the  use  of  chemical  irritants,  such  as  croton 
oil,  etc.,  but  this  does  not  occur  in  man.  It  is  also  true  that  in 
certain  abscesses,  notably  in  the  liver  and  in  pyosalpinx,  no  organ- 
isms can  be  found  in  the  pus  on  microscopical  or  cultural  examina- 
tion; this  is  usually  due  to  the  fact  that  the  bacteria  have  been 
destroyed  and  the  abscess  has  ceased  to  spread.  In  other  cases  the 
organisms  may  be  present  in  very  small  numbers,  or  may  not  grow 
on  the  ordinary  culture  media;  and  in  this  connection  it  may  be 
well  to  point  out  that  new  varieties  of  pathogenic  bacteria  are 
frequentfy  being  discovered. 

{h)  Bacteria  can  reach  the  area  which  becomes  inflamed  either  from 
ivithout  the  body  or  from  within.  The  former  method  is  the  more 
usual,  and  is  illustrated  by  the  observations  of  Garre  and  Bockhardt, 
who  rubbed  cultures  of  Staphylococcus  pyogenes  aureus  into  the  skin 
of  their  arms,  and  produced  acute  suppuration,  commencing  in 
superficial  pustules,  and  finishing  as  boils  or  carbuncles.  The 
Staphylococcus  pyogenes  is  commonly  present  in  the  skin,  and  fre- 
quently deposited  on  instruments,  dressings,  etc.,  from  the  air,  and 
it  is  to  infection  from  without,  due  to  bacteria  gaining  access  from 


72  A  MANUAL  OF  SURGERY 

one  or  other  of  these  sources,  that  the  majority  of  cases  of  suppura- 
tion are  due. 

In  some  cases,  however,  bacteria  may  gain  access  to  the  tissues 
from  tlie  blood ;  thus  it  sometimes  happens  that  a  deep  lesion  (such 
as  a  ruptured  nuiscle  or  hgamcnt)  results  in  suppuration,  although 
the  skin  over  it  is  unbroken,  and  the  intervening  tissues  are  ap- 
parently healthy.  Here  we  must  assume  the  possibility  of  auto- 
infection  (p.  7),  the  bacteria  reaching  the  blood  from  some  focus  of 
chronic  suppuration,  such  as  a  neglected  pyorrhoea,  or  ulceration 
of  the  mouth  or  intestine. 

In  other  cases  abscesses  may  be  due  to  organisms  which  have 
lain  latent  in  the  tissues,  it  may  be,  for  long  periods.  This  is  never 
very  easy  to  prove,  but  the  possibility  of  such  latency  is  shown  by 
the  fact  that  a  patient  may  develop  leprosy  many  years  after  ex- 
posure to  infection.  A  more  common  example  may  be  seen  in  the 
bone  abscesses  which  sometimes  develop  months  or  years  after  an 
attack  of  typhoid  fever,  and  which  are  due  to  the  typhoid  bacillus, 
though  in  this  case  we  cannot  exclude  the  possibility  of  a  subsequent 
infection  with  the  same  certainty  as  in  the  case  of  leprosy.  In  what 
state  the  bacteria  lie  latent  in  the  tissues  and  the  nature  of  the  con- 
ditions which  excite  them  into  activity  are  unsolved  problems;  we 
should  expect  the  latter  phenomenon  to  be  due  to  general  ill-health 
or  to  local  injury,  but  cases  occur  in  which  no  such  factors  can  be 
traced.  It  is  probable  that  they  would  regain  their  activity  if  an 
operation  took  place  in  the  region  in  which  they  were  deposited; 
suppuration  would  then  follow  in  spite  of  perfect  asepsis. 

Abscesses  of  a  ver}^  different  nature  occur  when  pyogenic  bacteria 
are  carried  from  a  suppurative  lesion  in  one  part  of  the  body  to 
another ;  these  are  termed  secondary  embolic  abscesses  and  develop  in 
pyaemia,  gonorrhoea,  etc. 

(c)  Sterilized  foreign  bodies  {e.g.,  silver  wire  or  glass  splinters)  do  not 
produce  suppuration,  except  in  the  rarest  of  cases,  by  auto-infection. 
Thus,  a  ragged  splinter  of  glass,  ij  inches  long  and  li  inches  wide, 
the  result  of  the  bursting  of  a  soda-water  bottle,  was  cut  out  of  the 
neck  of  an  hotel  porter  ten  months  after  it  had  entered;  it  was  en- 
capsuled  and  had  caused  no  trouble.  This  fact  is  constantly  made 
use  of  at  the  present  day  in  surgical  practice;  deep  layers  of  the 
tissues  are  brought  together  by  carefully  sterilized  buried  sutures, 
and  divided  structures  such  as  bones,  ligaments,  etc.,  are  approxi- 
mated and  held  in  position  by  wire,  screws,  pegs,  or  other  buried 
appliances,  which  would  cause  endless  trouble  but  for  their  complete 
sterihzation. 

In  conclusion,  therefore,  although  we  have  to  admit  that  suppura- 
tion may  be  experimentally  induced  in  animals  in  the  absence  of 
micro-organisms,  in  man  for  all  ordinary  conditions  suppuration  does 
not  occur  apart  frojn  the  presence  and  vital  activity  of  pathogenic  bacteria. 

The  causes  of  an  acute  abscess  may  be  grouped  for  practical 
purposes  under  the  three  following  headings:  (i)  The  individual 
affected  is  possibly  in  a  depressed  and  unhealthy  state,  and  the 


NON-SPECIFIC  PYOGENIC  INFECTIONS 


73 


germicidal  power  of  his  tissues  may  be  defective.  When  abscesses 
have  occurred  more  than  once  in  the  same  individual,  one  may 
rightly  suspect  the  existence  of  some  intrinsic  source  of  infection, 
such  as  oral  sepsis,  or  some  external  contamination,  as  from  defec- 
tive drains,  leading  to  escape  of  sewer  gas.  (2)  A  local  nidus  must 
exist,  which  is  in  a  condition  of  lowered  vitality  from  injury,  cold, 
or  otherwise;  and  (3)  this  spot  becomes  infected  with  pyogenic 
organisms  brought  to  it  either  from  within  or  without  the  body. 

Formation  and  Structure  of  an  Acute  Abscess. — The  bacteria  which 
have  gained  access  to  the  tissues  grow  and  produce  toxins  that  are 


Fig.   13. — Formation  of  Abscess  in  the  Kidney.     (Thoma.) 

In  the  centre  is  a  zoogloea  mass  of  organisms;  around  it,  a  zone  of  devitalized 
tissue;  and,  still  farther  out,  an  infiltration  of  the  living  tissues  with 
polynuclear  leucocytes. 


diffused  into  the  surrounding  structures,  giving  rise  to  acute  inflam- 
mation; the  vessels  dilate,  acceleration  of  the  blood-stream  occurs, 
and  is  followed  by  retardation  and  thrombosis,  and  the  leucocytes 
emigrate.  More  vigorous  action  of  the  toxins  on  the  injured 
tissues  destroys  their  vitality,  usually  by  a  process  of  coagulation- 
necrosis.  A  section  through  the  lesion  at  this  stage  will  show  two 
well-differentiated  zones  (Fig.  13):  a  central  area  in  which  the 
tissues  are  dead,  have  lost  their  staining  properties,  and  contain 
the  p3'ogenic  bacteria;  and  a  peripheral  zone  of  ordinary  acute  in- 
flammation, which  fades  gradually  into  the  surrounding  healthy 
tissues.     This  inflamed  zone  is  thickly  infiltrated  \vith  leucocjrtes, 


74  A   MANUAL  OF  SURGERY 

and  on  examination  these  will  be  found  to  be  inainly  of  the  poly- 
nuclear  variety,  since  the  products  of  pyogenic  bacteria  have 
special  attractive  (chemotactic)  powers  over  this  form  of  leuco- 
cytes. 

The  central  necrotic  mass  which  contains  the  bacteria  is  at  this 
stage  still  attached  to  the  surrounding  living  tissues,  and  if  the 
lesion  is  incised  it  will  appear  as  a  small  slough,  which  can  only  be 
removed  with  difficulty.  Hut  this  condition  soon  changes;  as  a 
result  of  increasing  exudation,  especially  of  plasma,  the  tension  in 
the  inflammatory  focus  becomes  so  great  that  the  cohesion  of  the 
tissues  around  the  central  slough  is  destroyed,  and  a  third  zone — 
of  polynuclear  leucocytes  swimming  in  fluid — is  formed  between  it 
and  the  inflamed  outer  zone.  Where  the  toxins  have  a  peptonizing 
enzyme  action,  it  is  possible  that  this  plays  some  small  part  in 
liquefying  the  tissues. 

The  fate  of  the  small  slough  varies  according  to  circumstances. 
It  may  occasionally  be  recognized  when  a  small  abscess  is  opened 
—e.g.,  the  core  of  a  boil — but  in  most  cases  it  is  absorbed  by  the 
leucocytes  or  digested  by  the  peptonizing  enzymes  which  many 
pyogenic  bacteria  form.  It  may  even  happen  that  no  definite 
slough  is  ever  formed  (Fig.  14),  the  earliest  effect  of  the  bacteria 
being  to  attract  the  leucocytes  in  vast  numbers  into  inflamed  but 
still  living  tissues,  which  are  then  killed  and  digested  cell  by  cell. 

This  collection  of  leucocytes  suspended  in  fluid  and  surrounded 
by  a  zone  of  inflamed  tissue  constitutes  an  abscess.  The  leucocytes 
and  fluid  are  collectively  termed  pus,  and  it  is  important  to  recognise 
that  the  characteristic  cells  of  the  pus  from  an  acute  abscess  are 
the  polynuclear  leucocytes.  These,  however,  differ  somewhat  from 
those  seen  in  blood-films.  Many  of  them  are  killed  by  the  toxin 
(as  can  be  seen  from  their  loss  of  motion  when  the  fresh  pus  is 
examined  on  a  warm  stage),  and  undergo  various  degenerative 
changes.     Some  of  them  may  contain  bacteria. 

At  first  the  abscess  often  extends  rapidly,  but  after  a  day  or  two 
(in  most  cases)  a  certain  amount  of  local  immunity  is  produced,  and 
the  abscess  spreads  more  slowly.  This  is  an  indication  of  the  fact 
that  the  tissues,  which  were  at  first  overwhelmed  by  the  action  of 
the  bacteria  and  their  toxins,  are  now  carrying  on  the  contest  on 
more  even  terms.  At  this  period  the  cavity  becomes  lined  by 
granulation  tissue  (Fig.  15),  which  forms  a  "thick,  soft  layer  of 
velvety  appearance  and  bright-pink  colour.  It  is  composed  of  large 
numbers  of  loops  of  newly-formed  bloodvessels  embedded  in  a  mass 
of  leucocytes  and  tissue-cells  in  a  state  of  active  proliferation.  Its 
appearance  does  not  necessarily  indicate  that  the  abscess  has  entirely 
ceased  to  spread,  for  the  toxins  may  still  be  powerful  enough  to  kill 
the  delicate  newly-formed  tissue  cell  by  cell;  but  in  most  cases  it  is 
the  first  indication  of  repair  and  of  "the  ultimate  victory  of  the 
tissues.  Leucocytes  continue  to  pass  from  the  thin-walled  vessels 
of  new  formation  into  the  abscess  cavity,  being  attracted  chemo- 
tactically  by  the  substances  present  in  the  pus;  hence  the  layer  of 


Fig.  14. — Abscess  Formation  in  the  Subcutaneous  Tissues  in  the 
Early  Stage  (Four  Days). 

To  the  right  of  the  illustration  are  seen  masses  of  round  cells  (polymorphonuclear  leucocytes), 
which  are  ready  to  break  down  into  pus.  To  the  left  is  seen  fatty  tissue,  permeated  by  strands 
of  fibrous  connective  tissue  in  a  state  of  cell  proliferation. 


Fig.    15. — Section  of  Abscess  in  Subcutaneous  Tissues  (Seven  Days). 

The  structureless  pus  is  seen  below  and  to  the  right,  and  above  it  the  intensely  cellular  linin?  of  the 
abscess  cavity,  which  is  in  reality  infiltrated  with  bacteria.  The  tissues  beyond  are  in  a  stage  of 
proliferation  similar  to  that  seen  in  Fig   14. 

(For  the  loan  of  these  illustrations  we  are  indebted  to  Mr.  G.  Lenthal  Cheatle.) 


76  A  MANUAL  OF  SURGERY 

granulation  tissue  appears  to  secrete  pus,  and  was  formerly  called 
a  '  pyogenic  membrane.'  Its  appearance  was  anxiously  looked  for 
by  surgeons  in  the  days  when  suppuration  was  considered  essential 
for  the  healing  of  wounds,  since  it  opposes  a  strong  barrier  to  the 
bacteria  and  their  toxins,  and  in  large  measure  prevents  their  enter- 
ing the  blood-stream.  Thus  the  formation  of  thick,  creamy  pus  of 
a  3'ellowash  colour,  such  as  is  produced  by  such  a  pyogenic  mem- 
brane, was  looked  upon  as  a  sign  that  the  patient  was  practically 
out  of  danger  of  '  blood-poisoning,'  and  the  pus  itself  was  termed 
'  laudable.' 

Abscesses  do  not  as  a  rule  spread  equally  in  all  directions,  since 
certain  structures,  especially  bone  and  fascia,  are  more  resistant 
than  cellular  tissue  or  fat.  The  process  of  extension  continues 
along  the  line  of  least  resistance  until  the  abscess  points  at  some 
surface,  and  finally  bursts  through  the  skin  or  into  the  ahmentary 
canal  or  other  cavity.  When  this  happens,  the  bacteria  and  their 
toxins  alike  are  able  to  escape,  and  in  consequence  their  action  on 
the  pyogenic  membrane  is  less  profound,  so  that  the  contest  between 
the  defensive  powers  of  the  tissues  and  the  destructive  powers  of 
the  bacteria,  in  which  the  latter  were  victorious  at  first,  turns  in 
favour  of  the  tissues.  The  bacteria  which  remain  are  attacked 
with  greater  effect  by  the  leucocytes,  and  are  gradually  removed; 
the  supply  of  toxin  diminishes;  the  inflammatory  process  in  the 
abscess  wall  becomes  less  severe,  and  finally  organization  of  the 
granulation  tissue  commences.  This  begins  at  the  bottom  of  the 
abscess  cavity,  the  walls  of  the  upper  portions  being  kept  apart  from 
one  another  by  the  pus  which  is  still  secreted,  though  in  gradually 
diminishing  quantity.  The  result  is  that  the  abscess  cavity  fills  up 
from  the  bottom,  and  finally  heals  altogether.  This  process  is 
facilitated  if  efficient  drainage  is  provided,  so  that  the  bacteria 
and  toxins  find  a  ready  exit. 

Occasionally  the  defensive  powers  of  the  body  are  sufficient  to 
kill  off  the  bacteria  after  pus  has  been  formed,  and  before  it  has 
escaped.  When  this  happens,  the  pus  may  become  absorbed  and 
the  ca\'ity  obliterated,  or  the  fluid  part  only  may  be  removed,  and 
the  leucocytes  (which  undergo  fatty  degeneration)  remain  as  a 
cheesy,  structureless  mass.  In  either  case  the  abscess  wall  organizes 
into  fibrous  tissue,  constituting  a  deep  scar,  in  the  centre  of  which 
ma}'  be  the  inspissated  pus.  It  is  rare,  however,  for  this  to  happen, 
except  in  the  abdomen,  and  then  usually  in  connection  with  the 
appendix,  Fallopian  tube,  or  liver. 

The  Clinical  Signs  and  Symptoms  of  an  acute  abscess  may  be 
arranged  under  three  headings: 

I.  The  local  signs  consist  of  a  patch  of  inflamed  tissue,  indicated  by 
heat,  pain,  redness,  and  swelling,  which  latter  is  at  first  hard  and 
brawny,  but  when  pus  forms,  the  centre  becomes  soft  and  elastic, 
whilst  superficial  oedema  is  more  marked,  and  the  pain  throbbing  in 
character.  Naturally,  the  amount  of  this  pain  depends  entirely  upon 
the  density  of  the  tissue  affected  and  the  supply  of  sensory  nerves  to 


NON-SPECIFIC  PYOGENIC  INFECTIONS  77 

the  part,  suppuration  beneath  a  resisting  membrane,  such  as  the 
palmar  fascia,  being  always  intensely  painful.  Fluctuation  is  the 
most  characteristic  sign  of  the  presence  of  fluid;  it  is  obtained  by 
making  firm  pressure  with  the  finger  or  fingers  of  one  hand  on  one 
part  of  the  swelhng,  whilst  the  fingers  of  the  other  hand  placed  on 
another  part  receive  the  impulse  transmitted  across  the  intervening 
space  in  the  form  of  a  fluid  wave.  Some  soft  sohds  give  a  sensation 
of  fluctuation — e.g.,  hpomata  and  soft,  rapidly-growing  sarcomata; 
whilst,  on  the  contrary,  it  may  be  absent  when  the  fluid  is  under  great 
tension,  or  surrounded  by  a  thick  wall,  or  widety  diffused  in  such 
a  structure  as  the  glandular  tissue  of  the  breast. 

Sometimes,  when  the  pus  is  small  in  quantity,  all  that  can  be 
detected  is  a  feehng  of  elastic  resistance  in  the  centre  of  the  brawny 
hyperamic  mass;  but  this,  to  the  practised  finger,  is  quite  as  con- 
clusive of  the  presence  of  fluid  as  fluctuation.  When  the  pus  is 
placed  deeply  under  muscular  and  fascial  planes,  very  careful 
examination  may  be  needed  in  order  to  determine  its  presence ;  the 
surgeon  must  not  be  misled  bj'  the  sense  of  fluctuation  obtained 
across  the  fibres  of  a  muscle;  none  is  noticed,  however,  by  palpating 
along  the  course  of  its  fibres.  j\Iarked  and  increasing  oedema  is 
frequently  conclusive  of  the  presence  of  deeply-seated  pus — e.g.,  in 
acute  osteomyeHtis,  and  suppurating  mastitis. 

If  left  to  itself,  an  abscess  sooner  or  later  points  and  bursts.  x\s  it 
increases  in  size,  it  travels  in  the  line  of  least  resistance,  and  so  may 
either  find  its  way  direct  to  the  surface,  or  may  burrow  along  mus- 
cular and  fascial  planes,  or  into  adjacent  cavities.  The  actual  burst- 
ing of  an  abscess  is  often  due  to  some  injury — it  may  be  a  shght  one 
— but  is  usually  preceded  by  ulceration  or  necrosis  of  the  integu- 
ment. 

2.  Pressure  effects  are  mainly  due  to  the  mechanical  influence  of 
the  swelhng  upon  surrounding  structures.  The  most  e\ident  are 
those  due  to  the  irritation  of  nerves,  as  a  result  of  which  neuralgic 
pain  may  be  present,  or  the  patient  may  refer  the  pain  to  some 
distant  unaffected  region.  In  some  cases,  where  large  bloodvessels 
traverse  the  suppurating  focus,  the  surrounding  tissues  may  be 
destroyed,  lea^dng  them  exposed  in  the  abscess  cavity  as  bands. 
Thrombosis  and  subsequent  obfiteration  may  result,  especially  in 
the  veins;  or  occasionally  haemorrhage  follows,  due  to  sloughing 
of  the  arterial  wall  (suppurative  periarteritis),  preceded  perhaps 
by  an  aneurismal  dilatation  of  the  vessel,  owing  to  its  loss  of  ex- 
ternal support.  Such  effects  occur  both  in  acute  and  chronic 
abscesses. 

3.  The  general  effects  of  the  formation  of  an  acute  abscess  are  those 
of  increased  fever,  sometimes  amounting  to  a  rigor,  and  leucocytosis. 
A  rigor  consists  of  a  definite  series  of  phenomena,  the  result  of  the 
stimulation  of  the  thermogenic  centres  by  an  accumulation  of  toxin 
in  the  blood.  It  is  very  similar  in  nature  to  an  attack  of  ague,  being 
ushered  in  by  a  feeling  of  intense  cold  and  discomfort ;  the  features 
are  pinched,  and  the  teeth  chatter.     The  skin,  however,  feels  dry 


78  A    MANUAL  OF  SURGERY 

and  hot,  and  the  temperature  of  the  body  rapidly  rises.  The  sensa- 
tion of  cold  is  partly  due  to  the  contact  of  air  at  a  maintained  normal 
temperature  with  the  hot,  dry,  unperspiring  skin,  and  also  possibly 
to  the  condition  of  superficial  anaemia  which  is  present.  After  this 
stage  has  lasted  a  variable  period,  the  patient  gradually  begins  to 
feel  warmer,  the  face  becoming  flushed,  the  thermometer  ceasing  to 
rise,  and  the  skin  commencing  to  act.  Finally  there  is  a  rapid  fall 
of  temperature  accompanied  by  profuse  perspiration,  which  probably 
eliminates  the  toxin,  but  leaves  the  patient  more  or  less  exhausted. 
For  leucocytosis  and  its  value  in  the  diagnosis  of  suppuration,  see 
p.  62. 

Pus  and  its  Constituents. — Normal  or,  as  it  v/as  formerly  called, 
healthy  or  laudable  pus  is  a  thick,  creamy  fluid,  having  a  specific 
gravity  of  about  1030,  an  alkahne  reaction,  no  smell  (unless  putre- 
fying or  due  to  the  activity  of  the  B.  coli),  and  containing  85  to 
90  per  cent,  of  water.  If  allowed  to  settle,  it  separates  into  two 
layers,  an  upper  or  fluid  part,  the  liquor  puris,  which  is  usually 
clear  or  shghtly  opalescent,  and  a  deposit  of  a  yellowish-gray  colour, 
which  is  usually  more  bulky  than  the  fluid  portion.  The  liquor 
puris  is  derived  from  the  plasma  exuded  from  the  vessels.  It  may 
undergo  coagulation  after  removal  from  the  body,  a  very  loose  clot 
being  formed.  Frequently,  however,  this  does  not  happen,  perhaps 
because  it  has  already  coagulated  within  the  abscess,  and  the  re- 
sulting fibrinous  network  has  been  dissolved  by  the  peptonizing 
ferment  of  the  toxins,  or  destroyed  by  the  leucocytes.  It  consists 
chemically  of  an  albuminous  fluid  very  similar  to  serum,  but  more 
dilute,  and  contains  bacterial  toxins,  enz3^mes,  proteoses  formed  by 
the  digestion  of  proteids,  etc.  Sometimes  (when  the  abscess  in- 
volves a  region  containing  fat)  a  few  globules  of  oil  fl.oat  on  the 
surface  or  occur  in  an  emulsified  form  in  the  fluid. 

The  sohd  portion  consists  in  the  main  of  pol^muclear  leucocytes, 
most  of  which,  as  has  been  already  pointed  out,  are  dead  and  de- 
generated, whilst  a  few  are  still  alive  and  capable  of  spontaneous 
movements.  In  addition,  there  are  fragments  of  cells  and  nuclei 
from  the  tissues,  shreds  of  fibrous  tissue,  granular  debris,  and 
bacteria.     A  few  red  blood  corpuscles  are  often  present. 

When  pus  is  mixed  with  blood,  it  is  termed  sanious  (short  for 
sanguineous) ;  when  thin  and  acrid,  it  is  ichorous;  curdy,  when  mixed 
with  curdy  shreds,  as  is  more  usuall}-  seen  in  chronic  suppuration  of 
a  tuberculous  nature.  Blue  or  green  pus  is  due  to  the  activity  of 
the  B.  pyocyaneus ;  the  colour  is  often  seen  best  on  the  outer  layers 
of  the  dressing  which  are  exposed  to  the  air.  Its  occurrence  is 
uncommon.  Muco-pus  is  of  a  sticky,  glairy  character,  and  arises 
from  inflammator}-  conditions  of  mucous  membranes;  sero-pus  is 
thiin  and  more  liquid  from  admixture  of  serum,  and  is  derived  from 
serous  membranes. 

Occasionally  an  abscess  contains  not  only  pus,  but  also  gas.  This 
may  be  due  to  the  existence  of  a  direct  communication  with  some 
hollow  viscus — e.g.,  the  stomach  or  intestine — and  hence  is  met  with 


NON-SPECIFIC  PYOGENIC  INFECTIONS  79 

in  many  cases  of  subphrenic  abscess.  In  some  of  the  many  types 
of  abscess  associated  with  appendicitis  the  gas  is  due  to  the  activity 
of  the  B.  coli  either  alone  or  mixed  with  other  germs.  In  the  limbs 
it  is  usually  the  result  of  infection  with  a  gas-producing  organism — 
e.g.,  the  B.  acrogenes  capstilatiis  or  B.  (vdematis  maligni,  and  is 
associated  with  an  acute  spreading  cellulitis  or  gangrene. 

Treatment  of  Acute  Abscess. — When  an  inflamed  area  is  threaten- 
ing to  suppurate,  the  formation  of  pus  can  be  but  rarely  prevented. 
In  the  early  stages,  elevation  and  rest  of  the  part,  together  with  the 
application  of  evaporating  lotions  and  the  administration  of  quinine 
with  iron,  may  sometimes  succeed  in  accomphsliing  this,  or  Bier's 
treatment  by  induced  hyperaemia  may  be  useful. 

In  a  few  regions  of  the  body,  pus  may  be  absorbed  after  its  forma- 
tion, but  only  when  situated  in  a  cavity  of  highly  absorbing  powers, 
such  as  the  anterior  chamber  of  the  eye  (hypopj'on)  or  the  peri- 
toneal ca\'ity.  In  the  former  the  process  of  absorption  may  cer- 
tainly be  observed  under  the  influence  of  local  and  general  treat- 
ment. 

As  a  rule,  however,  one  relieves  pain  and  encourages  suppuration 
by  applying  fomentations  (medicated  with  opium  or  belladonna)  or 
poultices  to  the  part,  and  then,  as  soon  as  pus  is  present,  an  incision 
is  made  to  evacuate  the  abscess  cavit}'.  The  opening  must  be  large 
enough  to  prevent  re- accumulation :  it  should  be  placed  at  a  spot 
suitable  for  drainage,  but  as  far  as  possible  from  sources  of  secondary 
contamination,  and  in  such  a  direction  that  movements  of  the  part 
do  not  close  it.  Where  the  opening  is  not  dependent,  it  may  be 
desirable  to  make  a  counter-opening  by  pushing  the  finger  or  a 
probe  through  the  abscess  wall  amongst  the  tissues,  making  it  pro- 
trude beneath  the  skin  at  some  dependent  spot,  and  cutting  down 
upon  it  in  this  direction.  In  dealing  mth  deep  abscesses  in  dan- 
gerous regions,  Hilton's  method  ma}'  be  advantageously  employed. 
This  consists  in  di\iding  merely  the  skin  and  superficial  structures, 
and  then  thrusting  a  pair  of  sinus  or  dressing  forceps  into  the  abscess 
ca\ity.  On  forcibly  separating  the  blades  a  sufficient  opening  is 
made  to  insert  the  finger,  and  subsequently  a  drainage-tube.  Rigid 
antiseptic  precautions  must  be  taken  in  opening  abscesses,  for, 
although  bacteria  are  present,  it  is  most  essential  that  no  fresh 
germs  be  admitted,  thereby  gi\'ing  rise  to  a  mixed  infection,  the 
presence  of  wliich  is  most  unfavourable  to  rapid  repair. 

It  is  ad\isable  to  remove  any  sloughs  that  are  present,  and  when 
the  abscess  has  burrowed,  or  if  the  canity  is  large,  it  should  be 
gently  explored  with  the  finger,  but  adhesions  or  bands  crossing  it 
should  not  be  indiscriminately  broken  down,  as  they  may  contain 
large  bloodvessels.  All  that  is  subsequently  needed,  if  there  is  no 
comphcation,  such  as  the  presence  of  dead  or  diseased  bone,  is  to 
arrange  for  drainage,  as  by  inserting  a  rubber  or  glass  drainage-tube 
or  a  shp  of  protective,  and  to  prevent  a  mixed  infection  by  a  care- 
fully-applied antiseptic  or  aseptic  dressing,  or  by  packing  the  cavity 
with  gauze  soaked  in  an  iodoform  emulsion  (10  per  cent.).     There 


So  A  MANUAL  OF  SURGERY 

is  often  a  considerable  loss  of  blood  during  the  first  twenty-four 
hours  from  the  yielding  of  the  capillaries  in  the  abscess  wall,  owing 
to  the  sudden  reUef  of  tension;  but  this  usually  ceases  of  itself,  or 
yields  to  moderate  pressure.  When  once  the  abscess  has  been  evacu- 
ated, no  more  pus  is  formed  if  external  contamination  {mixed  infection) 
has  been  avoided,  the  discharge  being  merely  serous,  and  the  wound 
rapidly  closing  and  healing,  and  this  in  spite  of  the  fact  that  bacteria 
are  for  a  while  present ;  they  are  evidently  unable  to  develop  or  do 
any  harm  as  the  result  -of  a  local  immunity.  An  abscess  cavity 
which  has  contained  foul  or  stinking  pus  usually  runs  a  healthy 
course  if  aseptic  conditions  are  maintained,  and  if  no  communication 
with  the  bowel  exists,  the  discharge  becoming  free  from  smell  in 
a  few  days. 

The  persistent  discharge  of  pus  from  an  abscess  which  has  been 
opened  means  either  that  the  opening  is  too  small,  or  that  matter  is 
pent  up  in  an  undrained  loculus,  or  that  a  mixed  infection  has 
occurred,  or  occasionally  that  the  vital  powers  of  the  patient  are  so 
deteriorated  that  it  is  difficult  to  establish  healthy  repair,  or  that  the 
part  is  not  kept  at  rest.  Free  drainage,  the  improvement  of  the 
general  health,  and  keeping  the  affected  part  at  rest  are  essential 
elements  in  the  successful  treatment  of  an  abscess.  A  small  open- 
ing must  be  enlarged;  loculi  must  be  drained,  and,  if  need  be,  a 
counter-opening  made.  DebiUtated  patients  may  sometimes  need 
to  be  sent  to  the  seaside  before  healing  will  occur. 

Chronic  Abscess  of  Pyogenic  Origin. 

A  chronic  abscess  may  be  defined  as  a  collection  of  pus  which 
forms  slowly  and  without  any  signs  of  active  inflammation,  so  that 
it  is  sometimes  termed  a  cold  or  congestive  abscess.  The  vast  majority 
are  tuberculous  in  origin,  but  a  few  may  be  due  to  the  liquefaction 
of  other  granulomatous  masses,  to  an  infection  with  pyogenic  bac- 
teria of  low  vitahty,  or  to  chronic  pyaemia.  The  chnical  phenomena 
are  alike  in  the  two  types,  and  will  be  dealt  with  later  (p.  182),  but 
there  is  one  important  distinction  between  them,  in  that  the  fining 
membrane  of  the  pyogenic  variety  is  merely  granulation  tissue  more 
or  less  active,  wlulst  in  the  tuberculous  fomi  it  contains  living  tuber- 
culous material.  Hence,  whilst  a  simple  incision  under  aseptic 
precautions  is  all  that  is  required  in  the  former,  the  latter  also  needs 
removal  of  the  tuberculous  tissue  by  scraping  or  some  such  agency. 

Sinus  and  Fistula. 

When  an  abscess,  acute  or  chronic,  has  been  opened,  and  does  not 
heal  completely,  a  communication  often  persists  between  the 
original  seat  of  the  disease  and  the  exterior,  which  is  known  as  a 
sinus  or  fistula.  A  Sinus  is  a  narrow  track  fined  wdth  granulations, 
penetrating  into  the  tissues,  open  at  one  end  and  closed  at  the  other; 
the  discharge  may  be  purulent  or  merely  serous.     A  Fistula  is  an 


NON-SPECIFIC  PYOGENIC  INFECTIONS  8i 

abnormal  communication,  congenital  or  acquired,  between  two 
cavities,  or  between  a  cavity  and  the  external  surface.  When  such 
conditions  result  from  the  non-closure  of  an  abscess  of  pyogenic 
origin,  the  walls  consist  of  an  external  libro-cicatricial  layer  and  an 
internal  hning  of  more  or  less  healthy  granulation  tissue.  Should 
the  abscess  have  been  of  tuberculous  origin,  the  lining  membrane 
will  also  contain  tubercles.  If  the  fistulous  track  is  short,  the 
granulating  wall  may  become  covered  with  epithelium,  and  under 
such  circumstances  the  fistula  cannot  be  expected  to  close  naturally. 

It  is  often  a  matter  of  difficulty  to  secure  the  heahng  of  a  sinus  or 
fistula,  and  the  following  are  the  main  causes  of  their  non-closure  : 
(i)  The  presence  of  some  chronic  irritant  in  the  depths  of  the  wound, 
such  as  a  piece  of  the  clothing,  a  catgut  ligature,  a  piece  of  silk  or 
silver-wire  used  in  an  operation,  or  of  some  diseased  tissue,  such  as 
a  fragment  of  dead  or  carious  bone;  (2)  the  irritation  of  discharges 
finding  an  exit  through  the  abnormal  opening,  such  as  urine,  faeces, 
or  foetid  pus ;  (3)  insufficient  drainage  of  a  deep  cavity,  so  that  there 
is  always  a  certain  amount  of  tension  in  the  wound ;  (4)  want  of  rest 
to  the  part,  due  either  to  voluntary  movements,  as  in  the  limbs,  or 
to  involuntary  muscular  action  in  the  immediate  neighbourhood,  as 
in  fistula-in-ano ;  (5)  tuberculous  infection  of  the  wall,  or  a  tuber- 
culous deposit  at  the  bottom  of  the  sinus;  (6)  the  growth  of  epithe- 
lium down  the  sinus  or  round  the  margin  of  the  fistula;  or  (7)  con- 
stitutional debility. 

The  orifice  of  a  sinus  often  looks  depressed  from  the  amount  of 
infiltration  around,  but  when  the  surrounding  tissues  are  healthy, 
puckering  in  of  the  orifice  is  a  good  sign;  in  cases  where  foreign 
bodies  are  lodged  within,  or  where  diseased  bone  exists,  it  is  usually 
surrounded  by  prominent  f ungating  granulations. 

Treatment. — The  removal  of  the  cause  is  the  first  thing  to  accom- 
plish in  dealing  with  a  sinus  or  fistula.  The  passage  must  be  dilated 
or  slit  up  to  allow  of  access  to  the  deeper  parts  of  the  wound,  to 
remove  any  foreign  body  which  may  be  present,  or  to  allow  of  the 
satisfactory  drainage  of  a  deep  cavity.  The  making  of  a  dependent 
counter-opening  often  suffices  to  cure  a  sinus.  A  thorough  disin- 
fection of  the  part  by  pure  carbohc  acid  or  chloride  of  zinc  (40  grains 
to  I  ounce)  must  also  be  undertaken,  and  the  wound  dressed  by 
packing  with  suitable  material  and  kept  at  rest,  whilst  the  general 
health  of  the  patient  is  improved  by  tonics.  Occasionally,  the 
pressure  of  a  roller  bandage  to  immobihze  the  part  is  all  that  is 
required,  or  the  application  of  a  suitable  splint.  The  most  complete 
and  certain  method  is  to  lay  the  sinus  open  and  destroy  the  hning 
granulation  tissue  by  scraping  or  cauterizing,  and  then  to  pack  the 
wound,  allowing  it  to  heal  from  the  bottom  by  granulation. 

Should  a  fistula  have  become  lined  with  epithehum,  the  edges  wll 
require  paring,  and  some  form  of  plastic  operation -must  be  under- 
taken to  close  the  opening. 

Sinuses  often  react  well  to  vaccine  treatment,  and  this  is  especially 
the  case  with  those  left  after  empyemata,  when  a  single  injection  of 


82 


A   MANUAL  OF  SURGERY 


50,000,000  to  100,000,000  dead  pneumococci  will  often  prove  effica- 
cious. Tuberculous  sinuses,  such  as  may  be  left  after  an  operation 
for  glands  in  the  neck,  etc.,  are  sometimes  curable  by  the  use  of 
tuberculin  (TR),  but  there  is  not  much  chance  of  success  if  the 
non-hcahng  is  clue  to  dead  bone,  movement,  etc. 


Results  of  Long-continued  Suppuration. 

When  an  abscess,  acute  or  chronic,  pyogenic  or  tuberculous,  is 
treated  antiseptically,  the  formation  of  pus  quickly  ceases;  the 
wound  may  not  heal  for  months,  but  the  discharge  is  merely  serous, 
and  no  constitutional  results  will  be  manifested.  The  temperature 
remains  normal,  and  the  general  health  unimpaired,  if  no  other 
disease  is  present.  Should  a  tuberculous  abscess  become  infected 
with  pyococci,  or  a  mixed  infection  occur  in  a  pyococcal  abscess, 


Fig.   16. — Temperature  Chart  of  Hectic  Fever. 

the  discharge  of  pus  continues  or  reappears,  and  fever  to  a  varying 
degree  follows.  When  an  extensive  or  deep  abscess  is  thus  involved, 
the  discharge  may  become  very  profuse,  high  fever  may  supervene, 
grave  visceral  changes  may  follow,  and  the  patient  may  lose  his  hfe 
through  toxaemia  and  cxliaustion.  Long-continued  suppuration  is 
always  an  evidence  of  persistent  infection,  and  prominent  amongst 
the  conditions  which  arise  therefrom  may  be  mentioned  hectic 
fever  and  lardaceous  disease  of  the  viscera. 

Hectic  Fever  may  be  defined  as  a  chronic  toxrcmia  due  to  the 
continued  absorption  of  small  doses  of  toxins,  and  is  met  with  in 
any  condition  of  chronic  infection — e.g.,  after  acute  or  chronic 
suppurative  affections  of  bones  or  joints,  in  tuberculous  disease  of 
the  lungs,  and  in  chronic  syphilitic  or  cancerous  ulceration.  It  is 
characterized    by  a  diurnal   elevation    of   temperature  .{Fig.   16) 


NON-SPECIFIC  PYOGENIC  INFECTIONS 


83 


during  the  afternoon  or  evening,  when  the  face  becomes  flushed 
{firtiic  flush  oi  the  cheeks),  the  eyes  are  bright  and  sparkhng,  the 
pupils  dilated,  and  the  patient  feels  better  and  stronger.  The  pulse, 
however,  is  small,  compressible,  and  ten  or  twenty  beats  quicker 
than  it  should  be.  This  condition  continues  till  late  in  the  night, 
by  which  time  the  temperature  may  have  risen  four  or  five  degrees. 
In  the  early  morning  it  falls  as  rapidly  as  it  had  formerly  risen,  and 
usually  drops  to  the  normal,  or  even  below  it,  and  this  is  accom- 
panied by  a  profuse  perspiration,  which  leaves  the  patient  in  a  much- 
exhausted  condition.  Day  by  daj^  this  continues,  the  fever  and 
sweating  together  causing  rapid  and  marked  emaciation. 


Fig.  17. — Amyloid  Kidney  in  Early  Stage.  (Ziegler.) 
(Treated  with  Muller's  fluid  and  perosmic  acid,  x  300.)  «,  Normal  capillary- 
loop;  b,  amyloid  capillary  loop;  c,  fatty  epithelium  of  glomerulus;  Cj,  fatt}^ 
epithelium  of  capsule;  d,  oil-drops  on  the  capillary  wall;  e,  fatty  epithelial 
cells  hi  situ;  f,  loosened  fatty  epithelial  cells;  g,  hyaline  coagula  (forming 
'  casts  ') ;  h,  fatt}^  cast  in  section;  i,  amyloid  artery;  k,  amyloid  capillar}^; 
I,  infiltration  of  connective  tissue  wdth  leucocytes;  m,  round  cells  (leuco- 
cytes) within  a  uriniferous  tubule. 

Amyloid,  Albuminoid,  or  Lardaceous  Disease  of  various  organs  is  a 
condition  due  to  the  deleterious  effects  of  toxic  compounds  circula- 
ting in  the  blood,  whereby  the  walls  of  the  smaller  arteries  (Fig.  17, 
h  and  i),  and  subsequently  the  protoplasm  of  certain  viscera,  are 
converted  into  or  infiltrated  with  a  waxy  substance,  from  which 
lardacein,  an  extremely  insoluble  proteid  body,  may  be  obtained. 
The  name  '  amyloid  '  is  an  entire  misnomer,  as  this  material  is  in 
no  way  akin  to  starch.     It  occurs  as  a  waxy  homogeneous  material, 


84  A   MANUAL  OF  SURGERY 

becoming  a  dirty  brown  on  the  application  of  tincture  of  iodine,  and 
an  inky  blue  when  sulphuric  acid  is  subsequently  added.  With 
methyl-violet  the  amyloid  substance  is  coloured  ruby-red,  whilst 
normal  tissues  are  stained  blue  or  indigo.  The  organs  mainly 
affected  are  the  liver,  spleen,  kidneys,  and  villi  of  the  intestines. 
The  liver  becomes  evenly  enlarged  to  a  considerable  degree,  often 
reaching  from  the  fifth  rib  to  the  umbilicus,  or  lower;  it  is  firm  in 
consistency,  like  indiarubber,  painless,  and  waxy-looking  on  section. 
The  arterioles  and  capillaries  in  the  intermediate  zone  of  the  lobules 
are  those  first  affected,  but  the  gland  cells  soon  participate  in  the 
change.  The  glycogenic  and  bile-producing  functions  are  naturally 
interfered  with,  so  "that  the  digestive  process,  and  especially  the 
power  of  absorbing  fats,  is  impeded,  although  the  appetite  may 
remain  good.  The  kidneys  become  similarly  enlarged,  the  change 
commencing  in  the  arterioles  leading  to  the  glomeruli  (Fig.  17), 
but  the  capillaries  and  the  tubal  epithelium  are  also  early  affected. 
In  this  stage  the  urine  is  very  abundant  (from  the  increased  filtra- 
tion through  the  degenerated  walls),  pale,  limpid,  and  containing 
a  few  hyahne  casts  and  fatty  cells;  later  on,  when  the  tubules  are 
more  largely  involved,  there  is  less  urine,  with  a  higher  specific 
gravity,  and  a  considerable  amount  of  albumen.  The  spleen  increases 
in  size,  but  not  always  to  so  great  an  extent  as  the  other  viscera;  the 
Malpighian  bodies  are  the  chief  seat  of  the  mischief.  The  capillaries 
in  the  villi  of  the  intestines  become  lardaceous,  and  allow  of  an  in- 
creased transudation  of  the  fiuid  parts  of  the  blood,  resulting  in 
diarrhoea;  the  absorption  of  nutriment  is  thereby  much  lessened, 
and  thus  both  by  increased  excretion  and  diminished  absorption  of 
food  the  strength  of  the  patient  is  steadily  undermined. 

Amyloid  changes  in  the  viscera,  far  from  being  a  contra-indication 
to  operation,  are  rather  to  be  considered  as  a  sign  that  radical  treat- 
ment is  urgently  necessary,  unless  the  general  condition  of  a  patient 
is  such  that  he  cannot  stand  the  strain  of  it.  If  by  an  operation — 
e.g.,  excision  or  amputation — the  local  disease  can  be  eradicated,  the 
amyloid  changes  in  the  viscera  may  totally  disappear.  At  the  same 
time  one  must  not  forget  that  the  kidneys  are  seriously  damaged, 
and  that  antiseptics,  such  as  carboHc  acid,  which  are  absorbed  into 
the  blood  and  eliminated  in  the  urine,  may  Hght  up  an  acute  nephritis 
with  possibly  fatal  results. 

Persistent  suppuration  is  present  in  a  large  series  of  other  condi- 
tions than  those  following  the  opening  of  an  abscess,  prominent 
amongst  them  being  that  known  as  oral  sepsis.  The  lesion  usually 
present  is  pyorrhoea  alveolaris  {q.v.),  in  which  suppurating  pouches 
form  in  the  gums  around  the  roots  of  teeth,  which  are  generally 
dirty,  decayed,  and  covered  with  tartar;  the  tongue  is  coated,  and 
the  breath  offensive.  Grave  results  may  follow,  partly  from  the 
constant  swallowing  of  bacteria  and  their  toxins,  partly  by  their 
direct  absorption  through  the  granulation  tissue  which  surrounds 
the  teeth,  (i)  The  ingestion  of  pyogenic  bacteria  and  their  toxins 
acts  injuriously  upon  the  gastric  and  intestinal  mucous  membranes, 


NON-SPECIFIC  PYOGENIC  INFECTIONS  85 

SO  that  the  natural  antiseptic  powers  of  the  gastric  juice  are  lost  or 
diminished;  and  thus  a  chronic  gastritis  may  ensue,  as  also  gastric 
or  duodenal  ulcers,  whilst  it  is  a  noticeable  fact  that  a  septic  state 
of  the  mouth  due  to  bad  teeth  is  constantly  found  in  the  subjects  of 
appendicitis.  In  this  connection  it  is  advisable  to  note  that  careful 
disinfection  of  the  buccal  cavity  should  always  follow,  as  well  as 
precede,  such  operations  as  gastro-enterostomy,  excision  of  the 
tongue,  removal  of  the  jaw,  etc.,  so  as  to  minimize  the  risks  of 
infection  which  might  follow.  (2)  The  air-passages  may  become 
infected  as  an  outcome  of  oral  sepsis,  in  the  form  of  a  tracheitis  with 
an  abundant  muco-purulent  expectoration.  Aspiration  pneumonia 
may  follow  the  administration  of  an  anaesthetic  in  such  cases.  (3)  A 
mild  aucemia  of  a  secondary  type  may  develop,  characterized  by  a 
blood  count  showing  3,000,000  or  so  red  corpuscles,  60  to  70  per  cent, 
of  haemoglobin,  and  a  moderate  leucocytosis.  Occasionally  the 
anaemia  may  be  of  a  graver  type,  corresponding  to  the  pernicious 
variety  (Hunter).  It  is  also  interesting  to  note  that  in  lymphatic 
leukaemia  ulceration  of  the  mouth  is  often  present.  (4)  Many  other 
general  conditions  may  ensue — e.g.,  a  constant  feeling  of  malaise, 
headache,  mild  furunculosis,  and  various  phenomena  due  to  neuritis. 
Occasionally  severe  pyrexia  of  a  typhoid  type  has  supervened,  the 
temperature  falling  rapidly,  and  the  patient  recovering  as  soon  as  the 
mouth  and  teeth  had  received  attention.  Chronic  osteitis  and 
arthritis  also  occur,  and  the  condition  described  hereafter  as  chronic 
osteo-arthropathy  is  due  to  the  chronic  absorption  of  toxic  material. 

II.  CelluUtis. 

Cellulitis  (or,  as  it  used  to  be  termed,  diffuse  phlegmon)  is  a  disease 
characterized  by  the  existence  of  a  spreading  inflammation  of  the 
subcutaneous  or  cellular  tissues,  due  to  the  activity  of  pyogenic 
organisms,  and  running  on  to  suppuration,  sloughing,  or  even  to 
extensive  gangrene. 

Causation. — The  one  essential  is  the  infection  of  the  cellular  tissues 
with  organisms  which  have  gained  an  entrance  through  an  operation 
wound,  or  through  an  accidental  breach  of  surface,  or  even  through 
some  slight  graze,  prick,  or  scratch.  Deep  infected  wounds  which 
are  not  properly  drained  are  amongst  the  most  favourable  for  the 
development  of  this  condition,  especially  if  the  general  health  of 
the  individual  is  bad,  if  he  is  suffering  from  albuminuria  or  diabetes, 
or  if  his  surroundings  are  of  an  insanitary  nature.  Wherever  much 
loose  cellular  tissue  is  present,  inflammatory  phenomena  readily 
supervene,  owing  to  the  absorption  of  bacteria  from  neighbouring 
contaminated  structures — e.g.,  pelvic  cellulitis  arising  from  an  in- 
fected uterus,  or  cellulitis  of  the  neck  from  an  ulcerated  throat. 

Bacteriology. — The  Streptococcus  pyogenes  is  the  organism  most 
frequently  found  in  cases  of  cellulitis,  particularly  when  there  is 
much  tendency  to  spread.  In  some  of  the  more  localized  forms  the 
Staphylococcus  pyogenes  is  present,  whilst  in  the  gravest  and  most 


86  A   MANUAL  OF  SURGERY 

acute  manifestation  the  B.  nedematis  maligni  is  responsible  for  the 
trouble  (p.  122),  and  the  disease  is  then  identical  with  what  is  usually 
known  as  acute  emphysematous  or  infective  gangrene. 

Clinical  History. — The  symptoms  necessarily  differ  somewhat 
according  to  the  site  of  inoculation  and  the  virulence  of  the  causa- 
tive microbes,  and  hence  anything  from  a  localized  suppuration  to 
the  acutest  form  of  spreading  gangrene  may  result.  In  a  case  of 
moderate  severity,  due  to  a  prick  or  abrasion  which  has  become 
infected,  there  is  often  a  period  of  quiescence  for  a  day  or  two, 
and  the  site  of  inoculation  shows  but  slight  signs  of  inflammation, 
beyond  being  a  little  tender.  The  patient,  though  feeling  somewhat 
seedy,  is  able  to  continue  his  work,  but  is  finally  obliged  to  give 
up,  owing  partly  to  the  increased  pain,  partly  to  his  general  con- 
dition. Fever  is  almost  always  present  to  a  greater  or  less  degree, 
and  in  the  more  severe  types  one  or  more  rigors  occur,  or  the  tem- 
perature may  be  subnormal,  owing  to  the  intensity  of  the  toxarniia. 
The  affected  part  is  found  to  be  hot,  tender,  and  infiltrated;  if 
superficial,  it  looks  red  and  angry,  and  feels  brawny.  In  some 
cases  local  haemorrhages  or  petechial  spots  are  found  in  addition  to 
the  other  inflammatory  phenomena.  The  course  of  the  case  de- 
pends to  a  very  large  extent  upon  the  treatment  adopted;  if  freely 
incised,  the  process  may  become  limited,  and  although  suppuration 
and  sloughing  occur,  repair  is  readily  effected;  if,  however,  the 
vims  is  very  active,  or  the  patient's  power  of  resistance  low,  or  if 
the  inflamed  area  is  left  to  itself  or  merely  poulticed,  the  process 
may  spread  rapidly,  and  extensive  destruction  follow.  Intense 
pain  and  sleeplessness,  accompanied  perhaps  with  delirium,  form  the 
most  prominent  symptoms,  and  these,  together  \\ith  the  toxic  fever, 
rapidly  exhaust  the  patient's  strength.  Suppuration  at  length  occurs, 
but  is  often  of  slow  development,  and  the  swelhng  may  remain  hard 
and  brawny  for  some  time  in  such  a  region  as  the  neck  with  no 
evidence  of  softening,  so  that  it  may  be  difficult  to  determine  whether 
pus  is  present  or  not.  The  infiltrated  cellular  tissues  are  likely  to 
slough,  and  in  a  hmb  extensive  subcutaneous  necrosis  may  occur, 
although  the  skin  only  gives  way  in  places ;  hence  it  is  often  possible 
to  pass  a  probe  between  the  skin  and  the  deep  fascia  over  a  con- 
siderable area.  Sometimes  the  inflammation  skips  a  part  of  the 
limb,  the  chief  focus  of  mischief  being  found  at  a  distance  from  the 
original  site  of  inoculation,  whilst  the  intervening  portion  is  but 
little  affected,  or  shows  the  characteristic  features  of  acute  lymph- 
angitis {q.v.).  This  is  due  to  the  organisms  or  their  toxins  being 
transmitted  along  the  lymphatics,  and  then  arrested  at  a  higher 
level.  Occasionally  the  trouble  spreads  along  the  deeper  areolar 
planes,  or  even  along  muscular  belUes,  which  may  be  infiltrated  with 
pus  or  may  actually  slough.  In  all  these  more  severe  forms  the 
patient  runs  a  considerable  risk  of  developing  general  septicaemia 
or  pyaemia. 

Treatment. — Careful  attention  to  the  dicta  of  antiseptic  surgery 
can  pre^^ent  the  occurrence  of  cellulitis  to  a  very  large  extent  in 


NON-SPECIFIC  PYOGENIC  INFECTIONS  87 

casualty  and  operative  work.  Abrasions  and  small  punctured 
wounds  should  always  be  protected,  and  all  penetrating  injuries 
disinfected,  especially  if  the  patient  runs  exceptional  risk  of  infection 
owing  to  his  occupation  or  surroundings,  or  to  the  nature  of  the 
injury.  Should  inflammatory  phenomena  supervene,  the  application 
of  antiseptic  fomentations,  such  as  the  boracic  poultice,  may  prevent 
their  extension,  whilst  the  bowels  should  be  freely  acted  upon  and 
the  general  health  attended  to.  If  suppuration  is  present  or  is 
threatening,  free  incisions  in  the  long  axis  of  the  limb  should  be 
made  into  the  brawny  tissues,  so  as  to  give  exit  to  the  serous  and 
irritating  discharges,  and  to  allow  sloughs  to  be  cut  or  scraped 
away;  the  wounds  thus  made  are  hghtly  packed  with  aseptic  or 
iodoform  gauze,  over  which  the  usual  dressings  are  appHed.  The 
object  of  this  is  to  drain  the  fluids  from  the  parts  by  capillary  action, 
and  hence  an  effective  junction  must  be  maintained  between  the 
gauze  drain  and  the  surrounding  dressing.  It  is  often  wise  to  incor- 
porate a  piece  of  sterilized  gutta-percha  tissue  or  mackintosh  in  the 
outer  folds  of  the  dressing,  so  as  to  keep  the  parts  moist  and  encour- 
age a  free  discharge.  Extension  of  the  mischief  requires  further 
incisions,  and  the  surgeon  must  follow  up  the  disease  with  the  knife. 
At  the  same  time  the  patient's  health  and  strength  must  be  main- 
tained by  the  administration  of  suitable  food,  drugs,  such  as  quinine, 
and  stimulants. 

After  the  bleeding  caused  by  the  incisions  has  ceased,  the  limb 
should  be  daily  immersed  in  a  warm  bath  for  some  hours  so  as  to 
dilute  the  toxins  and  render  them  innocuous.  The  bath  should  not 
continue  for  more  than  three  or  four  hours  at  a  time,  for  fear  of 
the  tissues  becoming  sodden.  Sterilized  salt  solution  at  a  tem- 
perature of  105°  to  110°  F.  does  perfectly  well;  antiseptics  are 
practically  useless  in  checking  the  disease  when  once  started;  the 
surgeon  has  to  depend  mainly  on  relief  of  tension,  the  removal  of 
toxic  discharges,  and  the  antiseptic  power  of  the  tissues.  At  the 
same  time  the  utmost  care  must  be  taken  to  prevent  any  fresh  or 
mixed  infection  of  wounds  from  decomposition  of  discharges. 

Polyvalent  antistreptococcic  serum  (p.  27)  has  also  been  employed 
as  a  curative  agent,  with  a  view  to  destroy  the  streptococci  (prob- 
ably by  a  bacteriolytic  action)  and  immunize  the  system  to  their 
further  development.  A  dose  of  20  c.c.  (i  c.c.  =  ili^xvii.)  may  be 
given  to  start  with,  followed  by  10  c.c.  twice  a  day  beneath  the 
skin  of  the  back  or  abdominal  wall.  The  results  have  been  very 
variable;  sometimes  it  is  apparently  effective,  but  not  unfrequently 
the  results  have  been  most  disappointing.  In  the  less  acute  cases 
vaccine  treatment  may  be  beneficial. 

Special  Varieties  of  Cellulitis. 

Cellulitis  of  the  Axilla  not  unfrequently  follows  an  infected  wound  of  the 
hand,  such  as  occurs  in  the  post-mortem  room,  and  hence  is  not  uncommon  in 
medical  practitioners,  students  or  nurses.  It  may  also  be  caused  by  extension 
from  an  axillary  lymphadenitis.  The  tissues  of  the  armpit  become  hai'd  and 
brawny,  the  pain  is  severe,  especially  on  movement  of  the  shoulder,  and  the 


88  A   MANUAL  OF  SURGERY 

disease  is  liable  to  spread  towards  the  chest  walls  under  or  between  the  pectoral 
muscles;  it  may  also  travel  upwards,  and  lay  open  the  shoulder-joint  from 
sloughing  of  the  capsule,  and  so  give  rise  to  an  acute  arthritis.  Early  and 
extensive  incisions  are  required  in  order  to  })rcvcnt  such  comjilications,  but 
respect  must  be  paid  to  important  vessels  and  nerves  contained  in  the  cavity. 

Cellulitis  of  the  Scalp^usually  results  from  a  wound  which  has  traversed  the 
occipito-frontalis  aponeurosis,  and  opened  up  the  subjacent  layer  of  loose 
areolar  tissue;  it  may,  however,  follow  a  simple  laceration  of  the  scalp  and 
remain  superficial.  In  the  latter  case  the  scalp  becomes  red,  oedematous, 
and  tender,  but  the  inflammation  remains  more  or  less  localized  ;  in  the  former, 
pus  forms  beneath  the  aponeurosis,  and  extends  to  its  limits  of  attachment, 
so  that  abscesses  are  likely  to  point  in  the  forehead  just  above  the  eyebrows, 
over  the  zygoma,  or  along  the  superior  curved  line  of  the  occipital  bone. 
The  whole  scalp  may  be  lifted  up,  and  the  patient  runs  a  risk  of  necrosis  of  the 
cranial  bones  and  of  various  intracranial  complications.  The  scalp  itself, 
however,  rarely  sloughs  owing  to  its  abundant  vascular  supply.  In  both  con- 
ditions the  temperature  is  often  high  and  the  patient  severely  ill.  The 
treatment  consists  in  making  early  and  free  incisions  parallel  to  the  lines  of  the 
vessels,  and  the  insertion  of  drainage-tubes  when  the  pus  is  beneath  the 
aponeurosis. 

Cellulitis  of  the  Orbit  is  not  an  uncommon  sequela  of  penetrating  wounds  in 
this  region,  owing  to  the  difficulty  of  rendering  them  aseptic  and  of  draining 
them.  It  may  also  result  from  inflammation  of  the  bony  walls,  secondary  to 
suppuration  within  the  cranial  sinuses.  The  orbital  tissues  become  infiltrated 
and  swollen,  the  lids  are  oedematous,  and  the  e^'eball  is  thrust  forwards 
(proptosis).  The  inflammation  may  spread  to  the  meninges,  owing  to  the 
dura  mater  being  continuous  with  the  orbital  periosteum  through  the  fora- 
mina by  which  the  nerves  and  vessels  enter.  Necrosis  of  the  orbital  walls 
may  also  occur,  whilst  the  eye  itself  may  suffer  either  from  an  infective  panoph- 
thalmitis due  to  lymphatic  infection,  or  from  optic  neuritis  secondary  to 
retro-ocular  inflammation  and  pressure,  or  at  a  later  date  from  optic  nerve 
atrophy  secondary  to  cicatricial  contraction  around  the  nerve.  If  the  cellular 
tissue  of  the  orbit  sloughs,  the  subsequent  movements  of  the  globe  may  be 
much  hampered,  or  indeed  lost,  whilst  the  lids  may  be  drawn  back  to  such 
an  extent  as  to  prevent  their  complete  closure. 

Treatment. — No  penetrating  wound  of  the  orbit  ought  to  be  closed  if  there 
is  any  question  of  its  infection;  indeed,  it  is  often  wise  to  increase  its  size 
slightly,  so  as  to  enable  the  deeper  parts  to  be  explored  and  drained.  If 
cellulitis  follows,  the  original  wound  must  be  opened  up,  and  possibly  fresh 
incisions  made  either  through  the  lids  or  through  the  fornix  conjunctivae. 
Antiseptic  fomentations  are  then  applied.  If  panophthalmitis  supervenes, 
the  eyeball  must  be  incised  crucially;  this  is  a  safer  proceeding  than  enuclea- 
tion, which  is  more  liable  to  be  followed  by  meningitis. 

Cellulitis  of  the  Neck  is  usually  secondary  to  lesions  in  the  throat,  and  there- 
fore associated  with  follicular  tonsillitis,  diphtheria,  or  scarlatina,  the  process 
probably  starting  in  a  deep  lymphatic  gland  ;  it  occasionally  follows  operations 
on  the  neck.  The  tissues  beneath  the  deep  cervical  fascia  become  infected, 
usually  with  streptococci,  and  sooner  or  later  suppuration  occurs.  The 
affected  side  of  the  neck  is  swollen,  red,  and  brawny;  severe  pain  of  a  deep 
tensive  character  is  experienced,  and  this  is  increased  by  movements  of  the 
head  or  jaw.  The  swelling  is  often  peculiarly  hard  and  resistant  (the  woody 
angina  of  French  writers),  and  although  redema  may  be  present,  it  may  be 
several  days  before  the  surgeon  can  detect  any  focus  of  softening  suggestive 
of  suppuration.  During  this  period  the  constitutional  symptoms  are  severe; 
fever  may  be  high,  and  the  pain  and  subsequent  sleeplessness  may  exhaust 
the  patient,  whilst  the  difficulty  of  swallowing  hinders  his  nutrition .  Dangerous 
symptoms  arise  from  pressure  on  important  vessels  and  nerves,  from  extension 
of  the  inflammation  to  the  mediastinum  or  to  the  glottis,  causing  oedema  and 
consequent  dyspnoea,  or  from  the  supervention  of  pyaemia  owing  to  venous 
thrombosis.  The  process  usually  ends  in  sloughing  of  the  cellular  tissue 
and  suppuration,  the  pus  burrowing  widely  if  a  free  exit  by  incisions  through 
the  deep  fascia  is  not  provided. 


NON-SPECIFIC  PYOGENIC  INFECTIONS  89 

Treatment. — The  causative  lesion  in  the  throat  must  be  attended  to,  any 
operation  wound  freely  opened  up  and  drained,  and  the  general  condition 
improved  by  the  administration  oi'  nourishing  lluid  food,  stimulants,  and 
quinine.  Antistreptococcic  serum  may  also  be  injected,  but  sometimes  anti- 
diphtheritic  serum  (given  hypodermically  or  by  mouth)  has  been  found  more 
useful.  Locally,  fomentations  are  applied  in  the  first  place;  but  on  the  onset 
of  suppuration,  or  before,  if  the  pressure  symptoms  are  severe,  or  if  the  affec- 
tion is  obviously  extending,  free  incisions  must  be  made  along  lines  of  safety 
beneath  the  deep  fascia,  so  as  to  relieve  tension  and  give  exit  to  discharges. 
It  must  be  remembered  that  the  tissues  are  matted  together  in  such  a  way  as 
renders  their  recognition  difficult;  and  inasmuch  as  the  pus  often  lies  deeply, 
the  greatest  caution  has  to  be  taken  to  avoid  injury  of  important   structures. 

Special  interest  has  been  directed  to  a  form  of  this  affection  which  occurs  in 
the  submaxillary  region,  and  is  known  as  Ludwig's  angina.  It  is  usually 
secondary  to  some  buccal  focus,  or  may  occasionally  result  from  the  extension 
of  inflammation  beyond  the  capsule  of  lymphatic  glands,  or  may  originate  in 
disease  of  the  middle  ear,  the  mischief  spreading  down  along  the  posterior  belly 
of  the  digastric.  The  swelling  in  these  cases  extends  forwards  beneath  the 
chin,  and  may  involve  the  floor  of  the  mouth  and  base  of  the  tongue,  pushing 
that  organ  forwards,  and  even  making  it  protrude  from  the  mouth.  (Edema 
of  the  glottis  may  supervene,  or  a  sublingual  abscess  form.  Treatment  is 
similar  to  that  indicated  above,  and  one  or  more  incisions  may  be  required. 
(Edenaa  of  the  glottis  will  probably  require  tracheotomy. 

Pelvic  Cellulitis  is  an  infective  inflammation  of  the  loose  cellular  tissue 
which  ensheaths  the  pelvic  viscera.  It  may  result  from  any  penetrating 
wound,  accidental  or  operative,  which  encroaches  on  this  region — e.g.,  extra- 
peritoneal rupture  or  perforation  of  the  bladder,  suprapubic  or  lateral  lith- 
otomy, injudicious  catheterism,  curetting  the  uterus,  and  sometimes  attempts 
to  induce  abortion.  It  may  also  be  due  to  the  absorption  of  bacteria  from 
any  of  the  pelvic  viscera — e.g.,  the  bladder,  prostate,  rectum,  uterus,  or 
Fallopian  tube.  It  is  associated  with  all  the  local  and  general  signs  of  deep 
inflammation,  and  often,  indeed,  with  peritonitis,  giving  rise  to  a  tense, 
flrm,  painful  swelling,  to  be  felt  per  rectum  or  per  vaginam,  and  sometimes 
to  an  indurated  mass  of  inflammatory  effusion,  dull  on  percussion,  above  the 
pubic  arch.  Abscesses  may  form,  bursting  either  externally  above  Poupart's 
ligament  or  into  some  of  the  viscera,  or  possibly  in  both  directions,  pro- 
ducing intractable  forms  of  urinary  or  faecal  flstulae,  whilst  venous  obstruction 
and  pyaemia  are  likely  to  develop. 

The  surgeon  may  be  called  on  to  deal  with  such  cases  either  in  the  early  pre- 
suppurative  stage,  when  rest,  limitation  of  diet,  small  doses  of  opium,  and 
fomentations  to  the  hypogastrium,  conjoined  perhaps  with  hot  antiseptic 
rectal  or  vaginal  douches,  should  be  adopted;  or  at  a  later  date,  when  pus  has 
formed  and  the  abscesses  need  to  be  opened.  An  incision  is  generally  made 
just  above  Poupart's  ligament  and  close  to  the  pubic  spine;  the  abdominal 
muscles  are  divided  to  a  sufficient  extent  to  enable  the  surgeon  to  work  down- 
wards between  the  transversalis  fascia  and  the  peritoneum,  which  must  be 
pushed  aside  in  order  to  reach  the  broad  ligament,  where  pus  is  frequently 
found.  As  soon  as  the  subperitoneal  tissue  is  opened,  the  knife  should  be 
discarded,  and  only  blunt  instruments  or  the  flngers  employed.  The  cavity 
of  the  abscess  should  be  well  washed  out  and  efficiently  drained,  and  possibly 
a  counter-opening  through  the  vagina  may  be  required. 

Intestinal  obstruction  may  develop  as  a  remote  sequela  from  the  contraction 
of  cicatrices,  and  hydronephrosis  may  arise  in  the  same  way  from  pressure  on 
the  ureter. 

III.  Wound  Infection. 

When  a  wound,  whether  accidental  or  operative,  has  become 
infected  with  micro-organisms,  healthy  reparative  action  ceases, 
and  is  replaced  by  an  inflammatory  process  of  a  suppurative  type 


go  A   MANUAL  OF  SURGERY 

with  the  object  of  coping  with  the  bacteria.  To  this  condition 
the  term  sepsis  was  formerly  applied,  but  with  our  modern  know- 
ledge the  terms  '  sepsis  '  and  '  septic  '  are  rarely  needed,  and, 
indeed,  are  better  avoided  where  possible.  The  organisms  usually 
present  are  staphylococci,  but  in  the  worst  cases  streptococci  may 
be  found,  and  in  others  the  presence  of  saproph^iiic  germs  may 
constitute  a  mixed  infection. 

In  casualty  work  wound  infection  is  often  unavoidable,  and  due 
to  the  dirty  state  of  the  skin  or  the  nature  of  the  accident;  and, 
however  thorough  the  subsequent  disinfection,  it  may  be  impos- 
sible to  render  the  parts  sterile.  After  an  operation,  wound  infec- 
tion is  usually  due  to  some  gross  avoidable  mistake  or  oversight, 
rarely  to  auto-infection.  Ineffective  sterilization  of  silk  or  catgut 
is  perhaps  the  most  frequent  cause  of  infection,  since  the  intro- 
duction of  rubber  gloves  has  safeguarded  the  hands  of  the  surgeon 
and  his  assistants. 

The  local  trouble  may  manifest  itself  merely  as  an  acute  or  sub- 
acute suppurative  process  within  the  wound,  or  as  an  active 
cellulitis  spreading  into  the  adjacent  tissues.  It  may  commence 
deeply  around  a  buried  stitch,  or  more  superficially.  In  the  latter 
case  the  lips  of  the  wound  look  red  and  puffy,  the  tissues  often 
swell  up  between  the  stitches,  which  look  as  if  they  were  too  tight, 
and  on  introducing  a  probe  pus  may  escape;  the  patient  complains 
of  pain,  usually  of  a  throbbing  nature,  and  there  is  some  rise  of 
temperature,  and  in  bad  cases  even  a  rigor.  In  the  milder  forms 
the  trouble  is  limited  to  the  immediate  neighbourhood  of  the 
wound;  but  if  neglected,  or  in  an  unhealthy  subject,  or  if  due  to 
virulent  germs,  the  phenomena  of  an  acute  cellulitis  may  superv^ene. 

When  the  process  starts  in  the  deeper  parts  of  the  wound,  nothing 
may  be  obvious  on  the  surface  for  a  few  days,  except  perhaps 
some  fulness  and  tenderness  on  pressure.  It  will  usuall}'  be  found, 
however,  that  the  temperature  is  shghtly  raised,  and  that  some 
tensive  pain  is  present.  Sooner  or  later  an  abscess  develops  and 
comes  to  the  surface,  and  a  sinus  is  likely  to  be  left  until  the  hgature 
or  buried  stitch  has  been  absorbed  or  removed.  The  same  holds 
good  as  regards  silver  wire,  screws,  plates,  etc.,  which  must  be 
removed  before  heahng  can  take  place. 

The  Local  Treatment  of  an  infected  wound  consists  essentially 
in  the  rehef  of  all  tension,  and  the  apphcation  of  warmth  and 
moisture  to  the  part,  to  encourage  the  local  reparative  acti\'ity  of 
the  tissues.  Stitches  must  be  immediately  removed,  and  the 
wound  widely  opened  up,  so  as  to  give  a  free  exit  to  the  pus.  Undue 
interference  with  the  wound,  as  by  squeezing,  scraping,  etc.,  is 
to  be  deprecated,  as  thereby  germs  may  be  disseminated.  Sloughs 
are  left  to  separate  by  natural  processes,  and  even  syringing  or 
washing  out  the  wound  must  be  limited  in  the  early  stages. 
Peroxide  of  hydrogen  (lo- volume  solution)  is  useful,  but  not  at 
first,  since  the  sudden  liberation  of  oxygen  may  drive  germs  into 
the  tissues,  and  therebv  increase  the  trouble.     The  application  of 


NON-SPECIFIC  PYOGENIC  INFECTIONS  91 

stronger  antiseptics  is  equally  futile,  since  the  germs  are  in  the 
tissues,  and  cannot  be  destroyed  without  also  involving  these 
structures;  moreover,  the  phagocytic  power  of  the  leucocytes  is 
checked  by  such  applications.  The  wound,  thus  opened  up,  is 
lightly  but  thoroughly  packed  with  gauze,  and  if  there  is  a  deep 
cavity  it  may  be  desirable  to  introduce  a  drainage-tube,  since  pus 
does  not  easily  escape  along  a  gauze  drainage-wick.  Warm  moist 
dressings,  such  as  an  antiseptic  fomentation,  are  then  apphed,  or 
the  limb  is  immersed  in  a  bath  at  a  temperature  of  105°  to  no  F. 
for  some  hours  daily.  At  the  same  time  the  bowels  must  be  freely 
opened,  and  the  general  health  of  the  patient  carefully  watched. 
In  a  few  days,  when  granulations  have  formed,  the  wound  may  be 
irrigated  with  salt  solution  or  swabbed  out  with  peroxide  of 
hydrogen.  Healing  is  finally  brought  about  by  granulation,  but 
can  sometimes  be  hastened  by  strapping  the  edges  of  the  wound 
together,  or  by  grafting.  j   •    r     ,  • 

The  general  phenomena  connected  with  wound  infection  vary 
chiefly  in  respect  of  the  dose  of  toxins  absorbed. 

I.  Acute  Toxsemia  (formerly  known  as  septic  traumatic  fever) 
results  from  the  absorption  of  a  large  dose  of  toxic  material  from 
some  focus  of  infective  inflammation  of  sufficient  extent  and  viru- 
lence. A  small  collection  of  pus  under  pressure  is  capable  of 
giving  rise  to  marked  toxic  symptoms,  whilst  in  spreading  inflamma- 
tions, such  as  erysipelas  and  celluhtis,  the  manifestations  are 
often  of  a  grave  type.  The  same  is  true  of  infective  inflammation 
of  the  peritoneal  cavity,  especially  when  the  upper  half  is  involved, 
since  the  communication  with  the  lymphatics  of  the  diaphragm 
is  very  free.  Toxaemia  is  not  unfrequently  associated  with  a  true 
septiccemia,  and  cHnically  it  may  be  almost  impossible  to  distinguish 
between  the  two.  . 

The  Symptoms  are  characterized  by  fever,  except  m  some  of  the 
gravest  cases,  when  the  temperature  may  be  subnormal,  although 
the  pulse  may  still  remain  high.  This  is  accompanied  by  loss  of 
appetite,  a  dry  tongue,  a  quick  pulse,  rapidly  becoming  w^k, 
severe  headache,  and  nocturnal  dehrium  of  some  intensity.  Ihe 
patient  is  at  first  constipated,  but  vomiting  and  diarrhoea  niay 
ensue  from  gastro-intestinal  irritation,  followed  by  fatal  exhaustion 
and  collapse;  or  he  may  become  comatose  and  unconscious  for  some 
time  before  death,  according  to  whether  the  toxins  act  principally 
upon  the  alimentary  or  nervous  systems.  Dyspnoea  from  puhnonary 
congestion,  and  albuminuria,  also  occur.  Effective  treatment  of  the 
cause,  as  by  opening  an  abscess,  or  drainage,  may  lead  to  a  speedy 
disappearance  of  the  symptoms,  but  in  spreading  inflammation  the 
toxaemia  may  not  subside  for  some  time.  _ 

Post-mortem  Appearances.— Decomposition  is  early,  rigor  mortis 
feeble,  and  cadaveric  hvidity  well  marked,  especially  along  the  hnes 
of  the  superficial  veins  and  posteriorly.  The  blood  coagulates 
imperfectly,  and  is  dark  and  tarry  in  colour;  if  allowed  to  stand, 
the  serum  which  separates  from  the  corpuscles  is  much  stained  trom 


92  A   MANUAL  OF  SURGERY 

the  breaking  up  of  the  red  blood  cells  which  occurs  in  all  acute 
infective  cases.  This  condition  explains  the  amount  of  cadaveric 
lividity,  and  also  the  post-mortem  staining  of  the  endocardium  and 
tunica  intima  of  the  larger  vessels,  which  is  such  a  marked  feature 
in  these  cases,  and  which  was  formerly  supposed  to  result  from 
a  diffuse  arteritis.  Most  of  the  serous  cavities  contain  a  certain 
amount  of  blood-stained  fluid,  and  under  almost  all  the  serous  mem- 
branes are  well-marked  petechise,  especially  under  the  pericardium 
and  pleura.  The  lungs  are  deeply  congested,  particularly  at  the 
back,  and  very  oedematous  ;  the  liver,  spleen,  and  kidneys  are 
enlarged,  pulpy,  soft,  and  congested,  notably  the  spleen.  The 
epithehum  of  most  of  the  secreting  glands,  if  examined  micro- 
scopically, gives  evidence  of  cloudy  swelling. 

The  Treatment  of  acute  toxaemia  must  be  chiefly  directed  to  the 
local  cause,  which  is  dealt  with  by  suitable  surgical  means.  General 
treatment  is  merely  symptomatic.  Possibly  a  good  purge  may  be 
advisable  in  the  early  stages,  but  in  the  later  a  supporting  and 
stimulating  plan  of  treatment  must  be  adopted.  Recently  the 
acute  toxaemia  of  peritonitis  and  similar  conditions  has  been  treated 
by  the  continuous  injection  into  the  rectum  of  large  quantities 
of  sahne  solution  (3i.  ad  Oi.),  and  excellent  results  have  been 
obtained;  the  injections  are  followed  by  diuresis  and  diaphoresis, 
which  presumably  assist  in  the  elimination  of  the  poison.  In  some 
cases  intravenous  injections  may  appear  desirable,  and  then  it  is 
wise  to  insert  the  needle  of  the  infusion  apparatus  directly  into  a 
vein  without  dissection,  as  the  wound  might  otherwise  become 
infected. 

2.  When  the  dose  of  toxins  is  smaller,  but  absorbed  regularly 
and  for  a  long  time,  a  definite  diurnal  range  of  temperature  follows, 
known  as  hectic  fever  (p.  82). 

3.  Acute  Saprsemia  is  a  term  that  is  now  rarely  employed  in 
surgical  practice,  but  is  rather  retained  for  a  condition  which  occurs 
during  the  puerperium,  due  to  the  decomposition  of  a  portion  of 
retained  placenta,  as  the  result  of  a  mixed  infection.  The  symp- 
toms are  moderately  severe,  and  entirely  due  to  chemical  poisoning. 
Removal  of  the  putrid  mass  results  in  almost  immediate  cessation 
of  the  fever  and  all  the  other  manifestations. 

IV.  Septicaemia. 

Septicaemia  is  an  acute  general  infective  disorder,  arising  from 
the  development  of  some  variety  of  pyogenic  organism  in  the  blood. 
It  differs  from  pj-aemia  in  the  absence  of  secondary  abscesses 
(although,  as  explained  later,  it  may  be  associated  with  it),  and  from 
toxaemia  or  saprsemia,  by  the  fact  that  the  latter  are  merely  due  to 
the  absorption  into  the  blood  of  toxins  generated  in  a  diseased  focus 
in  which  the  bacteria  themselves  remain  localized.  In  septicjemia 
the  organisms  circulate  in  the  blood,  though  in  many  cases  in  but 
scanty  numbers,  so  that  it  is  necessary  to  take  rather  large  quantities 


NON-SPECIFIC  PYOGENIC  INFECTIONS  93 

of  blood  (5  c.c.  or  more)  for  a  bacteriological  examination.  Further, 
even  in  severe  cases  of  septicemia  periods  occur  m  which  no  bacteria 
can  be  detected  in  the  blood,  so  that  too  much  weight  should  not  be 
attached  to  a  single  negative  result.  ■,     u^    n      +1, 

Bacteriology.  —  The  commonest  orgamsm  is  undoubtedly  the 
Strebfococciis  pyogenes,  which  is  found  in  about  50  per  cent  ot  all 
cases-  it  is  almost  always  present  in  the  septicemia  dependent  on 
puerperal  diseases  and  in  ulcerative  endocarditis,  where  the  lesion  m 
the  heart  acts  as  the  source  of  the  bacteria  m  the  circulating  blood. 
Next  in  frequency  is  t\iePneiimococciis,\\'hich  often  causes  septicsemia, 
even  when  no  puhnonarv  or  other  local  lesion  can  be  traced.  The 
Stabhvlococcus  pyogenes'  is  also  a  fairly  common  organism  m  this 
disease,  and  the  prognosis  is  then  decidedly  better  than  m  cases 
due  to  the  streptococcus  or  pneumococcus. 

Rare  causes  are  the  B.  coli  and  alUed  organisms,  B.  pyocyaneiis, 
B.  (Tdematis  maligni,  and  the  Gonococcns. 

Clinical  History.— Septicemia  occurs  most  commonly  from  direct 
inoculation  with  suitable  organisms  through  small  lesions,  such  as 
post-mortem  wounds,  or  from  scratches  or  punctures  wath  infected 
pins  or  instruments;  it  also  in  rarer  cases  follo^^^  operation  wounds 
and  severe  lacerated  injuries.  It  is  the  usual  accompamment  of 
acute  spreading  gangrene  (p.  122),  and  may  be  met  with  m  celluhtis 
and  cancrum  oris  (p.  123).  As  a  rule  the  individual  attacked  is  m  a 
depressed  and  debihtated  condition,  perhaps  deteriorated  by  alco- 
holic or  other  excesses,  so  that  the  inherent  germicidal  activity  o± 
the  tissues  is  markedly  insufficient  to  cope  mth  the  inroads  of  the 

^The  point  of  inoculation  mav  be  the  seat  of  any  of  the  forms  of 
local  trouble  which  we  have  akeady  described  under  the^title  of 
celluhtis,  and  this  may  vary  from  a  shght  inflammatory  blush  to 
the  acutest  form  of  spreading  gangrene.  ■,.••. 

The  General  Symptoms  are  those  of  fever,  often  ushered  m  by  a 
distinct  and  severe  rigor;  the  temperature  reaches  104  or  105  !<., 
and  usuallv  remains  liigh,  vvith  but  shght  remissions  and  no  inter- 
missions (Fig.  18).  Malaise  is  present,  ^^ith  loss  of  appetite,  and 
the  tongue  is  brown  and  parched.  The  pulse  is  quick  and  feeble, 
the  heart-sounds  are  weak,  and  the  heart  itself  dilated.  The  slan 
has  often  a  shght  icteric  ringe,  and  petechias  are  present  Diarrnoea 
usuallv  ensues,  and  may  be  blood-stained,  whilst  the  urme  is 
albuminous  and  contains  blood.  The  patient,  after  a  period  of 
dehrium,  becomes  comatose,  and  dies.  Dyspnoea  sometimes 
precedes  the  fatal  issue,  whilst  the  temperature  may  be  exceedingly 
high  or  occasionally  subnormal  ;  the  association, of  a  low  tempera- 
ture vvith  a  verv  rapid  pulse  is  always  of  grave  import.  Leucocytosis 
is  usuaUv  present  and  well  marked  in  the  earher  stages,  but  is 
absent  in  the  worst  cases  and  towards  the  fatal  issue  ;  even  under 
these  circumstances  there  is  a  relative  increase  m  the  number  ot 

^^Oc'SLsionally  a  case  takes  a  more  favourable  course  when  the 


94 


A   MANUAL  OF  SURGERY 


local  focus  of  trouble  has  been  effectively  dealt  with,  and  perhaps 
suitable  vaccine  treatment  adopted.  The  temperature  falls  gradu- 
ally, and  the  patient  slowly  though  surely  regains  his  health. 
The  accompanying  temperature  chart  represents  such  a  case, 
where  the  true  septicaemia,  as  demonstrated  by  a  blood  examina- 
tion, gradually  disappeared  after  the  uterus  had  been  effectively 
curetted  and  disinfected  (Fig.  i8). 

The  Post-mortem  Signs  are  those  found  in  all  cases  of  acute 
toxa:mia,  described  above  (p.  91),  with  the  addition  that  on  micro- 
scopical examination  bacteria  can  sometimes  be  demonstrated  in 
the  blood  and  internal  organs,  especially  the  spleen. 

The  Diagnosis  has  to  be  made  from  the  more  virulent  forms  of  the 
acute  exanthemata,  in  which  the  patient  is  destroyed  before  the  char- 


FiG.   18. — Temperature  Chart  of  a  Case  of  Puerperal  SEPTiCiEMiA. 

acteristic  appearances  are  manifested;  in  such  cases  a  definite 
opinion  as  to  the  nature  of  the  affection  is  often  impossible,  if  there 
is  no  clue  as  to  the  origin  of  the  infection.  Acute  foxcemia  is  always 
associated  with  some  very  obvious  focus  of  wound  infection,  but 
may  be  so  severe  as  to  cause  grave  anxiety  for  a  time  as  to  whether 
or  not  septicsemia  is  present.  If,  however,  the  wound  is  freely 
opened  up  and  drained,  the  rapid  disappearance  of  the  fever  proves 
that  the  mischief  was  merely  a  local,  and  not  the  more  serious 
general,  affection.  A  blood  examination  by  cultural  methods  may 
assist  in  clearing  up  the  diagnosis.  From  pycemia  it  is  known  by 
the  absence  of  repeated  rigors  and  secondary  abscesses. 

The  Prognosis  of  acute  septicaemia  is  always  very  grave,  but  it 


NON-SPECIFIC  PYOGENIC  INFECTIONS  95 

is  to  be  hoped  that  the  modern  plans  of  treatment  mentioned  below 
may  pro\'e  beneficial  in  diminishing  the  mortality. 

the  Treatment  consists  in  dealing  actively  with  anv  local  focus  of 
inflammation,  either  by  free  incisions,  purification,  and  drainage,  or 
by  amputation  ;  but,  unfortunately,  this  is  seldom  likely  to  be 
successful,  as  blood  infection  has  probably  already  occurred.  In 
addition  to  such  means,  tonics  and  stimulants,  \\ith  plenty  of  suit- 
able nourishment,  must  be  administered.  Antistreptococcic  serum 
(p.  27)  may  be  utihzed  when  the  streptococcus  is  responsible  for 
the  trouble,  and  cases  have  been  reported  as  cured  by  its  agency. 
Another  plan  which  has  been  adopted  is  the  intravenous  injection 
of  considerable  quantities  of  normal  sahne  solution,  repeated  two 
or  three  times  a  day;  by  this  means  diuresis  and  diarrhoea  are  in- 
duced, and  it  is  hoped  that  thereby  the  organisms  and  their 
products  may  be  ehminated.  This  treatment  will  probably  be 
of  greater  value  in  cases  of  toxaemia  than  in  those  of  true  infective 
septicaemia. 

A  few  cases  have  been  successfulty  treated  bv  means  of  auto- 
genous vaccines,  and  if  time  permit  (the  preparation  of  the  vaccine 
takes  three  or  four  da\-s)  this  method  should  be  tried.  In  the 
inter^-al  a  stock  vaccine  prepared  from  similar,  but  exogenous, 
organisms  may  be  employed.  It  is,  however,  not  hkely  to  be  of 
much  value  in  the  acute  and  rapidly  fatal  cases,  for  which  the 
serum  treatment  is  still  the  best  method  at  our  disposal. 

A  more  chronic  variety  of  septicaemia  is  also  recognised,  which  may- 
last  for  weeks  or  months.  The  history  usually  commences  with  some 
locahzed  inflammatory  trouble  from  which  the  patient  has  never 
properly  recovered.  The  temperature  becomes  of  the  hectic  type, 
running  up  3  or  4  degrees  every  night,  and  the  fever  is  associated 
with  profuse  nocturnal  sweats.  Bacteria  may  be  demonstrated 
in  the  blood  at  times.  The  probable  cause  of  the  trouble  is  the 
persistent  absorption  of  germs  into  the  blood-stream  from  some 
locahzed  source  of  suppuration — e.g.,  a  hepatic  abscess  or  a  sup- 
purating gall-bladder  or  appendix,  or  even  a  neglected  pyorrhoea 
alveolaris;  in  other  cases  infective  endocarditis  is  the  cause  of  the 
trouble.  The  patient's  health  and  strength  are  gradually  lost, 
and,  unless  the  local  focus  can  be  reached  and  dealt  with,  death  is 
hkely  to  result.  Surgical  interference,  though  dangerous  in  these 
debihtated  patients,  may  be  essential  in  order  to  attack  the  cause 
of  the  mischief.  Apart  from  this,  vaccine  treatment  must  be 
relied  on,  together  with  such  general  measures  as  shall  build  up 
the  general  health  and  improve  the  resistance  of  the  blood  and 
tissues. 

V.  Pyaemia. 

Pyaemia  (Greek  ttvov,  pus,  and  a.ip.a,  blood)  is  a  disease  character- 
ized by  fever  of  an  intermittent  type,  associated  with  the  formation 
of  multiple  abscesses  in  different  parts  of  the  bodv,  arising  from  the 
diffusion  of  pyogenic  materials  from  some  spot  of  local  infection. 


96 


A   MANUAL  OF  SURGERY 


Bacteriology. — Any  pyogenic  organism  may  cause  pyaemia,  and, 
theoretically,  pyremia  may  arise  as  a  complication  following  any  acute 
abscess.  As  a  rule,  however,  there  is  a  sufficiently  rapid  develop- 
ment of  granulation  tissue  to  limit  the  spread  of  infection.  The 
organism  most  commonly  found  is  the  Streptococcus  pyogenes,  but  in 
a  few  cases  the  Staphylococcus  pyogenes  aureus  has  been  observed, 
and  less  commonly  the  Pneumococcus,  Gonococcus,  or  B.  typhosus. 
The  mere  injection  of  cocci  into  the  circulation  is  not  sufficient  to 
give  rise  to  pyaemia;  if  they  are  few  in  number,  a  transient  pyrexia 
may  supervene,  and  then  the  germicidal  powers  latent  in  the  blood 
destroy  them;  but  if  the  dose  is  large,  or  the  individual  is  not  in  a 
very  resistant  condition,  septicaemia,  and  not 
pyaemia,  results,  unless  special  conditions  are 
present  which  determine  the  formation  of 
embolic  abscesses.  If  the  cocci  to  be  injected 
are  mixed  with  such  a  material  or  aggregated 
into  such  masses  that  the  organisms  are  carried 
on  particles  too  large  to  pass  through  the 
terminal  arterioles  and  capillaries,  abscesses 
develop  wherever  they  lodge.  In  human  path- 
ology the  infective  emboli  consist  of  zooglcea 
masses  of  organisms,  or  of  infected  particles 
of  disintegrating  blood-clot  (Fig.  19). 

The  Cause  of  pyaemia  may  be  stated  to  be 
any  condition  which  leads  to  the  formation 
and  detachment  of  infective  emboli  in  the 
circulation,  such  conditions  occurring  mainly 
in  the  veins  from  disintegration  of  a  throm- 
bus {infective  phlebitis),  but  occasionally  in 
the  heart  {infective  endocarditis).  Acute  in- 
fective inflammation  of  the  cancellous  tissue 
of  bones  is  very  commonly  associated  with 
pyaemia,  owing  to  the  veins  being  abundant 
and  thin-walled,  and  considerable  tension 
present  from  the  unyielding  condition  of  the 
surrounding  bony  structures.  Inflammation 
of  the  cranial  bones  coming  on  in  the  course 
of  middle-ear  mischief,  and  causing  thrombosis  of  the  lateral 
sinus,  also  leads  to  its  development.  The  presence  of  large  open- 
mouthed  veins  in  the  puerperal  uterus  favours  the  onset  of 
the  disease  after  parturition  if  infective  material  is  present  in  their 
vicinity. 

When  an  infective  embolus  lodges  in  any  region  of  the  body,  a 
thrombus  forms  upon  it,  and  in  this  the  micro-organisms  rapidly 
develop,  and  thence  pass  through  the  vessel  wall  into  the  sur- 
rounding tissues,  causing  inflammation,  which  is  likely  to  end  in 
suppuration.  In  the  lung  many  such  foci  occur,  distributed  mainly 
along  the  posterior  border  and  near  the  surface;  each  is  sharply 
limited  to  a  wedge-shaped  area  of  tissue,  with  the  base  directed 
towards  the  periphery.     It  is  at  first  reddish  in  colour  from  effusion 


Fig.  19.  —  Disintegra- 
ting Clot  lying  in 
A  Vein  in  a  Case 
OF  Pyemia.     (After 

TiLLMANNS.) 

The  apex  of  the  clot 
projects  into  a  larger 
trunk,  in  which  circu- 
lating blood  is  pres- 
ent, and  from  it  in- 
fected emboli  would 
be  detached. 


NON-SPECIFIC  PYOGENIC  INFECTIONS  97 

of  blood  (a  hcemorrhagic  infarct),  but  soon  becomes  grayish-yellow 
from  the  formation  of  pus.  These  abscesses  are  small,  and  rarely 
give  rise  to  any  physical  signs.  Similar  collections  of  pus,  preceded 
or  not  by  an  infarct,  may  be  found  in  any  organ  of  the  body.  The 
lungs,  acting  as  a  filter  to  emboli  derived  from  the  systemic  veins, 
are  naturally  the  first  organs  to  be  affected,  and  from  the  abscesses 
formed  therein  infection  of  the  arterial  system  may  take  place, 
resulting  in  fresh  suppurative  foci  in  the  liver,  spleen,  kidneys, 
brain,  and  in  or  around  joints,  etc.  If,  however,  the  causative 
phlebitis  is  situated  in  the  portal  area,  the  emboli  are  lodged  pri- 
marily in  the  liver,  giving  rise  to  what  is  known  as  pylephlebitis. 
When  the  emboli  are  many  in  number,  the  symptoms  are  severe, 
constituting  acute  pyaemia;  this  is  sometimes  associated  with  a  de- 
velopment of  micro-organisms  in  the  blood,  producing  pyosepti- 
ccBmia,  the  patient  perhaps  dying  before  the  secondary  abscesses 
have  fully  developed.  In  other  cases  the  general  symptoms  are 
due  rather  to  the  absorption  of  toxins  from  the  local  foci  than  to 
the  development  of  organisms  in  the  blood.  If  the  emboli  are  few 
in  number,  and  there  is  little  or  no  development  of  microbes  in  the 
blood,  the  disease  is  termed  chronic  pyaemia. 

Clinical  History, — The  most  marked  symptom  indicating  the 
onset  of  a  case  of  Acute  Pysemia  is  the  occurrence  during  a  period 
of  febrile  disturbance  of  a  severe  rigor,  which  is  repeated  with  a 
sort  of  irregular  periodicity,  most  frequently  at  intervals  of  about 
twenty-four  to  forty-eight  hours,  somewhat  simulating  an  attack 
of  ague  (Fig.  20).  The  rigors  do  not  differ  from  those  occurring  in 
other  diseases,  but  they  are  very  severe,  and  usually  followed  by 
profuse  sweating.  Between  the  rigors  the  temperature  may  fall  to 
the  normal,  but  more  commonly  remains  above  it.  The  skin  is 
hot  and  soon  develops  an  earth}-  or  dull  yellow  tint,  together  with 
erythematous  or  petechial  patches.  A  sweet,  mawkish,  hay-like 
smell  of  the  breath  is  very  characteristic.  S^^mptoms  of  grave  de- 
pression supervene,  and  the  patient  rapidly  wastes.  The  pulse 
becomes  soft  and  weak,  the  excretions  are  diminished,  and  a  certain 
amount  of  nocturnal  delirium  is  noticed,  but  no  loss  of  conscious- 
ness. The  presence  of  a  bruit  in  the  precordial  region  may  suggest 
the  existence  of  an  infective  endocarditis,  which  is  not  very  un- 
common. The  tongue  varies,  but  is  often  red  with  very  prominent 
papillae,  and  becomes  dry  and  brownish.  Towards  the  end  of  the 
first  week  secondary  abscesses  appear ;  they  are  sometimes  unaccom- 
panied by  local  pain  or  tenderness,  and  form  very  rapidly.  Joints 
are  not  infrequently  involved,  and  may  fill  with  pus,  with  little  or 
no  pain.  Unless  treated  early,  rapid  disorganization  and  disloca- 
tion may  follow.  The  effusion  may  be  puriform,  or  thin  and  oily; 
it  is  always,  however,  swarming  with  organisms.  In  the  viscera 
the  abscesses  are  as  a  rule  small  and  numerous;  if  they  occur  in 
vital  organs,  such  as  the  heart  or  brain,  death  may  result  from  their 
local  development.  Thej^  are  characterized,  at  first,  by  the  almost 
total  absence  of  a  barrier  of  granulation  tissue,  and  hence,  even 
when  opened  earty  and  aseptically,  are  likely  to  extend  and  continue 

7 


9S 


A   MANUAL  OF  SURGERY 


secreting  pus,  instead  of  following  the  usual  course  of  rapid  repair 
which  succeeds  the  aseptic  opening  of  an  ordinary  acute  abscess. 

Not  uncommonly  in  these  cases  painful  patches  occur  here  and 
there  in  the  subcutaneous  tissues,  accompanied  by  hypera;mia, 
which  fades  away  after  a  few  days.  These  are  probably  due  to 
the  presence  of  small  infective  emboli,  which  the  patient  has  suffi- 
cient \'italitv  to  get  rid  of  without  suppuration. 

In  Chronic  Pyaemia  the  febrile  symptoms  are  much  less  marked; 
the  abscesses  are  few  in  number,  and  not  dangerous  unless  forming 
in  important  structures.  Thus,  a  fatal  result  ensued  from  a  single 
abscess  which  developed  in  the  lateral  ventricle  of  the  brain  of  a 
patient  who  had  no  other  symptom  of  pyaemia  except  an  oscillating 
temperature:  it  followed  an  operation  on  an  infected  sinus  leading 
to  a  kidney  already  disorganized. 


Fig.  20. — Portion  of  Temperature  Chart  of  a  Case  of  Py^IiMia. 

If  the  disease  results  from  an  external  wound,  the  condition  of  the 
latter  is  always  most  unsatisfactory.  It  gapes  open  and  presents  an 
inactive,  dry,  glazed  surface,  any  newly-formed  scar  tissue  breaking 
down.  A  layer  of  healthy  granulations  is  an  almost  certain  barrier 
against  the  occurrence  of  pyaemia,  on  account  of  the  germicidal 
power  of  its  constituent  cells.  If  the  disease  arises  in  connection 
with  hone,  the  latter  structure  is  usually  seen  lying  bare  at  the 
bottom  of  the  wound,  denuded  of  its  periosteum,  and  the  cancelli 
filled  with  sloughy  fcetid  medulla  or  pus. 

Post-mortem  Appearances. — The  veins  leading  from  the  infected 
area  are  usually  in  a  state  of  phlebitis;  the  coats  are  thickened, 
and  the  lumen  is  filled  with  soft,  pale,  disintegrating  clot,  which 
extends  for  a  considerable  distance:  the  tissues  surrounding  the 


NON-SPECIFIC  PYOGENIC  INFECTIONS  99 

vein  are  also  involved  in  the  suppurative  process  (periphlebitis). 
Secondary  abscesses  are  found  in  various  parts  of  the  body,  most 
frequently  in  the  lungs,  and  their  different  stages  can  be  clearly 
demonstrated  from  the  embolic  colonies  of  micrococci,  through  the 
stage  of  haemorrhagic  infarction  to  the  complete  abscess.  The 
general  signs  common  to  all  cases  of  death  from  toxaemia  (p.  gi) 
will  also  be  manifest. 

The  Diagnosis  of  pyaemia  should  not  be  difficult  in  the  majority 
of  cases;  but  when  it  originates  without  any  obvious  external 
wound  from  a  deep-seated  focus,  or  if  the  importance  of  some 
local  lesion  has  not  been  appreciated,  the  initial  symptoms  may  be 
mistaken  for  those  of  acute  rheumalism  or  ague. 

The  Prognosis  depends  upon  the  inherent  vitality  of  the  patient 
and  the  virulence  of  the  disease.  In  acute  cases  it  is  extremely 
grave,  probably  terminating  in  a  week  or  ten  days,  whilst  in  the 
chronic  type  recovery  is  not  only  possible,  but  probable,  if  the  local 
abscesses  are  favourably  situated. 

The  ideal  local  Treatment  consists  in  preventing,  if  possible, 
the  further  contamination  of  the  general  blood-stream  by  the  dis- 
semination of  infected  emboli.  This  can  sometimes  be  accomplished. 
in  the  case  of  a  limb,  by  amputation  well  above  the  local  lesion; 
or  if  the  medullary  cavity  of  a  bone  is  the  source  of  trouble,  it  may 
be  possible  to  scrape  out  the  gangrenous  and  offensive  medullary 
tissue,  and  disinfect  the  cavity;  or  if  it  is  due  to  a  wound  in  the  soft 
parts,  it  may  be  feasible  to  dissect  out  the  implicated  vein  and  sur- 
rounding tissues,  or  at  any  rate  to  remove  the  disintegrating  clot 
after  placing  a  ligature  upon  the  vessel  between  the  thrombus  and 
the  heart.  A  typical  illustration  of  such  treatment  is  that  adopted 
for  infective  phlebitis  of  the  lateral  sinus  complicating  disease  of 
the  middle  ear,  where,  after  tying  the  internal  jugular  in  the  neck, 
the  sinus  is  exposed  by  the  trephine  or  gouge,  opened,  and  all  the 
infected  clot  removed,  partly  from  above,  partly  from  below;  ad- 
mirable results  have  been  thereby  obtained.  Where,  however, 
such  ideal  treatment  is  impracticable,  all  that  the  surgeon  can 
undertake  is  to  render  the  primary  focus  as  healthy  as  possible  by 
free  relief  of  tension  and  close  care  in  asepsis.  The  abscesses  must 
be  dealt  with,  when  possible,  by  early  opening  and  draining  them, 
or  by  aspiration;  such  wounds  often  heal  well,  and  joints  which 
have  been  distended  with  pus  may  recover  with  free  mobility. 
Occasionally,  however,  although  rigid  asepsis  has  been  maintained, 
the  suppuration  continues,  and  even  sloughing  of  the  abscess  wall 
may  follow.  If  the  general  condition  can  be  improved,  a  barrier 
of  granulation  tissue  will  fonii  in  time,  and  repair  be  established. 

Constitutional  treatment  consists  in  supporting  the  patient's 
strength  by  nourishing  diet  and  stimulants,  and  in  taking  pre- 
cautions to  avoid  bedsores  or  any  local  injury.  Salicylate  of  quinine 
may  be  administered,  though  its  value  is  doubtful.  The  anti- 
streptococcic serum  (p.  27)  may  also  be  utihzed,  and  it  may  do  good 
in  cases  which,  have  not  progressed  too  far.  Vaccine  treatment  may 
also  be  tried.  ,  , 


CHAPTER  \l. 

ULCERATION. 

Ulceration  has  been  defined  as  the  '  molecular  or  particulate  death 
of  a  part,'  by  which  is  meant  the  disintegration  of  the  superficial 
tissues,  which  hquefy  and  disappear,  and 'usually  \\athout  any 
obvious  slough.  It  differs  from  gangrene  in  that  the  latter  term  is 
used  to  denote  the  simultaneous  loss  of  vitaUty  of  a  considerable 
portion  of  tissue.  The  two  processes  are,  however,  often  closely 
associated — in  fact,  both  signify  tissue  necrosis;  in  the  former  the 
dead  particles  are  not  always  \asible  to  the  naked  e^-e,  whereas  in 
the  latter  the  necrotic  portions,  if  superficial,  can  always  be  seen. 

An  Ulcer  is  an  open  wound  or  sore  which  tends  to  persist,  prob- 
ably as  a  result  of  pyogenic  infection,  but  may  under  favourable 
circumstances  heal.  Any  part  of  the  surface  of  the  body  may  be 
affected,  but  especially  the  lower  extremities,  whilst  all  the  mucous 
membranes  suffer  similarly.  Many  small  ulcers  may  be  present, 
and  then  not  unfrequently  are  caused  by  infection  one  from  another; 
or  the  ulcer  may  be  solitary  and  of  large  dimensions. 

It  is  almost  impossible  to  classify  ulcers,  so  multifarious  are  they 
in  type  and  so  wedded  are  we  to  an  old-standing,  inexact  termin- 
ology. It  must  suffice  to  suggest  that  in  surgical  practice  three 
chief  classes  are  met  with — viz.: 

I.  Ulcers  due  to  traumatism  or  to  non-specific  pyogenic  bacteria, 
e.g.,  the  spreading,  healing,  chronic,  etc. 

II.  Ulcers  due  to  specific  bacteria,  e.g.,  soft  chancre,  lupoid,  tuber- 
culous, syphihtic,  etc. 

III.  Malignant  ulcers,  e.g.,  rodent,  epithehomatous,  scirrhous, 
and  fungating. 

Any  form  of  surface  irritant,  whether  chemical,  thermal,  me- 
chanical, or  infective,  may  cause  ulceration,  and  all  the  factors 
predisposing  to  inflammation  will  hasten  its  occurrence.  Faulty 
nutrition,  whether  from  anaemia  or  from  long-standing  congestion, 
is  particularly  hable  to  further  the  ulcerative  process;  thus, in  the 
lower  extremity  it  is  predisposed  to,  on  the  one  hand,  by  arterial 
disease  wliich  leads  to  anaemia,  or,  on  the  other,  by  the  passive  con- 
gestion dependent  on  varicose  veins.  General  debility,  such  as 
results  from   Bright's  disease,  diabetes,  etc.,  will  also  favour  the 


ULCERATION  loi 

occurrence  of  ulceration.  Moreover,  when  any  part  becomes 
aUc-Esthetic,  or  is  cut  off  from  its  trophic  centres,  the  continued 
presence  of  an  irritant  may  not  be  appreciated,  and  hence  destruc- 
tive intfammation  occurs,  e.g.,  corneal  ulcer  following  section  of 
the  hfth  nerve,  or  perforating  ulcer  of  the  foot  in  tabes.  In  ma- 
lignant disease  the  projection  of  the  mass  of  the  growth  ma}^  expose 
it  unduly  to  irritation;  but  the  chief  cause  of  ulceration  is  the  re- 
placement of  the  deeper  layers  of  the  skin  or  mucous  membrane 
by  the  cells  of  the  neoplasm,  so  that  when  the  superficial  epithelium 
wears  off  or  is  lost  it  cannot  be  reproduced. 

I.  Ulcers  due  to  Traumatism  or  to  Non-Specific  Pyogenic 
Bacteria. 

Clinical  History. — Every  ulcer  of  this  class  tends  sooner  or  later 
to  recovery,  and  so  may  be  said  to  pass  through  three  stages,  viz., 
(i)  that  of  ulceration  proper,  or  extension;  (2)  a  stage  of  transition, 
or  preparation  for  healing,  which  may  be  short  or  long,  according 
to  whether  the  ulcer  is  running  a  rapid  or  a  slow  course,  and  persists 
until  the  surface  is  covered  with  granulations;  and  (3)  the  stage  of 
healing  or  repair.  It  must  be  clearly  understood  that  the  first  stage 
alone  represents  the  true  ulcerative  process;  when  this  ceases, 
merely  a  superficial  loss  of  substance,  the  result  of  the  preceding 
ulceration,  remains,  and  to  this  sore  the  term  '  ulcer  '  would  scarcely 
be  applied,  unless  it  tended  to  persist.  If  every  simple  ulcer  passes 
through  these  three  stages,  then  every  variety  of  simple  ulcer  must 
necessarily  be  in  one  of  the  three  stages,  and  hence  may  be  described 
as  a  modification  of  a  typical  condition  representing  the  stage  to 
which  it  belongs.  Naturally,  in  a  large  ulcer  the  three  stages  may 
co-exist,  or  a  healing  ulcer  ma}'"  from  intrinsic  or  extrinsic  causes 
relapse  again  to  the  stage  of  tissue  destruction. 

Stage  I.:  Ulceration  Proper,  or  Extension. — The  special  charac- 
teristic of  this  stage  is  that  destructive  changes  are  progressing  with 
greater  or  less  rapidity,  and  hence  the  ulcers  may  be  described  as 
inflamed,  spreading,  or  sloughing. 

Naked-eye  Appearances. — Surface,  covered  with  ashy  gray  or 
dirty  yellow  material,  partly  slough,  partly  lymph,  partly  breaking- 
down  tissue;  no  granulations  are  present;  the  tendency  to  slough 
is  most  marked  when  the  organisms  are  particularly  virulent,  or 
if  the  resistance  of  the  tissues  is  much  diminished;  discharge,  con- 
siderable in  amount,  thin,  sanious,  and  often  irritating  and  offensive, 
rarely  purulent;  margins,  thickened  and  inflamed,  and  the  sur- 
rounding tissues  often  oedematous  and  infiltrated;  edge,  sharply  cut 
and  well  defined;  the  base  of  the  ulcer  is  thickened  and  fixed  to  the 
underlying  structures.  In  fact,  the  phenomena  are  those  of  an 
acute  spreading  superficial  inflammation,  which  terminates  in 
tissue  destruction. 

Treatment  resolves  itself  into  removing  the  cause,  and  protecting 
the  surface  from  mechanical  or  other  irritation.  The  inflamed 
part  must  be  kept  at  rest,  and  if  necessarj^  raised  from  a  dependent 


I02  A   MANUAL  OF  SURGERY 

position  {i.e.,  the  leg  must  not  be  allowed  to  hang  down),  whilst  the 
sore  IS  dressed  with  moist  and  warm  antiseptic  applications,  such  as 
a  boracic  fomentation.  When  the  parts  are  very  offensive,  a 
charcoal  and  linseed-meal  poultice  may  be  first  employed. 

Stage  II. :  The  Transition  Period  comprises  all  the  changes  which 
occur  from  the  termination  of  the  ulcerative  process  proper  to  the 
time  when  healing  is  fully  established  by  the  wound  becoming 
covered  with  granulations.  In  short,  it  may  be  described  as  the 
stage  of  preparation  for  healing. 

Naked-eye  Appearances. — When  the  destructive  process  has 
ceased,  the  surface  of  the  ulcer  begins  to  clean,  and  becomes,  as  it 
were,  glazed  over;  sloughs  are  either  removed  in  the  dressing  or 
absorbed.  The  discharge  becomes  less  abundant  and  more  serous 
in  character,  and  the  angry  red  blush  is  replaced  by  a  rosy  hyper- 
aemia.  The  infiltration  of  the  base  also  diminishes,  so  that  the 
tissues  around  are  less  fixed  and  more  supple.  The  film  on  the 
surface  becomes  more  and  more  defined,  and  in  the  course  of  time, 
shorter  or  longer,  according  to  circumstances,  little  red  spots  make 
their  appearance  here  and  there ;  these  gradually  increase  in  number 
and  size,  and  coalesce,  until  the  whole  surface  is  covered  by  what 
has  now  become  granulation  tissue.  The  processes  occurring  in 
this  stage  are:  (a)  the  removal  of  the  sloughs;  {b)  the  covering  of 
the  surface  with  a  cellulo-plastic  exudation;  and  (c)  the  vascular- 
ization of  this  newly-formed  material,  and  its  conversion  into 
granulation  tissue.  All  these  changes  do  not  necessarily  go  on 
equally  all  over  the  surface  of  the  ulcer  at  the  same  time,  and  hence 
much  variety  in  its  appearance  may  be  manifested;  whilst  at  times 
the  reparative  changes  may  come  entirely  to  a  standstill.  Hence 
all  the  forms  of  chronic  ulcer  which  are  neither  spreading  nor  actively 
healing  may  he  included  in  this  transitional  stage,  viz.,  the  indolent 
or  callous  ulcer,  the  irritable,  the  varicose,  etc. 

The  Indolent  or  Callous  Ulcer  occurs  most  frequently  on  the  legs 
of  women  about  the  middle  period  of  hfe.  The  size  varies  greatly, 
but  it  is  sometimes  so  extensive  as  to  involve  the  whole  circum- 
ference of  the  limb.  The  surface  is  usually  smooth  and  glistening, 
and  of  a  dirty  yellow  colour,  with  perhaps  a  few  badly-formed 
granulations;  the  edges  are  hard  and  sharply  cut,  and  elevated  con- 
siderably above  the  surface,  whilst  the  skin  around  may  be  heaped 
up  over  the  edge,  and  either  covered  with  sodden  cuticle  or  con- 
gested. The  skin  of  the  hmb  is  often  deeply  pigmented  from 
chronic  congestion,  the  pigmentation  starting  in  the  separate 
papillae  as  maculae,  which  gradually  coalesce.  The  discharge  is 
purulent  or  serous,  and  may  be  so  abundant  and  irritating  as  to 
cause  eczema  of  the  parts  around,  and  thus  give  rise  to  one  form  of 
eczematous  ulcer.  The  base  is  adherent  to  the  underlying  tissues. 
fascicC,  etc. ;  and  this  constitutes  one  of  the  main  difficulties  in 
healing,  as  contraction  is  thus  prevented.  If  the  ulcer  is  situated 
over  a  bone,  such  as  the  tibia,  chronic  periostitis  results,  and  a 
subperiosteal  node  is  formed,  corresponding  exactly  to  the  size  and 
situation  of  the  ulcer,  forming  a  mushroom-shaped  projection,  and 


ULCERATION  103 

possibly  going  on  to  necrosis  or  to  diffuse  osteo-periostitis  of  the 
whole  bone.  These  ulcers  are  sometimes  very  painful  from  pres- 
sure on  cutaneous  nerves,  or  from  a  localized  cellulitis,  associated, 
perhaps,  with  inflammation  of  veins  and  lymphatics.  Thrombosis 
not  infrequently  occurs  in  both  sets  of  vessels,  leading  to  chronic 
oedema  of  the  foot,  often  of  a  very  solid,  brawny  type,  and  the 
limb  may  even  pass  into  a  condition  of  pseud- elephantiasis. 

A  somewhat  similar  condition  may  also  follow  large  burns  on 
any  part  of  the  body;  heahng  proceeds  to  a  certain  extent,  and 
then  stops  from  the  fact  that  the  contraction  of  the  cicatricial 
tissue  already  formed  interferes  with  the  vitality  of  the  part  still 
unhealed  by  compressing  the  vessels,  and  so  cutting  off  the  granu- 
lations from  their  source  of  nutriment. 

The  so-called  Irritable  Ulcer  is  usually  met  with  in  this  stage. 
Its  chief  pecuharities  are  the  position,  generally  in  the  neighbour- 
hood of  the  ankle,  and  the  pain  which  accompanies  it.  The  surface 
of  a  healing  or  chronic  ulcer  can  usually  be  touched  without  the 
patient  complaining;  but  in  this  variety  the  pain  is  excessive, 
especially  at  night.  It  was  pointed  out  by  the  late  Mr.  Hilton  that, 
if  a  probe  is  run  lightly  over  the  surface  of  such  a  sore,  one  or  more 
spots  win  be  indicated  as  the  chief  seats  of  the  pain,  the  rest  being 
insensitive.  In  all  probabihty,  nerve  filaments  are  there  exposed, 
as  the  pain  has  a  very  marked  burning  or  shooting  character. 

The  Varicose  Ulcer  occurs  in  the  leg  of  a  patient  who  is  the  subject 
of  aggravated  varicose  veins,  especially  when  the  smaller  venules 
are  involved.  The  skin  becomes  passively  congested,  and  its 
nutrition  impaired;  any  injury  or  abrasion,  which  would  readily 
heal  in  a  sound  hmb,  is  likely  under  such  circumstances  to  give  rise 
to  a  chronic  sore.  Again,  it  may  be  preceded  by  eczema  resulting 
from  the  irritation  of  dirt  or  the  friction  of  hard  trousers,  whilst 
occasionally  it  is  due  to  the  jdelding  of  the  thinned  skin  which  forms 
the  only  covering  of  a  much  dilated  vein,  an  accident  often  leading 
to  severe  haemorrhage.  The  characters  of  a  varicose  ulcer  in  the 
main  correspond  to  those  of  the  indolent  variety;  it  is  usually 
situated  on  the  inner  and  lower  portion  of  the  leg,  whilst  syphihtic 
sores  are  more  often  placed  nearer  the  knee  and  on  the  outer  side. 

Treatment  in  this  stage  differs  according  to  the  conditions  present. 
If  it  is  merely  a  passing  phase  in  the  progress  of  an  ulcer  tending 
rapidly  to  repair,  the  same  course  of  treatment  should  be  adopted 
as  in  the  earlier  period,  viz.,  rest  and  protection  from  irritation.  It 
may  be  advisable  to  shield  the  surface  from  contact  with  dressings 
by  the  intervention  of  a  small  portion  of  purified  '  protective  '—i.e., 
oiled  silk  coated  with  dextrin — so  that  the  reparative  material  may 
not  be  damaged  during  their  removal. 

The  Chronic  Ulcer  needs  much  care  in  its  treatment,  and  some 
cases  require  operative  interference.  Rest  in  a  more  or  less  elevated 
position  is  absolutely  essential  in  order  to  reheve  the  congested 
condition  of  the  hnib;  whilst  if  the  surface  is  foul,  a  charcoal 
poultice  may  be  beneficial,  or  the  sore  may  be  dusted  over  with 
iodoform,   and  boracic  fomentations  apphed.     This  may  be  pre- 


I04  A   MAXUAL  OF  SURGERY 

ceded  in  some  cases  by  touching  the  surface  with  solid  nitrate  of 
silver,  or  with  a  solution  of  chloride  of  zinc  (40  grains  to  i  ounce). 

Pressure  has  been  hjund  of  considerable  service  in  the  treatment 
of  these  ulcers;  an  ordinary  bandage,  reaching  from  the  toes  to  the 
knee,  will  sufTice  in  some  cases,  a  suitable  dressing  of  boric  acid 
ointment,  with  perhaps  some  resin  ointment  added  to  make  it 
more  stimulating,  being  applied  beneath  it.  Marlins  indiarubber 
bandage  is  more  useful  when  the  veins  are  much  enlarged. 

The  method  of  dealing  with  chronic  ulcers  suggested  by  Pro- 
fessor Unna,  of  Hamburg,  has  given  excellent  results.  It  consists 
in  the  use  of  an  adhesive  plaster,  made  up  as  follows :  Gelatin,  5  parts; 
oxide  of  zinc,  5  parts;  boric  acid,  1  part;  glycerine,  8  parts;  water, 
6  parts;  to  this  ichthyol  (5  per  cent.)  may  be  added  with  advantage. 
The  limb  is  first  washed  thoroughly  with  soap  and  water,  and 
purified  with  carbolic  or  sublimate  lotion.  It  is  then  wrapped 
round  with  a  single  layer  of  sterile  gauze,  and  the  paste,  liquefied 
by  placing  it  in  a  gallipot  in  a  saucepan  of  boiling  water,  is  applied 
over  it  with  a  paint  or  paste  brush.  Another  layer  of  gauze  is 
placed  over  the  paste  and  a  thin  bandage  over  all,  and  the  whole 
allowed  to  dry.  Where  there  is  extensive  varix,  the  paste  should 
extend  from  the  ankle  to  the  knee,  and  may  sometimes  include  the 
foot.  If  there  is  much  discharge,  the  ulcer  should  not  be  covered, 
and  the  dressing  should  be  reapplied  daily;  but  after  it  has  di- 
minished in  amount,  the  paste  may  be  carried  right  over  the  sore, 
and  the  wiiole  application  left  in  position  for  a  week,  or  even  longer. 

When  the  edges  are  very  indurated  and  thickened,  and  all  action 
is  at  a  standstill,  Syme's  suggestion  may  be  followed,  viz.,  to  blister 
the  whole  surface,  as  well  as  the  surrounding  skin.  A  more  satis- 
factory method,  but  requiring  an  anesthetic,  is  to  scrape  the  surface 
with  a  sharp  spoon,  and  then  to  rub  in  a  strong  solution  of  chloride 
of  zinc.  When  healthy  action  has  been  obtained,  assistance  in 
healing  may  be  secured  by  the  use  of  such  stimulating  applica- 
tions as  scarlet-red  (a  coal-tar  derivative)  used  for  twenty-four 
hours  in  the  form  of  a  4  to  8  per  cent,  ointment,  after  effective 
purification,  followed  for  two  days  by  boric  acid  ointment,  and  then 
repeated;  or  the  liquid  extract  of  the  common  comfrey  {Symphytum 
officinale),  the  active  agent  in  wliich  is  allantoin,  will  stimulate 
the  growth  of  granulations;  or  allantoin  itself  may  be  employed  in 
a  5  per  cent,  solution.  Any  of  these  agents  will  hasten  a  cure. 
If,  however,  the  surface  to  be  healed  is  very  extensive,  skin-grafting 
may  be  employed,  if  necessary;  it  is  useless  to  undertake  this, 
however,  unless  the  patient  can  promise  to  rest  for  a  prolonged 
period,  and  even  then  elastic  support  will  be  subsequently  required. 
In  bad  cases  where  a  considerable  portion  of  the  circumference  of 
the  hmb  is  involved,  when  the  ulcer  is  very  callous  and  its  base 
attached  to  the  tibia,  causing  severe  pain  at  night  from  chronic 
periostitis,  and  especially  when  the  patient  cannot  obtain  prolonged 
rest,  amputation  may  be  the  best  treatment.  Farabceuf's  amputa- 
tion at  the  site  of  election  can  often  be  undertaken  with  advantage. 

Where  varicose  veins  exist,  treatment  is  of  little  avail  unless 


ULCERATION  103 

these  are  efficiently  dealt  with  either  by  operation  or  by  some 
suitable  support,  such  as  Unna's  paste.  It  is  often  undesirable  to 
attack  the  veins  locally  owing  to  the  dirty  condition  of  the  ulcer, 
which  must  be  dealt  with  by  rest  and  fomentations.  Operation 
consists  either  in  removal  of  the  dilated  veins  at  a  higher  level,  or 
in  Trendelcn]-)urg's  operation  {q.v.)  in  suitable  cases. 

The  Irritable  Ulcer  may  be  treated  by  discovering  the  painful  spots, 
and  incising  the  tissues  just  above  them  with  a  knife,  so  as  to  divide 
the  exposed  nerves;  but  thorough  scraping  under  an  anaesthetic  is 
preferable. 

The  Eczematous  Ulcer  must  be  dealt  with  differently  from  the 
others,  or  the  eczema  will  be  aggravated.  Soothing  apphcations 
are  needed,  such  as  lead  lotion,  and  when  once  the  acute  stage  has 
passed,  tarry  preparations  (liq.  carbonis  detergens,  i  ounce  to  i  pint 
of  lotio  plumbi),  or  an  ichthyol  ointment  (5-10  per  cent.),  may  be 
beneficially  employed.  A  mixture  of  benzoate  of  zinc  and  boric  acid 
ointments  is  a  very  useful  application,  or  Unna's  paste  v\ith  ichthvol 
may  be  utihzed. 

Stage  III. :  Repair  having  now  been  fully  estabUshed,  we  have  to 
deal  with,  not  a  healthy  ulcer,  for  such  a  condition  cannot  exist,  but 
a  healthy  granulating  wound,  the  result  of  ulceration,  or,  as  we  call 
it,  to  avoid  confusion,  a  '  healing  ulcer.' 

A  Healing  Ulcer  is  characterized  by  the  following  conditions: 
Surface,  smooth  and  even,  shelving  gradually  from  the  skin,  and 
covered  vnth  healthy  granulations ;  these  present  a  florid  red  appear- 
ance, are  piinless,  and  bleed,  but  not  readily,  on  being  touched. 
The  discharge  varies  according  to  the  plan  of  treatment  adopted :  if 
the  surface  is  kept  at  rest  and  free  from  all  irritants,  the  discharge 
is  merely  serous;  but  should  the  wound  become  infected,  or  be 
dressed  with  irritating  antiseptics,  ordinar\-  pus  is  formed.  The 
surrounding  skin  is  soft,  flexible,  and  free  from  inflammatory  con- 
gestion, and  the  base  is  similarly  free  from  fixity.  The  margins 
present  a  healing  edge,  which  has  been  described  as  manifesting 
three  coloured  zones:  within  is  a  red  area  consisting  of  granulation 
tissue,  covered  by  a  single  laver  of  epithehal  cells,  which  cannot  be 
seen  except  in  a  good  light;  next  comes  a  thin  duskv  purple  or  blue 
Hne,  w^here  the  granulations  are  covered  bv  a  few  lavers  of  epithe- 
lium, and  the  circulation  is  becoming  retarded  owing  to  cicatricial 
development;  whilst  outside  is  a  white  zone  due  to  the  heaping  up 
of  sodden  cuticle  upon  the  healthy  or  healed  part. 

The  method  of  repair  in  such  a  wound  consists  in  a  change  of 
the  deeper  layer  of  granulations  into  fibro-cicatricial  tissue,  which 
gradually  contracts  and  is  finallv  covered  with  epithelium.  For  full 
description  see  Chapter  X. 

If  emolhent  applications  are  used  too  long,  the  granulations 
become  pale,  protuberant,  and  oedematous,  and  the  heahng  process 
is  temporarily  checked.  A  depressed  general  condition  of  the 
patient,  or  a  varicose  condition  of  the  veins,  mav  also  account  for 
this,  and  the  term  a  weak  ulcer  is  applied  to  it,  whilst  the  prominent 
flabby  granulations  are  popularly  known  as  proud  flesh. 


io6  A   MANUAL  OF  SURGERY 

Treatment.--  The  part  must  be  kept  at  rest,  and  if  the  leg  is  the 
seat  of  the  trouble,  it  slunikl  not  be  allowed  to  hang  down.  The 
wound  must  be  protected  from  injury  by  a  dressing  which  can  be 
removed  without  damaging  the  surface.  A  piece  of  sterile  protective, 
the  exact  size  of  the  lesion,  may  be  placed  over  it,  and  covered  with 
sterile  gauze,  or  the  wound  may  be  dressed  with  a  simple  ointment 
{e.g.,  ung.  acidi  borici,  diluted  with  an  equal  part  of  vaseline)  spread 
on  sterile  butter-cloth  or  lint.  If  the  granulations  become  too 
prominent,  they  may  be  lightly  touched  with  nitrate  of  silver,  or  a 
stimulating  lotion  applied,  such  as  that  known  as  lotio  rubra 
(R  Zinci  sulphatis,  gr.  ii.;  tinct.  lavanduhe  co.,  spir.  rosmarini, 
aa  ni^xx.;  acidi  borici,  gr.  x. ;  aquam  destill.  ad  5i.). 

Large  ulcers  require  assistance  in  order  to  obtain  expeditious 
healing,  otherwise  a  time  comes  when  the  contraction  of  the  cica- 
tricial tissue  interferes  with  the  nutrition  of  the  granulations,  and 
retards  the  healing  process.  To  ob\nate  this  difficulty,  skin-grafting 
is  frequently  utilized. 

Skin-grafting,  or  the  transplantation  of  more  or  less  of  the  thick- 
ness of  the  skin  from  a  healthy  to  a  healing  part,  was  introduced  by 
Reverdin  in  1869,  and  has  since  been  much  elaborated.  The  follow- 
ing are  the  chief  methods  employed: 

1.  Transplantation  of  small  pieces  of  the  cuticle  and  cutis, 
Reverdin's  original  plan.  A  small  portion  of  the  cutaneous  tissue 
is  pinched  up  with  or  without  forceps,  and  removed  by  a  pair  of 
sharp  curved  scissors.  It  should  include  the  cuticle  and  a  portion 
of  the  cutis  vera,  so  that  a  drop  or  two  of  blood  will  slowly  ooze 
from  the  denuded  surface.  The  graft  is  gently  placed  cutis  down- 
wards on  the  surface  of  the  granulations  and  covered  with  purified 
protective.  Many  of  these  may  be  applied  at  the  same  time,  and 
the  whole  wound  carefully  dressed  and  protected.  If  there  is  much 
discharge,  the  grafts  will  not  '  take  ' ;  but  if  the  surface  is  healthy, 
there  should  be  no  difficulty  in  getting  them  to  grow.  Usually 
they  disappear  for  a  day  or  two,  from  the  cuticle  becoming  softened 
or  disintegrated;  but  soon  the  epitheUum  of  the  cutis  spreads,  and 
makes  itself  visible  as  a  distinct  centre  of  repair. 

2.  Transplantation  of  large  portions  of  cuticle  as  suggested  by 
Thiersch.  This  method  consists  in  removing  large  strips  of  cuticle 
with  a  razor,  and  implanting  them  on  a  fresh  wound  or  on  a  raw 
surface  denuded  of  granulations  by  scraping  ;  all  haemorrhage 
must  be  previously  stayed  by  pressure.  In  cutting  the  strips  of 
cuticle  care  must  be  taken  to  make  them  as  thin  as  possible;  the 
papillae  are  always  encroached  on,  however,  and  hence  some  amount 
of  blood  escapes,  in  which  the  grafts  are  allowed  to  remain  soaking 
until  required  for  use.  The  grafts  are  applied  in  such  a  way  that 
they  overlap  each  other  and  also  the  margins  of  the  defect.  There 
is  always  some  tendencv  for  the  edges  to  turn  in,  and  this  must 
be  prevented  by  gentle  manipulation.  They  are  then  dressed 
with  dry  sterile  gauze,  though  some  surgeons  still  prefer  tf) 
keep  the  grafts  covered  with  protective,   or  with   perforated   tin 


ULCERATION  107 

or  thin  silver-foil.  There  is  usually  no  need  to  look  at  the  wound 
for  some  days.  The  outer  sides  of  the  thigh  and  arm  are  the  best 
places  from  which  to  take  grafts;  the  wounds  caused  by  their  re- 
moval are  dressed  by  sterile  gauze  over  protective  or  by  gauze 
soaked  in  picric  acid,  and  usually  heal  quickly,  if  the  razor  has  not 
encroached  on  the  subcutaneous  tissues.  The  scar  which  results 
from  the  healing  of  the  grafts  is  generall}-  soft  and  supple,  and  free 
from  the  tendency  to  excessive  contraction  which  marks  the  ordinary 
cicatrix. 

3.  The  whole  thickness  of  the  skin  is  used  in  some  instances 
{Wolfe  graft).  The  graft  is  cut  rather  larger  than  is  necessary,  to 
allow  for  shrinkage,  and  all  subcutaneous  tissue  and  fat  removed 
therefrom.  It  is  applied  to  the  raw  surface  of  the  wound  after 
scraping  away  all  granulations,  and  stitched  into  position.  It  may 
also  be  apphed  to  the  raw  surface  of  an  operation  wound. 

II.  Ulcers  due  to  Specific  Bacteria. 

The  different  forms  of  infective  ulcers  met  with  in  surgical 
practice  will  be  described  under  the  appropriate  headings  in  different 
parts  of  the  book.     It  will  suffice  here  to  mention  them: 

Soft  Chancre  (p.  149). — This  may  be  taken  as  a  type  of  all  in- 
fective ulcers,  clearly  showing  the  stages  of  infection,  incubation, 
ulceration,  and  repair. 
Ulcers  due  to  Syphilis  : 

(a)  The  primary  sore  (p.  155). 

(&)  Secondary  ulcers,  mainly  of  mucous  membranes,  but 
sometimes  involving  the  skin  (p.  159). 

(c)  Intermediate,  rupial,  or  ecthymatous  sores  (p.  161). 

[d)  Tertiary    ulcers    from    the    disintegration    of    gummata 

(p.  163). 
Phagedenic  ulceration  (p.  157)  is  usually  associated  vnth  syphilis. 
Ulcers  due  to  Tubercle  : 

{a)  The    lupoid    ulcer,    due    to     a    cutaneous    tuberculosis 

(Chapter  XVII.),  or 
[h)  The  tuberculous  ulcer,  arising  as  a  rule  from  the  bursting 
of  a  subcutaneous  or  submucous  tuberculous  abscess 
(p.  182).  .... 

(f)  Various  other  tuberculous  ulcerative  lesions  of  the  skin 
are  described  by  dermatologists  under  the  title  '  scrof- 
ulodermia,'  whilst  Bazin's  disease  (or  erythema  in- 
duratum)  is  possibly  tuberculous  in  origin. 

III.  Malignant  Ulcers. 

These  are  due,  as  has  already  been  pointed  out,  not  to  any  in- 
flammatory process,  but  to  the  actual  replacement  of  the  skin  by 
the  growth,  so  that  loss  of  substance  necessarity  ensues.  They  will 
be  described  in  Chapter  IX. 


CHAPTER  VII. 

GANGRENE. 

By  gangrene,  or  necrosis,  is  meant  the  simultaneous  loss  of  vitality 
of  a  considerable  area  of  tissue.  If  the  process  is  limited  to  the  soft 
parts  of  the  body,  it  is  often  termed  sloughing  or  sphacelation,  and  the 
dead  mass  a  slough  or  sphacelus ;  if  a  tangible  portion  of  bone  dies,  the 
necrosed  mass  is  called  a  sequestrum  ;  while  the  term  gangrene  is  more 
especially  applied  to  a  necrotic  process  affecting  simultaneously  the 
hard  and  soft  tissues  of  a  limb. 

General  History  of  a  Case  of  Gangrene. 

Signs  of  Death. — Death  of  a  limited  portion  of  the  body  can  be 
recognised  prior  to  the  supervention  of  evident  post-mortem  changes 
within  it  by  five  characteristic  signs: 

1.  Loss  of  pulsation  in  the  vessels. 

2.  Loss  of  heat,  since  no  warm  blood  is  brought  to  it. 

3.  Loss  of  sensation  in  the  dead  part,  although  much  pain  of  a 
referred  type  may  be  experienced  whilst  death  is  occurring. 

4.  Loss  of  function  of  the  gangrenous  mass,  which,  if  it  is  a  limb, 
lies  flaccid  and  motionless. 

5.  Change  of  colour,  the  character  of  whicli  depends  on  the  amount 
of  blood  present  at  the  time  of  death;  if  the  part  is  full  of  blood,  it 
becomes  purple  and  mottled;  if  anaemic,  a  waxy  or  cream  colour 
results. 

These  five  signs  may  be  in  measure  present  when  the  vitality  of  a 
limb  is  seriously  depressed,  as  by  hgature  of  the  main  vessel  or  by 
its  embolic  obstruction;  but  if  they  continue  for  any  length  of  time, 
death  is  certain  to  ensue.  Sometimes  it  is  a  little  difficult  to  deter- 
mine whether  a  part  is  dead,  especially  when  it  is  engorged  with 
venous  blood  and  the  arterial  pulsation  has  ceased;  if  living,  it  will 
usually  be  found  that  pressure  causes  some  modification  of  the 
colour,  and  that  the  discoloration  returns  when  the  pressure  is 
removed. 

Changes  occurring  in  the  Dead  Tissues. — The  character  of  these 
depends  mainly  on  the  condition  of  affairs  at  the  time  of  death,  and 
whether  or  not  putrefaction  supervenes. 

108 


PLATE  II. 


Fig.  I. — Senile  Gangrene  of  Foot.  In  this  case  amputation  was  performed  above 
the  knee,  and  the  popliteal  artery  was  found  to  be  very  atheromatous  and  in  a 
condition  of  thrombosis. 


Fig.  2. — Keloid  of  Thoracic  Wall. 


\_To  face  page  1 08. 


GANGRENE  109 

1.  Dry  Gangrene  {=^  death  +  mummification)  can  only  occur  when 
the  tissue  involved  is,  previous  to  its  death,  more  or  less  drained  of 
its  fluids.  The  usual  cause  is  chronic  arterial  obstruction,  as 
brought  about  by  arterio-sclerosis  or  calcification  of  the  terminal 
arteries,  to  which  a  sudden  or  gradual  complete  occlusion  of  the 
main  trunk  is  often  superadded.  The  dead  part  becomes  hard, 
dry,  and  wrinkled,  and  is  of  a  dark  brown  or  black  colour  from  the 
diffusion  of  the  disintegrated  haemoglobin  (Plate  IL,  Fig.  i).  The 
more  fleshy  parts  {e.g.,  above  the  ankle)  rarely  undergo  perfect 
mummification,  and  are  often  considerably  inflamed,  and,  if  bacteria 
be  admitted,  horribly  offensive. 

2.  Moist  Gangrene  arises  when  a  part  of  the  body  full  of  fluid  dies, 
and  is  especially  associated  with  conditions  which  involve  venous 
obstruction  as  well  as  a  sudden  arterial  block— e.g.,  in  traumatic 
gangrene  due  to  pressure  upon,  or  rupture  of,  the  main  artery. 
Obviously,  such  a  condition  is  well  suited  for  the  development  of 
the  organisms,  which  always  exist  in  numbers  on  the  skin,  and  unless 
the  most  vigorous  efforts  are  made  to  render  it  aseptic  before  or 
immediately  after  death,  moist  gangrene  is  certain  to  be  associated 
with  putrefaction ;  but  it  must  be  clearly  understood  that  the  latter 
is  no  essential  part  of  the  gangrenous  process. 

Aseptic  Moist  Gangrene  is  characterized  by  the  dead  tissues  be- 
coming more  or  less  discoloured,  either  purple  or  any  shade  from 
black  to  yellow,  green  or  white.  It  remains  of  much  the  same  size 
and  consistency  as  at  the  time  of  death  so  long  as  it  is  kept  from 
contamination,  and  is  then  simply  and  quietly  cast  off  from  the 
surrounding  tissues  without  any  obvious  inflammatory  disturbance, 
although  a  certain  amount  of  toxsemia  may  result  from  the  absorp- 
tion of  various  products  from  the  dead  tissues. 

Septic  or  Putrid  Moist  Gangrene  (Fig.  21)  is  necessarily  associated 
with  a  rapid  breaking-up  and  disintegration  of  the  mass,  which 
becomes  black,  green,  or  yellow.  The  cuticle  is  raised  from  the 
cutis  vera  by  blebs  containing  stinking  serum,  or  even  bubbles  of 
gas,  and  these  can  be  readily  pressed  along  under  the  epidermis  for 
some  distance.  The  tissues"  of  the  hmb  are  soft  and  lacerable,  and 
on  grasping  it  emphysematous  crackling  is  usually  noted. 

The  Later  History  of  a  gangrenous  mass  depends  entirely  on  its 
asepticity  or  not,  and  on  its  bulk. 

[a)  If  the  necrotic  area  is  small  in  size  and  aseptic,  it  may,  under 
favourable  circumstances,  be  entirely  absorbed  in  the  same  way  as  is 
a  catgut  ligature.  This  is  often  observed  after  sloughing  of  small 
portions  of  amputation  flaps;  if  the  part  is  kept  dry  and  aseptic,  it 
is  gradually  removed,  and  when  the  process  is  completed  a  small 
dark  scab  will  fall  or  be  picked  off,  and  a  cicatrix  be  found  beneath 
it.  In  a  similar  way  dead  bone  may  be  absorbed,  if  the  sequestrum 
is  not  too  large  or  too  dense,  and  if  it  is  in  close  proximity  to  healthy 
vascular  tissue.  The  dead  portion  is  first  invaded  by  small  round 
cefls,  presumably  leucocytes,  which  infiltrate  and  gradually  remove 
the  part ;  granulation  tissue  replaces  it,  and  this  in  turn  is  converted 


no  A   MANUAL  OF  SURGERY 

into  a  cicatrix,  and  covered  with  cuticle  in  the  usual  way  (see  Repair, 
Cliapter  X.). 

{b)  If  the  mass,  though  aseptic,  is  of  such  a  size,  or  consists  of 
such  tissues,  as  to  prevent  its  total  absorption,  or  if  tlie  vital  activity 
of  the  patient  is  lowered,  a  modification  of  the  same  process  results 
in  partial  absorption  of  the  dead  material,  whilst  the  remainder  is  cast 
off  and  separated  by  a  simple  process  of  ancemic  ulceration.  The  dead 
part  immediately  contiguous  to  the  living  is  removed  and  replaced  by 
granulation  tissue,  and  this  change  continues  advancing  into  the 
mass  until  the  layer  of  granulations  which  has  penetrated  furthest  is 
at  such  a  distance  from  its  nutritive  basis  as  to  be  unable  to  derive 
from  it  sufficient  pabuhmi,  owing  to  the  contraction  of  the  cicatricial 
tissue  which  is  forming  behind;  and  then  a  simple  ulcerative  process 
from  defective  nutrition  causes  a  line  of  cleavage  to  form  between 
the  living  and  dead,  and  by  this  means  the  latter  is  separated  from 
the  body.     The  size  of  tlie  portion  thus  cast  off  is  distinctly  less  than 


/ 
/ 


/ 


^2). 


tiG.  21.- -Septic  Moist  Gangrene  of  Leg  fkom   Penetrating  Wound  of 

Femoral  Artery. 

that  of  the  original  necrotic  mass.  This  process  is  associated  with 
no  local  inflammatory  reaction,  and  but  little  resulting  constitutional 
disturbance;  it  is  slow  in  progress,  but  there  are  none  of  the  risks 
attaching  to  the  more  rapid  septic  proceeding.  Of  course,  the 
denser  and  harder  the  tissues,  the  longer  they  take  in  separating, 
and  hence  when  a  whole  limb  is  involved  it  is  possible  for  the  soft 
parts  to  have  separated,  and  the  wound  caused  thereby  to  have 
cicatrized  before  much  impression  has  been  made  on  the  bones. 
Considerable  retraction  ensues,  giving  rise  to  a  '  conical  stump  '  from 
the  apex  of  which  the  bone  protrudes. 

(c)  If  the  gangrenous  portion  is  septic,  its  separation  is  accom- 
plished by  an  inflammatory  act  taking  place  in,  and  at  the  expense 
of,  the  surrounding  living  tissues.  The  extent  of  the  gangrene  is 
primarily  indicated  by  a  line  of  demarcation,  due  to  the  change  in 
colour  occurring  in  the  dead  part,  the  hving  tissues  retaining  their 


GANGRENE  in 

normal  hue.  The  irritation  of  the  chemical  products  formed  in  the 
necrosed  mass  causes  inflammation  in  the  surrounding  structures, 
which  ends  in  suppuration,  whilst  a  layer  of  granulation  tissue 
forms  at  the  limit  of  the  li\ang  portion,  and  thus  the  final  line  of 
separation  is  produced.  Clinically,  one  notices  in  this  latter  stage 
a  bright  red  line  of  hypercemia  at  the  extremity  of  the  living  tissues, 
which  gradually  spreads  and  deepens  until  about  the  eighth  or  tenth 
day,  when,  if  the  cuticle  is  intact,  the  h\dng  and  dead  parts  are 
separated  bv  a  narrow  white  or  yellow  line,  which  is  proved,  on 
pricking  the  epidermis,  to  be  due  to  the  presence  of  a  layer  of  pus; 
as  the  pus  escapes,  a  shallow  groove  is  seen  running  between  a 
granulating  surface  on  the  side  of  the  h\dng  tissues  and  the  gan- 
grenous mass.  This  process,  gradually  extending  through  the  whole 
thickness  of  the  Hmb,  is  accompanied  by  the  local  signs  of  inflam- 
mation and  by  fever,  the  degree  of  the  latter  depending  on  the 
amount  of  toxic  material  absorbed.  The  inflammation,  moreover,  is 
not  alwavs  hmited  to  the  line  of  separation,  but  may  spread  upwards 
along  the  lymphatics  or  veins,  or  in  the  fascial  and  muscular  planes, 
until,  perhaps,  the  whole  limb  is  involved  in  an  extensive  suppura- 
tive process. 

The  Constitutional  Symptoms  of  gangrene  may  be  described  under 
two  distinct  headings : 

{a)  Those  general  conditions  which  predispose  to  the  occurrence 
of  gangrene,  and  which  are  mainly  of  a  debilitating  character, 
affecting  either  the  composition  of  the  blood  or  the  \atahty  of  the 
hmbs.  General  diseases,  such  as  diabetes  and  albuminuria,  may  be 
present,  as  also  the  constitutional  results  of  a  xdcious  hfe,  whilst 
local  e\ddences  of  malnutrition  often  manifest  themselves  before  the 
onset  of  gangrene. 

(b)  Those  conditions  depending  on  the  presence  and  connection 
with  the  body  of  the  dead  tissue.  Various  forms  of  toxsemia  result, 
usuallv  causing  fever,  asthenic  in  type  and  variable  in  amount. 
Pain,  moreover,  is  frequently  a  prominent  feature  in  some  forms  of 
gangrene,  and  the  patient  is  hable  to  become  exhausted  from  this 
cause. 

But  little  need  be  said  as  to  the  General  Treatment  of  gangrene, 
beyond  that  the  strength  of  the  patient  must  be  maintained  by 
plentv  of  easily  assimilable  food,  sufficient  stimulant,  and  tonics. 
Pain  and  sleeplessness  must  be  combated  by  the  administration  of  a 
suitable  amount  of  opium  or  morphia,  if  the  kidneys  are  healthy. 
Diabetes  and  albuminuria  need  dietetic  and  therapeutic  measures  in 
order  to  limit,  if  possible,  the  excretion  of  sugar  and  albumen.  The 
Local  Treatment  is  discussed  below. 

Varieties  of  Gangrene. 

The  following  classification  is  one  which,  though  admittedly  im- 
perfect, does  in  a  measure  group  together  allied  t^-pes  of  the  affection, 
and  will  serve  as  a  useful  one  for  practical  purposes : 


112  A   MANUAL  OF  SURGERY 

I.  Symptomatic  Gangrene,  or  that  predisposed  to  by  preceding 
vascular  or  general  conditions,  and  where  a  trauma,  if  present  at  all, 
is  of  very  slight  signiiicance. 

(a)  Gangrene  from  embolus. 

(b)  Senile  gangrene. 

(c)  Gangrene  from  arterial  thrombosis  (non-senile). 
{(i)  Diabetic  gangrene. 

(e)  Raynaud's  disease. 
(/")   Gangrt'ne  due  to  ergot. 

II.  Traumatic  Gangrene,  which  may  be  due  to  chrect  or  indirect 
injury,  and  where  the  damage  done  to  the  vessels  or  tissues  by 
the  trauma  is  the  immediate  cause  of  the  loss  of  vitahty.  Two 
varieties  may  be  described,  viz.  : 

(a)  The  indirect,  where  the  lesion  involves  the  vessels  of 
the  limb  at  some  distance  above  the  spot  where  the 
gangrene  occurs. 

(h)  The  direct,  where  the  gangrenous  process  is  limited  to  the 
part  injured. 

III.  Infective  Gangrene,  which  arises  from  the  activity  and  in- 
fluence of  micro-organisms. 

(a)  Acute  inflammatory  or  spreading  traumatic  gangrene. 

(b)  Wound  phagedena  and  hospital  gangrene. 

(c)  Noma  and  cancrum  oris. 

(d)  Carbuncle  and  boil. 

IV.  Gangrene  from  Thermal  Causes — frost-bite  and  burns. 
Each  of  these  varieties  must  now  claim  separate  and  indi\idual 

attention. 

I.  Symptomatic  Gangrene. 

((0  Embolic  Gangrene.  (For  general  details  as  to  emboli,  see 
Chapter  XIV.).  When  the  main  artery  of  a  limb  becomes  blocked 
by  a  simple  embolus,  the  condition  is  exactly  similar  to  that  which 
obtains  after  ligature,  and  imder  ordinary  circumstances  should  not 
lead  to  gangrene;  but  if  either  the  general  or  local  vitality  is  much 
reduced,  the  occlusion  of  the  main  trunk  may  be  sufficient  to  deter- 
mine the  death  of  more  or  less  of  the  limb.  Thus  it  may  occur: 
(i.)  Where  the  embolus  consists  of  a  fibrinous  vegetation  detached 
from  one  of  the  cardiac  valves  in  a  case  of  endocarditis  following 
rheumatic  or  other  fevers.  The  general  nutrition  has  been  depressed 
by  the  preceding  fever,  the  heart's  action  is  weak,  and  the  circulation 
possibly  impeded  by  the  valvular  lesion,  so  that  the  occlusion  of 
a  main  trunk,  even  in  a  young  person,  is  often  sufficient  to  determine 
gangrene,  (ii.)  It  also  follows  when  a  detached  atheromatous  plate 
blocks  the  main  vessel  of  a  limb  previously  rendered  anaemic  by 
arterial  degeneration,  an  occurrence  not  unusual  in  elderly  people. 

Emboli  are  most  commonly  arrested  at  the  sites  of  division  of  the 
main  trunks  (Fig.  22,  A),  or  where  the  calibre  is  suddenly  diminished 
by  the  origin  of  a  large  branch,  the  embolus  often  saddling  over  the 
bifurcation,  and  thus,  as  it  increases  in  size  by  the  subsequent  de- 


GANGRENE 


"3 


posit  thereon  of  fibrin,  effectually  closing  both  branches  (Fig.  22,  B) 
In  the  lower  limb  it  occurs  at  the  division  of  the  femoral  or  popUt'eal; 
in  the  upper,  at  the  origin  of  the  superior  profunda,  or  where  the 
brachial  divides. 

The  chief  early  Symptom  is  sudden  severe  pain  experienced  both 
at  the  point  of  impaction  and  also  down  the  limb  along  the  course 
of  the  vessel.  Pulsation  below  the  block  ceases,  the  limb  becomes 
useless  and  devoid  of  sensation,  and  its  temperature  rapidly  falls. 
If  the  vessels  are  healthy,  stagnation  of  blood  in  the  veins  is  an 
early  result,  the  terminal  portion  of  the  hmb  becoming  congested 
and  oedematous,  and  finally  passing  into  a  condition  of  moist  gan- 
grene. If,  however,  the  terminal  arteries  are  calcified  or  atheroma- 
tous, so  that  the  hmb  is  in  a  state  of  chronic  anaemia,  dry  gangrene  is 
likely  to  follow.  The  process  starts  peripherally,  and  spreads 
gradually  upwards  until  it  reaches  a  level  where  there  is  sufficient 


Fig.  22.- 


-DlAGRAMS    OF    EMBOLUS    SADDLING    THE    BIFURCATION    OF 

AN  Artery. 


In  A  the  embolus  is  seen,  and  the  commencement  of  a  thrombus  on  it  but  not 
yet  obstructmg  the  vessel:  in  B  both  branches  of  the  trunk  are' blocked 
by  the  growth  of  the  clot. 

circulation  to  maintain  the  life  of  the  part.  This  usually  obtains 
m  the  neighbourhood  of  a  joint,  since  there  is  always  a  more  free 
anastomosis  here  than  in  the  interarticular  portions  of  the  hmb; 
thus,  m  the  leg  the  gangrene  is  arrested  either  immediately  above  the 
ankle  or  below  the  knee. 

Treatment.— The  first  requisite  is  to  prevent  the  advent  of  in- 
fection, even  before  any  absolute  signs  of  death  are  manifest.  The 
nails  should  be  cut,  and  the  whole  limb  thoroughly  purified 
(Chapter  XL),  special  atteation  being  directed  to  "the  intervals 
between  the  toes  and  the  semilunar  folds  of  the  nails.  It  should 
then  be  wrapped  in  a  dry  sterilized  dressing,  with  plenty  of  wool, 
and  bandaged.  The  limb  is  kept  slightly  raised  so  as  to  assist  the 
venous  return  without  interfering  with  the  arterial  supply,  and  by 
this  means  gangrene  may  be  prevented.  Vigorous  massage  so  as  to 
break  up  the  clot  and  drive  it  on  into  the  peripheral  vessels  has  been 
advocated.     A  few  instances  are  also  on  record  of  the  artery  being 


ri4  A   MANUAL  OF  SURGERY 

opened,  and  attempts  made  to  extract  or  tunnel  the  clot;  the  results 
haA  e  not  been  very  favourable.  If,  however,  ^^angrene  ensues,  the 
same  measures  as  to  the  maintenance  of  asepsis  must  be  con- 
tinued until  a  natural  line  of  separation  forms.  In  old  people  with 
dry  gangrene  the  question  of  amputation  is  decided  by  rules  similar 
to  those  for  the  senile  type:  but  in  young  people  amputation  through 
the  living  tissues  a  little  above  the  line  of  se})arati()n  is  all  that  is 
required,  and  the  period  for  this  must  be  determined  by  the  local  and 
general  conditions.  If  the  parts  are  aseptic,  the  amputation  may  be 
delayed;  but  if  spreading  inflammation  exists,  one  may  have  to 
remove  the  limb  higher  up  than  would  be  otherwise  necessary,  and 
this  even  bc^fore  any  line  of  separation  has  formed. 

{h)  Senile  Gangrene  occurs  in  elderly  people,  and  is  the  result  of 
imperfect  nutrition  of  the  tissues  (Fig.  23).  The  toes  are  most 
frequently  affected,  but  it  is  also  seen  in  the  hand,  and  may  attack 
the  nose,  ears,  or  even  the  tongue. 


i  iG.  23. — Senile  Gangrene. 

Causes. — These  are  to  be  found  mainly  in  the  condition  of  the 
circulatory  organs,  {a)  Calcareous  degeneration  of  the  smaller 
arteries  of  the  limb  or  part  is  always  present,  as  also  possibly  ather- 
oma of  the  larger  trunks.  The  vessels  become  pipe-like  and  in- 
elastic in  consequence,  and  incapable  of  accommodating  themselves 
to  the  requisite  variations  in  the  blood -supply.  Hence  a  fixed 
minimal  amount  of  blood  enters  the  limb,  which  passes  into  a  chronic 
state  of  anaemia  and  malnutrition,  whilst  the  tunica  intima  is  often 
so  rough  as  to  predispose  to  thrombosis  with  or  without  injury,  {h)  A 
weak  heart  is  generally  present,  leading  to  low  pulse  tension,  and 
increased  difficultv  in  propelling  the  blood  through  the  rigid  and 
narrowed  vessels;  and  (c)  the  condition  of  the  blood  may  be  impover- 
ished by  albuminuria  or  glycosuria.  When  such  predisposing  factors 
are  present,  anything  that  results  in  (d)  thrombosis  either  in  the  main 


GANGRENE 


"5 


trunks  or  in  the  peripheral  arterioles  or  capillaries  is  likely  to  deter- 
mine the  onset  of  gangrene.  Thrombosis  of  the  main  vessels  may 
be  due  to  a  blow  or  strain  which  often  passes  unnoticed,  or  more 
frequently  arises  from  a  gradual  deposit  of  fibrin  on  the  already 
roughened  walls.  If  the  obstruction  originates  in  the  smaller  trunks 
or  capillaries,  it  is  generally  brought  about  by  inflammation  follow- 
ing some  slight  injury,  such  as  striking  the  ball  of  the  great -toe 
against  the  table,  or  even  cutting  a  corn.  Exposure  to  cold  may 
also  act  as  an  exciting  agent.  In  either  case  the  clotting  extends 
for  some  distance,  and  the  he'ght  to  which  the  gangrene  spreads 
will  vary  accordingly. 

Symptoms. — Evidences  of  malnutrition  of  the  limb  have  probably 
been  present  for  some  time  in  the  form  of  cramp  and  pain  in  the 
muscles,  which  become  fatigued  rapidly,  or  of  sensations  of  pins  and 
needles  or  numbness.  The  pulsation  in  the  tibials  may  be  so  slight 
as  to  be  scarcely  perceptible,  and  the  whole  limb  is  shrivelled  and 
feels  cold  and  heavy.  The  skin  is  often  passively  congested,  and 
hence  prone  to  low  forms  of  ulceration  or  eczema.  When  the 
gangrene  commences  as  a  result  of  some  peripheral  lesion,  an  area 
of  painful  redness  is  first  noticed,  perhaps  running  on  to  ulceration, 
and  in  the  centre  of  this  patch  a  slough  forms,  which  becomes  dry 
and  black;  the  process  gradually  spreads  from  this  focus  with 
more  or  less  inflammation,  so  that  it  is  sometimes  known  as  in- 
flammatory senile  gangrene.  If,  however,  it  results  from  thrombosis 
of  the  main  vessels,  death  occurs  without  the  supervention  of  local 
inflammatory  phenomena,  the  toes  merely  shrivelling  up  and  dying 
{non-inflammatory  senile  gangrene).  The  inner  side  of  the  great- 
toe  (Plate  II.,  Fig.  i)  is  perhaps  the  commonest  situation  for  the 
mischief  to  start,  and  thence  it  spreads  from  one  toe  to  another,  and 
also  along  the  instep  and  up  the  ankle  to  the  leg.  Pain  is  always  a 
marked  feature,  whilst  the  extent  of  the  gangrene  is  dependent 
partly  on  the  amount  of  general  and  local  vitality,  and  partly  on 
the  asepticity  or  not  of  the  surrounding  tissues.  As  the  disease 
spreads,  the  patient  becomes  exhausted  by  the  long-continued  pain 
and  want  of  sleep;  and  septic  fever,  bedsores,  or  the  intervention  of 
some  cardiac,  pulmonary,  or  renal  complication,  may  also  hasten  a 
fatal  termination. 

Treatment. — In  the  earlier  stages  of  malnutrition  of  a  limb  from 
a  defective  arterial  supply,  marked  by  coldness  and  a  sense  of  weight 
and  fatigue,  much  may  be  done  to  improve  the  vitality  of  the  part 
by  the  cautious  use  of  hot-air  baths,  massage,  etc.,  and  attention 
to  the  general  health.  The  patient  must  be  warned  of  the  danger 
of  small  injuries,  and  the  possible  harm  that  may  follow  the  in- 
judicious use  of  hot-water  bottles,  or  of  incautiously  cutting  corns. 
If  the  condition  progresses  and  actual  gangrene  is  threatening, 
arterio -venous  anastomosis  may  be  justifiable.  In  this  procedure 
the  circulation  is  deflected  from  the  obstructed  arteries  to  the  patent 
veins,  and  thereby  the  vitality  of  the  limb  may  be  preserved. 
Hunter's  canal  is  the  usual  site  of  this  operation.     The  vein  and 


ii6  A   MANUAL  OF  SURGERY 

artery  are  exposed  and  divided  transversely;  the  distal  end  of  the 
artery  and  the  proximal  end  of  the  vein  are  ]ifj;atured,  and  a  careful 
end-to-end  anastomosis  is  effected  between  the  ])ro\imal  end  of  the 
artery  and  the  distal  end  of  the  vein. 

When  gangrene  is  actually  present,  treatmt-nt  is  governed  l)y  the 
observation  that  after  an}^  attempt  to  amputate  through  neighbour- 
ing living  parts  the  gangrenous  process  is  certain  to  commence  again 
in  the  flaps;  if  merely  cutting  a  corn  suffices  to  originate  the  malady, 
nmch  more  will  so  severe  an  injury  as  an  amputation.  It  is  there- 
fore necessary  to  amputate  well  away  from  the  dead  mass  at  a  point 
where  the  blood-supply  is  sufficient  to  nourish  the  flaps,  and  yet  not 
so  near  the  trunk  as  to  threaten  life  seriously  through  shock.  This 
must  be  undertaken  early,  especially  when  pain  is  severe,  or  if  a 
spreading  cellulitis  is  present.  In  order  to  determine  the  most 
favourable  site,  the  main  artery  should  be  carefully  examined,  and 
if  feasible  no  operation  is  performed  at  a  level  where  it  appears  to 
be  occluded.  It  should  also  be  remembered  that  the  nmscles  are 
better  supplied  with  blood  than  the  overlying  skin.  The  condition 
of  the  limb  will  therefore  influence  the  surgeon's  decision;  if  thin, 
attenuated,  and  shrivelled,  it  will  be  wise  to  amputate  high.  The 
operation  should  inflict  as  little  damage  as  possible  on  the  parts, 
the  flaps  being  nearly  equal  in  length  and  sufficiently  thick  to  in- 
clude plenty  of  muscle.  Where  the  mischief  is  limited  to  the  foot, 
it  is  usually  advisable  to  amputate  through  the  lower  third  of  the 
thigh,  or  at  any  rate  in  the  neighbourhood  of  the  knee-joint,  though 
not  through  the  joint  itself,  as  the  flaps  in  that  operation  are  always 
rather  flimsy.  If  for  any  reason  amputation  is  contra-indicated, 
the  limb  is  kept  aseptic  (if  possible),  wrapped  up  warmly,  and 
elevated.  The  general  health  is  maintained  by  suitable  nourish- 
ment, tonics,  and  stimulants,  and  pain  alleviated  by  opium. 

(c)  Gdngrene  from  Arterial  Thrombosis  (non-senile)  is  not  a  com- 
mon occurrence.  It  arises  as  a  result  of  the  aft'ection  known  as 
endarteritis  obliterans,  and  also  develops  in  the  later  stages  of 
typhoid  fever  and  other  conditions  of  severe  toxsemia  as  an  outcome 
of  arterial  thrombosis,  caused  partly  by  the  increased  coagulability 
of  the  blood,  partly  by  a  localized  endarteritis,  lighted  up  by  the 
circulating  toxins.  The  femoral  artery  is  most  usually  blocked,  but 
occasionally  the  trouble  will  spread  up  to  the  aorta  and  involve  both 
legs  in  the  gangrenous  process.  Unless  the  vein  is  also  involved, 
the  gangrene  is  usually  of  the  dry  type.  It  is  wise  to  wait  until  a 
line  of  demarcation  has  formed,  and  then  amputate  well  above. 

A  similar  condition  is  met  with  chiefly  in  Russian  and  Polish  Jews 
who  are  heavy  cigarette  smokers,  resulting  from  an  affection  which 
has  been  designated  thrombo-angiitis  obliterans  (Leo  Buerger),  in 
which  extensive  thrombosis  occurs  first  in  the  arteries  and  later  in 
the  veins  of  the  leg.  In  the  earlier  stages  various  sensory  and  trophic 
changes  are  noticed,  and  in  the  later  gangrene,  usually  of  the  dry 
type,  occurs.  It  has  been  suggested  that  in  early  cases  arteriovenous 
anastomosis  between  the  femoral  artery  and  vein  might  be  useful. 


GANGRENE  117 

A  limited  gangrene  of  tlie  tips  of  one  or  more  fingers  of  a  dry  type 
may  occur  as  a  consequence  of  the  pressure  of  a  cervical  rib  on 
the  subclavian  vessels. 

A  curious  form  of  gangrene  occasionally  follows  the  application 
of  a  carbolic  acid  compress,  even  when  weak  solutions — e.g.,  i  in  60 — 
are  employed.  The  fingers  are  the  parts  usually  affected,  and  the 
gangrene  does  not  seem  to  be  due  to  tight  bandaging,  or  to  the 
presence  of  a  waterproof  covering.  Possibly  the  carbolic  acid 
determined  prolonged  arterial  spasm,  and  the  anaemia  was  followed 
by  local  necrosis. 

{d)  Diabetic  Gangrene  is  mainly  due  to  the  abnormal  condition  of 
the  blood  in  diabetes,  thereby  reducing  the  power  of  the  tissues  to 
resist  bacterial  invasion;  but  it  is  also  in  measure  the  result  of  a 
sclerosing  endarteritis  and  peripheral  neuritis.  It  is  not  generally 
met  with  in  the  subjects  of  acute  diabetes,  nor  in  people  under  forty 
years  of  age.  It  results  usually  from  some  slight  traumatic  or 
infective  injury,  and  often  commences  on  the  under  side  or  at  Ihe 


■^''-cftaaj 


Fig.  24. — Diabetic  Cellulitis  and  Gangrene  of  Foot  and  Leg. 

extremity  of  one  of  the  toes  as  a  bleb,  surrounded  by  a  dusky  purple 
areola.  When  the  bleb  is  opened  or  bursts,  the  central  portion  of 
the  underlying  tissue  is  found  to  be  necrotic,  and  from  this  focus  the 
gangrene  spreads.  If  the  part  is  kept  aseptic,  and  in  limbs  with 
some  degree  of  endarteritis,  the  dead  part  may  shrivel  and  dry  up, 
especially  when  suitable  dietetic  restrictions  are  enforced;  but  if  such 
local  and  general  precautions  are  not  observed,  extensive  suppura- 
tive infiltration  of  the  soft  parts  may  follow  (Fig.  24),  even  though 
the  necrotic  process  itself  be  of  slight  extent,  and  from  this  the 
patient  may  succumb,  the  fatal  issue  being  due  partly  to  diabetes, 
partly  to  toxaemia,  and  being  often  preceded  by  coma.  Not  un- 
commonly several  foci  of  mischief  develop,  and  the  extent  of  subcu- 
taneous involvement  is  sometimes  much  more  extensive  than  the 
limited  affection  of  the  skin. 

Treatment. — In  the  less  severe  cases,  involving  one  or  more  toes, 
it  will  often  suffice  to  keep  the  part  warm  and  aseptic,  until  it  is 
separated  by  natural  processes,  or  at  any  rate  the  surgeon  merely 
completes  the  work  by  dividing  or  dissecting  out  bones.     Naturally, 


ii8  A   MANUAL  OF  SURGERY 

the  elimination  of  sugar  must  be  checked,  if  possil)le,  by  suital)le 
diet  and  the  administration  of  codeia.  In  more  extensive  trouble 
the  character  of  the  treatment  turns  largely  on  the  amount  of 
vascular  disease  and  the  degree  of  the  accompanying  inflammati(jn. 
If  the  vessels  are  tolerably  healthy,  amputation  not  very  much  above 
the  upper  limit  of  the  gangrene  is  justifiable;  but  if  the  main  trunks 
are  probably  affected,  a  high  amputation  will  be  recjuired,  if  the 
patient's  general  condition  permits,  although  there  is  some  risk  that 
diabetic  coma  mav  supervene.  \Mien  extensive  suppuration  is 
present,  it  is  sometimes  wise  to  lav  the  parts  open  for  awhile  and 
drain  away  the  inflammatory  exudations  before  considering  the 
question  of  radical  treatment.  The  choice  of  the  anaesthetic  will 
also  require  careful  consideration;  and  spinal  analgesia  should  be 
employed  when  the  lower  extremitv  is  involved. 

(e)  Raynaud's  Disease,  <>r  Spontaneous  Symmetrical  Gangrene,  is 
a  condition  usually  met  with  in  ansemic  or  neurotic  voung  women 
between  the  ages  of  fifteen  and  thirty.  It  is  due  to  vaso-motor 
spasm,  dependent  on  some  deep  unrecognised  lesion  of  the  spinal 
cord,  or  in  some  cases  to  a  peripheral  neuritis.  Three  stages  are 
usually  described:  (i.)  local  syncope  or  anaemia,  due  to  arterial 
spasm,  and  characterized  bv  pallor  and  painfulness  of  the  part; 
(ii.)  local  asphyxia  or  congestion,  the  affected  tissues  being  blue  and 
cyanosed  from  venous  regurgitation;  and  (iii.)  necrosis,  the  part 
becoming  dry  and  black.  The  onset  is  often  sudden,  and  the  disease 
may  last  for  a  variable  time,  from  days  to  months.  If  gangrene 
supervenes,  the  latter  is  the  limit  more  often  reached;  but  it  by  no 
means  necessarily  follows  that  tissue  necrosis  occurs  in  every  case. 
The  disease  is  usually  symmetrical,  and  affects  the  fingers  rather 
than  the  toes,  but  superficial  patches  may  occur  on  any  part  of  the 
body ;  the  process  is  non-febrile  and  often  very  painful.  Paroxysmal 
haemoglobinuria  has  been  observed,  and  is  supposed  to  be  due  to 
vaso-motor  disturbance  of  the  kidneys.  Ankylosis  of  the  smaller 
interphalangeal  joints  and  localized  patches  of  anaesthesia,  associated 
with  neuralgic  pain,  are  sometimes  present,  resulting  from  peripheral 
neuritis.  The  condition  often  resembles  the  later  stages  of  a  chil- 
blain, but  is  distinguished  by  its  more  dusky  colour,  the  greater  pain, 
the  absence  of  itching,  and  the  fact  that  the  process  is  not  limited  to 
exposed  or  terminal  parts,  or  to  cold  weather. 

The  Treatment  in  the  early  stages  is  directed  to  the  prevention  of 
gangrene.  Iron,  quinine,  and  other  suitable  tonics  are  administered, 
and  menstrual  irregularities  are  attended  to.  Friction  with  stimu- 
lating embrocations,  warm  douches,  and  protection  from  cold  and 
injury,  may  be  employed  locally,  but  probably  the  best  results  will 
follow  the  use  of  electricity.  The  constant  current  is  employed,  and 
])referably  in  the  shape  of  the  electric  bath,  local  or  general  as 
required,  and  repeated  either  once  or  several  times  a  day.  \A' hen 
actual  gangrene  is  present,  the  dead  tissue  should  be  kept  aseptic, 
when  sooner  or  later  it  will  be  absorl)ed  or  separated. 

( /)  Gangrene  from  Ergot  is  a  rare  phenomenon,  but  it  has  been 


GANGRENE  iig 

known  to  occur  when  diseased  rye  has  been  used  in  the  manufacture 
of  bread.  The  resulting  gangrene  may  vary  in  extent  from  the  loss 
of  one  or  two  fingers  or  toes  to  the  sacrifice  of  the  greater  portion  of 
one  or  more  limbs. 

II.  Traumatic  Gangrene. 

B}'  traumatic  gangrene  is  meant  the  loss  of  vitality  of  some  part 
of  the  body  as  the  consequence  of  an  injury,  whether  applied  to  the 
main  bloodvessels  {indirect  traumatic  gangrene),  or  directly  to  the 
tissues  {direct  traumatic  gangrene). 

{a)  Indirect  Traumatic  Gangrene  arises  from  a  considerable  variety 
of  lesions,  and  the  course  and  clinical  history  are  similarly  variable. 

(i.)  Ligature  of  the  main  artery  does  not  produce  gangrene  in  a 
healthy  limb;  but  should  it  be  in  a  state  of  chronic  malnutrition  and 
anaemia  from  preceding  arterial  disease,  death  of  a  certain  portion 
may  ensue,  the  case  running  a  similar  course  to  one  of  gangrene  due 
to  embolus.  It  is  usually  of  the  dry  type,  and  limited  to  one  or  two 
toes,  or  to  a  patch  of  the  superficial  tissues;  but  if  it  reaches  the  more 
fleshy  portions,  the  moist  variety  supervenes. 

Treatment  consists  in  keeping  the  parts  warm  and  aseptic  until 
a  definite  line  of  separation  forms,  and  then  in  assisting  the  natural 
processes  at  this  spot  by  di^ading  tendons  and  bones.  If,  however,  a 
considerable  area  of  the  limb  loses  its  vitality,  and  especially  if  the 
dead  tissue  is  moist  and  putrid,  an  early  high  amputation  is  required. 

(ii.)  Arterial  thrombosis  from  injury  only  causes  gangrene  under 
special  circumstances,  the  course  and  treatment  being  similar  to  that 
resulting  from  an  embolus. 

(iii.)  Obstruction  to  both  main  artery  and  vein  is  an  almost  certain 
precursor  of  gangrene,  if  it  occurs  suddenly.  Cases  are  on  record  in 
which  both  vessels  have  been  ligatured,  or  even  portions  of  them 
removed  without  such  a  result,  as  in  dealing  with  cancerous  deposits 
in  the  axilla  or  in  the  extirpation  of  aneurisms;  but  in  both  these 
instances  obstruction  to  the  circulation  must  have  previously  existed, 
necessitating  the  opening  up  of  collateral  anastomotic  branches.  In 
a  normal  limb  the  simultaneous  occlusion  of  both  afferent  and 
efferent  trunks,  as  by  inclusion  in  a  ligature,  is  almost  certain  to 
determine  tissue  necrosis.  It  is  also  caused  by  the  strangulation 
of  organs,  either  within  the  body,  as  in  a  strangulated  hernia,  or 
outside  of  it,  as  when  a  ligature  is  tied  round  the  base  of  the  penis, 
or  a  bandage  apphed  too  tightly  round  a  fractured  limb.  It  may 
even  result  from  the  swelling  of  a  limb  under  a  bandage  which  has 
been  originally  applied  with  no  undue  tension. 

Gangrene  may  also  follow  the  rupture  of  a  main  artery  and 
compression  of  the  accompanying  vein  by  the  extravasated  blood, 
an  occurrence  perhaps  most  frequently  seen  after  fractures  and  dis- 
locations ;  it  is  then  alwa^^s  of  the  moist  type.      (See  Chapter  XX.) 

Treatment  varies  considerably  in  these  cases.  If  the  parts  are 
hopelessly  injured,  amputation  should  be  performed  at  once,  so  as  to 
prevent  the  risk  of  infection.     In  some  fractures  and  dislocations 


I20  A   MANUAL  OF  SURGERY 

with  vascular  lesions,  it  may  be  possible  to  save  the  limb  by  cutting,' 
down,  turning  out  clots,  and  securing  the  injured  vessels,  whilst  the 
bony  lesion  is  dealt  with  in  a  suitable  manner.  The  limb  should 
afterwards  be  elevated  slightly,  and  the  peripheral  segment  kept 
wami  and  aseptic.  Should  gangrene  supervene,  amputation  will  be 
required,  its  situation  depending  on  the  character  of  the  local  lesion; 
if  it  is  not  of  a  serious  nature — e.g.,  a  clean  fracture  or  simple  dis- 
location— it  is  wise  to  wait  for  a  line  of  demarcation;  but  if  com- 
minution of  bone  or  other  grave  local  trouble  is  present,  one  should 
am])utate  above  the  injury. 

{b)  Direct  Traumatic  Gangrene,  or  that  resulting  from  the  im- 
mediate effect  of  injury  to  the  parts,  is  similarly  due  to  a  variety  of 
lesions. 

(i.)  Severe  crushes  or  blows  are  a  common  cause  of  this  type  of 
gangrene;  thus  a  limb  may  become  mangled  between  the  wheels  of 
machinery,  or  by  heavy  weights  falling  on  it,  or  by  the  passage  of 
vehicles  over  it.  "  Not  only  are  the  parts  crushed,  severely  cont~used, 
or  even  '  pulped,'  but  the  bloodvessels  may  be  torn,  and  the  pressure 
of  extravasated  blood  contributes  to  the  result.  The  gangrene  is  of 
the  moist  type,  and  is  more  likely  to  supervene  in  patients  whose 
vitality  is  diminished.  Thus,  a  crush  of  the  foot  in  an  elderly 
person  is  often  followed  by  it,  when  in  a  young  and  healthy  adult  it 
could  be  prevented. 

Treatment.— If  the  part  is  hopelessly  damaged,  operation  should 
not  be  delayed,  on  account  of  the  dangers  of  infection;  and  therefore 
immediate  amputation  is  recommended.  The  question  of  shock  and 
its  influence  in  determining  operation  is  discussed  elsewhere.  When 
there  seems  a  reasonable  chance  of  saving  the  limb,  it  is  cleansed 
and  purified  under  the  strictest  antiseptic  precautions;  should 
gangrene  supervene,  it  may  be  removed  later. 

(ii.)  Prolonged  pressure  is  also  capable  of  producing  gangrene. 
Gangrene  from  splint  pressure  is  either  almost  unavoidable,  or  the 
result  of  carelessness.  When  the  fragm^ents  are  much  displaced 
after  a  fracture,  considerable  pressure  may  be  required  to  retain 
tliem  in  good  position,  and  then  in  spite  of  every  precaution  necrosis 
may  ensue.  Pain  of  a  neuralgic  type  is  usually  complained  of  for  a 
few"  days,  but  even  that  is  not  necessarily  severe  enough  to  attract 
much  attention;  when  the  limb  is  freed  later  on,  the  dead  portion  of 
the  skin  is  white,  anaemic,  and  insensitive.  The  necrotic  process 
may  extend  to  some  depth,  and  hence  the  greatest  care  must  be 
taken  to  keep  the  dead  tissues  aseptic,  thereby  avoiding  grave  local 
and  constitutional  disturbance. 

Bedsores  are  likely  to  occur  in  patients  who  are  kept  for  a  long 
time  in  the  recumbent  posture,  or  in  any  one  particular  position. 
The  parts  most  exposed  to  pressure  becorne  red  and  congested,  and 
finally  ulceration  or  actual  gangrene  supervenes.  Bedsores  arc  not 
usually  extensive  or  deep;  but  if  the  patient  is  debilitated  or  para- 
lyzed, \he  process  may  extend  rapidly,  destroying  fascia?,  laying  open 
muscular  sheaths,  and  even  leading  to  necrosis  or  caries  of  bene 


GANGRENE  121 

{acute  bedsore).  The  spinal  canal  itself  has  been  opened  in  this  way, 
and  death  from  infective  meningitis  has  resulted.  To  prevent  the 
occurrence  of  such  sores,  the  nurse  must  see  that  the  draw-sheet  and 
bed-linen  are  placed  smoothly  and  without  creases,  and  that  no 
contamination  by  urine  or  fasces  is  allowed.  The  skin  of  the  back 
is  daily  washed  with  some  unirritating  soap,  and  rubbed  with  a 
soothing,  strengtiiening,  and  hardening  application,  such  as  methy- 
lated spirit,  or  a  mixture  of  brandy  and  white  of  egg.  It  is  then 
dusted  over  with  a  powder,  consisting  of  equal  parts  of  oxide  of 
zinc,  boric  acid,  and  starch,  in  order  to  harden  and  dry  it.  If  the 
skin  becomes  red,  it  should  be  painted  with  a  mixture  of  equal  parts 
of  tincture  of  catechu  and  liquor  plumbi  subacetatis,  which  when 
dr}'  leaves  a  powdery  film  on  the  surface,  and  protected  from  pressure 
by  a  circular  hollow  water-pillow.  Paraplegic  patients  or  old  people 
should  be  placed  on  a  water-bed,  which  must  be  sufficiently,  but 
not  excessively,  distended.  If  there  is  too  httle  water,  the  weight  of 
the  bod}'  displaces  it  to  one  side,  and  no  good  results;  whilst  if  there 
is  too  much,  the  bed  becomes  hard  and  resistant,  and  fails  in  the 
object  for  which  it  is  employed.  When  an  open  sore  forms, 
fomentations  are  required  in  the  more  acute  stages,  whilst  later  it 
m.ay  be  dressed  either  with  diluted  boric  acid  ointm.ent,  or  in  the 
more  sluggish  cases  with  resin  and  boric  acid  ointments  mixed. 
Friar's  balsam,  mixed  with  castor-oil  (i  part  of  the  balsam  to  7  of 
the  oil),  is  useful  in  this  condition.  • 

(iii.)  The  action  of  corrosive  or  caustic  chemicals  is  followed  by  a 
localized  traumatic  necrosis,  the  degree  of  which  varies  with  the 
amount  and  character  of  the  irritant  present,  and  the  duration  of  its 
action.  All  that  is  needed  is  to  keep  the  parts  aseptic,  and  allow 
them  to  be  absorbed  or  separated  by  natural  processes. 

III.  Specific  or  Infective  Gangrene. 

{a)  Acute  Spreading,  Acute  Emphysematous,  or  Spreading  Trau- 
matic Gangrene. — This  disease  is  one  of  the  most  rapidly  fatal  and 
serious  met  with  in  surgerv. 

Causes. — (i.)  The  individual  attacked  is  often  debilitated  as  a 
result  of  vicious  or  careless  living,  heavy  drinking,  or  simple  mal- 
nutrition; but  even  healthy  individuals  may  be  attacked  if  the  virus 
is  active.  It  is  sometimes  seen  in  diabetics,  but  a  form  of  glycosuria 
occasionally  develops  in  the  course  of  the  disease. 

(ii.)  The  causative  lesion  is  usually  severe,  such  as  a  compound 
fracture  or  dislocation,  especially  if  the  soft  parts  are  much  contused 
or  ver}'  dirt}-.  Defective  purification  of  such  tissues,  and  injudicious 
attempts  to  save  them  by  accurate  and  close  stitching,  perhaps 
without  drainage,  are  amongst  the  most  frequent  causes  of  an 
outbreak  of  this  disease.  Less  frequently  it  follows  a  small  and 
insignificant  prick,  scratch,  or  abrasion,  through  which  a  virulent 
organism  gains  access  to  the  tissues.  In  this  way  post-mortem 
porters,  nurses,  or  pathological  demonstrators  may  become  infected. 


122  A   MANUAL  OF  SURGERY 

(iii.)  An  organism  frequently  present  is  the  Bacillus  (cdcmalis 
nialigni,  which  is  identical  with  the  Vibrion  septique  of  Pasteur  and 
the  French  writers.  It  is  a  rod-shaped  organism,  which  closely 
resembles  that  of  anthrax,  but  is  Gram-negative,  and  has  a  greater 
tendency  to  grow  into  long  threads.  It  is  actively  motile,  and  forms 
oval  spores,  which  may  be  placed  at  the  centre  <)r  at  the  end  of  the 
rod.  Cultures  only  develop  under  anaerobic  conditions;  and  if  the 
culture  medium  contains  glucose,  a  large  amount  of  foul-smelling 
gas  is  produced.  Mice  and  guinea-pigs  clie  within  twenty-four  hours 
of  inoculation;  locally  a  spreading  oedema  is  produced,  the  con- 
nective-tissue spaces  being  distended  with  fluid  containing  bacilli, 
and  perhaps  gas;  bacilli  are  also  found  in  the  exudations  which 
occur  in  the  serous  cavities,  in  the  connective  tissues  of  important 
organs,  and  in  the  blood  for  some  time  after  death.  The  B.  aerogenes 
capsiilaiiis  may  also  cause  acute  spreading  gangrene.  It  is  an 
anaerobe  with  a  similar  power  of  fermenting  sugar,  but  is  non- 
motile,  rarely  forms  spores,  and  is  Gram-positive.  It  usually 
possesses  a  well-defined  capsule,  but  this  is  not  invariable.  Careful 
investigation  of  fifty-eight  cases*  of  spreading  gangrene  demon- 
strated that  in  only  fourteen  cases  was  there  a  pure  infection,  with 
an  anaerobic  organism,  which  was  more  frequently  the  B.  aerogenes 
capsidatiis  than  the  B.  (vdematis  maligni.  A  special  feature  of 
infection  with  the  former  is  the  large  amount  of  gas  produced,  not 
only  in  the  tissues,  but  also  post-mortem  in  the  vessels,  and  notably 
in  the  liver,  from  which  it  can  easily  be  squeezed,  constituting  the 
foaming  liver  '  of  some  writers. 

Symptoms. — The  outbreak  of  this  disease  may  be  delayed  for  two 
or  three  days,  during  which  the  wound  is  perhaps  a  little  painful, 
but  shows  no  special  signs  of  activity ;  none  the  less,  mischief  is  going 
on  out  of  sight,  and  the  absence  of  discharge  is  a  bad  sign.  In  some 
cases  the  period  of  incubation  is  shorter.  Suddenly  and  perhaps 
with  little  warning  the  case  develops  as  a  hyperacute  cellulitis, 
accompanied  by  general  septicaemia.  The  wound,  when  opened  up, 
is  found  to  be  unhealthy,  the  surface  covered  with  sloughs,  and  a 
thin  serous  or  sero-purulent  discharge  escaping.  The  inflammatory 
process  rapidly  spreads  along  the  connective-tissue  planes  of  the 
limb,  which  becomes  swollen,  painful,  and  brawnv;  in  one  case  the 
gangrene  spread  from  the  foot  to  the  groin  within  twelve  hours. 
At  first  the  parts  are  occupied  by  a  bright  red  blush,  but  they  soon 
become  purple,  gangrenous,  and  crepitant.  The  emphysema 
spreads  widely  and  rapidly,  with  at  first  no  other  local  evidence  of 
mischief;  sloughing  will,  however,  follow  if  the  patient  live  long 
enough.  Evidences  of  profound  toxic  disturbance,  such  as  hyper- 
pyrexia and  delirium,  soon  manifest  themselves;  but  not  uncom- 
monly fever  may  be  entirely  absent,  the  temperature  being  sub- 
normal and  coma  present.  The  outlook  is  exceedingly  grave,  death 
usually  ensuing  in  two  or  three  days. 

*  See  Corner  and  Singer  on  '  Emphysematous  Gangrene,'  Trans.  Path.  Soc. 
Lond.,  vol.  Hi.,  1901,  p.  42;  Welch's  '  Shattuck  Lecture,'  Philadelphia  Med. 
Journ.,  August  4,  1900. 


GANGRENE  123 

Treatment. — It  is  impossible  to  emphasize  too  strongly  the  danger 
of  closing  up  completely  and  without  drainage  lacerated  and  con- 
tused wounds  which  have  been  caused  by  accidents  on  the  railways 
or  in  the  street,  whereby  the  damaged  tissues  have  been  brought 
into  contact  with  the  ground,  and  perhaps  infected  thereby. 
Dangerous  anaerobic  organisms  are  so  constantly  present  in  the 
soil,  that  to  close  up  such  a  wound  is  to  favour  their  development. 
Scrupulous  antiseptic  cleansing  of  the  wound,  and  especially  by  the 
use  of  oxidizing  agents,  such  as  peroxide  of  hydrogen,  sanitas,  etc., 
loose  suturing  of  the  parts,  and  free  drainage,  are  essential  if  dan- 
gerous consequences  are  to  be  avoided.  The  appearance  of  inflam- 
matory phenomena  will  necessitate  free  opening  of  the  wound, 
followed  by  incisions  through  infected  tissues  and  immersion  of  the 
hmb  in  a  wami  bath  containing  Condy's  fluid  or  sanitas.  If,  in 
spite  of  this,  the  disease  spreads,  a  high  amputation,  well  above  its 
upper  limits,  even  through  the  shoulder  or  hip-joint,  is  the  only  hope 
of  saving  life. 

(b)  Wound  Phagedena  and  Hospital  Gangrene  were  seen  often 
enough  in  the  pre- antiseptic  era,  but  are  now  practically  unknown. 
They  consisted  in  a  rapidly  spreading  ulceration  or  gangrene,  which 
attacked  operation  wounds  a  few  days  after  their  infliction,  and  as  a 
rule  led  to  rapid  death. 

(c)  Cancrum  Oris  and  Noma. — Cancrum  oris  is  an  infective  gan- 
grenous stomatitis,  affecting  young  children  living  in  squalid  sur- 
roundings in  over-populated  districts  of  large  cities.  The  patients 
are  always  in  a  low  state  of  health,  and  frequently  convalescing 
from  one  of  the  exanthemata,  particularly  measles.  The  process 
starts  in  an  abrasion  of  the  mucous  membrane,  which,  being  infected 
from  a  diseased  or  dirty  tooth,  becomes  inflamed  and  gangrenous. 
A  foul  ashy-gray  pultaceous  slough  forms  on  the  inside  of  one  of  the 
cheeks,  and  from  this  a  most  offensive  discharge  is  poured  into  the 
mouth  and  swallowed,  the  breath  in  consequence  becoming  intensely 
foetid.  The  gangrene  gradually  spreads  both  superficially  and 
deeply;  the  cheek  becomes  swollen,  shiny,  and  tense,  and,  should 
the  process  extend  through  its  whole  substance,  a  black  slough 
appears  on  its  outer  aspect.  In  bad  cases,  the  adjacent  bones  of 
the  face  may  be  affected  and  die,  and  the  tongue,  palate,  and  even 
the  fauces,  may  also  be  involved. 

The  general'phenomena  are  those  of  a  severe  toxsemia,  since  not 
only  are  the  toxic  products  swallowed,  but  they  are  also  absorbed  by 
the" lymphatics,  and  may  be  inhaled,  in  the  latter  case  giving  rise  to 
septic  pneumonia.  Moreover,  the  patient  runs  a  considerable  risk 
of  developing  pyaemia,  from  implication  of  the  facial  or  other  veins 
in  the  necrotic  process,  whilst  infective  septicaemia  may  also  super- 
vene. Rigors  and  high  fever  may  occur  early  in  the  case,  but  death 
is  usually  preceded  by  symptoms  of  collapse  and  coma,  wth  a 
subnormal  temperature.  .     . 

The  bacteriology  of  this  affection  is  a  little  doubtful,  but  it  is 
probably  due  to  the  Streptococcus  pyogenes  in  conjunction  with  one 


124  A   MANUAL  OF  SURGERY 

or  more  of  the  bacteria  always  present  in  a  dirty  mouth,  and  notal^ly 
the  spirillum  of  Vincent's  angina. 

The  Treatment  must  be  prompt  and  energetic  if  the  child's  life  is 
to  be  saved.  The  j^atient  should  be  an;esthetizcd,  and  all  the  pulta- 
ceous  slough  removed  by  cutting  or  scraping,  until  healthy  bleeding 
tissue  is  reached.  The  denuded  surface  ife  then  freely  rubbed  over 
with  pure  carbolic  or  strong  nitric  acid.  In  using  such  agents,  the 
throat  must  be  carefully  protected,  and  the  excess  of  acid  in  the 
case  of  the  former  dissolved  by  spirit,  and  in  the  latter  neutralized 
by  bicarbonate  of  soda.  If  the  bones  of  the  face  are  involved,  they 
must  be  removed,  as  also  any  offending  teeth.  Afterwards  the 
mouth  is  to  be  washed  out  frequently  with  antiseptic  lotions,  such 
as  a  solution  of  peroxide  of  hydrogen  (i  in  lo),  sanitas  (i  in  lo), 
boroglyceride  (i  in  20),  or  permanganate  of  potash.  The  child 
must  be  given  plenty  of  suitable  fluid  nourishment,  and,  if  need  be, 
stimulants.  In  the  most  severe  cases,  the  whole  thickness  of  the 
cheek  may  be  encroached  on ;  loss  of  substance  must  be  made  good 
by  subsequent  plastic  work.  Necessarily,  the  cicatrization  fol- 
lowing this  destructive  process  results  in  a  good  deal  of  permanent 
impairment  to  the  movements  of  the  jaw. 

Noma  is  the  name  given  to  a  similar  process  occurring  about  the 
genital  organs  of  children,  especially  the  vulva.  The  Treatment 
is  practically  the  same,  except  that  here  it  is  possible  to  immerse 
the  patient  in  a  warm  bath,  after  having  removed  the  infected 
tissues. 

{(i)  For  Carbuncle  and  Boil,  see  Chapter  XVI T. 

IV.  Gangrene  from  Thermal  Causes. 

I.  Frost-bite. — This  condition  is  not  often  seen  in  this  country, 
but  is  by  no  means  uncommon  in  regions  where  the  winter  is  colder, 
and  is  induced  more  readily  if  a  high  wind  is  blowing,  the  heat  of 
the  body  being  therebvmore  quickly  dispersed.  Children  and  old 
people  are  more  likely  to  be  attacked,  as  their  vital  powers  are  less 
marked  than  in  adults.     It  originates  in  one  of  two  ways: 

(a)  From  the  direct  effect  of  cold  on  the  tissues,  which  become 
shrunken,  hard,  and  of  a  dull  waxy  appearance.  No  pain  is  ex- 
perienced in  the  freezing  process,  so  that  onlookers  are  more  likely 
to  recognise  the  condition  than  the  individual  himself.  The  ex- 
tremities of  the  body,  where  the  circulation  is  a  little  sluggish,  and 
exposed  parts,  such  as  the  nose  and  ears,  are  chiefl}^  liable  to  be 
attacked.  Gradually  the  part  shrivels,  turns  black,  and  is  either 
absorbed  or  separated  by  a  process  of  ulceration,  with  or  without 
suppuration.  A  feature  of  gangrene  from  frost-bite  is  the  more 
extensive  implication  of  the  superficial  tissues  on  accoimt  of  their 
greater  exposure. 

(b)  From  the  subsequent  injiauunatiou  in  ])arts  which,  though  frozen, 
are  not  immediately  killed.  The  thawing  of  these  structures  is 
accompanied  by  severe  pain,  and  the  prolonged  anaemia  so  depresses 


GANGRENE  125 

the  vitality  of  the  vessel  walls  that  the  rc-adniission  of  the  circulating 
blood  is  likely  to  be  followed  by  an  acute  inflammation,  which  ter- 
minates in  necrosis  from  compression  of  the  vessels  by  the  rapidly- 
formed  exudation.  If  it  escapes  actual  death,  the  part  remains 
red,  congested,  and  painful  for  some  time,  and  superficial  ulcers 
may  even  develop;  eventually,  however,  it  recovers. 

Treatment. — Tlie  frozen  parts  must  be  thawed  very  gradually,  and 
the  blood  admitted  into  the  tissues  slowly,  if  inflammatory  gangrene 
is  to  be  avoided.  They  should  be  gently  rubbed  with  snow  or  cold 
water,  and  warmed  by  being  held  in  the  hands  of  the  manipulator, 
whilst  the  patient  should  be  placed  in  a  cool  room,  the  temperature 
of  which  is  slowly  raised.  As  reaction  comes  on,  a  small  amount  of 
warm  drink  may  be  cautiously  given.  Excessive  pain  or  congestive 
oedema  may  be  limited  by  elevation  of  the  part.  If  actual  gangrene- 
occurs,  the  dead  tissue  must  be  rendered  and  kept  aseptic,  and  the 
case  carefully  watched  until  a  definite  line  of  separation  has  formed. 

Indians,  lumbermen,  prospectors,  etc.,  in  North- West  Canada, 
where  frost-bites  are  common,  have  found  that  oil  of  turpentine  is  the 
best  apphcation  in  all  stages.  The  parts  are  kept  soaked  with  the 
fluid,  and  the  results  are  reported  as  phenomenal. 

2.  Burns  and  Scalds. — These  may  be  considered  as  a  special  variety 
of  wound,  not  necessarily  ending  in  gangrene,  brought  about  by  the 
action  of  heat;  burns,  either  by  the  close  proximity  to,  or  direct 
contact  with,  flame  or  heated  soHd  bodies ;  scalds,  by  the  action  of 
boiling  water,  superheated  steam,  or  other  hot  fluids  or  gases,  the 
difference  in  the  effects  being  comparable  to  the  distinction  between 
roasting  and  boiling.  Naturally,  fluids  such  as  oil,  which  boil  at  a 
higher  temperature  than  water,  produce  increasingly  severe  results. 

Six  different  degrees  of  burn  were  described  by  Dupuytren,  and 
his  classification  may  still  be  retained  with  advantage.  The  first 
degree  consists  merely  in  a  scorch  or  superficial  congestion  of  the 
skin,  without  destruction  of  tissue;  the  part  may,  however,  remain 
red,  painful,  and  prone  to  ulceration  for  a  time.  Should  the  scorch 
be  often  repeated,  as  bv  people  constantly  warming  their  legs  before 
the  fire,  the  skin  becomes  chronically  "pigmented  and  indurated 
{erythema  ah  igne).  In  the  second  degree  the  cuticle  is  raised  from  the 
cutis,  and  a  bleb  or  bhster  results.  When  this  bursts,  and  the 
cuticle  is  removed,  the  cutis  vera,  red  and  painful,  is  exposed  below. 
Permanent  discoloration  may  follow  this  lesion.  In  the  third 
degree  the  cuticle  is  destroyed,"  as  is  also  part  of  the  cutis  vera,  but 
the  tips  of  the  interpapillary  processes,  including  the  exquisitely 
sensitive  nerve  terminals,  are  laid  bare  and  left  intact;  consequently 
this  is  a  most  painful  form  of  burn.  The  deeper  structures  of  the 
skin— viz.,  the  sweat  and  sebaceous  glands,  and  the  hair  follicles — 
remain  untouched,  so  that,  although  the  surface  during  the  healing 
process  becomes  covered  with  granulations,  the  integument  is  very 
rapidly  replaced,  since  there  are  so  many  epithelial  elements  from 
which  it  can  grow.  The  cuticle  is  able  to  form  not  from  the  edge 
only,  as  must  occur  wherever  the  whole  of  the  cutaneous  envelope 


126  A   MANUAL  OF  SURGERY 

is  destroyed,  but  also  from  innumerable  foci  scattered  over  the 
wound  surface.  The  resulting  scar,  though  often  white  and  visible, 
undergoes  no  contraction:  it  is  supple  and  elastic  from  containing 
all  the  elements  of  the  true  skin.  In  the  fourth  degree  the  whole 
thickness  of  the  integument  is  destroyed,  as  well  as  part  of  the 
subcutaneous  tissues.  In  the  fif/h  the  muscles  are  also  encroached 
upon,  whilst  in  the  si.xih  the  whole  limb  is  charred  and  disorganized. 
In  the  last  three  forms  healing  can  only  occur  by  removal  of  sloughs 
and  the  formation  of  a  cicatrix,  which  by  its  contraction  may  lead 
to  deformity. 

The  Local  History  of  a  burn  may  be  described  in  three  stages, 
corresponding  to  the  three  stages  through  which  an  ulcer  or  a 
lacerated  wound  passes:  (i)  The  stage  of  destruction  or  burning, 
the  various  degrees  of  which  have  been  just  alluded  to;  (2)  the 
stage  of  inflammation  and  sloughing,  whereby  the  dead  tissue  is 
removed,  and  the  wound  converted  into  a  healthy  granulating  sore; 
(3)  the  stage  of  repair.  There  are  no  special  characteristics  of  these 
processes  which  call  for  particular  note,  except  that  they  are  usually 
associated  with  infection,  unless  the  burn  is  a  small  one.  The  skin 
is  generally  dirty  (from  a  surgical  standpoint)  at  the  time  of  the 
accident;  it  may  be  infected  from  the  clothes  which  are  being  worn, 
and  immediate  attention  may  be  impossible.  Moreover,  the  extent 
of  the  lesion  and  the  terrible  pain  caused  by  it  often  render  complete 
sterilization  impracticable. 

The  General  or  Constitutional  Conditions  which  correspond  to 
these  three  stages  require  a  little  fuller  notice. 

1.  In  the  early  stages  shock  is  usually  present,  and  its  intensity 
depends  as  much  on  the  extent  of  the  burn  as  on  its  depth,  so  that 
total  charring  of  a  limb  may  cause  less  depression  of  the  system  than 
an  extensive  superficial  scorch,  especially  if  the  latter  involves  the 
abdomen  or  the  head  and  neck.  It  frequently  passes  into  a  con- 
dition of  collapse,  due  in  measure  to  the  absorption  of  toxic  products 
from  the  burnt  tissues. 

2.  Subsequently  a  period  of  inflammatory  fever,  usually  of  infective 
origin,  follows,  and  may  last  four  to  fourteen  days.  The  viscera 
become  congested,  particularly  the  gastro-intestinal  canal,  liver, 
lungs,  and  brain,  and  various  complications  may  result  therefrom. 

One  of  the  most  interesting  sequelae,  though  at  the  present  day  it 
is  admittedly  uncommon,  is  Ulceration  of  the  Duodenum.  The  ulcer 
is  of  the  usual  duodenal  type,  and  occurs  close  to  the  orifice  of  the 
bile-duct.  It  probably  results  from  the  elimination  by  the  liver  of 
some  irritating  substance  derived  from  septic  changes  in  the  burnt 
tissues  which  is  capable  of  inducing  thrombosis,  or  of  producing 
ulceration.  In  one  case  under  observation,  a  post-mortem  examina- 
tion revealed  a  patch  of  well-marked  ecchymosis  in  the  duodenal 
mucosa  exactly  opposite  the  orifice  of  the  bile-duct.  Obviously  it 
was  the  early  stage  of  this  condition,  and  would  have  gone  on  to 
ulceration  had  the  patient  lived.  For  clinical  phenomena,  see 
Chapter  XXXV. 


GANGRENE  ^^7 


3.  When  healthy  repair  is  occurring  locally,  and  the  parts  are  kept 
aseptic,  no  abnormal  constitutional  condition  should  be  present, 
although  there  may  be  a  certain  amount  of  asthenia  or  ana;mia! 
Where,  however,  the  wounds  are  septic  and  suppurating  freely,  this 
tendency  will  be  much  more  marked,  and  the  patient  may  even 
develop  hectic  fever  and  amyloid  changes  in  the  viscera,  and  finally 
die  of  exhaustion. 

Causes  of  Death  from  Burns. — If  an  individual  is  burnt  to  death, 
the  fatal  event  is  usually  occasioned  by  asphyxia  from  the  smoke 
and  noxious  fumes  of  the  fire;  shock  and  syncope  from  fright  may 
perhaps  be  adjuvants,  especially  if  the  heart  is  weak  or  diseased. 
Within  the  first  few  days  death 'results  from  shock  or  collapse  from 
toxaemia;  in  the  second  stage,  from  infection,  internal  complications, 
ulceration  of  the  duodenum,  etc. ;  in  the  third  stage,  from  exhaustion 
or  intercurrent  maladies.  The  prognosis  in  children  is  always  more 
unfavourable  than  in  adults. 

Treatment. — In  superficial  scorches  without  vesication,  all  that  is 
needed  is  to  protect  the  affected  parts,  e.g.,  by  dusting  them  over 
with  boric  acid  powder  mixed  with  starch,  or  by  painting  them  with 
collodion.  Blisters,  when  present,  should  be  washed  antiseptically 
and  then  punctured,  so  as  to  allow  the  contained  serum,  which 
always  contains  bacteria,  to  escape;  the  separated  epidermis  should 
then  be  cut  away,  and  a  picric  acid  dressing  applied,  when  the  burnt 
area  is  not  too  extensive;  a  piece  of  steriHzed  gauze  or  lint  is  soaked 
in  a  sterilized  solution  of  picric  acid  (2  grains  to  i  ounce),  and  apphed 
to  the  burnt  surface,  and  over  this  a  pad  of  sterilized  wool.  Thus  a 
dry  dressing  is  produced,  which  may  be  left  in  situ  for  some  days, 
when  it  is  reapphed.     The  results  are  usually  most  satisfactory. 

Where  the  burn  includes  deeper  structures,  the  clothes  must  be 
removed  with  as  httle  dragging  as  possible,  being  cut  away  if 
necessary;  the  damaged  tissues  are  then  bathed  with  some  anti- 
septic, such  as  sublimate  lotion  (i  in  2,000),  and  covered  up  as 
rapidly  as  possible  with  sterilized  lint  or  gauze  soaked  in  eucal5^ptus- 
oil  or  weak  carbohzed  oil  (i  in  40).  In  some  cases,  where  the  skin 
and  surface  are  exceedingly  dirty,  it  is  well  to  anaesthetize  the  patient, 
cut  away  parts  which  must  obviously  slough,  and  purify  thoroughly 
the  wound,  which  is  covered  with  protective  and  dressed  with 
cyanide  gauze  or  some  such  material.  In  very  extensive  burns 
caution  must  be  exercised  in  the  use  of  poisonous  antiseptics,  such  as 
carbolic  acid  or  corrosive  sublimate,  or  serious  toxic  effects  may  be 
produced. 

If  the  patient  is  in  a  state  of  shock,  he  should  be  put  to  bed  and 
covered  with  warm  blankets  or  rugs,  whilst  perhaps  a  little  warm 
stimulating  fluid  is  administered,  and  a  dose  of  morphia  given  hypo- 
dermically;  in  bad  cases  an  intravenous  injection  of  hot  sahne 
solution  is  advisable,  and  it  may  often  be  repeated  with  advantage. 
In  the  case  of  children  with  very  extensive  burns,  it  is  sometimes 
useful  to  put  them  into  a  hot  bath,  to  which  some  eucalyptus-oil,  if 
obtainable,  or  Condy's  fluid,  has  been  added;  the  clothes  are  then 


128  A   MANUAL  Ol-  SURGERY 

removed  or  cut  away,  and  the  patient  allowed  to  remain  for  some 
time,  or  until  the  shock  has  subsided,  in  the  warm  water,  which 
should  be  replenished,  if  necessary.  It  may  be  desirable  to  repeat 
the  inmiersion  at  every  dressing.  The  wounds  are  then  dressed, 
and  the  little  patient  removed  to  bed,  where  special  attcnti(jn  must 
be  directed  towards  maintaining  tlie  bodily  heat,  as,  e.g.,  by  placing 
electric  lights  under  the  l^lankets  which  cover  a  cradle  placed  over 
the  patient. 

When  a  limb  has  been  hopelessly  charred  or  burnt  to  the  bone, 
it  is  useless  to  retain  it,  and  early  amputation  through  the  nearest 
healthv  tissues  should  be  undertaken. 

During  the  stage  of  inflammation  and  siougliing  the  only  requisite 
is  to  keep  the  parts  as  free  from  infection  as  possible,  assisting  the 
natural  processes  of  repair  by  warm  moist  applications,  and  snipping 
away  sloughs  as  they  loosen.  Subsequently  the  wounds  are  treated 
on  general  principles.  The  granulations  often  become  prominent, 
and  stimulating  applications,  such  as  touching  them  with  nitrate  of 
silver,  may  be  necessary.  In  large  wounds,  healing  should  be 
assisted  by  skin-grafting,  according  to  Thiersch's  method,  in  order 
to  pre\'ent  the  wound  becoming  chronic.  A  similar  proceeding 
should  be  undertaken  in  burns  which  involve  the  flexures  of  joints, 
so  as  to  avoid  subsequent  contractions. 


PLATE  III. 


Fig.  21.— Typhoid  bacilli,  showing  flagella.  Van  Ermengen's  stain.  Fig.  22. — 
Tubercle  bacilli  in  sputum.  Carbol-fuchsin  and  methylene  blue.  Fig.  23. — Tetanus 
bacilli,  some  showing  spores  :  from  a  culture.  Stained  by  carbol-fuchsin  and 
methylene  blue.  Fig.  24. — Anthrax  bacilli  in  blood.  Gram  and  eosin.  Fig.  25. — 
Leprosy  bacilli,  in  cells  from  the  spleen.  Carbol-fuchsin  and  methylene  blue. 
Fig.  26. — Bacillus  coli  in  urine,  with  a  few  pus  cells.     Methylene  blue. 

[To  face  page  128. 


CHAPTER  VIII. 
SPECIFIC  INFECTIVE  DISEASES. 

Erysipelas.* 

Erysipelas  is  a  contagious  infective  disease  due  to  the  development 
of  the  Streptococcus  pyogenes  in  the  smaller  l}-mphatics  of  the  skin  and 
occasionaUv  of  mucous  membranes,  with  a  decided  tendency  to 
spread  and  to  recovery  without  loss  of  tissue,  the  constitutional 
svmptoms  being  due  to  the  absorption  of  toxins  developed  locally. 
OccasionaUv  the  subcutaneous  connective  tissue  is  also  involved, 
constituting  the  varietv  known  as  cellnlo-cutaneoiis  erysipelas. 

There  has  been  considerable  discussion  as  to  whether  there  is  any 
difference  between  the  erj-sipelas  microbe  and  the  ordinary  Strepto- 
coccus pyogenes  found  in  spreading  suppuration,  but  it  is  now  gener- 
allv  admitted  that  thev  are  identical.  The  explanation  of  the 
dillerences  in  the  clinical  history  and  infectiousness  between  erysipe- 
las and  other  conditions  due  to  the  development  of  5.  pyogenes  is 
probably  to  be  found  in  the  method  of  invasion  and  in  the  differing 
virulence  of  various  strains  of  the  organism,  but  the  subject  is 
not  yet  fully  understood. 

The  Causes  of  ervsipelas  may  be  briefly  stated  as  follows:  (i.)  The 
existence  of  an  abrasion  or  wound  in  most  cases,  and  particularly  of 
an  unprotected  dirtv  wound.  Thus,  it  is  not  uncommon  to  find  it 
associated  with  neglected  scalp  wormds  or  with  those  communi- 
cating \\A\h  the  mouth.  In  the  so-called  idiopathic  erysipelas  the 
wound  may  be  verv  minute,  such  as  a  prick  or  scratch,  or  there  may 
be  no  ob^-ious  wound  at  aU,  infection  occurring  through  a  hair 
foUicle  in  healthy  skin,  (ii.)  A  weak,  depressed  state  of  the  constitu- 
tion, as  from  alcoholism,  deficient  or  bad  food,  vicious  li\ang, 
diabetes,  albuminuria,  etc.  Some  people,  moreover,  seem  naturally 
predisposed  to  the  disease,  particularly  plethoric  and  gouty  indi- 
viduals, and  one  attack  renders  the  subject  more  liable  to  recurrence 
after  a  short  period  of  immunity,     (iii.)  Bad  hygienic  surroundings 

*  It  is  becoming  more  ttian  ever  doubtful  wliether  erysipelas  is  to  be  looked 
on  as  a  specific  infection.  Careful  bacteriological  examination  is  indicating 
that  other  pyogenic  organisms  than  the  streptococcus  may  be  responsible  for 
its  appearance,  and  it  is  probable  that  hereafter  we  may  have  to  relegate  it  to 
the  chapter  dealing  with  non-specific  infections 

129  9 


I30  A   MANUAL  OF  SURGERY 

are  a  most  important  additional  factor  in  its  production,  especially 
overcrowding  in  hospitals  and  defective  ventilation.  But  these  are 
all  merely  predisposing  conditions;  the  only  exciting  and  absolute 
cause  is — (iv.)  infection  with  the  particular  micro-organism. 

The  Symptoms  of  the  disease  are  usually  ushered  in  by  a  period 
of  headache  and  malaise  for  about  twenty-four  hours.  These  symp- 
toms are  followed  by  a  slight  rigor,  well-marked  pyrexia,  and  the 
development  of  the  rash,  spreading  either  from  the  margin  of  the 
wound,  or  showing  itself  in  apparently  unbroken  skin  in  the  so- 
called  idiopathic  variety.  If  there  is  a  wound,  it  usually  presents 
a  yellowish,  unhealthy-looking  surface,  with  very  little  evidence  of 
repair.  In  an  unmixed  infection  the  healing  process  may  continue 
until  the  rash  appears  on  the  third  or  fourth  day,  when  the  young 
cicatrix  will  break  open  again,  exposing  a  dry  and  sluggish  surface 
with  a  thickened  margin.  The  rash  is  generally  of  a  characteristic 
vivid  rosy-red  colour,  disappearing  on  pressure,  and  accompanied 
by  a  sensation  of  stiffness  or  burning,  scarcely  amounting  to  pain, 
except  when  dense  structures,  such  as  the  scalp,  are  involved,  and 
then  the  pain  may  be  severe.  Swelling  is  not  marked,  except  in  lax 
areolar  tissues,  such  as  in  the  scrotum  or  eyelids;  the  oedema  may 
then  attain  considerable  proportions.  The  rash  continues  to  ad- 
vance more  or  less  rapidly,  with  a  continuous  slightly  raised  margin, 
and  as  it  spreads  to  new  regions  it  fades  away  from  those  already 
involved,  leaving  a  slight  brownish  stain  and  a  fine  brann\'  des- 
quamation. In  some  cases  it  does  not  spread  regularly,  buL  appears 
to  leap  over  an  interval,  and  then  the  intervening  lymphatics  are 
found  to  be  thickened.  Vesicles  and  bullae  foiTn  superficially,  con- 
taining serum,  which  speedil}^  becomes  turbid,  but  suppuration  is 
uncommon,  except  in  lax  oedematous  tissue,  such  as  the  e^'elids. 
Occasionally,  from  the  severity  of  the  inflammation  or  the  low  state 
of  vitality  of  the  tissues,  the  skin  may  become  gangrenous  and 
slough,  especially  about  the  umbilicus  and  genitals  of  young  chil- 
dren. Neighbouring  lymphatic  glands  are  always  enlarged  and 
painful,  and  this  may  even  be  noted  at  a  period  when  the  rash  has 
not  appeared.  Periphlebitis  may  also  be  caused,  leading  to  pyaemic 
complications.  Fever  is  present  as  long  as  the  rash  persists,  and 
merely  shows  slight  diurnal  variations.  It  is  not  uncommon  for 
the  temperature  to  rise  to  104°  F.,  but  anything  above  that  is  of 
grave  significance.  At  first  the  fever  is  of  a  sthenic  type,  the  pulse 
full,  and  the  delirium  noisy  and  active;  but  later  on  the  pulse 
becomes  quick  and  weak,  accompanied  by  low,  muttering  delirium 
and  great  prostration  of  the  vital  powers.  Delirium  is  usually  a 
well-marked  feature  in  erysipelas  of  the  scalp,  but  this  is  due  to 
the  general  rather  than  to  any  local  condition,  unless  meningitis 
supervenes.  Leucocytosis  is  moderate  in  degree  (15,000  to  20,000 
leucocytes  per  cubic  millimetre).  The  duration  of  the  attack  is  most 
variable,  lasting,  as  a  rule,  from  one  to  three  weeks,  but  relapses  are 
not  uncommon.  The  swelling  of  the  part  does  not  always  clear  up 
entirely,  owing  to  persistent  blocking  of  lymphatics;  when  repeated 


SPECIFIC  INFECTIVE  DISEASES  131 

attacks  occur,  this  swelling  may  become  so  great  as  to  constitute 
a  fonn  of  elephantiasis. 

The  so-called  Idiopathic  Erysipelas  mainl\'  affects  the  head,  and 
occurs  in  predisposed  individuals,  often  recurring  about  the  same 
time  of  the  year;  pain  and  delirium  are  prominent  symptoms,  and 
the  subcutaneous  tissue  of  the  face  becomes  so  swollen  that  the 
features  are  almost  unrecognisable.  Large  blebs  form,  and  ab- 
scesses are  not  uncommon  about  the  eyehds. 

Cellulo-cutaneous  Erysipelas  is  due  to  infection  of  the  subcu- 
taneous tissues  as  well  as  of  the  skin  with  the  specific  virus,  and 
results  in  suppuration  and  sloughing  both  of  the  skin  and  subjacent 
cellular  tissue.  To  the  ordinary  phenomena  of  erysipelas  are  added 
a  diffuse  infiltration  of  the  subcutaneous  tissues,  brawny  at  first  in 
t\-pe,  but  subsequently  softening  and  becoming  boggy,  the  skin 
finally  giving  wa}-,  and  allowing  exit  to  the  pus  and  sloughs.  The 
general  s\Tiiptoms  are  correspondingly  severe,  and  pyaemia  may 
supervene.  As  distinguishing  features  from  ordinary  erysipelas,  it 
it  stated  that  the  margin  of  the  redness  is  less  defined,  and  that  the 
lymphatic  glands  are  less  enlarged. 

Erysipelas  of  the  Scrotum,  or,  as  it  is  sometimes  termed,  '  acute 
inflammatory  oedema, '  is  characterized  by  the  part  becoming  greatly 
distended  by  serum,  but  wdthout  an\'  marked  redness.  Suppuration 
and  sloughing  are  not  unlikety  to  follow^  It  thus  somew'hat 
simulates  the  appearance  produced  by  extravasation  of  urine,  but 
is  distinguished  from  it  by  the  facts  that  micturition  is  usually  not 
interfered  wnth,  and  that  the  swelling  is  not  limited  in  the  same  way 
as  in  the  latter  aft'ection. 

Pathological  Anatomy. — On  microscopic  section  of  the  affected 
skin,  colonies  of  cocci  arranged  in  chains  will  be  found  invading  the 
lymphatics  just  beyond  the  spreading  margin,  w^hilst  in  the  inflamed 
area  there  is  a  considerable  excess  of  leucoc}i;es,  blocking  the  l^-mph- 
atics,  and  e\ddently  engaged  in  the  destruction  and  removal  of  the 
cocci,  since  phagoc\i;ic  inclusion  of  the  organisms  is  frequently 
observable.  The  lymph  glands  will  also  be  found  enlarged  and 
congested.  Fatal  cases  merely  show  the  ordinar}^  post-mortem 
signs  of  death  from  a  general  toxsemia  (p.  91). 

Diagnosis. — There  is  not  much  difficulty  in  recognising  a  case  of 
erv'sipelas,  if  the  distinguishing  features  of  the  rash  are  remembered, 
viz.,  its  method  of  extension  by  a  broad,  sharply-defined,  slightly 
raised  and  infiltrated  red  margin,  and  its  almost  invariable  associa- 
tion \Ndth  superficial  vesicles,  perhaps  visible  only  on  examination 
with  a  lens,  or  wdth  obvious  pustules  or  bullae.  Aninfected  wound  with 
pent-up  discharge  closeh'  simulates  erysipelas;  but  the  redness  has 
not  such  an  accurately  defined  margin  and  does  not  spread  beyond  the 
immediate  neighbourhood  of  the  wound;  cutaneous  vesicles  are  not 
usual  in  ordinary  sepsis,  whilst  hTuphatic  enlargement  is  uncommon. 
A  patch  of  cellulitis  will  also  be  distinguished  by  the  same  features. 

Prognosis. — Erysipelas  is  not  peculiarly  dangerous  in  itself  (Osier 
gives  the  death-rate  as  7  per  cent,  in  hospital  patients),  but  may 


132  A   MANUAL  OF  SURGERY 

become  so  from  the  complications.  The  most  important  of  these 
are  inflammatory  conditions  of  tlic  brain,  kmj/s,  and  otlier  viscera, 
especially  of  tlie  kidneys.  Erysipelas  is  usually  attended  with 
danger  to  life  in  old  people,  drunkards,  and  infants,  whose  vital 
powers  become  rapidly  exhausted.  It  is  interesting  and  important 
to  note  that,  after  an  attack  has  passed,  wounds,  even  if  previously 
chronic  and  sluggish,  often  manifest  marvellous  reparative  power, 
provided  no  other  complication  is  present.  Chronic  lupoid  and 
syphilitic  ulcers  may  also  rapidly  cicatrize,  and  even  malignant 
sores,  especially  sarcomata,  have  been  known  to  be  cured. 

Treatment. — Erysipelas  is  a  notifiable  disease  under  the  Infectious 
Diseases  Acts,  1889  and  1899,  and  the  patient  must  be  isolated  or 
removed  if  possible  from  a  surgical  ward.  If  unfortunately  this  is 
impracticable,  the  patient  must  be  placed  as  far  away  from  others  as 
possible,  and  especially  from  those  with  open  wounds,  which  from 
their  position  {e.g.,  the  mouth)  cannot  be  properly  protected  from  in- 
fection. It  is  wise  under  these  circumstances  to  put  off  all  operations 
that  can  be  safely  postponed;  the  bed  should  be  surrounded  with 
sheets  kept  moist  with  carbolic  lotion,  and  the  floor  around  sprinkled 
with  the  same.  Special  nurses  and  dressers  must  be  told  off  to  attend 
to  the  case,  which  should  never  be  dressed  with  ungloved  hands. 

Local  Treatment  is  concerned  with  two  chief  objects,  viz.,  to 
check  the  spread  of  the  disease,  and  to  cure  the  locahzed  outbreak, 
(i)  Anything  that  will  determine  a  local  accumulation  of  leucocytes 
in  the  skin  beyond  the  spreading  edge  should  be  beneficial  in 
checking  its  advance,  and  perhaps  the  best  and  simplest  method 
of  effecting  this  is  by  painting  over  the  health}'  skin  w-ith  two  or 
three  coats  of  liniment  of  iodine  (the  tincture  is  not  strong  enough), 
and  repeating  this  daily  until  the  disease  has  disappeared.  Kraske's 
plan  of  scarifying  the  skin  all  round  at  a  distance  of  an  inch  or  two 
from  the  spreading  margin,  the  knife  just  going  deep  enough  to  draw 
blood,  acts  in  a  similar  manner  and  is  effective;  but  it  is  painful 
and  requires  an  anaesthetic.  (2)  Where  tension  and  pain  are 
severe,  fomentations  containing  opium  or  belladonna  {e.g.,  i  ounce 
of  laudanum  to  i  pint  of  lotio  plumbi)  may  be  applied;  but  the 
best  local  applications  are  ichthyol  or  thiol,  the  latter  being  an 
artificial  sulphur  compound  much  resembling  ichthyol,  but  without 
the  objectionable  smell.  A  20  to  40  per  cent,  aqueous  solution  is 
painted  over  the  affected  area  several  times  a  dav  until  the  fever 
disappears;  a  subsidiary  advantage  of  this  treatment  is  that  the 
stickiness  of  the  preparation  hinders  the  diffusion  of  the  virus. 

In  cellulo-cutajieons  erysipelas  early  and  free  incisions  must  be 
made  to  relieve  tension,  and,  if  possible,  anticipate  suppuration. 
The  tissues,  when  incised,  look  gelatinous  from  the  oedema  present, 
and  much  fluid  of  a  sero-purulent  type  will  escape.  Antiseptic 
fomentations  should  be  employed  after  the  incisions  have  been  made, 
until  granulations  have  developed. 

Constitutional  Treatment  must  be  of  a  tonic  and  supporting 
character.     Good  food,  easy  of  assimilation,  and  quinine,  should  be 


SPECIFIC  INFECTIVE  DISEASES  133 

freely  administered,  whilst  the  tincture  of  the  perchloride  of  iron 
in  J-drachm  doses,  repeated  three  or  four  times  a  day,  is  still  looked 
on  b}^  many  as  a  specific.  The  latter  drug  must  be  combined  with 
salines  or  purgatives,  so  as  to  avoid  constipation.  Antistrepto- 
coccic serum  (p.  27)  should  be  employed  as  early  as  possible,  10  or 
15  c.c.  of  the  polyvalent  serum  being  given  subcutaneously  as  a 
dose,  and  repeated  once  or  twice  a  day.  The  results,  however,  have 
not  been  as  satisfactory  as  was  originally  expected. 

Diphtheria. 

Diphtheria  is  an  infectious  disease,  characterized  by  a  fibrinous 
exudation  which  is  closely  incorporated  with  the  superficial  layers 
of  the  tissues  affected,  and  results  in  a  peculiar  form  of  toxaemia. 
It  usually  involves  the  mucous  membranes,  particularly  those  of  the 
pharynx,  larynx,  and  nasal  cavities;  occasionally  it  attacks  open 
wounds,  the  skin,  conjunctiva,  and  the  genitals.  It  is  due  to  the 
Bacillus  diphtheric^  (or  Klebs-Loffier  bacillus),  which  is  a  non-motile 
organism  about  3  /x  in  length.  It  grows  on  all  ordinary  culture 
media,  but  most  readily  in  the  presence  of  blood-serum.  It  is 
Gram-positive,  and  often  stains  unevenly. 

The  laboratory  diagnosis  of  diphtheria  depends  chiefly  on  the 
recognition  of  the  organism  in  the  exudate  and  its  cultivation. 
The  process  usually  adopted  is  as  follows:  The  outfit  necessary 
consists  of  a  culture- tube  of  blood-serum  and  a  sterilized  cotton- 
wool swab  in  a  test-tube.  If  the  throat  is  to  be  examined,  the 
patient  should  be  placed  in  a  good  light,  and,  if  a  child,  securely 
held.  The  tongue  being  depressed,  the  cotton-wool  swab  is  with- 
drawn from  the  test-tube,  and  gently  rubbed  over  any  visible  mem- 
brane. The  plug  is  then  withdrawn  from  the  culture-tube,  and  the 
swab  lightly  wiped  over  the  surface  of  the  blood-serum.  The  swab 
is  then  replaced  in  its  tube,  and  both  tubes  plugged.  The  culture- 
tube  is  incubated  at  37°  C.  for  twelve  hours,  and  then  examined; 
if  the  Klebs-Loffler  bacillus  is  present,  a  growth  of  small,  opaque, 
white  colonies,  slightly  raised  above  the  surface,  will  appear. 
Direct  films  may  also  be  made  from  the  swab  and  stained.  The 
operator  must  always  be  on  his  guard  lest  the  patient  cough  pieces 
of  membrane,  etc.,  into  his  face  during  the  operation. 

The  serious  feature  of  an  attack  of  diphtheria  is  the  absorption 
of  the  diphtheria  toxin,  for  the  bacilli  are  almost  always  localized. 
The  toxin  is  an  exotoxin,  and  not  only  produces  fever,  but  also  has 
a  marked  action  on  motor  nerves,  "thereby  producing  paralysis. 
This  is  most  often  shown  in  the  palatal,  orbital,  and  ocular  muscles, 
but  may  affect  the  muscles  of  the  trunk  and  limbs.  Cardiac  weak- 
ness is  common,  and  is  partly  due  to  degeneration  of  muscle,  and 
partly  to  action  on  the  vagus.  The  toxin  has  considerable  poisonous 
effect  on  the  kidneys,  and  albuminuria  is  common. 

The  character  of  pharyngeal  and  laryngeal  diphtheria  is  treated 
of  under  their  respective  headings.    ' 


134  A   MANUAL  OF  SURGERY 

Treatment. — The  most  important  point  is  the  administration  of 
antitoxin,  in  doses  of  from  4,000  to  50,000  units.  The  unit  is  the 
amount  of  antitoxin  which,  injected  into  a  guinea-pig  of  250  grammes 
weight,  neutrahzes  100  times  the  minimum  lethal  dose  of  toxin 
of  standard  strength.  In  addition,  local  antiseptics  are  useful, 
and  in  laryngeal  cases,  where  dyspnoea  occurs  from  obstruction  of 
the  larynx  bv  membrane,  tracheotomy  or  intubation  may  be 
necessary. 

Tetanus. 

Tetanus  is  a  local  infective  disease,  due  to  the  BacilUts  tetani, 
associated  with  a  characteristic  toxaemia.  The  bacilli  or  their  spores 
are  found  to  be  very  widely  disseminated,  and,  indeed,  are  present  in 
almost  every  sample  of  garden  or  field  soil ;  they  have  been  found 
in  the  grime  on  a  working  man's  hand  and  on  dirty  surgical  instru- 
ments. Great  difficulty  was  experienced  in  isolating  the  bacillus, 
but  at  last  Xicolaier  and  Kitasato  succeeded,  by  heating  the  pus 
from  an  infected  wound  to  a  temperature  of  80°  C.  for  an  hour, 
thereby  destroying  all  the  pyogenic  organisms.  It  occurs  in  the 
form  of  dehcate  straight  rods,  which  sometimes  grow  into  long 
threads.  It  is  a  strict  anaerobe,  ceasing  to  grow  if  the  smallest 
trace  of  oxygen  is  present,  and  is  usually  cultivated  in  an  atmo- 
sphere of  hydrogen  or  nitrogen;  no  gas  is  produced  by  its  growth. 
It  forms  characteristic  spores  which  are  nearly  spherical  in  shape 
and  situated  at  the  extreme  end  of  the  bacillus,  giving  it  the  appear- 
ance of  a  drumstick  (Plate  III.,  Fig.  27);  these  appear  both  in  the 
pus  of  the  wound  and  in  cultures.  It  stains  by  Gram's  method 
and  possesses  numerous  flagella.  The  bacilli  themselves  are  not 
powerful  parasites,  and  when  separated  completely  from  their  toxins 
often  fail  to  cause  infection,  even  when  injected  into  susceptible 
animals;  should,  however,  a  minute  trace  of  toxin  be  present,  it  so 
depresses  the  vitality  of  the  surrounding  tissues  that  the  bacilH 
continue  to  grow  and  produce  more  toxin. 

.ajtiology. — The  causative  organism  is  a  facultative  saprophyte — 
i.e.,  is  capable  of  continuing  its  development  apart  from  the  body — 
and  is  almost  constantly  found  in  garden  soil,  stable  refuse,  and  dust 
or  dirt  of  any  kind,  those,  therefore,  who  are  likely  to  be  much 
brought  in  contact  with  the  ground — e.g.,  negroes  and  agricultural 
labourers — are  specially  liable  to  the  disease,  owing  to  their  more 
constant  exposure  to  infection.  Horses,  also,  are  peculiarly  sus- 
ceptible to  tetanus,  and  the  bacilli  are  usually  present  in  their 
faeces;  hence  stablemen  and  others  brought  into  contact  with  horses 
are  attacked  with  comparative  frequency.  The  disease  is  more 
frequently  seen  in  the  tropics  than  in  other  climates,  probably 
owing  to  the  heat  favouring  the  development  and  virulence  of  the 
organisms  in  the  soil. 

The  existence  of  a  wound  can  almost  always  be  demonstrated, 
and  it  is  usually  of  a  dirty,  lacerated  or  punctured  character,  and 
suppuration  is  generally  present.     Any  part  of  the  body  may  be 


SPECIFIC  INFECTIVE  DISEASES  135 

tluis  affected,  but  perhaps  those  regions,  such  as  the  sole  of  the  foot 
or  the  pahn  of  the  hand,  which  are  likely  to  be  brought  into  contact 
with  the  soil,  are  most  often  involved.  Serious  street  accidents, 
especially  those  due  to  tramcars  and  motor  vehicles,  are  only  too 
likely  to"  be  followed  by  tetanus.  The  depressed  vitality  of  the 
tissues  ownng  to  the  bruising  and  tearing,  the  irritation  caused  by 
the  growth  of  pyogenic  organisms,  and  the  absorption  by  the  latter 
of  any  oxygen"  present,  thereby  determining  a  condition  of  an- 
aerobiosis,  co-operate  in  favouring  the  development  of  the  tetanus 
baciUi.  Hence  it  is  rare  for  the  disease  to  affect  wounds  where 
asepsis  has  been  maintained  and  rapid  repair  has  been  effected, 
and  it  is  very  uncommon,  though  possible,  for  it  to  develop  after 
blows  or  bruises  with  no  breach  of  surface.  Gunshot  wounds  due 
to  blank  cartridges  are  often  followed  by  it,  since  the  injun,-  is  largely 
due  to  the  wad,  which  is  made  of  coarse  horsehair  felt,  and  is  there- 
fore hkely  to  contain  spores  of  the  bacillus.  Commercial  gelatin, 
derived  from  the  hoofs,  etc.,  of  horses,  often  contains  the  bacilh, 
and  the  injection  of  this  substance  in  the  treatment  of  aneurisms 
has  been  followed  bv  this  disease. 

Pathology.— Tetanus  forms  the  best  example  in  pathology  of  a 
local  infection  with  general  toxsemia.  The  bacilli  remain  locahzed 
in  the  neighbourhood  of  the  wound,  and  do  not  enter  the  blood  or 
reach  distant  parts  of  the  body.  The  toxins  produced  locally  act 
on  the  cells  of  the  central  ner^-bus  system  in  a  manner  very  similar 
to  strychnine.  There  is,  however,  "a  very^  unusual  feature  in  the 
mode  of  passage  of  the  toxin  from  the  local  lesion  to  the  brain  and 
cord,  in  that  it  appears  to  travel  in  the  ner\'es  themselves,  and  not 
in  the  blood,  as  in  other  infections.  One  or  two  of  the  proofs  that 
have  been  advanced  in  support  of  this  theory  may  be  quoted. 
Tetanus  mav  be  caused  by  the  injection  of  a  very  small  dose  of 
toxin  directlv  into  a  nerve,  whereas  the  animal  may  resist  the 
injection  of  four  or  five  times  this  am.ount  into  a  muscle;  and  if 
the  ner\'e  is  cut  between  the  site  of  inoculation  and  the  central 
nervous  system,  the  spasms  may  be  delayed,  or  even  prevented 
altogether.  This  may  explain  the  beneficial  effects  which  sometim.es 
followed  the  now  abandoned  operation  of  ner\-e  stretching  or  section 
in  tetanus.  Further,  the  toxin  can  be  demonstrated  in  the  ner^-es 
themselves,  since  they  give  rise  to  tetanus  when  introduced  into  a 
susceptible  animal. 

The  post-mortem  anatomical  changes  are  not  characteristic.  The 
muscles  are  often  pale,  or  show  e\adences  of  rupture  or  extravasa- 
tion of  blood.  The  peripheral  ner^^es  extending  from  the  wound 
may  be  red  and  congested  for  some  distance:  this  may  not  be  due 
to  the  action  of  the  toxin  (which  appears  to  produce  no  demonstrable 
lesions  of  the  nerves  themselves),  but  to  p3^ogenic  inflammation. 
The  nerve-centres  frequentlv  present  areas  of  softening  and  pen- 
vascular  cellular  exudation,  \\-ith  some  hyperemia,  especially  m  the 
pons  and  medulla.  Degenerative  changes  may  also  be  evident  m 
the  ganglion  cells  of  the  cord. 


136  A   MANUAL  OF  SURGERY 

Clinical  History. — Acute  Tetanus  usually  manifests  itself  in  this 
country  two  or  three  weeks  after  infection,  but  sometimes  abroad 
as  early  as  a  few^  hours  or  days.  The  causative  wound  is  usually 
suppurating  and  looks  unhealthy,  but  when  infection  is  delayed  it 
may  be  healed.  The  patient  generally  complains  first  of  a  diffi- 
culty in  opening  the  mouth,  associated  with  a  cramp-like  pain  in 
the  muscles  of  mastication  and  of  the  neck.  This  soon  becomes  so 
marked  that  it  may  be  difficult  even  to  insert  a  paper-knife  between 
the  teeth  {trismus,  or  lock-jaw),  causing  great  difficulty  in  the  ad- 
ministration of  food;  to  it  is  added  a  fixed  and  rigid  condition  of  the 
muscles  of  the  back  of  the  neck  and  of  the  face,  the  latter  producing 
a  curious  grin-like  appearance  (risus  sardonicits),  whilst  dysphagia 
is  sometimes  caused  by  spasm  of  the  pharyngeal  muscles.  A  con- 
siderable degree  of  fever  is  often  manifested,  but  in  some  cases  an 
apyrexial  course  is  maintained  until  nearly  the  end.  The  spasms 
soon  extend  to  the  trunk  and  extremities,  accompanied  by  cramp- 
like pains,  and  when  fully  established  they  may  be  excessively  pain- 
ful and  violent,  and  the  remissions  between  them  but  partial.  For- 
tunately, the  disease  usually  involves  the  respiratory'  muscles  late  in 
the  attack.  The  more  severe  spasms  can  be  excited  bv  any  form  of 
stimulus,  such  as  the  slamming  of  a  door,  a  draught  of  cold  air,  or 
some  voluntar}^  movement,  and  are  ahvays  of  a  tonic  {i.e.,  con- 
tinuous) character.  The  body  is  contorted  in  various  directions, 
and  respiration  may  be  much  impeded  by  the  fixation  of  the  thorax. 
Occasionally  the  body  is  arched  backwards  {opisthotonos)  bv  the  con- 
traction of  the  muscles  of  the  back,  the  recti  abdominis  being  firm 
and  tense- — '  as  hard  as  boards  ' ;  sometimes  it  is  doubled  forwards 
(emprosthotonos),  and  in  rare  cases  laterally  {pleurosthoionos).  The 
muscles  may  contract  so  violently  as  to  be  ruptured,  whilst  teeth 
have  been  broken  and  the  tongue  has  been  almost  bitten  off.  The 
intellectual  faculties  usually  remain  clear  to  the  end,  which  is  gener- 
alh'  due  to  exhaustion  from  a  repetition  of  the  convulsions,  or  more 
rarely  to  asphyxia  induced  by  a  prolonged  fixation  of  the  respiratory 
muscles.  Before  death  the  temperature  sometimes  runs  up  to  io8°, 
or  even,  in  one  case,  to  112""'  F.,  and  it  often  continues  to  rise  for  a 
degree  or  two  after  death ;  such  hyperpyrexia  is  mainh^  due  to  the 
continuous  muscular  contractions.  The  surface  of  the  body  is 
bathed  in  sweat,  and  the  urine  is  scanty,  and  occasionally  albu- 
minous. Death  may  occur  in  twent^'-four  hours  from  the  onset  of 
the  disease,  or  not  for  four  or  five  days. 

Chronic  Tetanus  usually  begins  later  after  infection,  is  less  severe 
in  its  symptoms,  and  more  likely  to  be  recovered  from.  The  course 
is  usually  afebrile,  and  the  spasmodic  contractions  mav  be  limited  to 
the  wounded  part  of  the  body  whence  the  infection  has  arisen,  or 
may  be  general.  Sometimes  the  patient  lies  in  bed  with  his  jaw 
partially  fixed,  and  the  muscles  of  his  neck,  back,  and  abdomen 
rigidly  contracted,  but  with  none  of  the  characteristic  convulsions. 

A  special  and  uncommon  variety  known  as  cephalo-teianits,  or 
T.  paralyticus  (German,  kopf -tetanus),  follows  injuries  within  the  area 


SPECIFIC  INFECTIVE  DISEASES  137 

of  distribution  of  tlic  cranial  nerves,  and  especially  those  about  the 
supra-orbital  margin.  It  is  characterized  by  the  association  of 
trismus  with  facial  paralysis  on  the  affected  side,  and  for  a  time  this 
may  constitute  the  whole  picture,  so  that  the  patient  may  walk  to 
see  the  doctor;  but  later  on  the  usual  tonic  spasms  occur  in  other 
parts  of  the  body,  and  other  cranial  nerves  may  become  paralyzed, 
especiall}^  the  third,  leading  to  strabismus.  Spasm  of  the  muscles  of 
deglutition  and  attacks  of  maniacal  frenzy  are  sometimes  present, 
and  hence  the  name  T.  hydrophobiciis  which  has  been  applied  to  it. 

Diagnosis. — In  the  early  stages  tetanus  must  be  distinguished 
from  simple  trismus  arising  from  dental  irritation,  or  from  inflamma- 
tory ankylosis  of  the  temporo-maxillary  joint.  This  may  be  readily 
accomplished  by  noting  that  rigidity  of  the  neck  muscles  is  also 
present  in  tetanus.  Strychnine-poisoning  leads  to  a  very  similar 
group  of  symptoms,  but  is  recognised  from  tetanus  by  the  contrac- 
tions being  more  sudden  and  violent,  the  relaxation  of  the  muscles 
between  the  spasms  complete  so  that  the  mouth  can  readily  be 
opened,  whilst  the  hands  are  involved  in  the  contractions,  a  rare 
sign  in  tetanus,  and  the  muscles  of  mastication  often  escape. 

No  difficulty  should  be  experienced  in  distinguishing  tetanus  from 
hydrophobia,  owing  to  the  very  different  nature  of  the  convulsions 
in  the  latter  case — i.e.,  clonic  and  not  tonic;  moreover,  they  affect 
the  muscles  of  respiration  and  deglutition,  whilst  the  history  of  the 
case,  the  early  hallucinations,  and  the  absence  of  tonic  muscular 
contractions,  are  also  characteristic  features. 

Laboratory  methods  are  usually  unnecessary  for  the  diagnosis  of 
the  disease  when  developed,  but  in  case  of  doubt  the  best  method  is 
to  collect  some  of  the  discharge  from  the  deeper  portions  of  the 
wound,  dilute  it  with  broth,  and  divide  it  into  two  parts:  one  of 
these  is  to  be  injected  into  a  mouse  or  guinea-pig,  whilst  the  other 
portion  is  mixed  with  i  c.c.  of  tetanus  antitoxin  and  then  injected 
into  another  animal.  If  the  former  animal  develops  tetanic 
symptoms,  whilst  the  latter  escapes,  the  diagnosis  is  assured. 

The  Prognosis  is  unfavourable  in  any  case,  but  the  longer  it  lasts, 
and  the  lower  the  temperature,  the  more  likely  is  the  patient  to 
recover,  whilst  an  acute  onset,  hyperpyrexia,  sleeplessness,  de- 
lirium, and  strabismus  are  bad  signs.  The  length  of  the  incubation 
period  is  also  a  most  important  factor;  for  even  when  antitoxin  is 
administered,  the  mortality  in  cases  with  an  incubation  period  of 
less  than  ten  days  is  at  least  20  per  cent,  higher  than  when  the 
appearance  of  the  disease  is  delayed  to  a  later  period. 

Treatment. — In  places  where  tetanus  is  known  to  be  rife,  it  is  a 
wise  precaution  to  administer  antitetanic  serum  as  a  preventive  or 
immunizing  agent  in  cases  of  wounds  or  abrasions  that  might  pos- 
sibly be  infected,  especially  if  due  to  street  accidents,  or  if  suspicious 
bacilli  are  found  on  microscopic  examination  of  a  scraping  from  the 
deeper  parts  of  the  wound.     The  dose  need  not  be  large  (1-5  c.c). 

After  the  disease  has  appeared,  the  originating  sore,  if  accessible, 
should  be  freely  excised  and  the  wound  cauterized,  or  the  hmb  may 


138  A   MANUAL  OF  SURGERY 

be  amputated;  ]>ut  even  tlion  convulsions  may  persist  for  a  time,  or 
prove  fatal,  from  the  amount  of  toxin  already  in  the  system. 

In  addition  to  these  local  measures,  the  specific  antitetanic  serum, 
prepared  from  the  blood-serum  of  an  immunized  animal,  should  be 
injected  (p.  27).  The  serum  is  purely  antitoxic,  and  has  no  effect 
upon  the  development  of  the  bacilli,  for  the  destruction  of  which 
local  phagocytosis  or  other  immunizing  action  has  to  be  relied  on. 
Any  toxin  circulating  in  the  blood  is  readily  destroyed  or  neutralized ; 
but  inasmuch  as  the  toxin  travels  by  the  nerves  and  rapidly  unites 
with  the  protoplasm  of  the  nerve-centres,  and  then  cannot  be 
influenced  by  the  antitoxin,  the  results  of  its  use  are  often  disap- 
pointing. The  treatment  should  always  commence  with  a  large 
dose,  and  smaller  amounts  should  then  be  administered  once  or 
twice  a  day,  varying  with  the  severity  of  the  symptoms;  20  to 
30  CO.  may  be  given  as  the  initial  subcutaneous  injection,  followed 
by  doses  of  to  to  15  c.c.  twice  a  day.  It  is  better,  however,  to  intro- 
duce somewhat  smaller  doses  into  the  veins,  or  into  the  subdural 
space  after  lumbar  puncture.  Intracerebral  injections  have  been 
discontinued  owing  to  the  risks  associated  therewith,  but  there  is  no 
objection  to  '  blocking  '  the  passage  of  toxins  up  the  main  nerves  in 
early  cases  by  injecting  them  with  antitoxin.  Another  plan  of 
treatment,  suggested  by  Baccelli,  consists  in  the  hypodermic  injection 
of  carbolic  acid;  10  or  15  minims  of  a  2  per  cent,  solution  are  injected 
two  or  three  times  a  day,  and  although  its  action  cannot  be  explained, 
yet  the  percentage  mortality  of  cases  treated  in  this  way  hitherto  re- 
ported is  certainly  less  than  that  accompanying  the  serum  treatment. 

The  patient  should  be  kept  absolutely  quiet  in  a  darkened  room, 
and  free  from  all  sources  of  irritation.  The  spasms  may  be  dimin- 
ished or  almost  abolished  by  the  injection,  either  subcutaneously  or 
by  lumbar  puncture,  of  a  sterihzed  solution  of  magnesium  sulphate, 
which  acts  solely  by  reducing  the  excitability  of  the  motor  cells, 
and  has  no  action  on  the  tetano-toxin,  fixed  or  free.  The  dose 
subcutaneously  is  10  to  20  c.c.  of  a  10  per  cent,  solution  every  four 
hours;  whilst  intraspinally  2  to  4  c.c.  of  a  25  per  cent,  solution  can 
be  injected  daily  without  ill-effect.  Chloroform  may  be  adminis- 
tered with  the  same  object.  Opium,  chloral  hydrate,  bromide  of 
potash,  physostigma,  and  curare,  have  been  vaunted  as  beneficial 
drugs,  but  probably  cases  which  have  recovered  after  their  exhibition 
would  have  done  so  ^^^thout.  Food  should  be  nutritious,  fluid,  and 
unstimulating;  it  has  been  suggested  to  feed  the  patient  twice  a  day 
by  a  stomach-pump  under  chloroform,  or  by  a  soft  rubber  catheter 
through  the  nose,  but  rectal  feeding  can  be  tolerated  just  as  well,  and, 
indeed,  the  patient  must  be  given  an  abundance  of  normal  saline 
solution  by  this  route  in  order  to  help  in  the  elimination  of  toxins 
and  relieve  his  thirst. 

Hydrophobia. 

Hydrophobia  is  an  acute  general  infective  disease,  transmitted  from  animals 
to  men,  especially  from  rabid  dogs,  cats,  wolves,  etc.  It  consists  in  an  affection 
of   the   central  nervous  system,  and  one  of  its  most  marked  features  is  the 


SPECIFIC  INFECTIVE  DISEASES  139 

long  and  variable  incubation  period.  It  never  originates  idiopathically  either 
in  animals  or  man,  infection  usually  following  a  bite;  but  if  the  teeth  pass 
first  through  a  garment,  the  virus  may  be  wiped  off,  and  the  individual  may 
escape.  It  has  also  been  proved  that  if  an  infected  animal  merely  licks  an 
abraded  surface  the  disease  may  be  transmitted,  even  when  the  animal  has 
not  at  the  time  shown  any  of  the  more  typical  signs  of  rabies. 

In  the  Dog,  rabies  manifests  itself  three  to  five  weeks  after  infection,  but  the 
period  varies  considerably;  the  original  wound  usually  heals  perfectly,  or  there 
may  be  some  inflammatory  thickening  about  it.  The  disease  commences 
with  a  stage  of  depression,  which  is  manifested  by  snappishness  and  irrita- 
bility, especially  towards  other  animals,  by  restlessness,  and  by  the  dog 
moping  in  dark  corners,  with  a  depraved  appetite,  eating  any  kind  of  rubbish 
or  dirt,  and  even  its  own  excreta.  This  period  lasts  for  two  or  three  days, 
and  is  perhaps  the  most  dangerous,  since  there  is  nothing  very  suggestive 
about  the  symptoms.  It  is  usually  followed  by  a  stage  of  paralysis,  going  on 
to  death.  During  the  whole  attack  the  mouth  is  filled  with  ropy  saliva, 
which  the  animal  vainly  tries  to  scratch  away;  the  bark  loses  its  ring  and 
becomes  hoarse,  and  as  the  disease  progresses  the  lower  jaw  becomes  para- 
lyzed ;  finally,  after  partial  or  general  convulsions,  the  animal  dies  five  or  six 
days  from  the  onset.  In  a  few  cases  a  stage  of  maniacal  frenzy  occurs,  when 
the  animal  runs  '  amok  '  and  bites  anything  and  everything  that  comes  in 
its  way. 

In  Man  the  incubation  period  is  most  variable,  lasting  from  days  to  months 
or  years,  but  as  a  rale  it  does  not  exceed  six  weeks.  During  this  interval  the 
wound  heals,  although  the  scar  may  remain  tender  and  neuralgic.  The 
disease  is  ushered  in  by  a  vague  sense  of  terror,  with  illusions  of  the  senses 
and  disturbance  of  the  mind,  lasting  for  about  twenty-four  hours.  Restless- 
ness, sleeplessness,  loss  of  appetite,  and  a  repugnance  to  fluids  follow,  with 
perhaps  some  slight  febrile  disturbance.  The  more  characteristic  symptoms 
are  inaugurated  by  a  convulsive  stiffness  of  the  tongue,  neck,  and  especially 
of  the  muscles  of  deglutition  and  respiration,  which  becomes  more  marked  if  any 
attempt  is  made  to  swallow.  The  typical  convulsions  are  clonic  in  character, 
and  thus  differ  from  those  of  tetanus;  they  become  more  and  more  generalized, 
being  brought  on  after  a  time  by  almost  any  afferent  impulse,  however  slight — 
such  as  a  blast  of  cold  air,  a  flash  of  light,  a  sudden  noise,  especially  such  as  is 
caused  by  the  movements  of  fluids;  swallowing  is  quite  impracticable.  The 
mouth  is  usually  filled  with  ropy  mucus,  which  is  very  difficult  to  remove. 
The  respirations  become  catchy,  and  a  loud  hiccoughing  noise  may  be  pro- 
duced by  spasm  of  the  diaphragm,  which  is  sometimes  thought  to  resemble 
the  barking  of  a  dog.  Finally,  the  convulsions  may  entirely  cease,  and  the 
patient  dies,  retaining  his  consciousness  to  the  end,  the  fatal  issue  being  due 
to  the  destructive  changes  taking  place  in  the  medulla,  or  to  exhaustion ;  it 
may,  however,  occur  earlier,  from  spasm  of  the  glottis.  The  disease  lasts 
about  a  week,  but  may  be  more  rapid,  killing  even  in  two  days. 

The  Post-mortem  Changes  are  mainly  negative.  Evidences  of  acute  inflam- 
mation of  the  lower  part  of  the  medulla,  including  the  centres  for  the  gth,  loth, 
and  nth  nerves,  are  observed  on  microscopic  examination,  the  vessels  being 
thrombosed,  and  the  connective  tissue  infiltrated  with  leucocytes.  The  nerve 
fibres  and  ganglion  cells  may  also  be  found  degenerated.  The  salivary  glands 
are  always  somewhat  enlarged.  The  disease  may  be  diagnosed  in  the  lower 
animals  by  the  recognition  of  the  Negri  bodies  in  the  hippocampus  major  and 
cerebral  cortex.  They  are  minute  cell-like  bodies,  consisting  of  a  large  or 
small  central  mass,  or  of  a  cluster  of  minute  corpuscles,  surrounded  by  a  homo- 
geneous hyaline  zone,  around  which  there  is  a  delicate  membrane.  These  are 
found  in  nearly  all  cases  of  the  disease,  and  are  thought  to  represent  a  stage 
in  the  life-history  of  a  protozoal  parasite.  They  can  be  demonstrated  in  a 
few  hours,  and  afford  a  means  of  detecting  the  presence  of  rabies  in  a  dog 
without  waiting  for  the  results  of  inoculation  experiments.  They  have  also 
been  found  in  man,  and  have  been  cultivated  by  Noguchi. 

Preventive  Measures  should  be  adopted  immediately  in  all  cases  of  bites  from 
dogs  which  are  either  rabid  or  may  possibly  become  so.     The  circulation  in  the 


t40  A   MANUAL  OF  SURGERY 

limb  should  be  arrested  by  a  string  or  bandage,  bleeding  encouraged,  and 
some  powerful  caustic,  e.^'.,  j)ure  carbolic  acid,  applied  as  soon  as  possible.  A 
free  excision  of  the  part  is,  ho\ve\er,  preferable. 

Pasteur's  Preventive  Inoculation  is  based  on  the  discovery  that  the  injection 
of  an  attenuated  virus  in  increasing  iloses,  and  in  gradually  increasing  strength, 
protects  an  animal  or  individual  from  the  disease,  and  will  even  catch  up  the 
poison  already  inoculated,  and  save  the  patient  from  its  subsequent  develop- 
ment, if  too  long  a  start  has  not  been  given.  The  method  employed  is  as 
follows:  A  virus  of  constant  and  maximum  intensity  is  first  obtained  by 
passing  the  poison  from  a  dog  through  a  series  of  rabbits,  until  the  animal 
dies  with  regularity  on  the  seventh  day,  all  parts  of  the  cord  being  then 
equally  virulent.  The  material  inoculated  is  olataincd  by  mashing  up  a  por- 
tion of  the  spinal  cord  or  medulla  of  the  diseased  dog  in  sterilized  broth,  and 
injecting  it  with  a  hypodermic  syringe  beneath  the  arachnoid  after  tre- 
phining. All  that  is  now  needed  is  to  take  a  series  of  these  virulent  cords, 
and  dry  them  by  hanging  in  a  glass  bell-jar  with  some  caustic  potash  at  the 
bottom  for  variable  periods,  the  virus  being  thus  weakened  in  its  intensity, 
until  at  the  end  of  fourteen  days  it  is  completely  destroyed.  Indi\iduals  are 
inoculated  with  portions  of  such  cords,  pounded  up  in  sterilized  broth,  be- 
ginning with  the  weakest,  and  gradually  increasing  the  strength  of  the  injec- 
tion, until  a  preparation  of  a  cord  which  has  merely  hung  one  day  is  used. 
This  method  of  treatment  was  introduced  in  1S85,  and  the  results  hitherto 
obtained  have  been  such  as  to  indicate  that  we  have  here  a  most  potent  pre- 
ventive agent  a.gainst  hydrophobia,  granted  that  the  disease  has  not  been 
allowed  too  long  a  start.  When  the  disease  has  attacked  an  indivitlual,  only 
palliative  treatment  can  l;e  adopted.  Every  source  of  irritation  and  dis- 
turbance must  be  removed,  and  the  patient  kept  absolutely  quiet.  With  a 
view  to  diminish  the  spasms,  chloral  may  be  administered  internally,  or 
chloroform  inhaled,  or  cocaine  sprayed  on  the  fauces.  All  the  nourishment 
that  the  patient  can  possibly  take  should  be  administered,  and  preferably 
by  rectum. 

Anthrax. 

This  disease  results  from  infection  with  the  Bacillus  anihracis,  which  pro- 
duces in  sheep,  cattle,  and  other  animals  the  so-called  '  splenic  fever,'  charac- 
terized by  well-marked  fever  and  enlargement  of  the  spleen.  In  man,  if  the 
microbe  is  inoculated  through  the  skin,  it  produces  a  local  inflammatory 
swelling,  known  as  a  '  malignant  pustule,'  or  a  more  diffuse  condition  termed 
'anthrax  oedema';  sometiines  the  latter  follows  the  former.  If  the  virus 
is  absorbed  by  the  lungs  or  intestinal  canal,  it  originates  a  general  inflammatory 
disorder,  known  as  '  woolsorter's  disease,'  or  anthracaemia. 

The  B.  anthracis  (Plate  III.,  Fig.  28)  is  one  of  the  largest  of  the  pathogenic 
organisms,  measuring  5  to  20  ix  in  length,  and  i  to  i'50  yit  in  breadth.  It  is 
found  in  the  blood  of  diseased  animals  in  the  form  of  rods  or  threads,  com- 
posed of  a  variable  number  of  individual  elements  (from  two  to  ten).  It  is 
aerobic,  immobile,  grows  best  at  about  blood-heat,  and  liquefies  gelatin.  Well- 
marked  spores  are  formed  within  the  bacillus  when  cultivated  artificially  and 
in  the  presence  of  oxygen ;  but  spore-formation  has  not  been  observed  in  the 
living  tissues.  The  bacilli  are  readily  killed  by  boiling  for  a  few  seconds, 
whilst  the  decomposition  of  the  carcass  in  which  they  are  present  causes  their 
death  in  about  a  week.  The  spores,  however,  are  very  resistant ;  for  whilst 
a  I  per  cent,  solution  of  carbolic  acid  kills  the  bacilli  in  two  minutes,  the 
spores  remain  alive  after  a  week's  immersion.  Moreover,  alcohol  and  even  a 
5  per  cent,  solution  of  carbolic  acid  have  no  effect  on  them,  unless  acting  for 
a  long  time.  If  a  mouse  is  inoculated,  say,  at  the  root  of  the  tail  with  a 
needle,  the  point  of  which  has  been  dipped  in  the  blood  of  an  animal  which 
died  of  splenic  fever,  it  succumbs  in  less  than  twenty-four  hours,  and  bacilli 
are  found  in  nearly  every  organ  of  the  body. 

Some  animals  are  immune  against  the  attacks  of  anthrax,  especially  the  do^^, 
and  rat;  and  one  of  Pasteur's  most  useful  discoveries  was  that  of  ]irov  din- 
artificial    immunity   for    cattle    and    sheep   by    inoculating   them  with    an 


SPECIFIC  INFECTIVE  DISEASES  141 

atknuatfd  virus,  obtained  by  exposing  a  cultivation  for  some  time  to  a  high 
lfni[)cTaturc. 

Symptoms. — Infection  with  this  organism  usually  occurs  amongst  graziers 
who  tend  the  living  animal,  or  butchers  who  deal  with  the  carcass;  it  is  also 
met  with  amongst  workers  in  hides  or  wool. 

Malignant  Pustule  is  usually  seen  on  the  face  or  forearm,  and  commences  as 
an  angry  red  pimple  at  the  site  of  inoculation,  which  rapidly  spreads,  with 
much  infiltration  of  the  base,  whilst  the  centre  becomes  covered  with  vesicles, 
the  serum  within  which  becomes  blood-stained  or  dark  brown  in  colour,  and 
contains  the  typical  bacilli.  This  stage  is  associated  with  no  pain,  but' only 
with  great  itching  and  irritation.  As  the  pustule  extends,  the  centre  becomes 
gray,  and  finally  black,  constituting  an  eschar  or  slough,  whilst  around  it  upon 
an  area  of  deep  brawny  congestion  and  oedema  is  a  narrow  ring  of  vesicles. 
The  process  gradually  becomes  more  marked  locally,  whilst  the  lymphatic 
glands  and  vessels  are  also  enlarged  and  involved  in  the  disease.  Generally, 
there  is  a  certain  amount  of  fever  and  malaise,  which  does  not  become  pro- 
nounced until  about  the  fourth  or  fifth  day.  The  temperature  then  rises  to 
102°  or  103°  F.,  the  pulse  becomes  rapid  and  irregular,  and  gastric  irritability, 
vomiting,  and  flatulence  more  marked.  Should  the  disease  progress  un- 
checked, the  surrounding  parts  are  involved  in  a  rapidly  spreading  cedema; 
thus  from  the  face  it  may  extend  to  the  neck,  chest,  and  back.  The  respira- 
tions become  shallow  and  embarrassed,  whilst  signs  of  grave  constitutional 
mischief,  such  as  delirium  or  coma,  manifest  themselves,  and  the  unfortunate 
individual  rapidly  succumbs,  generally  in  less  than  a  week  from  the  onset, 
but  sometimes  in  thirty  to  forty  hours.  More  commonly  the  case  runs  a 
more  favourable  course,  limiting  itself  to  the  local  manifestations,  which 
gradually  clear  up,  the  slough  separating  and  the  oedema  disappearing.  Of 
course,  should  there  be  more  than  one  focus  of  mischief,  the  prognosis  is 
much  worse. 

Anthrax  csdema  runs  a  rapidly  fatal  course;  it  is  usually  seen  about  the  face 
and  eyelids,  the  skin  becoming  red  and  brawny,  as  in  erysipelas,  and  after  a 
time  covered  with  vesicles,  whilst  finally  gangrenous  patches  appear.  The 
lymphatic  trunks  and  glands  are  also  involved. 

The  condition  may  be  mistaken  in  the  localized  form  for  accidental  vaccina- 
tion or  a  staphylococcic  infection,  but  is  recognised  by  the  presence  of  the 
bacilli  in  the  serum  of  the  vesicles;  in  cases  of  doubt  cultures  should  be  made. 

Woolsorter's  Disease  (or  anthracsemia)  is  the  term  applied  to  the  general 
condition  resulting  from  the  development  of  these  bacilli  in  the  body  without 
any  external  lesion.  The  virus  gains  access  to  the  system  by  either  sv/allowing 
or  inhaling  the  dried  spores.  If  they  enter  the  respiratory  tract,  the  patient 
complains  of  fever  and  malaise  for  a  few  days,  followed  by  the  development  of 
a  sero-fibrinous  pleuro-pneumonia,  the  exudation  containing  large  numbers  of 
bacilli.  This  runs  a  rapid  course,  with  high  fever,  great  dyspnoea,  impairment 
of  the  circulation,  and  finally  collapse  in  a  great  majority  of  the  cases.  If  the 
bacilli  enter  the  stomach,  they  are  usually  destroyed  by  the  acid  chyme;  but 
should  any  of  them  or  their  spores  reach  the  intestine,  the  alkaline  contents 
form  a  suitable  breeding-ground,  and  the  walls  of  the  gut  are  soon  attacked 
and  the  disease  becomes  general.  Colic,  cramps,  vomiting,  and  blood-stained 
diarrhoea  are  the  most  marked  features  in  such  a  case.  The  intestinal  type 
appears  to  be  not  quite  so  virulent  or  fatal  as  the  pulmonary,  but  is  decidedly 
worse  than  the  cutaneous. 

Treatment. — In  the  cutaneous  affection,  excision  of  the  necrotic  patch  and  of 
all  the  infiltrated  tissues  around,  and  the  application  of  the  actual  cautery  or 
of  pure  carbolic  acid,  used  to  be  recommended,  though  those  who  have  had 
much  experience  of  the  affection  think  such  treatment  of  little  value,  and 
trust  in  fomentations  for  the  localized  variety. 

Several  sera  (p.  28)  have  been  introduced  for  the  treatment  of  anthrax,  and 
good  results  have  been  obtained,  especially  in  the  localized  forms  of  the  disease. 
Sclayo's  is  most  used;  it  is  obtained  by  immunizing  asses  or  goats  with  Pas- 
teur's vaccine  (p.  15),  followed  by  injection  of  large  doses  of  virulent  cultures. 
The  dose  is  20-40  c.c.   (340-680  minims),  repeated  in    twenty-four  hours,  if 


142  A   IVANUAL  OF  SURGERY 

necessaiy;  in  severe  cases  tlic  lirst  dose  may  be  injected  intravenously. 
Sobcnhciin's  serum  is  prepared  in  a  ditierent  way,  and  also  Rives  good  results; 
the  dose  is  the  same.  The  use  oi  either  serum  may  be  followed  by  fever  and 
sweating,  and  improvement  is  often  very  rapid.  They  appear  to  stimulate 
phagocytosis. 

Gonorrhoea. 

Gonorrhoea  is  an  infective  process  due  to  the  action  of  a  specific 
micro-oig  inism,  the  Gonococcus  or  Diplococcus  gonorrhnece  (Plate  I., 
Fig.  3),  and  characterized  (in  its  commonest  form)  by  a  discharge  of 
pus  from  the  urethra.  The  organism  is  a  diplococcus,  and  each 
coccus  of  the  pair  is  usually  kidney-  or  bean-shaped,  and  the  two  lie 
with  their  concave  borders  facing  one  another.  Single  cocci  and 
tetrads  sometimes  occur.  It  is  not  easily  cultivated,  and  hccmo- 
globin  is  necessary  for  its  growth ;  the  simplest  method  of  preparing 
a  suitable  culture  medium  is  to  spread  some  sterile  blood  on  the 
surface  of  ordinary  agar.  The  colonies  are  small  and  translucent, 
appearing  like  droplets  of  dew.  Such  cultures  set  up  gonorrhoea 
when  injected  into  the  human  urethra,  thus  proving  the  causal  rela- 
tion of  the  organism  to  the  disease,  as  all  of  Koch's  postulates  are 
fulfilled.  The  lower  animals  are  all  immune.  The  gonococcus  does 
not  stain  by  Gram's  method;  this  fact  is  of  great  importance  in 
diagnosis,  since  most  of  the  diplococci  with  which  it  might  be  con- 
founded retain  the  stain.  It  occurs  in  large  quantities  in  the  pus 
from  a  gonorrhoeal  lesion,  and  in  most  cases  it  is  found  within  the 
polynuclear  leucocytes.  This  is  very  characteristic,  as  also  the  fact 
that,  whilst  most  of  the  cells  are  usually  free  from  organisms, 
those  that  are  invaded  by  cocci  contain  them  in  abundance  (see 
Plate  I.,  Fig.  3,  in  which  some  of  the  cells  are  free  from  gemis,  but 
in  others  the  diplococci  can  be  seen  clustered  round  the  poly- 
morphous nuclei).  The  pus  also  contained  desquamated  epithelial 
cells,  in  or  on  which  many  cocci  may  often  be  seen. 

The  laboratory  diagnosis  of  gonorrhoea  does  not  usually  in\"olve 
cultural  methods,  but  can  be  made  by  an  examination  of  stained 
pus-films.  The  best  way  is  to  stain  by  Gram's  method,  and  to 
counterstain  by  dilute  carbol-fuchsin.  In  this  way  the  gonococci 
will  be  coloured  red,  whilst  most  of  the  other  cocci  with  which  they 
could  be  confounded  are  deep  violet.  The  intracellular  distribution 
of  the  cocci  and  the  freedom  of  most  of  the  pus-cells,  whilst  others 
are  packed  full  of  organisms,  are  points  of  great  diagnostic  value. 
Sometimes,  however,  most  of  the  gonococci  are  extracellular. 

In  the  male  the  primary  lesion  is  an  acute  catarrhal  inflammation 
of  the  anterior  portion  of  the  urethra,  which  quickly  runs  on  to 
suppuration,  and  is  likely  to  spread  back  towards  the  deeper  portions 
of  the  urethra,  or  even  to  the  prostate,  bladder,  or  epididymis. 
These  lesions  usually  constitute  the  whole  of  the  disease,  but  in  some 
cases  the  gonococci  enter  the  blood-stream  and  affect  distant 
organs.  The  joints  are  most  frequently  affected,  but  occasionally 
typical  pysemic  phenomena  supervene  (gonococcaemia),  with 
secondary  abscesses  and  even  ulcerative  endocarditis. 


SPECIFIC  INFECTIVE  DISEASES  143 

The  Symptoms  of  Acute  Gonorrhoeal  Urethritis  (male)  usually  com- 
mence within  a  few  days  of  the  infection,  varying  from  two  to  eight. 
Most  commonly  the  discharge  appears  about  the  third  or  fourth  day, 
being  preceded  by  itching  of  the  meatus  and  a  scalding  pain  on 
passing  urine.  The  lips  of  the  meatus  are  congested  and  swollen, 
and  the  discharge,  which  is  at  first  thin  and  mucoid,  soon  becomes 
thick,  abundant,  and  yellow  in  colour.  This  stage  lasts  for  a  variable 
time,  and  is  sometimes  associated  with  a  good  deal  of  dragging  pain 
in  the  back  and  loins,  together  with  some  constitutional  disturbance 
and  fever.  The  bowels  are  usually  constipated,  and  the  appetite 
impaired.  Occasionally  the  swelhng  and  congestion  of  the  mucous 
membrane  are  so  great  as  to  lead  to  retention  of  urine  or  haemorrhage 
from  the  urethra.  The  first  attack  is  always  more  serious  than  subse- 
quent ones,  although  it  is  often  more  amenable  to  treatment.  Gouty 
and  rheumatic  people  are  especially  difficult  to  treat,  and  relapses 
frequently  occur  after  the  discharge  has  apparently  ceased ;  it  is  said 
that  fair  people  suffer  more  than  those  who  are  dark. 

If  suitable  treatment  is  adopted,  the  discharge  entirely  ceases  at 
the  end  of  two  or  three  weeks;  but  if  neglected,  or  sometimes  in 
spite  of  treatment,  the  inflammation  spreads  backwards,  giving  rise 
to  what  is  usually  termed  a  Posterior  Urethritis,  since  it  involves 
that  portion  of  the  canal  which  Hes  behind  the  deep  constrictor.  It 
generally  becomes  evident  about  the  end  of  the  second  week,  and  is 
characterized  by  frequent  and  painful  micturition,  a  sense  of  pain 
and  hea\dness  in  the  perineum,  possibly  a  httle  blood  in  the  urine, 
and  a  general  feehng  of  depression.  This  extension  backwards  is 
always  serious,  since  it  is  hkely  to  be  followed  by  comphcations  in- 
volving the  prostate,  testis,  or  seminal  vesicles,  whilst  it  is  an  ex- 
tremely common  cause  of  Chronic  Gonorrhcea  or  Gleet,  in  which  a 
more  or  less  abundant  discharge  continues  for  some  time  without 
any  other  troublesome  symptom  than  occasional  scalding  on  passing 
urine.  The  discharge  is  often  thin  and  muco-purulent,  and  may  be 
so  shght  as  merely  to  cause  the  lips  of  the  meatus  to  stick  together, 
or  may  only  be  evident  on  squeezing  the  urethra  after  a  night's 
rest.  This  may  last  for  a  long  time,  even  years,  and  it  must  be  re- 
membered that  even  in  this  stage  the  disease  can  be  transmitted  to 
women.  Gleet  is  sometimes  due  to  an  ulcerated  or  granular  con- 
dition of  some  portion  of  the  mucous  membrane;  the  discharge  is 
then  yellow,  and  the  urethra  is  tender  on  the  passage  of  a  sound; 
the  presence  of  the  ulcer  or  granular  patch  can  be  recognised  by 
the  urethroscope.  In  other  cases  gleet  arises  from  chronic  prostatitis, 
a  condition  not  uncommonly  associated  with  chronic  enlargement  of 
the  vesiculce  seminales.  The  latter  condition  may  be  recognised  on 
rectal  examination,  whilst,  when  the  prostate  is  involved,  floccuh  of 
mucus  in  the  shape  of  worm-Hke  threads  may  be  detected  in  the 
urine,  especially  after  massage  of  the  gland  by  the  finger  introduced 
into  the  rectum. 

When  the  disease  has  lasted  for  a  considerable  time,  or  after 
repeated  attacks,  a  certain  amount  of  peri-urethral  infiltration  is 


144  ^  MANUAL  OF  SURGERY 

certain  to  follow,  and  a  stricture  of  the  urethra  may  result :  this 
may  also  be  due  to  the  cicatrization  of  the  ulcerated  and  granular 
patches  in  the  urethral  wall,  alluded  to  above. 

A  routine  examination  of  the  urine  in  cases  of  gonorrhoea  will  often  throw 
much  light  on  the  course  and  extent  of  the  disease.  In  the  acute  stage  4  or 
5  ounces  are  passed  into  one  glass,  and  the  remainder  into  a  second ;  if  the 
anterior  urethra  is  alone  involved,  the  discharge  will  be  swept  out  in  the 
first  few  ounces,  and  the  urine  in  the  first  glass  is  alone  turbid,  containing 
threads  or  small  fiakes  of  pus.  Involvement  of  the  posterior  urethra  causes 
the  urine  in  the  second  glass  to  be  nearly  as  turbid  as  that  in  the  first,  and 
the  co-existence  of  cystitis  would  make  it  even  more  turbid.  In  the  chronic 
state,  when  merely  a  gleet  is  present,  it  is  essential  to  wash  out  the  anterior 
urethi-a  with  5  or  6  ounces  of  boric  acid  solution,  which  are  retained  for 
examination,  and  then  the  urine  is  passed  into  two  glasses,  as  suggested 
above.  Unless  this  preliminary  irrigation  is  undertaken,  the  stream  of  urine 
may  wash  out  the  discharge  from  the  posterior  urethra  and  invalidate  the 
test.  Examination  by  the  urethroscope  or  endoscope  is  also  necessary  in  cases 
of  gleet.  The  instrument  consists  of  a  metal  tube  fitted  with  electric  illumina- 
tion in  such  a  way  as  to  render  visible  the  walls  of  the  urethra,  which  are 
advisably  distended  with  air  by  a  bellows.  A  commencing  stricture  can  be 
easily  recognised,  as  also  ulcerated  areas,  patches  of  granulations  more  or 
less  poh'poid,  etc.,  whilst  suitable  local  treatment  can  also  be  undertaken. 

Every  purulent  discharge  is  not  necessarily  gonorrhoeal,  since  a 
simple  urethritis  may  follow  connection  with  a  woman  who  is  simply 
suffering  from  leucorrhoea,  or  has  scarcely  recovered  from  her 
menstrual  period,  but  with  no  suspicion  of  a  venereal  taint.  In 
these  cases  infection  may  be  due  to  ordinary  pyogenic  cocci,  or 
possibly  to  the  B.  colt  communis,  which  is  known  to  be  not  an  un- 
I'requent  cause  of  vulvo-vaginitis.  A  diagnosis  of  simple  urethritis 
may  be  suggested  by  the  history,  but  only  a  microscopical  examina- 
tion of  the  pus,  and  a  demonstration  of  the  absence  of  gonococci, 
can  establish  it  with  certainty.  It  must  be  remembered,  however, 
that  gonococci  are  capable  of  remaining  in  a  latent  or  passive  state 
for  a  very  long  time  in  the  folds  or  crypts  of  a  mucous  membrane, 
and  hence  a  person  who  has  once  suffered  from  it  may  be  capable  of 
transmitting  the  disease,  although  no  obvious  evidence  of  its  exist- 
ence is  present.  Moreover,  a  highly  acid  condition  of  the  urine  in  a 
gouty  patient,  especially  if  loaded  with  uric  acid  crystals,  may  hght 
up  into  activity  a  urethritis  which  has  been  quiescent  for  some  time. 
The  practitioner  is  not  unfrequently  consulted  as  to  the  ad\asability 
of  marriage  after  an  attack  of  gonorrhoea;  the  cessation  of  the  dis- 
charge is  not  sufficient  to  warrant  such  a  step.  The  only  safe  test 
is  to  light  up  a  fresh  attack  of  urethritis  by  the  injection  of  some 
chemical  irritant — e.g.,  a  solution  of  nitrate  of  silver  (i  in  100) — 
and  to  examine  the  discharge  bacteriologically  for  the  presence  or 
not  of  gonococci. 

In  the  Treatment  of  the  early  stages  of  acute  gonorrhoea  it  is 
essential  to  keep  the  urine  free  from  acidity  by  the  use  of  alkahes, 
to  maintain  a  free  action  of  the  bowels,  and  to  allay  the  irritabihty 
of  the  parts  by  sedatives,  such  as  tincture  of  henbane.  The  diet 
should  be  hght  and  unstimulating,  and  all  alcoholic  drinks  pro- 
hibited, as  also  strong  tea  and  coffee,  whilst  the  patient  should  be- 


SPECIFIC  INFECTIVE  DISEASES  145 

recommended  to  drink  plenty  of  bland  fluids,  such  as  barley-water, 
or  milk  and  soda-water.  The  scrotum  should  be  supported  in  a 
suspender,  and  the  patient  advised  against  taking  severe  or  pro- 
longed exercise.  No  local  treatment  is  necessary,  although  the  use 
of  hot  hip-baths  may  reheve  the  pain  and  irritation;  indeed,  at  this 
period  injections  are  harmful.  The  same  treatment  must  be  adopted 
as  long  as  the  discharge  is  copious  and  the  scalding  continues.  As 
soon  as  these  symptoms  moderate,  oleo-balsams  in  the  form  of  oil 
of  sandal-wood  (10  minims,  in  capsules,  three  to  six  times  a  day), 
copa.iba  (lo  minims,  in  capsules  or  mixture,  thrice  daily),  or  cubebs 
(|-  to  I  drachm  doses,  wrapped  in  wafer-paper),  may  be  advan- 
tageously employed.  Both,  cubebs  and  copaiba,  especially  the 
latter,  are  capable  of  producing  a  bright  red  erythematous  rash 
which  causes  much  irritation,  and  may  be  extensively  diffused  over 
the  body. 

The  value  of  injecfloiis  in  the  treatment  of  the  disease  has  been 
much  discussed,  and  is  a  point  on  which  difference  of  opinion  exists. 
On  the  whole,  we  are  inclined  to  think  that  many  of  the  less  severe 
cases  of  acute  gonorrhoea  can  be  successfully  treated  without  them, 
and  that  they  should  not  generally  be  em.plo\'ed  when  marked  local 
irritation  or  scalding  is  present;  but  when  the  discharge  persists, 
or  the  urethra  has  become  thickened  by  previous  attacks,  and 
especially  in  gleet,  their  use  is  imperative.  To  employ  them  with 
advantage,  the  following  plan  should  be  adopted:  The  urethra  is 
first  washed  out,  so  as  to  remove  any  discharge  from  it;  for  this 
purpose  the  nornial  act  of  micturition  answers  admirably,  so  that 
the  injection  should  be  used  immediately  after  passing  water.  The 
rounded  nozzle  of  a  small  glass  syringe,  containing  about  half  an 
ounce,  is  inserted  into  the  meatus,  the  lips  of  which  are  compressed 
over  it.  The  fluid  is  thrown  into  the  urethra,  and  held  there  for 
about  twenty  seconds  by  compressing  the  orifice  with  the  linger  and 
thumb,  as  the  syringe  is  withdrawn ;  then,  on  relaxing  the  pressure, 
the  fluid  escapes.  Other  forms  of  syringe,  on  the  principle  of  the 
indiarubber  bottle,  etc.,  are  recommended,  but  the  glass  is  un- 
questionably the  cleanest.  Of  the  many  injections  employed,  one 
of  the  best  consists  of  a  mixture  of  tincture  of  catechu  (10  minims 
to  I  ounce  of  water)  and  sulphate  of  zinc  (2  grains  to  i  ounce) ; 
but  solutions  of  permanganate  of  zinc  (J  grain  to  i  ounce),  or 
nitrate  of  silver  (J  grain  to  i  ounce),  or  protargol  (i  per  cent.),  are 
also  very  effective.  The  great  secret  consists  in  using  the  injection 
four  or  five  times  a  day  at  first,  and  afterwards  night  and  morning, 
even  after  all  visible  signs  of  the  discharge  have  ceased.  The  fluid 
should  always  be  at  a  temperature  of  100°  F.,  and  care  taken  not 
to  use  too  strong  a  solution. 

One  is  bound  to  admit,  however,  that  many  genito-urinary 
surgeons  hold  views  verj^  different  to  these,  and,  indeed,  maintain 
that  gonorrhoea  can  be  aborted,  or,  at  any  rate,  rapidly  brought 
under  control  at  any  stage  by  large  injections  of  a  weak  solution  of 
permanganate  of  potash,  introduced  with  sufficient  force  to  distend 

10 


146  A   MANUAL  OF  SURGERY 

the  urethra  in  all  its  parts  and  enter  the  bladder;  all  the  crypts  and 
lacun;e  are  thus  reached  l^y  the  antiseptic. 

The  Treatment  of  Gleet  is  always  a  matter  of  difficulty.  The 
general  habits  of  the  patient  must  be  attended  to,  as  in  the  acute 
stage,  whilst  the  bowels  must  be  opened,  and  absolute  sexual 
continence  enjoined  to  prevent  the  spread  of  the  infection.  Large 
doses  of  the  liq.  ferri  perchlor.,  combined  with  a  sufficient  amount  of 
Epsom  salts  to  guard  against  constipation,  may  be  given.  Local 
treatment  is  generally  necessary  in  the  shape  of  injections  as  already 
described,  and  the  passage  of  a  cold  solid  metal  bougie  every  three 
or  four  days  has  sometimes  an  excellent  effect.  Methodical  dilata- 
tion of  the  urethra  is  also  advised  so  as  to  compress  all  the  crypts 
and  lacunae,  and  remove  pent-up  secretion.  Massage  of  the  prostate 
and  vesicula;  per  recftini,  once  or  twice  a  week,  is  also  advisable  when 
these  parts  are  affected.  Patches  of  granular  urethritis  must  be 
treated  topically  by  applications  of  nitrate  of  silver  (beginning  with 
a  solution  of  i  in  i,ooo)  through  the  endoscope.  Should  these 
measures  fail,  direct  treatment  of  the  posterior  urethra  by  such 
reagents  as  solutions  of  nitrate  of  silver  (i  in  i,ooo),  or  permanganate 
of  potash  (i  in  i,ooo),  must  be  undertaken;  perhaps  the  simplest 
method  of  effecting  this  is  to  pass  a  measured  length  of  a  rubber 
catheter  into  the  urethra  (about  7J  inches),  and  then  inject  the  fluid; 
this  must  be  undertaken  two  or  three  times  a  week. 

Vaccine  Treatment  in  Gonorrhoea  and  its  complications  has  been 
proved  to  be  of  considerable  value,  though  not  so  much  for  the 
treatment  of  the  urethral  discharge  as  for  that  of  the  complications. 
However,  in  some  cases  of  a  chronic  gleet,  or  in  the  subacute  stage 
when  the  discharge  is  slackening  off,  it  may  sometimes  be  used  with 
advantage.  In  the  gonorrhceal  affections  of  joints,  of  the  eye,  or  of 
internal  organs,  vaccines  are  most  useful.  The  vaccine  is  prepared 
as  described  on  p.  26,  and  the  usual  dose  is  from  100,000,000  to 
500,000,000  dead  gonococci. 

Complications  of  Gonorrhoea.^These  may  be  conveniently  ar- 
ranged under  the  following  headings : 

I.  Complications  due  to  Direct  Extension. — //;  the  male,  the  follow- 
ing may  be  described: 

Balanitis  is  of  frequent  occurrence  in  patients  with  long  foreskins, 
and  is  ordinarily  due  to  pyogenic  organisms,  and  not  to  gonococci. 
As  a  secondary  result,  inflammation  of  the  lymphatics  of  the  penis 
and  inguinal  bubo  may  follow.  Sometimes  this  inflammation  results 
in  the  development  of  red  papillomatous  outgrowths,  known  as 
gonorrJural  ivarfs,  which  are  found  mainly  on  the  glans  penis,  but 
occasionally  on  the  preputial  margin  (Chapter  XLI.). 

Lacunar  Abscess  arises  from  infection  of  one  or  more  of  the  lacunae 
with  the  gonococcus  or  accompanying  pyogenic  organisms.  A  tense 
painful  swelling  forms  along  the  floor  of  the  urethra,  which  may 
project  into  the  passage  and  discharge  either  into  the  urethra,  or 
externally,  or  both;  in  the  latter  case  a  penile  fistula  will  result. 
The  abscess  should  be  opened  as  early  as  possible  from  without, 
so  as  to  prevent  the  latter  occurrence,  which  is  often  very  difficult 


SPECIFIC  INFECTIVE  DISEASES  147 

to  treat.  If  a  fistula  forms  within  a  short  distance  of  the  meatus— 
a  common  situation— it  seldom  heals  of  itself,  but  may  in  some  cases 
be  closed  by  an  application  of  the  electric  cautery  or  a  weak  solution 
of  nitrate  of  silver.  If,  however,  it  remains  intractable,  the  fistula 
should  be  laid  open  into  the  meatus.  When  it  occurs  in  the  body 
of  the  penis,  a  plastic  operation  is  usually  required;  it  consists  in 
paring  the  edges  and  dissecting  up  the  skin  on  either  side  so  as  to 
bring  it  together  in  the  median  line. 

Chordee  results  from  inflammatory  infiltration  of  the  corpus 
spongiosum  or  one  of  the  corpora  cavernosa,  so  that  the  penis,  when 
erect,  is  bent  downwards  or  to  one  side.  It  is  exceedingly  painful,  and 
most  marked  at  night  when  the  patient  becomes  warm  in  bed.  'it  is 
best  prevented  by  the  use  of  bromide  of  potassium  or  other  sedative 
at  bedtime,  and  when  present  may  be  treated  by  cold  applications. 

Inflammation  of  Cowper's  Glands  may  in  some  cases  give  rise  to 
deep  suppuration  in  the  perineum,  and  unless  treated  eariy  by 
incision  may  lead  to  a  urinary  fistula. 

Inflammatory  conditions  involving  the  prostate,  seminal  vesicles, 
epididymis,  and  bladder,  and  caused  by  gonorrhoea,  are  discussed 
elsewhere. 

11.  Complications  arising  from  Direct  Transmission  of  the  Virus.— 
Gonorrhoeal  Proctitis  sometimes  results  in  the  female  from  infection 
by  the  discharge  which  escapes  from  the  vulva,  whilst  in  both  sexes 
it  may  be  due  to  unnatural  practices.  It  is  characterized  by 
tenesmus  and  a  thick  muco-purulent  discharge,  and  is  treated  by 
injecting  lotions  of  acetate  of  lead  and  opium,  or  of  boric  acid. 

Gonorrhoeal  Rhinitis  has  also  been  seen  in  a  few  cases.  It  leads 
to  an  abundant  discharge  of  pus,  and  should  be  treated  by  warm 
soothing  injections,  followed  after  a  time  by  dilute  astringents. 

Gonorrhoeal  Conjunctivitis  occurs  either  in  adults,  when  it  is  uni- 
lateral to  start  with,  or  in  infants,  when  it  is  bilateral,  and  due  to 
infection  during  transit  through  the  maternal  passages  [ophthalmia 
neonatorum).  It  is  a  remarkable  fact  that,  although  gonorrhoea  is  so 
very  prevalent,  such  a  small  proportion  of  the  patients  suffer  from 
conjunctival  infection;  it  would  appear,  therefore,  that  not  only 
must  there  be  direct  contact  with  the  gonorrhoeal  poison,  but  in 
addition  the  mucous  membrane  must  be  in  a  receptive  state.  In 
the  adult  variety  it  is  ushered  in  by  redness  and  irritability  of  the 
eye,  followed  quickly  by  a  discharge  which  is  at  first  mucous,  but 
soon  becomes  purulent.  The  eyehds  are  red  and  swollen,  the  con- 
junctiva is  thickened  and  oedematous  (chemosis),  and  the  discharge 
hable  to  accumulate  within  the  conjuncrival  sac.  If  allowed  to 
progress  unchecked,  ulceration  or  even  necrosis  of  the  cornea  may 
ensue,  and  possibly  general  panophthalmitis.  This  is  pre-eminently 
the  commonest  cause  of  bhndness  in  children.  The  first  detail  in 
the  Treatment  consists  in  protecting  the  opposite  eye  by  means  of 
what  IS  known  as  Buller's  shield;  a  watch-glass  is  fixed  in  a  piece 
of  mackintosh  over  the  eye,  and  kept  in  position  by  plaster.  The 
affected  conjunctiva  must  be  unremittingly  attended  to  night  and 
day,  so  as  to  prevent  accumulation  of  discharge;  it  is  frequently 


148  A   MANUAL  OF  SURGERY 

irrigated  with  warm  boric  acid  lotion,  and  every  four  liours  after 
washing  out  with  this,  the  membrane  is  dried  and  gently  irrigated 
with  a  solution  of  nitrate  of  silver  (5  grains  to  i  ounce),  followed  by 
sterilized  salt  solution.  Between  the  applications  lint  wrung  out  of 
iced  boric  acid  lotion  is  kept  over  the  eye.  This  plan  of  treatment 
is  continued  until  the  suppuration  ceases,  and  then  the  silver  salt  is 
omitted,  and  simple  astringents,  such  as  chloride  or  sulphate  of  zinc, 
are  substituted. 

In  infants  the  disease  often  runs  a  rapid  and  severe  course,  and  is 
very  likely  to  lead  to  ulceration  or  sloughing  of  the  cornea,  a  com- 
plication not  uncommonly  followed  by  escape  of  the  lens  and  blind- 
ness. Crede's  preventive  treatment  should  always  be  adopted  for 
new-born  childern,  viz.,  washing  out  the  conjunctival  sac  with  a 
weak  solution  of  nitrate  of  silver  {2  per  cent.)  or  corrosive  sublimate 
soon  after  birth.  When  suppuration  occurs,  the  treatment  to  be 
adopted  is  practically  identical  with  that  detailed  above,  except  that 
it  is  useless  to  attempt  to  limit  the  trouble  to  one  eye. 

III.  Complications  resulting  from  General  Absorption. — Gonor- 
rhoea! Affections  of  Joints  are  not  uncommon  sequelae,  arising  usually 
in  the  subacute  stage  of  the  disease.  For  clinical  features  and 
treatment,  see  Chapter  XXIII. 

Gonorrhoea!  Fibrositis. — Any  muscular,  tendinous,  ligamentous, 
or  aponeurotic  tissues  may  become  inflamed  and  painful  during  the 
course  of  an  attack  of  gonorrhoea.  Involvement  of  the  ligaments 
supporting  the  arch  of  the  foot  is  important,  since,  if  the  patient  is 
still  allowed  to  walk,  the  arch  may  be  lost,  and  a  permanent  flat- 
foot  result. 

Gonorrhoea!  Sclerotitis,  or  inflammation  of  the  deep  subconjunc- 
tival fibrous  tissue,  is  a  rare  affection,  arising  quite  independently 
of  gonorrhoeal  conjunctivitis.  It  is  characterized  by  marked  sub- 
conjunctival redness,  the  globe  of  the  eye  becoming  distinctly  tender. 
Local  applications  of  atropine  are  required,  and,  if  need  be.  leeches 
to  the  temples. 

The  pathology  of  the  comphcations  described  in  the  last  two 
paragraphs  is  uncertain.  They  are  probably  due  to  the  presence  in 
the  tissues  of  a  small  number  of  gonococci  of  enfeebled  virulence, 
or  may  be  caused  by  toxins  absorbed  from  the  local  lesion. 

A  true  Gonorrhoea!  Pyaemia  (gonococcaemia)  occasionally  develops, 
characterized  by  a  formation  of  secondar}^  abscesses  in  various  parts 
of  the  body,  containing  only  the  gonococcus.  Tliey  usually  com- 
mence deeply,  and  at  first  are  somewhat  chronic,  but  subsequently 
the  ordinary  phenomena  of  suppuration  supervene.  They  must  be 
laid  freely  open,  and  as  a  rule  heal  satisfactorily,  if  slowly. 

Occasionally  the  cardiac  valves  become  infected  and  inflamed,  and 
an  ulcerative  endocarditis  due  to  gonococci  has  been  observed. 
More  rarely  a  true  septicaemic  invasion  has  destroyed  the  patient  by 
a  generalized  development  of  gonococci  in|the  blood. 

Gonorrhoea  in  Women  is  by  no  means  uncommon,  even  apart  from 
prostitutes,  in  whom  it  is  more  or  less  constant ;  it  is  often  overlooked 


SPECIFIC  INFECTIVE  DISEASES  149 

or  unrecopjnised,  and  is  a  frequent  source  of  uterine  and  pelvic 
trouble.  This  is  probably  due  to  the  fact  that  an  uncured  gleet  in  a 
man  is  not  looked  on  as  a  bar  to  marriage.  Occasionally  the  disease 
is  contracted  from  the  infected  seat  of  a  public  water-closet,  or 
from  the  use  of  infected  towels,  garments,  etc. 

The  primary  lesion  is  usually  either  in  the  urethra  or  in  the  cervical 
endometrium,  or  in  both.  Vulvitis  is  by  no  means  uncommon,  but 
in  the  adult  a  gonorrhoeal  vaginitis  is  unusual.  Sometimes  dis- 
charges from  the  cervix  accumulate  in  the  vagina  and  undergo  septic 
changes,  producing  a  simple  vaginitis  by  the  direct  action  of  the 
bacterial  toxins,  but  the  gonococci  do  not  attack  the  vaginal  mucosa. 
In  children  a  true  vulvo-vaginitis  occurs. 

The  symptoms  in  acute  cases  are  those  of  heat  and  burning  about 
the  genitalia,  combined  with  a  purulent  discharge  and  painful  mic- 
turition. The  urethra  can  be  seen  and  felt  to  be  swollen,  and  its 
orihce  is  red  and  congested;  on  pressing  it,  pus  escapes.  If  the  cer- 
\ax  is  involved,  the  uterus  becomes  congested  and  painful;  severe 
backache  is  noticed,  and  perhaps  some  tenderness  on  hypogastric 
pressure,  with  a  blood-stained  discharge.  In  the  more  chronic  cases 
nothing  may  be  noted  except  that  the  periods  are  painful,  and  that 
there  is  a  certain  amount  of  leucorrhoea,  with  occasional  attacks  of 
discomfort  and  frequency  in  micturition. 

In  all  cases  the  inflammation  is  likely  to  spread,  either  to  the 
bladder,  or  up  the  uterus  to  the  Fallopian  tubes  (salpingitis),  ovaries, 
or  peritoneum.  In  the  latter  case  the  inflammation  may  be  local- 
ized, producing  adhesions  around  the  fimbriated  extremities  of  the 
tubes,  and  these  are  often  an  important  cause  of  sterilit3^  Occasion- 
ally a  more  generalized  peritonitis  results  {q.v.). 

Treatment  consists  in  the  use  of  frequent  mild  antiseptic  douches 
{e.g.,  lysol,  I  in  2,000),  and  in  measures  directed  towards  the  urethra 
or  cervax.  When  there  is  much  urethral  swelling  and  discharge, 
the  diet  is  regulated  and  alkalies  ordered,  as  for  men ;  balsams  may 
be  useful,  and  even  injections.  In  the  later  stages  the  shortness  of 
the  urethra  pennits  topical  applications  of  nitrate  of  silver  to  be 
made  readily,  and  it  is  unusual  for  the  inflammation  to  persist  for 
long.  In  gonorrhoeal  endocer\Tcitis  the  parts  should  be  thoroughly 
cleansed  by  douching,  and  then  a  10  per  cent,  solution  of  nitrate  of 
silver  applied  through  a  speculum. 

Soft  Chancre  {Ulcus  Molle). 

A  Soft  Chancre  is  a  local  infective  disorder,  which  is  rarely  seen 
elsewhere  than  on  the  genital  organs,  and  is  almost  invariably  the 
result  of  impure  connection.  It  is  due  to  a  specific  bacillus,  which 
was  first  described  by  Ducrey,  and  occurs  in  the  form  of  short  chains 
consisting  of  extremely  slender  rods,  which  do  not  form  spores  or 
stain  by  Gram's  method.  The  organism  has  been  cultivated,  though 
With,  difficulty,  and  there  appears  to  be  no  doubt  as  to  its  causal 
relation  to  the  disease,  though  ordinary  pyogenic  organisms  are 
often  present  as  well.     If  artificially  inoculated,  a  typical  series  of 


I50  A   MANUAL  OF  SURGERY 

events  ii)lknvs.  A  red  papule  appears  in  twenty-four  hours,  whilst  in 
two  or  three  days  a  vesicle,  surrounded  by  a  zone  of  angry  hypenemia, 
is  seen.  The  serum  witliin  the  vesicle  soon  becomes  turbid,  and  by 
the  fourth  or  fifth  day  a  fully-developed  pustule  is  present;  as  soon 
as  the  cuticle  is  lost,  an  ulcer  forms  with  cleanly-cut  edges  and  a 
sharp,  distinct  outline.  The  chancre  gradually  increases  in  size  up 
to  a  certain  limit,  and  then  if  kept  clean  heals  in  about  three  weeks. 
Such  sores  may  be  met  with  on  any  part  of  the  penis,  but  more 
especially  on  the  prepuce  and  glans,  or  on  the  corona  glandis,  and 
are  very  painful  and  tender.  The  secretion  is  highly  infective,  and 
if  inoculated  elsewhere  on  the  patient  produces  a  typical  sore, 
showing  that  the  condition  is  purely  local,  and  that  no  constitutional 
immunity  results  from  its  presence.  The  discharge  from  a  true 
syphilitic  chancre  may  produce  a  localized  pustule  on  auto-incjcula- 
tion,  but  no  typical  sore.  Frequently  several  soft  sores  are  present 
at  the  same  time,  and  the  discharge  from  one  chancre  is  very  likely  to 
produce  a  similar  affection  ('  satellite  '  chancre)  on  any  cutaneous 
or  mucous  surface  brought  into  contact  with  it;  e.g.,  it  may  spread 
from  prepuce  to  glans,  or  vice  versa,  or  from  one  lip  of  the  vulva  to 
the  other.  It  is  a  curious  but  well-authenticated  fact  that  soft 
chancres  are  rarely  seen  on  any  part  of  the  body  other  than  the 
genital  organs. 

Various  Modifications  of  the  typical  chancre  are  seen,  usually  re- 
sulting from  neglect  or  carelessness  on  the  part  of  the  patient.  Thus, 
if  a  long  foreskin  is  present,  the  discharge  may  be  retained  behind  it, 
and  extensive  ulceration  occur,  which  may  even  result  in  the  glans 
protruding  through  the  upper  part  of  the  prepuce,  which  drops 
beneath  it.  If  the  fra^num  is  involved,  haemorrhage  may  supervene 
from  ulceration  into  a  branch  of  the  artery  found  in  that  structure. 
When  there  is  much  inflammation,  the  base  of  the  sore  becomes 
indurated  and  infiltrated,  somewhat  resembling  the  Hunterian 
chancre.  Not  unfrequently  syphilitic  infection  occurs  at  the  same 
time  as  a  soft  chancre  is  contracted,  or  subsequently;  the  sore 
then  runs  a  longer  course,  does  not  heal,  even  if  kept  clean, 
and  after  a  time  the  patient  presents  the  characteristic  signs  of 
syphilis. 

In  all  cases  the  neighbouring  Lymphatic  Glands  become  enlarged 
and  tender,  and  the  process  is  very  liable  to  terminate  in  suppura- 
tion, constituting  a  bubo.  Two  forms  of  this  affection  are  described : 
(a)  The  simple  or  sympathetic  buho  results  from  the  absorption  of 
ordinary  pyogenic  organisms  from  the  abraded  surface.  The  pus  in 
this  case,  if  inoculated  elsewhere,  may  produce  a  pustule,  but  not  a 
true  chancre.  The  process  is  usually  limited  to  the  interior  of  the 
lymphatic  glands,  {b)  The  virulent  bubo  is  due  to  the  absorption, 
not  only  of  pyogenic  organisms,  but  also  of  the  specific  virus,  so 
that  the  pus,  if  inoculated,  always  produces  a  typical  soft  sore.  In 
these  cases  suppuration  occurs  not  only  within,  but  even  more 
abundantly  around  the  Ivniphatic  glands  {periadenitis),  so  that  the 
skin  becomes  considerably  undermined,  and  the  wound  produced  by 


SPECIFIC  INFECTIVE  DISEASES  151 

opening  the  abscess  may  take  on  the  form  of  a  large  soft  chancre  in 
the  groin,  in  the  centre  of  which  is  seen  the  lymphatic  gland  only 
slightly  enlarged.  The  process  is  often  slow,  and  a  good  deal  of 
cutaneous  redness  is  present  with  but  little  pus. 

Treatment  consists  in  keeping  the  sore  clean,  dusting  its  surface 
with  iodoform,  and  covering  it  with  lint  dipped  in  lotio  nigra  or 
boric  acid  lotion,  healing  usually  occurring  in  from  ten  to  twenty 
days ;  where  much  balanitis  exists,  it  may  be  necessary  to  slit  up  the 
prepuce,  but  circumcision  should  not  be  undertaken  until  the  sores 
have  healed.  The  application  of  pure  carbolic  or  nitric  acid  may 
destroy  the  organisms  and  hasten  a  cure,  but  they  need  not  be 
employed  unless  the  routine  treatment  fails  to  check  the  spread  of 
the  sore.  If  the  smell  of  iodoform  is  objected  to,  iodol  or  aristol 
may  be  substituted. 

Buboes  are  treated  in  the  early  stages  by  keeping  the  patient  at 
rest  and  applying  fomentations  or  Klapp's  suction  balls,  when 
resolution  sometimes  occurs.  If  suppuration  ensues,  the  abscess 
should  be  incised  vertically,  so  as  to  allow  free  exit  to  the  pus,  even 
when  the  patient  is  sitting,  the  cavity  being  subsequently  dressed 
by  packing  it  with  gauze  impregnated  with  iodoform.  Some  sur- 
geons make  small  incisions,  and  trust  to  the  suction  effect  of  Klapp's 
apparatus;  other's  recommend  that  the  enlarged  glands  should  be 
freely  removed  by  dissection,  but  such  is  not  often  required.  The 
tissues  surrounding  them  are  so  extensively  infiltrated  that  it  is 
sometimes  impossible  to  define  their  limits,  and  surrounding  tissues 
of  importance  may  be  encroached  on.  Moreover,  complete  removal 
of  the  lymphatic  glands  in  the  groin  is  sometimes  followed  by  serious 
evidences  of  lymphatic  obstruction  in  the  limb  or  external  genital 
organs  (Fig.  120).  Prolonged  rest,  free  incisions,  and  scraping  of 
abscess  cavities  and  sinuses,  followed  by  packing  with  iodoform 
gauze,  usually  result  in  a  cure;  when  repair  is  slow,  a  visit  to  the 
seaside  will  often  be  beneficial. 

Syphilis. 

It  is  now  fairly  certain  that  the  cause  of  syphilis  is  a  protozoal 
parasite  discovered  by  Siegel  and  Schaudinn  in  1905,  and  termed 
the  SpirochcBta  pallida  or  Treponema  pallidum  (Fig.  31).  Spiro- 
chetes and  spirilla  are  common  in  the  mouth  and  in  dirty  wounds ; 
but  this  organism  can  readily  be  distinguished  from  unimportant 
forms  by  its  morphology  and  staining  reactions.  It  has  recently 
been  cultivated  by  Noguchi  on  a  mixture  of  agar  and  ascitic  fluid 
under  strict  anaerobic  conditions.  It  stains  with  difficulty,  a  fact 
which  accounts  for  its  having  eluded  observation  for  so  long.  Mor- 
phologically, it  is  a  very  delicate  spiral  filament,  having  eight 
to  twelve  fairly  regular  whorls;  its  ends  are  sharply  pointed, 
and  each  terminates  in  an  exceedingly  delicate  flagellum.  It  varies 
in  length,  but  on  an  average  is  about  equal  in  length  to  the  diameter 
of  a  red  blood-corpuscle,  and  each  whorl  occupies  about  i  /a.     The 


152 


A   MANUAL  OF  SURGERY 


common  5.  refringens,  which  is  frequently  met  with  in  the  mouth, 
ulcers,  etc.,  is  larger,  broader,  has  blunter  ends,  and  a  smaller  number 
of  less  regular  whorls.  Little  is  known  of  the  life-history  of  the 
syphilitic  form. 

The  proof  of  its  specificity  lies  mainly  in  the  fact  that  it  can  be 
found  in  the  great  majority" of  all  cases  of  syphilis— the  proportion 
depending  on  the  care  taken  and  the  skill  of  the  observer— and  that 
it  is  found  in  regions  in  which  accidental  contaminations  could  hardly 
occur,  e.g.,  in  the  lungs,  liver,  spleen,  and  other  viscera  of  still-born 
syphilitic  foetuses  (Fig.  32).  In  acquired  syphilis  it  may  be  demon- 
strated in  the  earliest  stages  of  the  sore  that  precedes  the  typical 
primary  chancre,  or  in  scrapings  thereof;  in  the  secondary  stage  it 
occurs  in  the  corresponding  glands,  the  skin  lesions,  or  in  the  fluid 
of  blisters  raised  near  them,  in  the  spleen,  and  has  been  demon- 


V 


K)  oi  -^ 


Fig.  31. — Spiroch^ta  Pallida.  Fig.  32. — Sechun  uf  Llng  in  Dead 

(x   1,500.)  AND  Macerated  Syphilitic  FcETus, 

SHOWING      THE      TISSUES       CROWDED 
WITH    SPIROCHi^TES.       (X    I,000.) 

(For  the  preparation  and  loan  of  these  two  specimens  we  are  indebted  to 
Dr.  Eardley  Holland.) 

strated  in  the  blood,  though  rarely;  in  the  tertiary  stage  it  has  been 
found  in  small  numbers  in  gummata  and  other  specific  lesions,  but  in 
the  majority  of  cases  it  can  only  be  demonstrated  vAih  great  diffi- 
culty and  after  prolonged  search;  especially  is  this  the  case  in  the 
so-called  parasyphilitic  affections  of  the  nervous  system. 

Syphilis  only  occurs  naturally  in  man,  but  it  may  be  inoculated 
into  the  higher  apes,  which  develop  a  disease  comparable  in  most  of 
its  features  to  human  syphilis.  Frequently  repeated  experiments 
on  these  animals  have  yielded  results  of  much  clinical  interest.  The 
disease  has  been  transmitted  by  material  obtained  from  the  human 
subject  in  all  stages — e.g.,  by  the  blood,  the  semen,  discharges  from 
the  primary  sores,  from  secondary  lesions,  and  even  from  gummata. 
The  incubation  period  is  from  three  to  four  weeks,  and  then  an 


SPECIFIC  INFECTIVE  DISEASES  153 

indurated  nodule  appears  which  undergoes  ulceration,  and  is  accom- 
panied by  enlarged  lymphatic  glands.  Mild  secondary  symptoms 
usually  follow,  but  tertiary  manifestations  have  not  been  observed. 
It  has  been  proved  that  the  inunction  of  calomel  ointment  locally 
can  prevent  infection,  even  up  to  twenty  hours  after  inoculation; 
but  removal  of  the  inoculated  region  has  proved  useless  except 
when  undertaken  within  eight  hours  after  infection. 

The  methods  employed  in  the  Laboratory  Diagnosis  of  s^^philis 
consist  in  the  demonstration  of  the  spirochaste  or  in  the  Wassermann 
reaction.  The  Treponema  pallidum  can  usually  be  found  without 
difficulty  in  the  serum  which  oozes  from  the  margin  of  the  supposed 
chancre  after  scraping  it  lightly  with  a  scarifier,  or  which  can  be 
expressed  after  puncture  of  an  enlarged  lymphatic  gland.  Long 
before  the  sore  has  taken  on  a  typical  appearance  the  spirochetes 
can  be  seen  and  a  diagnosis  made,  and  it  is  important  to  realize  that 
the  induration  of  the  sore  is  Nature's  attempt  to  shut  in  the  organ- 
isms, and  therefore  it  is  the  more  difficult  to  reach  them  by  drugs. 
No  antiseptic  should  be  applied  to  the  sore  before  examination,  as 
thereby  the  spirochsetes  are  driven  into  the  deeper  tissues.  Three 
methods  of  demonstration  may  be  emploj-ed:  (i)  The  material  may 
be  examined  fresh  under  dark  background  illumination  (ultra- 
microscope).  This  is  the  best  method,  the  organisms  being  easily 
seen  and  their  characteristic  movements  recognised.  (2)  Appear- 
ances somewhat  similar  can  be  secured  by  mixing  the  secretion  with 
fluid  Indian  ink,  spreading  it  out  into  a  film,  and  allowing  it  to  dry 
on  a  slide.  Here  also  the  organisms  appear  colourless  on  a  dark 
ground,  but,  of  course,'  there  is  no  movement.  This  is  a  simple  and 
quick  method.  (3)  There  are  numerous  staining  methods,  most 
being  modifications  of  Romanowski's;  photographic  processes 
depending  on  the  reduction  of  silver  salts  are  also  used,  especially 
when  the  organisms  have  to  be  sought  for  in  the  tissues. 

The  Wassermann  reaction  depends  on  the  fact  that  in  the  late 
primary,  secondary,  and  tertiary  stages  of  the  disease  the  blood- 
serum  usually  contains  a  substance  which,  when  incubated  with  an 
alcoholic  extract  of  heart  or  liver  (diluted  with  saline  solution), 
removes  complement  (p.  22)  from  the  mixture.  This  is  demon- 
strated by  adding  sensitized  red  corpuscles,  which  are  dissolved  if 
complement  is  present,  but  which  remain  unaltered  if  it  is  absent. 

A  positive  Wassermann  reaction  is  obtained  in  a  few  diseases 
other  than  syphilis — viz.,  in  yaws,  leprosy,  and  scarlet  fever,  but  in 
the  last  it  is  inconstant  and  only  present  for  a  few  days.  In  syphilis 
the  positive  reaction  usually  appears  about  the  time  of  induration 
of  the  sore.  It  is  present  in  all  late  primary  and  secondary  cases. 
At  the  onset  of  the  tertiary  period  a  few  patients  are  found  in  whom 
it  is  absent,  and  these  gradually  increase  in  number,  until  in  very 
old-standing  cases  the  positive  results  fall  from  95  to  somewhere 
about  80  per  cent.* 

*  These  figures  I'efer  to  patients  who  have  been  treated  in  the  old-fashioned 
way  by  mercury  only. 


154  A  MANUAL  OF  SURGERY 

The  Clinical  History  of  syphilis  varies  widely  in  dift'erent  cases 
according  to  the  virulence  of  the  infection  and  the  degree  of  resist- 
ance of  the  tissues,  but  as  a  rule  the  three  stages  suggested  by 
Kicord  are  observable.  The  primary  stage  includes  a  varying 
period  of  incubation,  and  the  appearance  of  a  sore,  usually  known 
as  a  '  hard  chancre.'  This  is  followed  in  the  course  of  a  few  weeks 
by  evidences  of  general  infection,  referred  mainly  to  the  skin,  mucous 
membranes,  and  lymphatic  glands,  comprising  the  secondary  stage. 
After  a  variable  time,  perhaps  extending  to  many  years,  during 
which  symptoms  may  be  absent,  tertiary  manifestations  (gummata, 
etc.)  may  show  themselves  in  any  and  every  part  of  the  body. 

Mode  of  Infection. — Acquired  syphilis  is  almost  always  due  to 
infection  of  the  genital  organs  arising  from  impure  connection. 
Occasionally  cases  are  met  with  in  which  the  disease  is  acquired 
innocently  by  direct  or  indirect  contact  with  syphilitic  lesions 
{syphilis  insontinm),  and  then  the  primary  lesion  is  often  located 
on  some  other  part  of  the  body  {extragenital  chancres).  Thus,  the 
lip  may  be  infected  as  a  result  of  drinking  out  of  the  same  glass  or 
smoking  the  same  pipe  as  a  syphilitic  patient,  or  even  by  kissing. 
Metchnikoff  has  proved  that  the  spirochsete  is  a  delicate  organism, 
and  quickly  loses  its  virulence  outside  of  the  body.  This  probably 
explains  the  rarity  of  infection  by  indirect  contact.  An  additional 
protection  is  the  fact  that  the  organisms  cannot  enter  the  system 
through  unbroken  skin  or  mucous  membrane.  The  disease  is  not 
equally  infectious  in  all  its  stages;  in  the  primary,  the  discharge 
derived  from  the  chancre  will  alone  convey  the  contagion;  in  the 
secondary  period  the  virus  is  present  in  the  blood,  and  consequently 
in  all  pathological  exudations,  as  also  in  the  semen.  Pure  secretions 
— e.g.,  tears,  milk,  or  urine — are  free  from  infection,  although,  if 
mixed  with  a  serous  exudate  from  abraded  surfaces,  as  so  frequently 
occurs  in  the  case  of  the  saliva,  they  at  once  become  infective.  It 
is  uncommon,  but  by  no  means  impossible,  for  infection  to  be  con- 
veyed by  patients  in  the  tertiary  stage. 

One  attack  of  syphilis  usually  confers  immunity  on  the  patient 
from  further  outbreaks  of  the  disease,  even  if  exposed  to  infection. 
This  protection  is  not  always  permanent,  since  well-authenticated 
cases  have  been  observed  of  second  attacks  of  syphihs. 

The  stage  of  Incubation  lasts  for  a  variable  period,  extending  from 
two  to  six  weeks;  as  a  rule,  evidences  of  induration  of  the  sore  can 
be  detected  about  the  third  week.  Removal  or  destruction  of  the 
local  lesion  has  not  the  slightest  influence  upon  the  progress  of  the 
case,  unless  it  is  undertaken  immediately  after  infection,  or  unless 
the  patient  is  being  treated  by  salvarsan.  Many  spirochaetes  are 
shut  up  udthin  the  chancre,  and  as  these  are  inaccessible  to  the 
drug,  it  is  advisable  to  remove  them  by  operation.  During  the  in- 
cubation period  the  local  sore  may  heal  completely,  if  it  is  purely 
syphilitic,  and  nothing  further  is  noticed  until  the  typical  induration 
manifests  itself.  Not  unfrequently,  however,  pyogenic  infection 
occurs,  or  a  soft  chancre  is  also  present;  in  the  latter  case  the  lesion 


SPECIFIC  INFECTIVE  DISEASES 


155 


does  not  heal  satisfactorily,    and  the  base  of  the  ulcer  becomes 
indurated  after  a  time. 

I.  The  Primary  Stage  of  syphihs  is  characterized  by  the  develop- 
ment of  a  sore,  associated  with  enlargement  of  the  neighbouring 
lymphatic  glands.  It  is  usually  situated  on  the  base  of  the 
prepuce,  close  to  the  corona  glandis  (Fig.  33),  or  on  the  frcenum; 
in  the  female  the  inner  aspects  of  the  labia  majora  or  nymphs  are 
the  most  common  sites,  but  it  often  causes  so  little  inconvenience  as 
to  be  overlooked. 

The  primary  sore  does  not  invariably  present  the  same  appearance, 
although  it  is  typicahy  characterized  by  a  certain  amount  of  infiltra- 
tion and  induration.  The  following  are  the  chief  forms  in  which  the 
chancre  manifests  itself:  {a)  The  desquamating  papule  is  a  shghtly 
elevated  spot,  which  is  irritable,  of  a  dusky  colour,  and  free  from 
ulceration.  It  is  usually  small,  but  hard,  and  its  surface  covered 
with  epithehal  scales.  If  exposed  to  friction  or  to  the  irritation  of 
retained  discharges,  ulceration 
is  very  likely  to  take  place,  and 
an  ordinary  Hunterian  chancre 
will  then  "  form.  Unless  this 
occurs,  it  may  run  its  course 
unobserved,  and  thus  a  patient 
becomes  syphilitic  without  being 
able  to  trace  the  time  or  source 
of  infection.  (6)  The  indurated, 
hard,  or  Hvmterian  chancre  is  that 
most  commonly  seen;  it  results 
from  the  irritation  of  a  papule, 
or  is  developed  in  association 
with  a  soft  sore.  Should  the 
initial  superficial  abrasion  have  p^^  33IIHARD  Chancre,  displayed 
healed,    a    localized    growth    ot  gy  Eversion  of  Prepuce. 

almost    cartilaginous     hardness 

forms  in  the  cicatrix,  closely  adherent  to  and  invading  the  cutis; 
but  if  a  soft  sore  has  first  developed,  the  surface  remains  ulcerated 
more  or  less  deeply,  with  a  well-defined  margin,  though  the  base  be- 
comes indurated  (Fig.  34).  In  some  cases  there  may  be  but  little 
elevation  of  the  growth,  and  the  surface  is  free  from  ulceration,  con- 
stituting the  variety  known  as  the  '  parchment  induration '  of  Ricord- 
and  most  frequently  seen  on  the  glans  penis.  Where,  however,  the 
prepuce  or  body  of  the  penis  is  involved,  the  induration  is  more 
diffuse,  owing  to  the  laxity  of  the  connective  tissue.  When  affecting 
the  base  of  the  prepuce,  the  induration  usually  spreads  transversely, 
producing  a  collar-hke  mass,  which  on  retraction  of  the  part  rolls 
back  en  bloc  in  a  very  characteristic  manner  (Fig.  33).  When  the 
orifice  of  the  prepuce  is  involved,  the  part  becomes  generally  infil- 
trated and  hard,  so  that  retraction  is  impossible,  and  a  form  of 
phimosis  is  thus  acquired.  Examined  microscopically,  the  new 
formation  consists  merely  of  a  mass  of  round  and  spindle  cells 


156 


A   MANUAL  OF  SURGERY 


packed  closely  together,  witli  a  certain  amount  of  intercellular  fibrous 
tissue;  giant  cells  are  sometimes  seen.  The  blood-supply  of  the  i)art 
is  scanty,  a  fact  which  explains  the  readiness  with  which  ulceration 
occurs.  It  is  all-important,  however,  to  remember  that  a  diagnosis  of 
syphilis  can  be  made  by  the  microscope  long  before  this  typical  induration 
appears,  and  unless  this  early  diagnosis  is  made,  and  elective  treatment 
commenced,  the  possibility  of  a  complete  cure  is  much  lessened. 

Several  chancres  may  be  seen  on  the  same  individual  if  the  infec- 
tion occurs  at  one  time,  and  it  is  possible  that  a  patient  may  be 
infected  at  two  different  periods  if  only  a  short  interval  elapsed 
between  the  inoculations;  but  the  disease  is  not  generally  auto- 
inoculable,  and  when  once  a  hard  chancre  has  developed  on  the 
under  surface  of  the  prepuce,  the  glans  does  not  become  infected 
from  contact.      Multiple   chancres  are  always  of  small  size,   and 

the  induration  is 
less  marked  than 
usual. 

A  Uje'thral 
Chancre  is  usually 
situated  just  with- 
in the  lips  of  the 
meatus,  constitu- 
ting a  sore  with 
an  indurated  base. 
It  may  be  felt  as 
a  hard  nodule  on 
grasping  the  ure- 
thra between  the 
fingers,  and  gives 
rise  to  a  thin 
serous  discharge, 
often  blood-stained.  The  orifice  itself  is  sometimes  the  site  of  a 
hard  chancre,  which  may  encircle  it,  and  be  followed  by  a  stricture. 
Extragenital  Chancres  are  most  commonly  observed  on  the  lips, 
finger,  and  nipple.  They  are  often  characterized  by  much  infiltra- 
tion, due  to  pyogenic  inflammation,  and  less  distinct  and  definite 
induration  than  in  the  forms  met  with  on  the  genital  organs;  hence 
the  swelling  is  more  prominent  and  vascular,  and  if  ulceration  occurs 
there  is  a  greater  amount  of  discharge,  which  forms  a  thick  scab 
over  the  surface.  Neighbouring  lymphatic  glands  arc  often  much 
enlarged,  and  surrounded  by  infiltrated  tissue.  This  condition  has 
been  mistaken  for  epithelioma,  from  which,  however,  it  can  be  dis- 
tinguished by  the  induration  and  sharp  limitation  of  the  sore,  its 
rapid  development,  and  the  earlier  enlargement  of  the  glands.  The 
course  of  the  case  is  sometimes  more  severe  than  when  the  primary 
lesion  is  in  the  usual  situation,  a  fact  possibly  explained  by  the 
disease  remaining  unrecognised  till  secondary  symptoms  develop. 

Digital  Chancres  are  usually  seen  in  nurses,  surgeons,  and  accou- 
cheurs, and  start  by  the  side  of  the  nail.     An  indolent  sore  appears. 


Fig.  34.- 


-Hard  Chancre  of  Abdominal  Wall 
IN  Suprapubic  Region. 


SPECIFIC  INFECTIVE  DISEASES  157 

which  becomes  infiltrated  and  ulcerates,  spreading  under  the  matrix 
and  along  the  semilunar  fold.  There  is  a  good  deal  of  discharge  and 
pain,  and  the  terminal  phalanx  becomes  swollen  and  bulbous.  The 
epicondyloid  and  axillary  glands  are  enlarged  as  the  case  progresses, 
and  the  condition  has  more  than  once  been  mistaken  for  mahgnant 
disease.  Occasionally,  however,  the  sore  has  been  so  small  and  so 
little  obvious  as  to  be  overlooked. 

Phagedena  is  a  form  of  spreading  ulceration,  rarely  met  with  at  the  present 
time,  except  in  connection  with  venereal  disease,  and  seldom  apart  from 
syphilis.  It  always  attacks  unhealthy  and  debilitated  individuals,  and  is 
largely  due  to  the  retention  of  discharges  resulting  from  phimosis.  The  pre- 
puce and  end  of  the  organ  become  red,  swollen,  and  infiltrated.  On  dividing 
or  retracting  the  foreskin,  the  affected  surface  is  found  to  be  sloughy,  and  the 
ulceration,  unless  checked  by  treatment,  rapidly  spreads,  and  may  destroy 
glans  and  prepuce,  and  even  attack  the  body  of  the  penis.  Treatment  con- 
sists in  division  of  the  foreskin  if  that  structure  has  not  been  already  destroyed, 
followed  by  repeated  immersion  of  the  patient  in  a  hot  hip-bath.  In  the 
intervals  the  wound  should  be  dusted  with  iodoform,  and  dressed  with  lint 
dipped  in  lotio  nigra.  The  later  treatment  is  conducted  as  for  primary  syphilis, 
although  the  depressed  condition  of  the  general  health  may  necessitate  the 
administration  of  tonics,  and  even  a  visit  to  the  seaside.  Should  treatment 
by  immersion  in  hot  water  be  for  any  reason  impracticable,  the  old-fashioned 
plan  must  be  resorted  to — viz.,  scraping  the  sore,  and  freely  cauterizing  the 
base  with  pure  carbolic  or  fuming  nitric  acid.  Possibly,  where  there  is  much 
slough,  this  latter  method  may  advantageously  precede  immersion  in  a  bath. 

The  Lymphatic  Glands  which  receive  lymph  from  the  region  in 
which  the  sore  is  situated  become  characteristically  enlarged.  Thej' 
move  freely  under  the  skin  and  feel  hard,  like  bullets,  pellets  of 
cartilage,  or  almonds  (hence  the  term  '  amygdaloid  '  which  has  often 
been  apphed  to  them) ;  they  are  usually  quite  painless,  and  do  not 
suppurate  unless  the  original  sore  is  inoculated  with  the  virus  of  a 
soft  chancre  or  with  pyococci. 

Occasionally  the  lymphatic  vessels  extending  from  the  sore  to  the 
glands  become  the  seat  of  a  chronic  lymphangitis,  and  may  be  felt 
as  hard  cords  beneath  the  skin.  The  dorsal  l\Tnphatic  of  the  penis 
is  frequently  blocked  in  this  way,  and  gives  rise  to  solid  or  lymphatic 
oedema  of  the  prepuce  and  glans.  Should  the  chancre  suppurate,  an 
abscess  may  also  form  in  the  course  of  the  lymphatics. 

The  Diagnosis  of  a  syphilitic  from  a  soft  sore  is  not  always  easy. 
Of  course,  where  there  is  no  ulceration,  and  the  typical  induration 
of  the  base  can  be  felt,  no  doubt  need  arise.  But  when  the  primar}/ 
sore  suppurates,  and  an  excavated  ulcer  is  present,  surrounded  by 
infiltrated  and  hyper^emic  tissues,  it  is  difficult  to  be  certain  as  to 
the  nature  of  the  case.  The  inguinal  glands  are  enlarged  in  both 
varieties,  and  the  fact  that  suppuration  occurs  proves  nothing.  Even 
the  existence  of  a  '  satellite  '  chancre  from  auto-inoculation  only 
demonstrates  the  presence  of  a  soft  chancre;  it  does  not  prove  the 
absence  of  sj^phihs.  The  presence  of  the  typical  spirochaete  in 
scrapings  from  a  chancre,  or  in  juice  removed  by  a  hypodermic  needle 
from  an  enlarged  inguinal  gland  after  massage,  is  conclusive  e\ndence. 
Rarely  is  it  necessary  to  wait  for  the  development  of  secondary 
symptoms  before  a  decided  opinion  can  be  given. 


158  A    MANUAL  OF  SURGERY 

The  Duration  of  the  primary  sore  varies  in  different  cases,  and 
depends  in  a  great  measure  on  whether  treatment  is  commenced  early 
or  late.  If  the  patient  comes  under  observation  during  tlie  first  six 
weeks,  and  a  mercurial  course  is  at  once  started,  the  chancre  heals, 
and  tlie  induration  usually  disappears  in  from  six  to  eight  weeks. 
The  glands  in  the  groin,  however,  remain  enlarged  for  some  time. 
The  longer  the  case  is  left  untreated,  the  more  slowly  does  the 
hardness  disappear.  If  no  mercury  is  given,  the  induration  may 
last  for  twelve  months  or  more,  and  then  slowly  passes  off,  although 
it  may  run  a  much  shorter  course.  From  an  uncomplicated  syphilitic 
sore  but  httle  scar  results,  although  a  well-marked  cicatrix  may 
follow  a  soft  or  suppurating  chancre. 

Re-induration  of  the  cicatrix  (relapsing  chancre)  sometimes  occurs 
from  too  early  a  cessation  of  the  mercurial  course,  or  from  some 
localized  irritation,  or  from  a  fresh  exposure  to  infection.  It  is 
occasionally  due  to  a  tertiary  or  gummatous  development,  and  will 
then  be  free  fromi  lymphatic  complications. 

II.  Secondary  Syphilis. — In  the  secondary  stage,  the  virus  is 
diffused  generally  throughout  the  body  by  means  of  the  blood,  which 
is  itself  infective.  A  certain  amount  of  constitutional  disturbance 
may  exist,  the  patient  feehng  '  seed}^ '  and  out  of  sorts,  whilst  in 
some  cases  distinct  pyrexia,  wasting,  and  headache  have  been  noted. 
Well-marked  anaemia  is  often  present,  and  on  examination  the  red 
corpuscles  are  found  to  be  deficient  in  number,  and  defective  in  the 
amount  of  haemoglobin  contained  within  them.  A  moderate  leuco- 
cytosis  is  present,  chiefly  involving  the  lymphocytes  and  plasma 
cells.  The  chief  secondary  manifestations  consist  in  a  general 
enlargement  of  the  lymphatic  glands,  together  with  the  appearance 
of  various  forms  of  rash  on  the  skin  and  mucous  membranes,  loss 
of  hair,  and  other  less  common  phenomena,  involving  the  eyes, 
brain,  etc. ;  these  usually  show  themselves  in  from  six  to  nine  weeks 
from  the  time  of  inoculation,  although  they  may  be  delayed  to  a 
much  later  date.  Their  intensity  varies  considerably,  the  phenom- 
ena being  sometimes  scarcely  evident,  and  at  others  very  marked. 
They  are  also  influenced  greatly  by  the  period  at  which  treatment 
commences;  the  earlier  it  begins,  the  less  obvious  are  the  secondary 
phenomena. 

The  Cutaneous  Eruptions  of  secondary  syphilis  are  chiefly  char- 
acterized by  the  fact  that,  although  any  form  of  rash  may  be 
simulated,  no  specially  distinctive  variety  is  originated.  Moreover, 
in  the  same  individual  the  eruption  is  not  always  of  the  same 
character  throughout,  several  distinct  types  developing  in  different 
parts  of  the  body  {polymorphism).  The  rashes  are  usually  more  or 
less  symmetrical,  the  colour  in  the  early  stages  being  a  dusky  red, 
resembling  that  of  raw  ham ;  occasionally,  however,  they  may  be  a 
bright  rosy  red.  Syphilitic  rashes  disappear  after  a  time,  but  often 
leave  a  coppery-brown  discoloration  of  the  skin  for  a  while;  more- 
over, they  do  not  completely  fade  on  pressure,  but  leave  a  similar 
brown  stain,  and  give  rise  to  but  httle  irritation  or  itching;  they 


SPECIFIC  INFECTIVE  DISEASES  159 

always  tend  to  progress  from  the  simpler  types,  due  to  hyperrcmia, 
to  the  more  serious,  in  which  infiltration  and  overgrowth  are  evident. 

Tlie  simplest  form  consists  of  a  mere  hyperemia,  sometimes 
appearing  as  a  dusky  mottling  of  the  skin  [roseoloits  syphilide),  which 
quickly  fades  or  may  persist  whilst  other  types  are  developing. 
Sometimes  distinct  papillae  become  infiltrated  and  hyperaemic 
{papular  syphilide) ;  at  others,  vesicles  or  pustules  appear  {vesicular 
or  pustular  syphilides);  the  latter  change  is  uncommon,  and  only 
appears  in  bad  cases  or  in  debiHtated  patients.  Another  form  of 
eruption  is  the  squamous  syphilide,  characterized  by  patches  of 
hyper?emia  and  infiltration,  combined  with  superficial  desquamation. 
It  is  usually  bilateral,  and,  unlike  simple  psoriasis,  affects  the  flexor 
rather  than  the  extensor  surfaces.  In  the  later  stages,  distinct 
nodules  or  tubercles  are  produced  in  the  skin,  which  may  even  run 
on  to  ulceration  {tuhercnlar  syphilide). 

As  to  the  situation  of  the  rash,  the  roseola  is  usually  limited  to  the 
trunk,  whilst  the  other  forms  are  often  scattered  widely  over  the 
trunk  and  extremities,  involving,  however,  the  flexor  more  than  the 
extensor  surfaces  of  the  limbs.  A  somewhat  characteristic  phenom- 
enon is  the  appearance  of  a  papular  rash  on  the  forehead,  sometimes 
known  as  the  corona  Veneris. 

The  Mucous  Membranes  may  be  affected  in  much  the  same  way 
as  the  skin.  The  fauces  become  red  and  congested,  the  hyperaemic 
area  being  abruptly  hmited,  and  semicircular  in  outline;  symmetrical 
ulceration  usuahy  follows,  starting  near  the  anterior  pillars  of  the 
fauces,  and  spreading  to  the  tonsils  and  along  the  soft  palate  to  the 
uvula.  These  ulcers  are  shallow,  have  sharply- cut  edges,  and  often 
present  a  characteristic  grayish  appearance,  constituting  what 
is  known  as  a  '  snail-track '  ulcer.  The  secondary  sore  throat 
rarely  results  in  extensive  loss  of  substance,  and  hence  pharyngeal 
stenosis  is  not  produced.  Smoking  undoubtedly  aggravates  these 
conditions.  Concurrently  with  these  manifestations  in  the  fauces 
bare  patches  from  loss  of  epithehum  may  be  seen  on  the  dorsum  of 
the  tongue,  or  several  small  superficial,  but  very  painful,  ulcers  may 
develop  on  the  inside  of  the  cheeks  or  lips,  or  along  the  borders  of 
the  tongue,  from  the  irritation  of  the  teeth. 

Mucous  tubercles  and  condylomata  are  somewhat  similar  affec- 
tions, though  more  pronounced,  arising  in  the  secondary  stage  in 
connection  with  mucous  membranes  and  those  parts  of  the  skin 
which  are  soft  and  moist.  Mucons  Tubercles  consist  of  slightly- 
raised  patches  of  enlarged  and  infiltrated  papillae,  white  in  appear- 
ance from  the  superficial  epithehum  becoming  sodden,  and  often 
progressing  to  actual  ulceration.  Examined  microscopically,  the 
papiflae  are  found  to  be  definitely  enlarged,  and  the  epithehum 
heaped  up  over  them.  They  are  most  commonly  observed  at  the 
corners  of  the  mouth,  on  the  inner  aspect  of  the  cheeks,  the  side  of 
the  tongue,  or  the  margin  of  the  anus;  in  the  last-named  situation 
they  are  usually  s\Tnmetrical,  one  side  being  infected  from  the  other. 
They  are  also  not  at  all  uncommon  between  the  toes,  and  the  ulcers 


i6o  A   MANUAL  OF  SURGERY 

caused  thereby  become  exceedingly  offensive.  Condylomata  are 
similarly  the  result  of  overgrowth  of  the  papilla-,  differing  from 
mucous  tubercles  merely  in  the  extent  to  which  this  has  been  carried. 
They  consist  of  definite  wart-like  masses,  which  may  attain  a  great 
size,  constituting  a  caulifiower-like  growth.  They  are  most  com- 
monly seen  about  the  anus  or  vulva,  in  the  former  situation  being 
often  mistaken  by  the  patient  for  piles;  they  give  rise  to  an  abun- 
dant, highly  infective  discharge.  A  similar  condition  is  sometimes 
met  with  on  the  dorsum  of  the  tongue,  and  is  then  known  as 
'  Hutchinson's  wart.' 

The  Lymphatic  Glands  are  usually  enlarged  throughout  the  body 
during  this  period  of  the  disease,  being  felt  as  round,  hard  swellings 
beneath  the  skin.  Tlie  extent  of  the  glandular  complication  is 
possibly  a  measure  of  the  degree  of  virulence  of  the  affection. 
Chronic  enlargement  of  tlie  nuchal  and  epicondyloid  glands,  in  the 
absence  of  any  ob\nous  local  cause,  is  always  suggestive  of  the 
existence  of  syphilis. 

Syphililie  Alopecia. — The  hair  becomes  dull  and  lustreless,  and 
either  comes  out  in  patches  from  the  scalp,  eyebrows,  beard,  etc.,  or 
there  is  a  general  '  thinning.'  The  follicles,  however,  are  not 
destroyed,  and  after  a  time  the  hair  will  grow  again  as  before. 

Later  secondary  manifestations  consist  of  flying  pains  in  the  bones 
(osteocopic),  iritis,  and  various  nervous  lesions,  whilst  periosteal 
nodes  may  form  on  the  tibiae  and  other  bones,  or  a  symmetrical 
chronic  effusion  develop  within  the  synovial  membrane  of  joints. 

Syphilitic  Iritis  is  characterized  by  pain  in  the  eye,  generally 
referred  to  the  supra-orbital  nerve,  together  with  some  interference 
with  vision,  and  possibly  a  little  lachrymation  and  photophobia. 
On  examination  a  bright-red  circular  zone  immediately  surrounds 
the  cornea,  resulting  from  hypera^mia  of  the  ciliary  vessels.  The 
iris  is  lustreless,  and  its  definition  somewhat  blurred.  Its  colour  is 
changed,  a  blue  iris  becoming  greenish-yellow  from  the  presence  of 
lymph.  The  pupil  is  diminished  in  size,  and  perhaps  irregular;  its 
movements  are  always  considerably  hampered,  and  sometim.es 
entirely  prevented,  by  the  foniiation  of  adhesions  either  to  the  back 
of  the  cornea  (anterior  synechia)  or  to  the  lens  capsule  (posterior 
synechia.*).  Occasionally  small  yellowish  nodules  are  seen  on  its 
surface,  consisting  of  plastic  lymph. 

The  Duration  and  character  of  the  secondary  stage  vary  consider- 
ably. The  sooner  effective  treatment  is  commenced,  the  less  severe 
the  secondarv  phenomena,  whilst  cases  in  which  treatment  has  been 
delayed  are  likely  to  be  more  troublesome.  Hence  the  disease  is 
often  of  an  aggravated  type  when  following  extragenital  chancres,  as 
also  in  women,  by  whom  the  primary  lesion  often  passes  unnoticed. 
When  treatment  is  commenced  within  four  or  five  weeks  of  infection, 
the  secondary  stage  may  be  slight,  and  all  traces  of  its  existence 
may  pass  off  in  two  months  or  less;  if  treatment  is  delayed  until 
the  cutaneous  eruption  has  appeared,  this  stage  is  likely  to  last 
longer.     The  condition  of  the  patient's  health  is  an  important  factor. 


SPECIFIC  INPECTIVE  DISEASES  i6i 

as  also  the  previous  habits,  particularly'  as  to  temperance,  since 
syphilis  alwa^'s  follows  a  more  aggravated  course  in  the  weakly  and 
the  dissipated.  Patients  suffering  from  the  debility  caused  by 
malaria  or  other  tropical  affections  are  particularly  bad  subjects, 
and  the  disease  may  then  run  a  virulent  course.  Even  under  the 
best  circumstances,  the  patient  is  liable  to  relapses  during  the  first 
twelve  months,  which  are  usually  due  to  intermissions  in  the  treat- 
ment. The  rash  which  appears  under  these  circumstances  is  often 
of  a  more  characteristic  type,  the  papules  being  grouped  into 
rounded  or  confluent  figures. 

III.  The  Intermediate  or  Late  Secondary  Stage  constitutes  a  hnk 
between  the  symptoms  already  described  and  the  tertiary  phe- 
nomena; no  distinct  limits  to  this  period  can  be  defined,  nor  need  it 
appear  at  all  if  the  patient's  general  health  is  good,  and  the  treat- 
ment has  been  carried  out  regularly.  Some  of  the  secondary  mani- 
festations, especially  those  of  the  bones  and  joints,  may  persist 
through  this  period,  whilst  even  if  they  have  disappeared  the 
patient  is  liable  to  suffer  from  '  reminders  '  in  the  shape  of  various 
cutaneous  affections,  and  perhaps  epididymitis.  The  bloodvessels  are 
not  unfrequently  affected  in  this  and  later  stages  of  the  disease,  the 
endothelium  of  the  tunica  intima  undergoing  prohferation  (Figs.  97 
and  98) ;  the  lumen  is  thereby  diminished,  and  the  nutrition  of  the  part 
supplied  may  be  lowered.  Arterio-sclerosis  of  the  larger  trunks  may 
be  induced  by  an  affection  of  this  type  involving  the  vasa  vasorum, 
and  various  forms  of  nerve  trouble  may  be  lighted  up  if  the  cerebral 
vessels  are  involved.  Paralysis  of  a  single  limb  (monoplegia)  may 
result,  or  of  one  side  of  the  body  (hemiplegia) ;  but  the  affection  may 
be  limited  to  a  single  cranial  nerve,  or  merely  result  in  a  severe 
headache.  Unfortunately,  treatment  may  be  incapable  of  remedy- 
ing the  mischief  caused  in  this  manner.  Deep  ocular  lesions  {e.g., 
choroido-retinitis)  are  also  not  unusual.  The  principal  cutaneous 
affection  is  the  so-called  syphilitic  psoriasis,  most  frequently  seen 
on  the  palms  and  soles.  A  squamous  syphilide  is  often  observed 
in  the  secondary  stage,  but  is  then  symmetrical  and  readily  in- 
fluenced by  mercury.  In  this  intermediate  period  the  lesion  may 
be  bilateral  or  limited  to  one  side,  according  to  whether  it  appears 
early  or  late.  In  the  former  there  is  a  considerable  tendency  to 
proliferation  of  the  epithelium,  together  with  deep  cracks  and 
fissures;  in  the  latter  there  is  less  epithelial  overgrowth,  but  the 
edges  are  often  distinctly  serpiginous  in  outline,  and  there  is  an 
infiltrated  border. 

Rupia  and  Ecthyma  are  both  met  with  in  this  stage  of  the  disease, 
but  chiefly  in  patients  whose  nutrition  is  defective.  They  are 
characterized  by  an  infiltration  of  the  skin  (in  reality  gummatous), 
which  progresses  to  ulceration.  In  rupia  the  discharge  forms  a 
distinct  scab  on  the  surface,  which  increases  in  thickness  by  the 
deposit  of  successive  layers  one  under  the  other,  each  being  some- 
what larger  than  the  one  which  precedes  it;  hence  a  scab  shaped 
like  a  limpet-shell  is  produced,  resting  on  an  inflamed  and  liypenLmic 


l62 


A   MANUAL  OF  SURGERY 


surrounded  by  an  area  of  vivid  congestion. 


base  (Fig.  35);  any  part  of  the  body  may  be  affected  in  this  way. 
In  ecthyma^no  scab  forms  over  the  ulcerated  surface,  or,  if  formed, 
it  readily  comes  away,  leaving  exposed  a  hollow  punched-out  sore. 

Under  appropriate 
treatment  these 
conditions  dis- 
appear, but  leave 
depressed,  whitish 
cicatrices,  often  sur- 
rounded by  pigmen- 
tation. 

A  somewhat  un- 
usual intermediate 
manifestation  is  a 
subacute  symmetri- 
cal epididymitis,  in 
which  the  cord  also 
becomes  thickened, 
enlarged,  and 
tender. 

IV.  Tertiary  Sy- 
philis. —  The  phe- 
nomena occurring 
in  this  stage  may 
appear  within  six 
months  of  infection, 
or  not  for  twenty  or 
thirty  3'ears.  They 
are  mainly  charac- 
terized by  infiltra- 
tion and  overgrowth  of  the  connective  tissues  of  the  body.  Such  may 
occur  in  one  or  many  places,  and  may  be  diffuse  or  localized.  When 
diffuse,  the  organ  or  part  affected  becomes  enlarged  and  hard,  and 
unless  the  condition  is  treated  promptly,  remains  permanently 
sclerosed  from  the  development  of  fibro-cicatricial  tissue.  If,  how- 
ever, the  process  is  localized,  a  Gumma  is  formed. 

Any  tissue  in  the  body  may  be  the  seat  of  a  gummatous  deposit, 
which  apparently'  arises  without  any  definite  cause,  although 
occasionally  its  onset  may  be  determined  by  an  injury.  The  in- 
volved area  becomes  infiltrated  with  large  oval  endothelial  cells  and 
small  round  cells  (lymphocytes) ;  plasma-cells  are  usualh-  present  in 
considerable  numbers.  The  constituents  of  this  mass  are  quite 
similar  to  those  which  are  found  in  a  tubercle,  but  without  the 
grouping  into  small  nodules  and  the  more  or  less  orderly  arrange- 
ment in  zones ;  giant  cells  are  usually  absent,  though  their  presence 
is  by  no  means  rare,  and  they  may  closely  simulate  the  tuberculous 
type.  Very  few  vessels  penetrate  into  the  mass  thus  formed,  which 
otherwise  resembles  granulation  tissue;  it  gradually  increases  in 
size,  infiltrating  and  replacing  the  normal  tissues  of  the  part.     The 


Fig.  35. — RupiA  OF  Face.  (From  Wax  Model  in 
Museum  of  Royal  College  of  Surgeons.) 

A  diagrammatic  section  of  the  rupial  patch  is  shown 
at  the  side.  A,  Scab  formed  of  successive  layers 
of  dried  discharge;  resting  on  B,  ulcerated  granu- 
lomatous surface  of  gumma. 


SPECIFIC  INFECTIVE  DISEASES  163 

fate  of  the  fully-formed  gumma  varies  according  to  circumstances. 
If  the  infection  is  a  mild  one,  and  especially  if  appropriate  treat- 
ment is  adopted,  the  bulk  of  the  cells  become  absorbed,  and  the 
remainder  are  organized  into  fibrous  tissue;  even  a  large  gumma  may 
almost  entirely  disappear,  leaving  but  a  small  fibrous  scar. 

In  the  absence  of  proper  treatment  most  gummata  undergo  a 
necrotic  change,  which  commences  at  the  centre  of  the  nodule  and 
spreads  towards  the  periphery.  This  may  be  a  comparatively  slow 
process,  accompanied  by  fatty  degeneration  and  caseation  somewhat 
similar  to  that  seen  in  tubercle ;  or  it  may  be  more  rapid,  the  tissues 
undergoing  a  kind  of  mucoid  degeneration,  forming  a  gummy  mass 
from  which  the  lesion  acquires  its  name.  Sections  through  such 
a  gumma  will  show  a  large  white  structureless  centre  of  necrotic 
or  caseous  material,  surrounded  by  a  shell  of  cellular  tissue,  which 
gradually  merges  into  the  normal  structure  of  the  part.  Two  factors 
are  concerned  in  the  production  of  this  necrosis:  the  toxins  pro- 
duced by  the  causative  organisms,  and  the  deficient  blood-supply  of 
the  central  portions  of  the  cellular  mass.  The  vessels  of  the  gumma 
are  deficient  from  the  first,  and  after  a  time  the  amount  of  blood 
which  reaches  them  is  diminished  as  the  result  of  syphiHtic  endar- 
teritis. Moreover,  some  gummata  do  not  commence  to  undergo 
central  necrosis  until  a  certain  amount  of  transformation  into  cica- 
tricial tissue  has  taken  pi  ace,  in  which  case  a  still  further  interference 
with  the  blood-supply  may  be  caused  by  the  compression  of  the 
vessels  traversing  the  newly-formed  fibrous  tissue. 

Under  appropriate  treatment  the  whole  of  the  gummatous  mass 
may  be  absorbed,  even  when  caseation  or  necrosis  has  taken  place; 
but  not  unfrequently  the  gummy,  semi-purulent  fluid  which  is 
formed  at  the  centre  of  the  mass  finds  its  way  to  the  surface  and  is 
discharged.  Where  the  necrotic  mass  is  large,  a  portion  of  it  may 
remain  adherent  to  the  surrounding  tissues  after  ulceration  has 
taken  place,  looking  somewhat  like  a  piece  of  wet  wash-leather. 
Occasionally  the  central  slough  may  become  encysted  by  the  forma- 
tion of  a  fibrous  capsule,  and  calcification  may  occur;  this  is  most 
frequently  found  in  the  brain,  testis,  and  liver. 

Clinically,  the  appearances  vary  according  to  whether  the  gumma 
is  cutaneous  or  subcutaneous. 

Cutaneous  gummata  are  very  frequently  observed  in  tertiary 
syphilis,  especially  in  the  earlier  stages.  They  occur  as  rounded 
dusky  red  nodules  of  firm  consistencj',  but  slightly  painful,  and  if 
they  break  down  give  rise  to  typical  circular  ulcers  (Fig.  36).  Many 
such  growths  are  often  grouped  together  in  one  region,  and  when 
ulceration  has  occurred  they  produce  by  their  confluence  sores 
with  a  rounded  or  serpiginous  outline.  Considerable  destruction  of 
tissue  follows,  but  they  are  readily  cured,  giving  rise  to  depressed 
white  cicatrices,  surrounded  by  pigmentation.  Any  part  of  the 
body  may  be  involved,  but  a  very  common  site  is  about  or  just 
below  the  knee  on  the  outer,  rather  than  the  inner,  aspect  of  the  leg. 

Occasionallv  a  diffuse  infiltration  of  the  skin  is  met  with  in  this 


i64  A   MANUAL  OF  SURGERY 

stage,  appearing  as  a  red  hvpcnemic  area  with  a  rounded  or  ser- 
piginous border,  and  not  at  all  unlike  lupus  in  appearance  (Fig.  37). 
It  spreads  rapidly  at  the  margin,  which  is  distinctly  thickened, 
and  may  contain  scattered  nodules  undergoing  ulceration.  W'liether 
ulceration  occurs  or  not,  a  cicatrix  is  produced.  It  is  readily 
amenable  to  treatment,  and  runs  a  much  more  rapid  course  than 
lupus;  the  apple-jelly-like  granulations  so  typical  of  the  latter 
disease  are  of  course  not  present. 

KA  subcutaneous  gumma  develops  as  a  firm  nodule  or  an  indeimite 
thickening,  which  gradually  increases  in  size  b\-  the  infiltration  of 

urrounding  tissues,  and  sooner  or  later 
"  ■ -'i^  "^    approaches  the  surface;  the  centre  of 

^:  the  tumour  in  time  becomes  elastic  and 

fluctuant;  a  certain  amount  of  pain  and 
tenderness  is  noticed,  and  when  the  skin 
is  affected  it  becomes  dusky,  and  even 
redematous.  If  ulceration  follows,  the 
\  •        contents  of  the  gumma  escape,  and  the 

'•        sore  produced  is  circular  and  deep,  the 
►.w*'  edges    being  sharply  cut   and   perhaps 

^iit ;.  ^         undermined;  the  base  of  the  ulcer  con- 

l         sists  of  granulation  tissue,  although  it 
(         is  sometmies  covered  by  the  character- 
istic slough. 

The  tertiary  syphilitic  affections  of 
^  special  organs  will  be  described  under 
the  appropriate  headings;  but  the 
general  relation  of  syphilis  to  the 
\  nervous  system  (the  so-called  hara- 
syphilis)  has  been  purposely  omitted, 
since  it  belongs  rather  to  the  physician 
than  to  the  surgeon. 

The    Prognosis  of  syphilis 
has  been  transformed  of    re- 
cent   years    by   two    factors, 
(fl)    The   possibility  of   dem- 
i  onstrating    the     presence    of 

Fig.  36.-CUTANEOUS  GuMMATA  of  Leg    the  spiiocha^te  in  the  primary 
AND  Pigmented  Scars.  sore,   before  any  typical  in- 

duration has  occurred,  has 
placed  in  our  hands  a  means  of  early  diagnosis  which  is  certain, 
and  of  which  every  advantage  should  be  taken  by  the  practitioner. 
[h)  The  discovery  of  salvarsan  enables  us  to  destroy  the  spirocha'tes. 
which  are  accessible  to  its  inliuence.  Organisms  which  are  shut  up 
in  the  fibrous-tissue  meshes  of  a  chancre,  or  in  the  deeper  recesses 
of  the  cerebro-spinal  axis,  are  to  a  large  extent  inaccessible.  Hence 
the  prognosis  of  syphilis  may  be  stated  to  be  entirely  a  matter  of 
early  diagnosis. 

It  is,  of  course,  at  present  a  little  too  soon  to  dogmatize  on  the 


SPECIFIC  INFECTIVE  DISEASES 


165 


ultimate  results  of  modern  treatment,  but  the  statistics  published 
by  both  naval  and  military  surgeons,  who  have  a  unique  oppor- 
tunity of  studying  the  disease,  are  most  encouraging,  and  hold  out 
hopes  that  this  scourge  of  mankind  has  at  length  been  brought 
under  control.  Thus  Gibbard  and  Harrison*  state  that,  of  378 
patients  treated  exclusively  by  regular  courses  of  mercury,  83  per 
cent,  relapsed  clinically  at  least  once  during  the  first  year;  whereas, 
of  152  patients  treated  by  salvarsan  and  mercury,  only  3-9  per 
cent!^  relapsed  clinicallv  ^^■ithin  a  year  of  the  suspension  of  treat- 
ment. Similarlv,  Bodley  Scottf  expresses  his  conviction  that  99  per 
cent,  of  cases  could  be  cured  effectively  if  a  diagnosis  were  reached 
and  treatment  commenced  \\athin  a  few  days  of  infection;  whereas 
if  treatment  is  delayed  until  the  Wassermann  reaction  becomes 
positive  or  the  sore  indurated,  only  60  per  cent,  of  cures  will  result. 


Fig.  37. — Diffuse  Gummatous  Sore  of  Forearm. 

and  doubts  as  to  the  permanence  of  ,  he  cure  may  well  exist  for  the 
next  fifteen  years.  Prolonged  treatment  by  mercury  alone  gives 
moderately  good  results  if  the  disease  is  recognised  early. 

Some  strains  of  the  spirochsete  appear  to  be  more  virulent  than 
others,  especiallv  those  acquired  in  the  tropics,  and  some  systems 
are  apparentlv  'more  receptive  than  others.  Idiosyncrasies  pre- 
venting the  administration  of  salvarsan,  mercury,  or  iodide  of 
potassium,  are  particularly  unfortunate.  The  state  of  health  of  the 
patient  at  the  time  of  inoculation  may  influence  the  evolution  of  the 
case,  whilst  the  co-existence  of  tuberculous  disease  may  render  the 
outlook  verv  unfavourable,  especially  when  the  syphilis  is  inherited. 
The  character  of  the  secondary  rash  and  the  extent  of  the  general 

*  Colonel  Gibbard  and  Major  Harrison,  Brit.  Med.  Joiirn.,  November  22. 
1913,  p.  1341.  , 

t  Surgeon    Bodley    Scott,   R.N.,  Brit.  Med.  Jonrn.,  November    22,   1913 

P-  1344- 


1 66  A   MANUAL  OF  SURGERY 

glandular  enlargement  may  give  some  indication  of  the  gra\ity  of 
the  case;  a  pustular  eruption  is  almost  always  of  grave  import. 

Death  is  rarely  ^^roduced  by  any  of  the  secondar\'  manifestations, 
except  in  the  virulent  forms  developed  in  the  tropics;  but  it  is  not 
uncommon  in  the  tertiary  stage,  when  important  viscera,  such  as 
the  brain,  spinal  cord,  liver,  etc.,  are  involved.  Affections  of  the 
nervous  system,  such  as  tabes  and  general  paralysis,  are  likely  to  be 
developed  in  patients,  such  as  doctors  and  lawyers,  whose  life-work 
entails  considerable  nervous  and  m.ental  strain.  Certain  cases  are 
to  be  looked  on  as  practically  incurable  {maligiuint  syphilis), 
owing  probably  to  the  xnrulence  of  the  infection,  and  to  the  late 
period  at  which  treatment  was  commenced.  This  condition  is  most 
often  seen  in  women,  and  in  them  the  rash  quickly  becomes  of  a 
rupial  or  gummatous  type,  the  secondary  manifestations  running 
over  into  those  of  the  tertiary  period  at  an  early  date. 

It  is  probable  that  syphilis  can  be  prevented  by  w'ashing  the  part 
exposed  to  infection  with  a  solution  of  corrosive  sublimate,  and  rub- 
bing in  a  calomel  ointment  (30  per  cent.),  if  such  treatment  is  under- 
taken within  an  hour  or  two  of  infection.  This  has  been  proved 
experimentally  in  apes,  and  certainly  in  one  carefully  observed  case 
in  the  human  subject. 

The  Treatment  of  syphilis  has  been  transformed  of  recent  years 
by  the  recognition  of  its  protozoal  origin,  and  its  kinship  to  sleeping 
sickness  and  other  similar  diseases.  Attempts  to  treat  it  with 
organic  preparations  of  arsenic  w-ere  not  very  successful  at  first; 
substances  of  the  arylarsonate  type,  such  as  atoxyl,  soamin,  ars- 
acetin,  etc.,  were  tried,  but,  although  a  few  good  results  were  obtained, 
the  majority  were  disappointing,  and  some  disastrous,  inasmuch  as 
the  prolonged  use  of  such  drugs  was  found  to  be  followed  by  toxic 
phenomena,  amongst  which  optic  nerve  atrophy  was  one  of  the 
most  serious.  Experiments  in  this  direction  w'ere  still  maintained 
by  Ehrlich  and  Hata,  and  finally  they  introduced  a  substance  now 
known  as  salvarsan,  or  '  606  '  (diox3^-diamido-arseno-benzol),  which 
seems  to  hold  out  a  brilliant  future  in  the  treatment  of  this  dread 
disease.  It  is  a  bright  yellow  powder,  slowly  soluble  in  water,  and 
strongly  acid  in  reaction.  It  may  be  administered  by  intravenous 
or  intramuscular  injection,  preferably  the  former.  The  dose  for 
an  adult  varies  from  0*3  to  o"6  gramme,  which  is  dissolved  in 
sterile  normal  saline  solution,  made  with  distilled  water.  It  is  then 
converted  into  a  sodium  salt  of  the  base  by  adding  a  sufficient 
quantity  of  15  per  cent,  solution  of  sodium  hydrate  to  redissolve 
the  precipitate  formed  when  it  is  first  added.  This  solution  is 
then  made  up  to  250  or  300  c.c.  \vith  saline  solution,  and  introduced 
into  one  of  the  veins  of  the  ami  at  the  body  temperature.  The 
patient  must  be  carefully  prepared  as  for  an  operation,  a  purgative 
being  given  overnight,  and  no  food  being  permitted  for  three  or 
four  hours  before  or  after  the  administration.  He  must  stay  in  bed 
for  twenty-four  hours,  or  longer  if  he  manifests  any  evidence  of 
pyrexia,  muscular  pains,  headache,  or  other^type  of  reaction,  and 
should  take  things  quietly  on  the  day  after  the  dose. 


SPECIFIC  INFECTIVE  DISEASES  167 

The  effect  of  salvarsan  is,  apparently,  to  destroy  all  the  spirochaetes 
that  are  accessible  to  its  influence — i.e.,  in  the  circulating  blood  or 
in  the  looser  tissues;  where,  however,  the  infection  is  of  longer 
duration,  and  a  certain  niunber  of  spirochaetes  have  become  locked 
up  in  sclerosed  tissues,  such  as  the  indurated  chancre,  or  disseminated 
through  a  fluid  medium,  such  as  the  cerebro-spinal  fluid,  it  is  im- 
possible for  the  salvarsan  to  act  on  these  organisms,  and  conse- 
quently a  complete  sterilization  of  the  system  cannot  occur.  Under 
the  influence  of  treatment  these  cellular  infiltrations  are  absorbed 
in  a  few  weeks,  and  a  certain  number  of  spirochaetes  buried  therein 
are  again  set  free,  and  to  rid  the  system  from  these  a  further  dose  or 
tw^o  of  salvarsan  will  be  needed.  It  must  be  clearly  remembered 
that  sah'arsan  has  not  pushed  mercury  aside  in  the  treatment 
of  svphilis;  it  has  added  an  element  of  safety  and  security,  and 
thereby  has  diminished  the  amount  of  mercury  required  and  short- 
ened the  length  of  treatment. 

The  course  of  treatment  recommended  by  arm}^  surgeons  lor  cases 
seen  in  the  earliest  stages  consists  in — (i)  An  intravenous  injection 
of  0'6  gramme  salvarsan;  (2)  five  weekly  injections  of  mercurial 
cream;  (3)  a  second  intravenous  injection  of  o'6  gramme  salvarsan; 
(4)  five  more  weekl}'  mercurial  injections;  and  (5)  a  final  intravenous 
injection  of  o-6  gramme  salvarsan.  All  cases  are  kept  carefully 
under  observation  for  at  least  a  year,  and  this  should  include  the 
testing  of  the  blood  for  the  Wassermann  reaction,  at  first  every 
month,  and  subsequently  every  three  months.  The  shghtest  sign 
of  relapse,  either  clinically  or  by  the  Wassermann  test,  indicates 
the  prescription  of  a  second  course  of  treatment  similar  to  the 
above.  If  the  patient  was  brought  under  treatment  in  the  early 
primary  stage,  and  his  blood  has  shown  no  sign  of  relapse  during 
twelve  months  subsequent  to  the  cessation  of  treatment,  it  is  un- 
hkely  that  he  wnll  have  any  later  manifestations.  If  he  first  came 
under  observation  at  a  later  date,  and  the  blood  is  already  positive 
to  Wassermann's  test,  or  secondary  s^miptoms  are  already  present, 
it  is  probably  wise  to  make  the  mercurial  course  longer,  and  in 
severe  cases  to  give  mercury  for  twelve  months.  Relapses  are  more 
common,  and  the  patient  must  be  watched  for  two  years.  In 
tertiary  sj^philis  salvarsan  is  useful  in  helping  in  the  cure  of  active 
manifestations  of  the  ulcerative  type,  but  mercury  and  iodide  of 
potassium  still  maintain  their  position,  and  must  be  chiefly  relied 
on.  Over  the  deep  lesions,  especially  of  the  parasyphilitic  type, 
salvarsan  has  but  little  influence. 

Various  modifications  of  administration  are  utilized  by  different 
surgeons,  but  they  are  comparatively  unimportant.  Neo-salvarsan 
(o'75  gramme  for  a  dose)  is  sometimes  substituted,  and  other 
methods  of  giving  mercury  are  employed — e.g.,  by  inunction.  The 
intervals  between  the  doses  of  salvarsan  are  also  different,  but 
the  essential  universally  recognised  is  the  combination  of  salvarsan 
and  mercury.  Occasional  bad  results,  such  as  localized  paralysis 
or  deafness,  have  been  reported  after  a  dose  of  salvarsan,  and  even 


»68  A   MANUAL  OF  SURGHRY 

death;  but  such  a  mishap  is  exceedingly  rare.  The  reaction  is 
sometimes  unduly  severe,  possibly  due  to  the  rapid  destruction  of 
large  numbers  of  spirochaetcs  in  the  blood  and  the  setting  free  of 
a  large  amount  of  endotoxin,  but  the  percentage  of  such  bad  results 
is  surprisingly  low. 

The  value  of  this  treatment  cannot  be  over-estimated,  not  only 
from  the  personal,  but  also  from  the  public,  point  of  view.  The 
former  has  been  already  alluded  to,  and  the  future  can  alone  dis- 
close the  ultimate  percentage  of  freedom  from  relapse.  From  the 
public  standpoint,  the  chief  advantage  lies  in  quickly  rendering  the 
patient  non-infectious,  and  thereby  diminishing  enormously  the 
chances  of  spreading  the  disease  to  others.  The  chief  limitation 
to  its  utiUty  is  the  expense  and  the  amount  of  special  work  required 
in  order  effectively  to  carry  out  the  treatment.  It  is  possible  that 
the  Government  will  have  to  step  in  and  render  such  assistance 
available  to  all  members  of  the  community. 

Failing  the  employment  of  salvarsan,  the  practitioner  can  alone 
depend  on  the  administration  of  mercury,  and  this  must  be  thorough 
and  prolonged,  and  even  then  good  results  cannot  be  ensured. 
Many  different  methods  have  been  suggested  in  order  that  the 
patient  miay  derive  the  greatest  amount  of  benefit  from  the  drug 
with  the  minimum  of  inconvenience,  [a]  It  is  often  given  by  the 
mouth,  and  preferably  in  the  form  of  pills,  composed  of  gray  powder 
(grs.  i. — iii.,  t.d.s.),  or  of  the  green  iodide  (gr.  | — i.,  t.d.s.).  Gray 
powder  is  perhaps  the  best  means  of  administering  the  drug  ;  the 
patient  should  commence  with  2  grains,  three  times  a  day,  or  in  some 
cases  i^  grains  four  times  a  day,  combined  with  a  little  extract  of 
opium  or  pulv.  ipecac,  co.  if  it  causes  diarrhoea;  but  this  addition 
is  not  always  needed,  (b)  Inunction  of  the  mercurial  ointment  is 
also  frequently  adopted,  and  with  great  success,  inasmuch  as  it  is 
less  likely  to  cause  digestive  derangemicnts.  If  the  ordinary  officinal 
ointment  is  employed,  a  portion  as  large  as  a  hazel-nut  is  rubbed 
into  the  groin  or  axilla  nightly,  the  part  being  washed  the  following 
morning,  and  not  used  again  for  this  purpose  for  three  or  four  days; 
if  the  ointment  is  made  up  with  lanoline,  a  somewhat  smaller  amount 
is  required.  This  is  one  of  the  best  ways  of  bringing  a  patient 
rapidly  under  the  influence  of  the  drug.  At  Aix-la-Chapelle  and 
Harrogate  this  treatment  is  a  speciality,  and  is  combined  with  the 
daily  use  of  sulphur  water  and  baths.  The  mercurial  ointment  is 
rubbed  in  daily  by  glass  rubbers  or  the  hand,  and  the  course  lasts  six 
weeks,  being  repeated  within  the  year,  (c)  Mercurial  vapour  baths 
may  be  advantageoush'  emploved  where  the  cutaneous  eruption  is 
very  extensive.  The  patient  sits  naked  on  a  cane-seated  chair,  and 
covered  with  a  blanket  or  specially-constructed  cloak  reaching  from 
the  neck  to  the  ground,  and  not  touching  the  body;  20  or  30  grains 
of  calomel  are  placed  on  a  metal  plate  surrounded  by  a  trough  con- 
taining about  an  ounce  of  water.  The  water  is  boiled,  and  the 
calomel  sublimed,  by  means  of  a  spirit-lamp  placed  under  the  chair. 
In  about  twentv  minutes  all  the  calomel  will  be  volatilized,  and 


SFi-:ciFic  infective:  diseases  169 

deposited  in  part  upon  tlic  skin  of  the  patient,  who  perspires  freely 
during  the  process.  Fie  then  gets  into  bed  between  warm  blankets, 
without  wiping  the  skin.  This  treatment  may  be  combined  with 
medication  by  the  mouth,  [d]  The  intramusculay  miQcWon  of  mer- 
curial preparations  has  much  to  recommend  it,  and  although 
alarmists  have  emphasized  the  dangers  of  suppuration,  salivation, 
and  emboli  associated  with  it,  yet  increasing  experience  has  proved 
it  to  be  safe  and  efficacious  in  careful  hands,  and  with  due  regard  to 
asepsis.  The  satisfactory  results  following  its  extensive  adoption 
by  military  surgeons  are  strong  arguments  in  its  favour.  Insoluble 
preparations  of  mercury  are  mainly  relied  on,  and  especially  in  the 
form  of  metalhc  mercury  suspended  in  a  cream.*  The  dose  is 
injected  deeply  into  the  gluteus  maximus,  and  the  absorption,  if 
slow,  is  regular,  so  that  it  is  httle  hkely  to  cause  toxic  symptoms. 

During  the  course  of  mercury,  the  patient's  general  health  and 
habits  must  be  carefully  regulated;  alcohol  is  forbidden,  exercise 
limited,  and  strict  instructions  are  given  as  to  keeping  the  teeth  and  _ 
gums  clean.  An  astringent  mouth-wash  containing  alum  and 
chlorate  of  potash  should  be  ordered,  and  it  may  be  necessary  to 
remove  or  stop  diseased  teeth,  but  the  dentist  must,  of  course,  be 
informed  of  the  nature  of  the  case.  To  minimize  the  risk  of  throat 
and  mouth  trouble,  it  is  wise  to  stop  all  smoking  for  at  least  six 
months.  The  dose  of  m.ercury  required  varies  in  different  indi- 
viduals, being  increased  in  robust  people,  and  diminished  in  those 
who  are  weak  or  unhealthy.  It  should  always  be  pushed  until  mild 
physiological  effects  are  produced  in  the  shape  of  shght  tenderness 
of  the  gums,  but  salivation  of  the  patient  is  undesirable.  Full  doses 
are  usually  required  for  four  or  five  months,  followed  by  a  milder 
course,  which  should  extend  till  the  end  of  the  first  year.  It  is 
advisable,  however,  to  insist  on  a  three  months'  course  of  mercury 
tv\dce  a  year  for  two  and  a  half  or  three  years. 

Symptoms  of  mercMrialism  are  induced  in  some  people  by  very 
small  quantities  of  the  drug,  and  hence  treatment  should  always 
commence  with  small  doses.  The  gums  become  soft  and  spongy, 
and  bleed  readily  on  pressure ;  sahvation  follows,  or  even  acute 
glossitis,  whilst  the  breath  becomes  offensive.  The  teeth  are 
loosened  and  may  be  shed,  and  the  alveoU  may  undergo  necrosis. 
Digestive  derangements,  such  as  cohc  and  diarrhoea,  are  also 
observed.  Treatment  consists  in  suspending  the  drug  for  a  time, 
and  giving  a  sharp  saline  purge,  whilst  the  spongy  state  of  the  gums 
is  remedied  by  the  use  of  an  alum  or  chlorate  of  potash  mouth-wash. 

Iodide  of  potassium  is  essential  in  the  treatment  of  the  tertiary 
and  intermediate  stages.     It  appears  probable  that  its  chief  action 

*  A  useful  preparation  is  as  follows: 

1^     Hydrargyri     .  .  .  .  .  .  •  •  •  ■     5ss. 

Adipis  lanae  anhyd.    ..  ..  ..  ••      §ii- 

Paraffini  liq.  (carbolized  2  per  cent.)  ad  5V.  (by  volume). 
Finished  product  =  gr.  i.  in  min.  x. 
Min.  X.  as  a  maximum  dose  once  a  week. 

Lambkin  {Bril   Med.  Journ..  November  11,  1905)- 


lyo  A   MANUAL  OF  SUh'GI'h'Y 

is  the  removal  of  gummatous  tissue,  and  that  it  has  httle  infkience 
upon  the  causative  disease;  in  order  to  prevent  recurrence,  salvarsan 
or  mercury  is  still  required.  The  dose  of  iodide  should  not  exceed 
5  grains  to  start  with,  and  is  graduall3Mncreased,  until  in  some  cases 
I  drachm  four  times  a  day  has  been  reached.  Plenty  of  water  should 
always  be  taken  immediately  afterwards  to  assist  in  its  dilution  and 
facilitate  its  absorption.  A  feeling  of  depression  and  sinking  at  the 
epigastrium  is  sometimes  produced,  but  may  be  alleviated  by  the 
addition  to  the  mixture  of  sal  volatile  (m^xv.)  or  carbonate  of  am- 
monia, as  suggested  by  the  late  Sir  James  Paget.  S\aTiptoms  of 
coryza  often  follow,  and  an  acnciform  eruption  over  the  shoulders 
and  face,  which  may  disappear  on  increasing  the  dose.  Occasionally 
a  vesicular,  or  even  bullous,  rash  is  caused  by  this  drug.  When  large 
doses  are  given,  bicarbonate  of  soda  or  potash  must  be  combined 
with  it,  in  order  to  prevent  its  decomposition  by  the  gastric  juice. 
If  mercury  is  required,  it  is  better  to  give  it  in  the  form  of  gray 
powder  than  to  add  liquor  hyd.  perchlor.  to  the  iodide  in  a  mixture, 
as  the  latter  usually  disturbs  the  digestion.  Other  drugs,  such  as 
sarsaparilla,  arsenic,  and  iron,  are  often  combined  with  iodide  of 
potassium  in  the  later  stages  of  the  disease,  and  may  be  useful. 

The  Local  Treatment  of  syphilitic  sores  consists  mainly  in  the 
application  of  various  preparations  of  mercury.  The  primary  chancre 
should  be  treated  by  excision,  cauterization,  or  the  use  of  calomel 
ointment  (30  per  cent.),  with  the  object  of  removing  or  destroying 
the  spirochaetes  which  may  be  locked  up  in  the  fibrous  interspaces 
and  are  inaccessible  to  salvarsan.  Mucous  tubercles  in  the  neigh- 
bourhood of  the  anus  or  vulva,  or  between  the  toes,  are  best  dealt 
with  by  keeping  them  scrupulously  dry  and  clean  and  dusting  them 
over  with  powdered  calomel  and  starch,  or  by  the  application  of 
calomel  ointment,  a  piece  of  lint  being  inserted  between  opposing 
surfaces  to  keep  them  from  rubbing  one  against  the  other.  Secondary 
ulceration  of  the  throat  does  not  usually  require  local  treatment,  as 
it  soon  disappears  under  the  influence  of  mercury.  A  mercurial 
gargle  may,  however,  be  employed,  or  in  bad  cases  the  affected 
parts  should  be  painted  with  glyc  hyd.  perchlor.  (i  in  2,000). 
Superficial  gummatous  ulcers  are  treated  by  removing  the  scabs,  and 
applying  some  form  of  mercurial  ointment.  A  determined  attempt 
should  be  made  to  keep  deep  gummatous  ulcers  in  an  aseptic  condi- 
tion, since  the  advent  of  sepsis  to  such  sores,  especially  if  they  are 
connected  with  bones,  makes  a  marked  difference  in  their  progress. 
In  neglected  cases  the  wound  may  become  exceedingly  foul,  and  in 
chronic  cases  a  hectic  temperature  and  amyloid  degeneration  of  the 
viscera  have  been  observed.  When  gummata  come  to  the  surface 
and  point,  they  should  be  opened  with  the  same  precautions  as  are 
adopted  in  the  case  of  an  abscess,  and  either  dressed  antiseptically 
or  their  cavity  packed  with  sterilized  lint  or  gauze  soaked  in 
sterilized  lotio  nigra. 


SPECIFIC  INFECTIVE  DISEASES  171 

Inherited  Syphilis. 

The  offspring  of  syphilitic  parents  often  fails  to  arrive  at  maturity, 
the  mother  miscarrying  at  the  end  of  six  or  seven  months.  The 
child  may  be  well  formed,  and  may  even  hve  independently  for  a 
short  while,  but  not  unfrequently  it  is  dead,  and  in  many  cases 
macerated;  under  these  circumstances  the  tissues  of  the  body  are 
often  swarming  with  spirochsetes  (Fig.  32).  The  miscarriage  may 
be  repeated  for  several  pregnancies,  and  then  a  living  child  is  pro- 
duced. In  other  instances,  however,  a  hving  child  is  born  at  full 
term  at  the  end  of  the  first  pregnancy  in  spite  of  the  syphiUtic 
infection  of  the  parents.  This  child  may  show  evidences  of  the 
disease  at  birth,  but  more  frequently  appears  to  be  healthy,  specific 
manifestations  not  showing  themselves  for  some  weeks. 

Much  discussion  has  arisen  in  the  attempt  to  explain  these 
phenomena,  and  also  as  to  the  relative  frequency  of  infection  by  the 
father  or  mother.  Theoretically,  infection  may  occur  at  one  of 
three  periods:  (a)  At  impregnation  the  disease  may  be  conveyed 
by  one  or  both  parents,  either  the  ovum  or  spermatozoon,  or  both, 
carrying  the  spirochaetes.  The  organism  has  been  demonstrated  in 
the  semen  of  human  beings  as  well  as  of  apes.  Infection  ab  initio 
is  likely  to  be  followed  by  a  general  development  in  the  tissues,  and 
possibly  the  cases  where  the  mother  aborts  early  and  produces  a 
dead     foetus    infiltrated    with    spirochsetes    belong   to    this    type. 

(b)  During  the  pregnancy  infection  of  the  foetus  may  occur  through 
a  specific  infection  of  the  endometrium,  especially  involving  that 
portion  of  the  decidua  which  enters  into  the  formation  of  the 
placenta.  As  a  general  rule  the  foetal  and  maternal  circulations  do 
not  commingle,  but  when  the  placenta  is  diseased  it  is  easy  to 
understand  that  the  spirochaetes  might  pass  from  mother  to  foetus. 

(c)  It  is  possible  that  infection  may  be  delayed  until  parturition,  the 
organisms  then  finding  their  way  from  the  separating  placenta 
through  the  umbihcal  vein.  Such  an  occurrence  may  explain  the 
delay  of  symptoms  in  the  infant  for  some  weeks  after  birth,  although 
possibly  this  is  due  to  a  removal  of  toxins  into  the  maternal  circula- 
tion during  pregnancy,  so  that,  although  the  foetus  is  infected, 
symptoms  are  kept  in  abeyance.  In  this  connection  it  is  interesting 
to  note  that,  although  infective  lesions  may  be  present  in  the 
maternal  passages,  primary  chancres  are  not  seen  in  infants;  they 
are  presumably  protected  either  by  a  previous  infection  or  by  the 
presence  of  the  vernix  caseosa. 

In  some  cases  the  mother  has  shown  no  obvious  evidence  of 
syphiHs,  and  yet  is  able  to  suckle  her  child  without  harm,  even 
though  there  are  ulcerating  lesions  on  the  child's  gums  and  lips, 
whereas  a  healthy  wet-nurse  develops  a  chancre  of  the  nipple. 
This  is  known  as  Colles's  Laiv,  and  was  first  stated  by  him  in  1837. 
The  immunity  of  the  mother  under  these  circumstances  was  formerly 
attributed  to  the  production  of  antibodies  in  the  foetus  and  trans- 
mission to  the  maternal  blood;  but  the  researches  of  Neisser  on  the 


172 


A   MANUAL  OF  SURGERY 


higher  apes  have  shown  that  the  serum  of  a  syphiHtic  subject  contains 
neither  protective  nor  curative  substances,  and  it  is  therefore 
probable  that  the  maternal  immimity  is  due  to  a  mild  and  un- 
recognised infection  with  the  disease  itself. 

Profeta's  Law  is  the  reverse  of  Colles's,  and  asserts  that  the  child 
of  a  syphililic  m.other  or  father  is  immune  to  syphilis,  although  it  has 
never  presented  evidences  of  infection  with  the  disease.  In  the  light 
of  modern  research  it  seems  extremelN-  probable  that  this  is  not  true. 
The  length  of  time  during  which  a  syphilitic  patient  retains  the 
power  of  transmitting  the  disease  to  the  foetus  is  an  exceedingly 
difficult  point  to  determine,  and  one  which  is  constantly  coming 
before  the  practitioner,   who  is  asked  to  decide  at   what  period 

marriage  is  safe. 

The  rule  of  prac- 
tice generally 
followed  is  that 
no  one  suffering 
from  syphilis 
should  be  allowed 
to  marry  until  the 
Wassermann  re- 
action has  re- 
mained negative 
and  he  or  she  has 
been  free  from  all 
symptoms  for  two 
years,  and  even 
then  it  is  advis- 
able that  a  mild 
course  of  mercury 
shoiild  be  given 
for  about  three 
months  shortly 
before_marriage. 

The  question  of 
transmission  to 
the  third  genera- 
tion is  one  of  much  interest,  concerning  which  a  good  deal  of  conflict- 
ing evidence  has  been  forthcoming.  The  dependence  of  this  disease 
upon  a  recognised  organism,  which  it  has  been  possible  to  demon- 
strate in  late  tertiary  stages,  is  presumptive  evidence  in  favour  of  its 
transmissibility ;  but,  naturally,  one  of  the  chief  difficulties  is  the  de- 
monstration of  the  sexual  purity  of  the  second  generation.  Further 
evidence  of  an  assured  character  on  this  point  is  much  needed. 

At  birth  the  child  often  appears  healthy  and  well  nourished,  but 
is  sometimes  small  and  imperfectly  developed.  The  first  definite 
symptoms  of  the  disease  manifest  themselves  at  a  variable  period, 
extending  from  three  weeks  to  three  months,  after  birth;  the  child 
becomes  thin  and  emaciated;  the  skin,  which  hangs  in  wrinkles 


Fig.  38. — Child  with  Inhekited  Syphilis,  showing 
Radiating  Scars  round  the  Mouth.  (From  a 
Photograph  kindly  lent  by  Dr.  G.  F.  Still.) 


SPECIFIC  INFECTIVE  DISEASES 


173 


over  the  body,  changes  to  a  dull  earthy  colour,  whilst  the  features 
looked  pinched  and  wizened,  like  those  of  an  old  man.  Marked 
anaemia  is  always  present,  and  may  persist  for  a  considerable  time. 
Speaking  generally,  the  s\-mptoms  of  inherited  syphilis  are  similar 
to  those  of  the  acquired  disease,  except  that  the  primary  lesion  is 
absent.  Thus,  during  the  ftrst  year  of  hfe  the  child  develops  various 
cutaneous  eruptions,"  mucous  tubercles,  and  superficial  ulceration 
of  the  mucous  membranes.  A  dusky  red  roseola,  especially  about 
the  nates  (napkin  area),  may  first  be  noticed,  but  does  not  last  long. 
This  is  usually  followed  by  the  appearance  of  mucous  tubercles  at 
the  angles  of  the  mouth,  in  the  nose,  and  around  the  anus,  as  also  in 
the  moist  folds  of  the  groin,  and  between  the  scrotum  and  thigh. 
The  sores  on  the  lips  are 
sometimes  very  marked, 
giving  rise  to  ulcerated  sur- 
faces, which,  by  their  sub- 
sequent cicatrization,  leave 
radiating  scars  (or  rha- 
gades),  especially  about  the 
angles  of  the  mouth  (Fig. 
38).  Other  cutaneous  affec- 
tions, such  as  squamous 
syphilides  of  the  soles  of 
the  feet,  together  with 
papular  s\^hilides  of  the 
body,  and  a  bullous  erup- 
tion becoming  pustular 
(pemphigus),  are  also  ob- 
ser^'ed,  the  last-mentioned, 
however,  only  occurring  in 
debilitated  infants.  A  ca- 
tarrhal rhinitis  is  a  very 
early  and  constant  manifes- 
tation, gi\dng  rise  to  ob- 
structed nasal  respiration, 
or  snuffles.  This  affection 
is  often  protracted,  going 
on  to  ulceration  and  de- 
struction of  the  nasal  bones 
and  cartilages ;  their  subsequent  development  is  thus  prevented  or 
impaired,  and  hence  the  bridge  of  the  nose  remains  depressed  and 
sunken,  even  when  adult  life  is  reached  (Fig.  39).  Enlargement  of 
the  spleen  and  liver  is  also  common. 

Many  infants  during  the  first  year  of  life  die  from  malnutrition  or 
marasmus;  but  if  properly  treated  a  considerable  proportion  regain 
their  health  within  six  or  eight  months,  all  the  m.anifestations 
described  above  disappearing,  although  their  scars  may  remain. 
The  child's  subsequent  development  is  frequently  impaired,  and  it 
often  retains  an  almost  pathognomonic  facies. 


Fig.  39  — Head  and  Face  of  a  Patient 
WITH  Inherited  Syphilis,  showing  De- 
pressed Bridge  of  Nose  and  Frontal 
Bosses.     (From  a  Photograph.) 


174 


A   MANUAL  OF  SURGERY 


After  the  first  year,  any  of  the  tertiary  phenomena  which  appear 
in  acquired  sypliilis  may  develop,  but,  in  addition  to  these,  pecuhar 
manifestations  may  be  produced,  especially  affecting  the  teeth, 
bones,  and  cornea;  deafness  from  disease  of  the  internal  ear  is  also 
not  uncommon. 

The  Teeth  in  inherited  syphilis  are  sometimes  very  characteristic. 
The  temporary  teeth  usuall\'  appear  early,  are  discoloured,  and 
crumble  away.  The  permanent  teeth  are  often  sovmd  and  healthy, 
but  are  sometimes  deformed.  The  central  incisors  of  the  upper  jaw 
are  those  most  particularly  affected,  but  the  upper  laterals  and  the 
incisors  of  the  lower  jaw  may  also  be  involved.  Instead  of  being 
broader  at  the  crown  than  at  the  root,  they  diminish  in  size  from 
root  to  crown,  being  stunted,  and  separated  from  one  another  by 
interspaces.  The  angles  of  the  crown  are  rounded  off,  and  a  distinct 
notch,  forming  a  large  segment  of  a  small  circle,  occupies  the  centre 
(Fig.  40).  The  enamel  is  often  imperfecth^  developed,  and  hence 
they  decay  early.  Occasionally  they  may  be  shaped  like  a  screw- 
driver, narrowing  from  root  to  crown,  and  with  a  straight  free  border. 
The   notched   and  stunted  teeth  ^described   above   are  sometimes 

known  as  '  Hutchinson's 
teeth,'  but  they  are  not 
very  commonly  seen  at 
the  present  day. 

The  Bone  affections 
observed  in  inherited 
s\-philis  will  be  described 
in  Chapter  XXI. 

Interstitial  Keratitis,  or 
diffuse  inflammation  of 
the  cornea,  usually  occurs  about  the  age  of  pubert3^  or  earher.  It  is 
limited  at  first  to  one  eye,  but  the  other  is  almost  certain  to  be  similarly 
affected  at  a  later  date.  It  commences  as  a  diffuse  haziness  of  the 
cornea,  which  looks  somewhat  like  ground  glass,  associated  with 
hyperaemia  of  the  ciliary  region.  Red  areas,  or  '  salmon  patches,' 
may  be  produced  in  the  midst  of  the  opacity,  due  to  a  new  formation 
of  minute  vessels.  There  is  no  tendency  to  ulceration,  but  in  pro- 
tracted cases  the  anterior  part  of  the  eye  may  bulge  forwards, 
constituting  a  condition  known  as  '  anterior  staphyloma.'  The  in- 
flammation may  spread  to  the  iris  and  ciliar}'  body.  With  suitable 
precautions  the  cases  usually  do  well,  although  treatment  for  several 
years  may  be  necessary,  and  some  corneal  opacity  may  persist. 

The  Wassermann  reaction  in  congenital  syphilis  is  usually  positive 
in  the  earlier  more  active  stages,  but  in  ihe  later  it  may  be  absent, 
as  in  the  late  tertiary  stage  of  the  acquired  variety. 

The  Treatment  of  inherited  syphilis  should  commence  as  soon  as 
definite  manifestations  of  the  disease  are  present.  The  general 
health  must  be  attended  to,  and  if  the  mother  is  unable  to  nurse  the 
child  it  must  be  brought  up  by  hand;  on  no  account  mnsi  it  be  given 
to  a  wet-nurse.     Mercury  is  best  administered  by  anointing  the  under 


•Fig. 


40. — Hutchinson's  Teeth  in  Inherited 
Syphilis. 


SPECIFIC  INFECTIVE  DISEASES  175 

surface  of  the  flannel  belly-band  with  mercurial  ointment,  or  the 
same  preparation  ma}^  be  rubbed  into  the  soles  of  the  feet  every 
night.  This  should  be  continued  until  all  secondary  phenomena 
have  disappeared,  and  advisably  until  the  child  is  a  year  old.  It 
is  sometimes  advisable  to  replace  this  by  the  internal  administra- 
tion of  gray  powder,  gr.  |  or  i.  t.d.s.,  with  a  little  sugar.  Cod- 
liver  oil  may  also  be  ordered  with  advantage  in  some  cases,  and 
everj"  possible  means  adopted  to  improve  the  general  nutrition. 
When  tertiary  symptoms  appear,  iodide  of  potassium  and  mercury 
should  be  given  in  suitable  doses. 

The  local  treatment  of  external  lesions  is  conducted  according  to 
the  rules  laid  down  for  the  acquired  type  of  the  disease. 

Yaws  [Framboesia  tropica)  is  a  disease,  rarely  seen,  in  Europeans,  endemic 
in  various  parts  of  the  tropics,  and  due  to  a  spirochaste,  5.  pertenuis,  which 
is  transmitted  from  the  discharge  of  the  sores  by  direct  contact,  or  indirectly 
by  clothes,  flies,  or  other  agents.  It  is  characterized  by  the  development  of 
granulomata,  which  break  down  and  ulcerate.  The  primary  lesion,  often 
found  on  the  face,  is  generally  single,  and  its  appearance  is  associated  with 
pain  and  fever.  Secondary  nodules  appear  either  in  the  neighbourhood  of 
the  original  lesion  or  elsewhere,  and  the  process  goes  on  spreading,  some  of  the 
sores  healing,  and  others  invading  deeper  tissues,  which  may  be  destroj^ed 
and  give  rise  to  serious  deformities.  The  condition  is  closely  akin  to  s^^shilis, 
but  it  is  not  so  certainly  influenced  by  mercury  or  iodide  of  potassium.  In 
salvarsan,  however,  we  have  an  almost  certain  and  very  rapid  cure. 

Tuberculosis. 

By  tuberculosis  is  meant  a  condition  resulting  from  the  develop- 
men.t  within  the  tissues  of  the  body  of  certain  definite  anatomical 
structures,  known  as  tubercles,  and  caused  by  the  grovkdih  and 
activity  of  the  Bacillus  Uiherculosis. 

MiicAo^y. — i.  It  is  more  than  doubtful  whether  heredity  plays 
such  an  important  part  as  was  formerly  attributed  to  it  in  the 
production  of  this  disease,  which  is  much  more  commonly  due  to 
direct  infection.  That  there  are  famihes  in  which  tuberculosis  is 
specially  prone  to  occur  cannot  be  doubted,  but  the  children  are 
rarely  born  tuberculous,  and  only  become  infected  under  suitable 
conditions.  Unfortunately,  tuberculous  indi\dduals  often  have  a 
considerable  degree  of  philo-progenitiveness,  and  may  be  remark- 
ably prohfic.  Although  tuberculous  disease  is  most  frequently  seen 
in  children  or  young  people,  no  age  is  extempt  from  its  attacks,  even 
elderly  people  being  affected.  These  senile  manifestations  differ  in 
no  wa3^  from  those  met  with  in  the  young. 

2.  A  depressed  condition  of  the  general  health,  by  lowering  the 
general  resistance  of  the  body,  is  a  much  more  common  and  impor- 
tant cause  of  tuberculosis.  Thus  not  unfrequently  the  trouble 
starts  in  children  after  attacks  of  the  exanthematous  fevers,  or  as  a 
sequela  of  rickets,  whooping-cough,  or  other  childish  ailments. 
Many  of  them  leave  an  inflamed  condition  of  the  mucous  lining  of 
the  pharynx  or  intestine,  and  thus  pro\dde  a  suitable  entrance  for 
the  germs.     Even  in  adults  the  debihtating  effects  of  influenza,  a 


176  A   MANUAL  OF  SURGERY 

neglected  cold,  or  persistent  overwork  may  be  followed  by  an  out- 
break of  the  disease. 

3.  Still  more  is  this  likely  to  happen  if  the  patient  lives  in  un- 
healthv  or  had  hygienic  surroundings.  Hot  and  ill-ventilated  work- 
rooms, dirty  dwelling-houses,  overcrowded  schoolrooms,  etc.,  are 
themselves  "harmful  by  lowering  vitality,  but  they  often  become 
hotbeds  of  infection  if  once  consumptive  patients  are  admitted  and 
contaminate  the  air  by  expectorating.  This  probably  explains  the 
terrible  frequency  with  which  tuberculous  trouble  occurs  in  many 
parts  of  the  country  where  one  would  expect  the  inhabitants  to  be 
particularly  healthy — e.g.,  some  of  the  holiday  resorts  of  Scotland, 
Wales,  and  Ireland]  unfortunately,  the  houses  are  small,  dark,  often 
dirty,  and  so  hopelessly  devoid  of  ventilation  that,  if  tubercle  bacilh 
once  gain  an  entrance,  they  become  virulently  effective  in  producing 
disease.  Naturally,  tuberculosis  is  most  common  am.ongst  the  poor, 
but  it  is  onlv  too  frequent  in  the  well-to-do,  arising  usually  from 
improper  feeding  and  unwise  coddling  of  the  children,  or  from  faulty 
hygiene  or  carelessness,  especially  as  to  jud^'cious  clothing,  in  adults. 

4.  A  local  nidus  suitable  for  the  development  C'f  tl:e  micro-organ- 
ism usually  exists,  although  tuberculous  infection  occasionally 
follows  wounds  and  punctuies  in  previously  healthy  parts.  Thus, 
chronically  iniiamed  lymphatic  glands  form  a  suitable  breeding- 
ground  for  the  bacillus,  as  also  bones  and  joints  in  a  state  of  con- 
gestion resulting  from  slight  and  often  overlooked  injuries. 

5.  The  ultim.ate  exciting  cause  of  tuberculosis  is  the  development 
within  the  tissues  of  the  B.  htberculosis  of  Koch  (Plate  IIL,  Fig.  26). 
They  usually  occur  in  the  form  of  slender  rods,  which  are  straight  or 
slightly  curved;  they  are  about  4  or  5  /x  in  length  and  0-2  or  0-3  /a 
wide,  but  sometimes  form  long  branched  filaments,  especially  in 
cultures.  These  characters  differentiate  them  strongly  from  m.ost 
bacilli,  and  suggest  that  the  organism  is  in  reality  allied  to  the 
streptothrices,  and  probably  several  members  of  this  group  may 
produce  the  disease.  This  is  interesting  in  view  of  the  close  clinical 
resemblance  between  tuberculosis  and  the  other  diseases  due  to 
streptothricial  infections  (the  .so-called  actinomycosis).  The  tubercle 
bacillus  is  a  typical  acid-fast  organism,  and  when  stained  by  the 
Ziehl-Nielsen  method  appears  in  the  form  of  slender  pink  rods, 
which  are  often  stained  only  in  part,  so  that  they  seem  to  consist  of 
short  red  lengths  alternating  with  unstained  areas,  the  whole  looking 
not  unhke  a  chain  of  very  minute  streptococci.  In  vitro  they  de- 
velop very  slowly,  two  or  three  weeks  elapsing  before  growth  is 
visible,  and  require  a  temperature  approaching  that  of  the  body  and 
an  abundant  supply  of  oxygen.  Many  culture  media  are  available, 
and  all  are  im.proved  by  the  addition  of  3  or  4  per  cent,  of  glycerine. 
The  colonies  consist  of  yellowish,  white,  or  gray  scales,  which  have 
a  dryish  look.  The  tubercle  bacillus  does  not  liquefy  blood-serum ; 
it  isnon-motile,  has  no  flagella,  and  is  not  known  to  possess  spores. 

The  question  of  the  identity  of  human  and  bovine  tuberculosi'-. 
raised  h\  Koch  is  still  under  discussion.     Both  can  apparently  cause 


SPECIFIC  INFECTIVE  DISEASES  177 

tuberculosis  in  human  beings,  but  it  seems  probable  that  the  bovine 
variety  is  mainly  responsible  for  intestinal  and  surgical  forms  of 
the  disease — e.g.,  those  including  glands,  bones,  and  joints^ — whilst 
the  human  variety  leads  to  pulmonary  phthisis  and  to  acute  general 
tuberculosis.  Cultural  distinctions  are  readily  estabhshed  by  the 
use  of  egg  media,  the  bovine  variety  growing  scantily,  and  the 
human  form  abundantly,  especially  in  the  presence  of  glycerine. 
Inoculation  experiments  in  rabbits  also  differ,  in  that  human 
tubercle  produces  but  little  effect  and  rarely  kills,  whereas  the 
bovine  virus  is  actively  fatal. 

The  organism  gains  access  to  the  body  in  one  or  other  of  the 
following  ways : 

{a)  Most  commonly  by  inhalation.  The  sputum  of  consumptives 
contains  vast  numbers  of  tubercle  bacilli,  and,  as  drying  does  not 
immediately  kill  them,  they  frequently  occur  in  the  dust  and  in  the 
air.  But  little  advance  will  be  made  towards  stamping  out  this 
disease  until  consumptive  patients  can  be  prevented  from  expectora- 
ting in  public  places.  Even  more  important  is  the  fact  that  in 
coughing  and  talking  the  tuberculous  sputum  is  expelled  in  a  state 
of  very  fine  division,  and  the  infective  particles  remain  suspended 
in  the  air  for  long  periods.  It  is  therefore  obvious  that  the  strict 
enforcement  of  suitable  regulations  is  necessary  for  the  protection 
of  the  public  from  this  disease.  Tuberculosis  acquired  by  inhalation 
usually  manifests  itself  in  the  form  of  pulmonary  disease,  but  may 
appear  as  a  primary  affection  of  the  bronchial  glands,  from  which 
tfie  infection  may  be  disseminated  to  other  organs. 

{b)  By  ingestion — e.g.,  of  infected  milk  from  cows  with  tuberculous 
disease  of  the  udders.  This  is  by  no  means  rare  in  children,  the 
bacilli  entering  through  the  tonsils  or  other  lymphadenoid  tissues  of 
the  pharynx  and  invading  the  cervical  glands,  or  passing  through 
the  stomach  imharmed  and  infecting  the  intestine  and  mesenteric 
lymph  glands.  Examinations  of  tuberculous  material  from  the 
cervical  glands  in  72  cases  in  Edinburgh  resulted  in  the  discovery 
that  in  65  {i.e.,  90  per  cent.)  the  bovine  bacillus  was  present.* 
Facts  such  as  these  indicate  the  crying  need  for  some  effective 
control  of  the  milk-supply  of  our  great  towns. 

(c)  By  inoculation.  This  is  very  unusual,  and  occurs  chiefly  in 
pathologists,  post-mortem  room  porters,  etc.,  in  the  form  of  a 
verruca  necrogenica  (p.  252).  A  few  cases  of  tuberculous  infection 
from  an  accidental  cut  inflicted  by  a  broken  sputum  cup  have  been 
recorded. 

The  laboratory  diagnosis  of  tuberculosis  is  conducted  on  one  or 
other  of  the  following  lines : 

I.  By  the  microscopic  identification  of  the  tubercle  bacillus  after 
staining  by  the  Ziehl-Nielsen  method.  This  is  sufficient  when  bacilli 
are  present  in  large  numbers,  as  in  the  sputum ;  but  when  this  is  not 
the  case  (as  frequently  happens  in  the  urine,  pus,  pleuritic  fluids, 
etc.)  it  is  necessary  to  have  recourse  to  other  methods. 
*  Mitchell,  Brit.  Med.  Journ.,  January  17,  1914- 


178  A   MANUAL  OF  SURGERY 

2.  Inoculation  of  susceptible  animals,  especially  guinea-pigs,  is  a 
most  delicate  test.  The  material  is  usually  inserted  beneath  the 
skin  of  the  groin,  and  the  animal  killed  in  three  weeks,  when  the 
lymph  glands  and  probabh-  the  internal  organs  will  be  found 
tuberculous. 

3.  Tuberculous  exudates  differ  from  many  others  in  that  the  cell 
which  occurs  most  abundantly  is  the  lymphocyte,  and  this  fact  is 
made  use  of  in  the  examination  of  pleuritic  and  peritoneal  exudates, 
the  fluid  obtained  by  lumbar  puncture  of  the  spinal  meninges,  etc. 
It  is  useful,  but  must  not  be  regarded  as  an  absolute  test. 

4.  In  some  cases  a  portion  of  the  lesion  may  be  excised  and 
submitted  to  microscopic  examination,  which  should  include  a 
search  for  bacilli,  since  other  infections  may  give  rise  to  lesions 
indistinguishable  microscopicall}'  from  tuberculosis. 

5.  Tuberculin  (as  originally  prepared  by  Koch)  is  obtained  by 
filtering  off  the  bacilli  from  a  glycerine-broth  culture  of  the  organism 
and  suitably  diluting  the  filtrate,  which  obviously  contains  merely 
the  exotoxins.  It  has  been,  and  still  is,  used  as  a  diagnostic  agent. 
When  injected  into  a  healthy  person,  it  produces  no  effect,  but  in 
tuberculous  persons  a  sharp  rise  of  temperature  occurs  in  a  few 
hours.  The  test  is  not  altogether  devoid  of  danger,  and  should 
never  be  used  unless  one  is  certain  of  the  absence  of  a  secondary 
infection,  e.g.,  with  streptococci.  Two  modifications  of  the  test  are, 
however,  useful.  In  Calmette's  reaction  a  drop  or  two  of  diluted 
tubercuhn  (i  in  100  or  1  in  200)  is  dropped  into  the  conjunctival 
sac.  In  tuberculous  patients  this  is  followed  by  mild  conjunctivitis, 
which  commences  in  a  few  hours,  and  has  usually  passed  off  in 
twent^^-four.  The  test  is  somewhat  dangerous,  cases  of  severe 
conjunctivitis,  corneal  ulceration,  and  even  loss  of  the  eye,  having 
followed  its  use.  A  safer  procedure  is  that  known  as  Von  Pirquet's 
skin  reaction,  which  is  apparently  free  from  danger.  It  consists  in 
inoculating  a  small  superficial  scratch  with  a  drop  of  20  or  25  per 
cent,  tuberculin.  The  reaction  consists  in  the  development  in  from 
twenty-four  to  forty-eight  hours  of  a  small  papule  surrounded  by  a 
ring  of  hyperaemia.  This  test  is  certainly  of  great  value  in  children 
up  to  twelve  j-ears  of  age,  but  of  course  the  tuberculous  deposit 
may  be  of  a  quiescent  character.  As  a  therapeutic  agent  the  original 
tuberculin  failed  signally,  and  has  been  replaced  by  many  other 
types  which  are  more  liopeful  (p.  184). 

6.  The  opsonic  index  is  sometimes  of  value  in  diagnosis  (see  p.  24). 
In  a  healthy  individual  it  ranges  between  o-8  and  i-2,  and  figures 
above  or  below  that  limit  are  highly  suggestive ;  whilst  considerable 
variations,  even  from  day  to  day,  are  very  characteristic  of  pro- 
gressive tuberculosis. 

Pathological  Anatomy.^ — The  characteristic  lesion  is  the  miliary 
tubercle,  a  cellular  mass  2  or  3  millimetres  in  diameter,  and  when 
isolated  readily  visible  to  the  naked  eye.  \\'hen  young  and  in 
course  of  active  evolution,  tubercles  are  soft,  translucent,  and  of  a 
gra}^  colour;  after  a  time  they  undergo  fatty  degeneration  and  be- 


SPECIFIC  INFECTIVE  DISEASES 


179 


come  yellowish  and  opaque.     It  is  often  impossible  to  recognise 
them  macroscopically,  since  when  closely  set  they  fuse  together. 

A  typical  fully-formed  tubercle  without  retrogressive  changes 
can  be  best  studied  in  sections  from  the  meninges  in  tuberculous 
meningitis,  or  from  the  liver  or  kidney  in  a  case  of  general  tuber- 
culosis. In  the  centre  of  the  mass  there  is  a  giant  cell*  (Fig.  41), 
the  diameter  of  which  may  be  many  times  that  of  a  red  blood- 
corpuscle.  It  has  usually  an  oval  or  circular  shape,  and  its  outline 
is  regular;  it  has  many  oval  nuclei,  and  these  are  arranged  round  the 
periphery  of  the  cell,  their  long  axes  lying  in  a  radial  direction. 
Around  the  giant  cell  there  is  a  zone  of  endothehoid  cells,  usually 
oval  in  shape,  and  rather  larger  than  a  leucocyte;  each  has  a  single 
nucleus,   which  closely 


resembles    one    of    the 
nuclei  of  the  giant  cell. 
Beyond    this   comes   a 
third  or  outer  zone  of 
small  round  inflamma- 
tory cells,  which  appear 
to    be    identical    with 
lymphocytes.     It  must 
be  understood  that 
tubercles   do   not   con 
form    exactly    to    this 
typical     descriptit 
The   giant    cell, 
example,  is  frequently 
missing,    especially 
acute    cases,    or    there 
may  be  several  cells 
this  type,   though  this 
is  unusual.     Moreover, 
the  width  of  the  zones 
varies  greatly;  in  some 
cases   the  endothehoid 

cells  may  appear  to  be  absent,  but  can  be  detected  mixed  up  with 
the  lymphocytes,  which  extend  to  the  centre  of  the  tubercle. 

It  must  be  clearly  understood  that  a  '  tubercle  '  in  the  histological  sense  is 
not  peculiar  to  tuberculosis,  in  the  sense  of  a  disease  due  to  the  tubercle 
bacillus.  It  is  simply  the  reaction  of  the  tissues  to  an  irritant  of  comparatively 
feeble  activity.  Thus  it  occurs  in  actinomycosis  (see  Fig.  45,  where  a  typical 
histological  tubercle  is  shown  surrounding  a  colony  of  actinomyces) ,  and  may 


Fig.  41.- 


MILIARV'TUBERCLE  WITH  GlANT  CeLLS. 

(X  120.) 


*  It  may  be  well  to  notice  here  that  three  forms  of  giant  cell  occur  patho- 
logically, and  are  of  very  different  significance:  (i)  Those  described  above 
(the  tuberculous  type),  having  their  nuclei  arranged  around  the  periphery 
of  the  cell;  (2)  Myeloplaxes,  which  occur  in  myelomata,  and  have  many 
nuclei  grouped  irregularly  round  the  centre  of  the  cell;  (3)  Parenchymatous 
giant  cells  occurring  in  the  substance  of  tumours,  especially  sarcomata  and 
carcinomata.  These  have  usually  a  single  nucleus,  or  at  most  a  few,  which 
may  be  of  large  size  and  have  no  definite  arrangement. 


i8o  A   MANUAL  OF  SURGERY 

be  produced  by  an  unabsorhed  ligature,  irritants,  such  as  grains  of  pepper, 
etc.  Hence  it  is  not  always  safe  to  make  a  diagnosis  of  tuberculosis  from  an 
examination  of  sections,  unless  the  characteristic  bacilli  are  demonstrated. 

The  (kvelopmeiit  of  a  tubercle  is  not  yet  fully  understood.  The 
bacilli  appear  to  gain  access  to  a  lymph  space  or  to  a  small  vessel, 
where  they  set  up  an  overgrowth  oi  the  endothelial  cells  which 
constitute  the  middle  zone.  The  giant  cell  appears  to  be  composed 
of  a  mass  of  these  cells,  in  which  the  nuclei  have  undergone  re- 
peated divisions,  but  the  protoplasm  has  remained  unsegmented. 
The  source  of  the  lymphocytes,  and  whether  the^^  are  produced 
locally  or  attracted  from  the  blood-stream,  has  been  hotly  debated. 
Probably  they  are  formed  locally,  perhaps  by  a  process  of  budding 
from  pre-existing  endothelial  cells. 

Miliary  tubercles  may  be  embedded  in  practically  normal  tissues, 
but  in  most  cases  an  inflammatory  process  can  be  traced  beyond 
the  nodules.  It  may  be  of  a  chronic  type,  with  an  increased  forma- 
tion of  fibrous  tissue;  but  in  the  more  active  forms  the  intervening 
structures  disappear,  being  replaced  by  granulation  tissue,  which  is 
often  oedematous  and  of  a  gelatinous  appearance.  This  latter  is 
especially  frequent  in  tuberculosis  of  the  bones  and  joints.  The 
inflammation  also  involves  the  smaller  vessels,  and  particularly 
the  arterioles,  the  lumiina  of  which  may  become  greatly  narrowed,  or 
even  entirely  obliterated,  by  a  process  of  endarteritis.  True  tuber- 
cles may  also  be  produced  in  the  vessel  walls,  but  this  is  much  rarer. 
In  either  case  the  vascular  affection  diminishes  the  blood-supply  of 
the  tuberculous  mass  (already  defective  owing  to  the  non-vascularity 
of  the  tubercles),  and  increases  the  likelihood  of  degenerative 
changes,  such  as  caseation. 

A  fully-formed  tubercle  may  undergo  evolution  along  one  of  the 
following  lines,  according  to  the  virulence  of  the  bacilli  and  the 
resisting  powers  of  the  patient. 

1.  When  the  bacilh  are  but  slightly  virulent  and  the  patient's 
susceptibility  moderate,  the  tubercle  undergoes  fibrosis ;  this  is  the 
natural  method  of  cure.  The  endothelioid  cells  become  spindle- 
shaped,  their  nuclei  elongated,  and  the  cells  are  converted  into  fibro- 
blasts. The  periphery  of  the  giant  cell  becomes  drawn  out  into 
delicate  ramifying  processes  which  penetrate  amongst  the  endothe- 
lioid cells,  and  join  with  them  in  forming  fibrous  tissue.  The 
lymphocytes  become  less  numerous,  and  ultimately  the  tubercle  is 
represented  by  an  ill-defined  nodule  of  new  fibrous  tissue. 

2.  When  the  bacilli  are  virulent  and  the  patient  in  a  non-resistant 
condition,  caseation  occurs.  This  is  a  process  of  fatty  degeneration 
and  necrosis  of  the  nodule,  which  is  transformed  into  a  uniform 
structureless  mass  staining  only  with  acid  dyes,  such  as  eosin 
(Fig.  42).  It  is  not  often  possible  to  demonstrate  bacilli  in  this 
cheesy  mass;  they  are  there,  however,  as  inoculation  experiments 
show.  Caseation  occurs  in  lesions  other  than  tuberculosis,  and  is 
due  to  the  action  of  toxins  on  the  tissues;  it  is  especially  common 
in  this  disease,  since  no  vessels  penetrate  the  tubercles,  which  are 
m  consequence  badly  nourished. 


SPECIFIC  INFECTIVE  DISEASES  i8i 

Ciire  may  take  place  at  this  stage  by  a  process  of  fibrosis  of  the 
surrounding  parts,  so  that  the  caseous  mass  becomes  walled  in  by 
a  zone  of  fibrous  tissue;  the  cheesy  material  gradually  dries  up, 
and  may  become  calcified.  It  is  possible,  however,  that  living  bacilh 
are  present  even  in  dried-up  caseous  substance,  and  under  suitable 
conditions  recrudescence  may  ensue,  even  after  an  interval  of  years. 

3.  In  most  cases  in  which  caseation  is  present,  the  process  con- 
tinues to  spread,  and  involves  not  only  the  tubercles,  but  also  the 
intervening  tissues;  in  this  way  a  cheesy  mass  of  considerable  size 
may  be  produced.  Not  unfrequently  an  exudation  of  fluid  takes 
place  into  this  mass,  and  the  result  is  a  chronic  tuberculous  abscess. 


.■y-i.'-.i«f 
■  •:»:^  ■-.Cry 


Fig.  42. — Early  Stage  of  Tuberculous  Abscess  in  Lymphatic  Gland. 

(x  3°-) 
In  the  centre  is  a  caseating  focus  on  the  point  of  suppuration;  outside  it, 
granulation  tissue,  in  which  several  giant  cells  can  be  seen;  and  external 
to  this  a  zone  of  fibro-cicatricial  tissue. 


Wherever  tubercle  is  deposited,  a  chronic  abscess  may  form;  but  it 
occurs  most  frequently  in  bones,  joints,  and  lymphatic  glands. 

The  pus  from  such  an  abscess  consists  of  disintegrated  fatt}' 
material  mixed  \vith  a  variable  quantity  of  fluid,  so  that  it  is  some- 
times thin  and  milk}^  sometimes  so  thick  that  it  will  scarcely  flow 
through  a  cannula.  It  often  contains  masses  or  flakes  of  curdy 
debris,  and  on  microscopic  examination  a  few  lymphocytes  may  be 
found,  together  with  large  quantities  of  fatty  granular  m.aterial  which 
will  not  stain.  Tubercle  bacilli  may  be  found  without  much  diffi- 
culty in  the  more  active  cases,  but  in  chronic  forms  they  are  often 
few  and  far  between,  or  possiblj^  cannot  be  demonstrated  without 


i82  A   MANUAL  OF  SURGERY 

inoculation  experiments.  In  old-standing  cases  the  presence  of 
cholesterine  crystals  may  be  recognised  by  the  ghstening  sheen  or 
greasy  appearance  imparted  to  the  pus;  microscopically,  they  appear 
as  flat  rhomboidal  plates  with  one  corner  notched  out. 

Secondary  infection  with  pyogenic  bacteria  may  also  lead  to  the 
formation  of  an  abscess  in  a  tuberculous  nodule.  This  is  an  entirely 
different  process,  and  one  that  is  usually  much  more  serious  for  the 
patient.  The  pus  in  such  a  case  may  not  differ  appreciably  from 
the  ordinary  pus  of  acute  abscesses,  and  the  fact  that  it  contains 
tubercle  bacilli  may  only  be  demonstrable  by  inoculation. 

The  microscopic  appearance  of  a  tuberculous  abscess  ivall  is  quite 
characteristic.  The  cavity  is  lined  by  a  layer  of  gray,  yellowish- 
gray,  or  pinkish,  pulpy  granulation  tissue,  containing  miliary 
tubercles,  perhaps  undergoing  caseation.  Its  colour  and  vitality 
are  dependent  upon  the  chronicity  or  not  of  the  process ;  the  longer 
the  abscess  is  in  forming,  the  less  vascular  the  membrane,  owing 
to  the  associated  sclerosis  of  the  surrounding  structures  leading  to 
compression  of  the  bloodvessels,  whilst  it  has  been  already  men- 
tioned that  endarteritis  always  accompanies  a  chronic  inflammation, 
and  helps  to  render  the  parts  non- vascular.  This  lining  membrane, 
when  necrotic,  is  but  loosely  connected  with  a  layer  of  fibro-cica- 
tricial  material,  which  forms  the  outer  part  of  the  wall,  and  from 
which  it  can  be  readily  detached  by  the  finger  or  a  sharp  spoon. 

A  chronic  abscess  forms  a  soft  fluctuating  swelling  which  gradually 
increases  in  size,  and  may  become  painful  by  exerting  pressure  on 
nerves  or  other  sensitive  structures.  Should  it  be  superficial,  it  will 
probably  come  directly  to  the  surface  and  burst ;  the  pus  and  caseous 
detritus  will  be  discharged,  and  possibly,  if  the  general  health  is 
good,  the  wound  may  slowh^  granulate  and  heal;  but  not  unfre- 
quently  the  tuberculous  tissue  left  behind  prevents  heahng,  and  a 
tuberculous  ulcer  develops.  A  similar  condition  is  found  in  connec- 
tion with  mucous  membranes,  the  tuberculous  foci  starting  in  the 
submucosa,  and  subsequently  bursting  through  the  mucous  mem- 
brane (Fig.  43).  Whatever  their  location,  the  ulcers  are  characterized 
by  an  irregular  and  ragged  margin  with  undermined  and  congested 
edges;  the  base  is  formed  by  pulpy  granulation  tissue  containing 
caseous  foci  (z\),  which  must  be  removed  before  heahng  can  occur. 

On  the  other  hand,  a  deep  abscess  is  hkely  to  burrow  along 
fascial  planes,  and  may  become  superficial  at  a  distance  from  its 
original  source,  e.g.,  in  a  psoas  abscess  due  to  tuberculous  disease  of 
the  spine.  The  far-reaching  extent  of  these  abscesses,  the  impossi- 
bility of  dealing  adequately  with  the  lining  membrane  or  with  the 
original  focus  of  the  mischief,  render  them  most  difficult  to  treat, 
and  fully  account  for  the  dread  of  opening  them  experienced  by 
surgeons  in  pre-antiseptic  days;  for  under  the  best  of  circumstances 
a  sinus  is  hable  to  develop  and  persist,  and  without  the  most  minute 
precautions  pyogenic  infection  is  likely  to  ensue,  and  then  the 
result  is  an  increased  discharge  of  pus,  absorption  of  the  chemical 
products  of  putrefaction,  aggravation  of  the  original  disease,  and 


SPECIFIC  INFECTIVE  DISEASES 


1^3 


only  too  frequently  death  from  chronic   toxaemia,  associated  with 
hectic  fever  and  amyloid  disease  (p.  83). 

Natural  Cure.— A  tuberculous  abscess,  if  left  to  itself,  does  not 
necessarily  come  to  the  surface.  Occasionally  one  meets  with  a  mass 
of  putty-like  consistency  lying  in  front  of  the  spme  m  the  body  of  a 
patient  who  has  been  cured  of  spinal  disease.  This  is  evidently  the 
desiccated  remains  of  a  chronic  abscess,  the  fluid  portion  having  been 
absorbed,  and  the  sohd  elements  left  behind,  encapsuled  and  perhaps 
infiltrated  with  lime  salts.  Such  debris  can  become  the  seat  of 
recurrent  inflammatory  mischief  years  later,  when  suppuration  may 
suddenly  occur,  giving  rise  to  what  is  known  as  a  residual  abscess. 


Fig. 


a. 


43 .—Tuberculous    Ulceration    of  Large   Intestine.     (x30-) 

(ZlEGLER.) 

Mucosa;  b,  submucosa;  c,  inner  transverse  muscular  coat;  ^  outer  longi- 
tudinal muscular  coat;  e.  serosa;  /,  tuberculous  focus  m  solitary  giana , 
9  mucosa  infiltrated  with  cells;  h.  tuberculous  ulcer;  hy.  focus  of  softening 
or  tuberculous  abscess;  i,  early  tubercle,  with  giant  cell  m  centre; 
ij,  caseous  tubercle. 

Probably  a  large  amount  of  cholesterine  will  be  found  among  its 
contents.  The  prognosis  of  such  an  abscess  is  good,  and  a  cure  may 
often  be  obtained  by  one  tapping  and  free  lavage. 

One  of  the  chief  dangers  of  tuberculous  disease  is  its  great  ten- 
dency to  diffusion,  which  is  sometimes  Hghted  up  by  injudiciously 
vigorous  operative  interference.  It  mav  occur  (a)  locally,  by  direct 
continuity  of  tissue,  e.g.,  from  the  testis  by  way  of  the  vas  deferens 
to  the  prostate  and  seminal  vesicles,  or  by  extension  along  neighbour- 
ing lymphatics  or  bloodvessels ;  or  (b)  distant  viscera  or  organs  may 
become  infected,  probably  by  embohc  dissemination  m  the  blood- 
stream.    Thus,  phthisis  is  a  not  uncom.mon  sequence  of  a  similar 


i84  A   MANUAL  OF  SURGERY 

affection  of  bones,  joints,  or  lymphatic  glands,  whilst  meningeal 
tuberculosis  is  more  frec^uently  associated  with  tuberculous  affec- 
tions of  the  genital  organs,  (c)  Moreover,  any  tuberculous  lesion 
may  lead  to  acute  general  tuberculosis,  in  which  the  disease  is  scat- 
tered widely  throughout  the  body,  giving  rise  to  rapid  emaciation, 
high  fever  of  an  intermittent  type,  and  usually  severe  diarrhoea, 
dyspnoea,  and  delirium  or  coma,  death  ensuing  in  a  lew  weeks. 

Treatment. — When  Koch  first  discovered  the  tubercle  bacillus,  a 
great  impetus  was  given  to  operative  treatment,  and  some  authori- 
ties went  so  far  as  to  maintain  that  every  particle  of  the  diseased 
tissue  must  be  extirpated  with  as  much  care  as  in  the  case  of  cancer. 
The  pendulum  has  now  swung  slowly  back,  and  we  are  relying  more 
and  more  on  the  natural  powers  of  repair  inherent  in  the  patient, 
and  are  endeavouring  to  maintain  and  increase  these  in  every  way 
by  suitable  general  and  local  treatment,  reserving  operative  measures 
for  the  comparatively  small  class  of  cases  which  resist  such  treat- 
ment, or  to  the  larger  class  where  such  conservative  treatment,  for 
various  reasons,  most  often  financial,  cannot  be  carried  out. 

I.  General  Treatment  consists  chiefly  in  giving  the  patient  an 
abundance  of  fresh  air,  as  free  from  germs  as  possible.  For  surgical 
cases  residence  by  the  seaside,  especially  in  bracing  places,  is  usually 
recommended.  Equally  good  results  will  often  follow  residence  in 
hilly  districts,  provided  that  they  are  not  too  heavily  wooded,  that 
there  is  plenty  of  sunshine,  and  that  the  soil  dries  quickly  after 
rain.  Faihng  seaside  or  country,  it  is  wonderful  what  exposure  to 
the  air  in  suburban  gardens  or  even  on  town  roofs  will  do.  The 
patient  must  be  kept  warm  and  well  wrapped  up,  and  given  an 
abundance  of  nutritious  food,  such  as  milk,  cream,  and  eggs,  in 
addition  to  fresh  butcher's  meat  (not  too  much  cooked),  fat  bacon, 
and  other  commodities  which  tend  to  increase  the  patient's  weight. 
The  weighing-machine  must  be  consulted  weekly,  and  a  steady 
increase  in  weight  is  the  best  possible  prognostic  sign.  The  amount 
of  exercise  must  be  strictly  limited  so  as  to  conserve  the  patient's 
energies  towards  the  cure  of  his  disease,  and  in  this  connection  it  is 
well  to  point  out  that  prolonged  rest  in  a  spinal  carriage  is  suitable 
for  many  conditions  other  than  disease  of  the  spine  or  of  the  lower 
extremities.  The  internal  administration  of  cod-liver  oil,  the  phos- 
phates and  iodides  of  iron,  organic  preparations  of  iodine,  guaiacol, 
arsenical  preparations,  and  other  tonics  is  also  indicated. 

As  already  mentioned,  many  forms  of  tuberculin  have  been  intro- 
duced since  the  failure  of  Koch's  original  variety  as  a  therapeutic 
agent,  most  of  them  involving  the  trituration  of  the  bacilli  so  as  to 
include  the  endotoxins.  Thus,  Tuberculin  O  was  prepared  by 
grinding  up  the  dried  bacilli  from  young  cultures,  adding  water, 
and  centrifugalizing;  the  clear  fluid  thus  obtained  was  the  tuber- 
culin. Tuberculin  R  (TR)  was  prepared  by  repeating  this  process 
until  no  solid  residuum  was  obtainable,  and  mixing  all  the  fluids 
(except  the  Tuberculin  O).  A  '  New  Tuberculin  '  has  also  been  pre- 
pared,  consisting  of  a  suspension  in  glycerine  and  water  of   the 


SPECIFIC  INFECTIVE  DISEASES  185 

ground-up  substance  of  dried  bacilli.  The  human  and  bovine  forms 
arc  both  prepared  in  this  manner,  and  a  combined  variety  is  also 
obtainable  (^Tuberculin  PTO).  Opinions  vary  much  as  to  the 
exact  dosage  of  patients  in  difterent  forms  of  tuberculous  disease, 
but  as  a  rule  in  surgical  cases  small  doses  should  be  utihzed.  In  a 
child  o-ooooi  milligramme  given  hypodermically  might  be  employed 
to  start  with,  increased  gradually  up  to  o-ooi  milhgramme,  whilst 
an  adult  may  start  with  a  dose  of  o-oooi  or  0-0002  milligramme. 
It  may  also  be  administered  by  mouth,  and  seems  to  act  quite  well. 
The  result  may  be  controlled  by  observations  of  the  opsonic  index, 
but  usually  the  temperature,  pulse,  and  weight  wih  be  sufficient 
guides  as  to  the  good  or  bad  results.  The  injection';  should  not  be 
repeated  under  ten  or  fourteen  days,  and  should  never  be  attempted 
when  a  mixed  infection  is  present.  In  some  cases  good  results 
follow,  but  in  many  the  effect  is  disappointing,  and  in  all  its  use 
must  never  supersede  the  hj^gienic  and  surgical  measures  required 
in  the  treatment  of  the  disease. 

2.  Local  Treatment  (Non-operative). — In  the  first  place  all  tuber- 
culous foci  must  be  kept  free  from  irritation,  whether  extrinsic  or 
intrinsic.  Thus,  wherever  possible  the  affected  part  must  be  main- 
tained at  rest,  both  from  movement  and  pressure.  Joints  should  be 
immobihzed  by  plaster  of  Paris  or  suitable  sphnts ;  the  effect  of  the 
weight  of  the  body  minimized  by  recumbency  or  other  means  when 
the  disease  affects  the  spine  or  lower  extremities;  a  tuberculous 
testis  should  be  supported  by  a  suspensory  bandage,  etc.  The 
advent  of  a  mixed  infection  must  be  carefuUy  guarded  against,  if 
possible,  and  especially  in  connection  with  lymphatic  glands.  A 
patient  with  glandular  trouble  in  the  neck  should  be  carefully  treated 
for  any  peripheral  septic  lesions,  such  as  sore  hps,  dirty  teeth,  im- 
petigo capitis,  or  otorrhoea;  enlarged  tonsils  and  adenoids  should 
also  be  removed,  inasmuch  as  bacteria  are  often  lodged  in  the  crypts 
of  the  former  or  between  the  lamellae  of  the  latter. 

These  measures  may  be  supplemented  by  counter-irritation — e.g., 
blisters,  iodine  paint,  or  Scott's  dressing,  and  Bier's  method  of  pas- 
sive congestion  (p.  41).  Parenchymatous  injections  of  iodoform,  or 
of  some  sclerogenic  agent  such  as  chloride  of  zinc,  have  also  been  em- 
ployed, acting  probably  by  determining  an  increased  flow  of  blood  to 
the  part,  and  thus  strengthening  the  protective  mechanism  of  Nature. 

3.  Operative  Treatment  is  required  when  the  measures  indicated 
above  have  failed  to  check  the  disease,  or  when  accidental  comphca- 
tions — e.g.,  abscesses — develop  in  the  course  of  the  case,  or  when  the 
disease  is  so  extensive  or  progressive  as  to  make  it  inadvisable  to 
trust  alone  to  the  natural  processes  of  repair.  Obviously,  extirpa- 
tion of  the  tubercular  focus,  if  practicable,  is  the  ideal  treatment 
in  all  cases,  and  for  some  conditions  no  other  treatment  need  be 
considered.  Thus,  in  superficial  lymphatic  glands  in  the  neck 
excision  is  the  best  tieatment  whenever  progress  to  recovery  is 
delayed  or  absent.  In  many  other  conditions,  as  in  bone  and 
joint  disease,  total  extirpation  is  practicable  by  excision  or  amputa- 


i86  A   MANUAL  OF  SURGERY 

tion ;  but  such  a  proposal  involves  the  consideration  of  many  other 
questions,  such  as  the  operative  risk,  the  possibility  of  diffusing 
tuberculous  material  into  the  system  generally  by  the  necessary 
manipulations,  the  possible  infection  of  the  wound  or  surrounding 
healthy  tissues  by  tubercle,  and  the  degree  of  post-operative  dis- 
ability that  may  result.  The  cure  by  a  local  excision  is  not  always 
certain,  and  the  after-treatment  is  often  very  prolonged.  On  the 
other  hand.  Nature's  cure  may  be  equally  uncertain,  possibly  less 
satisfactory,  and  the  chances  of  dissemination  and  diffusion  are  not 
absent.  The  final  decision  as  to  the  advisability  of  undertaking  a 
radical  operation  of  this  type  must  be  made  bv  a  careful  considera- 
tion of  (i)  the  stage  of  the  disease,  whether  early  or  late;  (2)  its 
position  and  extent;  (3)  its  character,  v/hether  active  and  progres- 
sive, or  chronic;  (4)  the  probable  resisting  power  of  the  patient  to 
the  spread  of  the  disease;  and  (5)  the  hygienic  conditions,  etc., 
under  which  treatment  has  to  be  undertaken. 

Partial  operations  are  sometimes  required,  consisting  in  cutting 
or  scraping  away  as  nmch  of  the  diseased  tissues  as  is  practicable, 
swabbing  out  the  cavity  thus  produced  with  some  powerful  germi- 
cide, such  as  liquefied  carbolic  acid,  and  dressing  the  part  with 
gauze  soaked  in  some  modifying  or  antiseptic  substance,  such  as  an 
emulsion  of  iodoform,  the  wound  being  left  to  heal  by  granulation. 
Diseased  bones,  glands,  and  sinuses  have  often  to  be  dealt  with  in 
this  way,  and  satisfactory  cures  ma}'  be  established  after  a  while. 
Open-air  treatment  must  be  instituted  at  the  same  time,  or  com- 
menced as  soon  after  as  possible.  Theoretically,  it  is  better  to  do 
the  operation  in  the  country  rather  than  in  town,  but,  of  course, 
this  is  not  always  practicable. 

When  the  patient  has  more  than  one  focus  of  disease — e.g., 
pulmonary  phthisis  at  the  same  time  as  disease  of  some  joint,  or 
of  the  testis — it  is  often  found  that  no  progress  is  being  made 
towards  recovery,  in  spite  of  suitable  treatment.  It  then  may  be 
advisable  to  remove  entirely  one  of  the  foci,  if  such  be  possible, 
when  steady,  and  perhaps  rapid,  repair  will  show  itself  in  the  other. 

The  manifestations  of  tubercle  as  it  affects  special  organs  are 
dealt  with  elsewhere  under  the  appropriate  headings  (see  diseases  of 
skin,  bones,  joints,  lymphatic  glands,  kidney,  testis,  etc.). 

The  Treatment  of  Chronic  Tuberculous  Abscess  must  necessarily 
vary  considerably  according  to  the  position  and  condition  of  the 
part.  A  superficial  chronic  abscess  is  comparatively  easy  to  treat, 
but  one  placed  deeply,  and  connected  with  such  an  affection  as 
tuberculous  disease  of  the  spine,  must  be  approached  with  the 
utmost  caution,  in  order  to  avoid  pyogenic  contamination. 

1.  In  certain  cases  of  external  chronic  abscess,  especially  when  connected 
with  lymphatic  glands,  it  may  be  possible  to  dissect  out  the  whole  cavity  en 
masse,  and  if  such  be  feasible,  it  is  the  most  satisfactory  plan  to  adopt. 

2.  WTien  the  skin  is  thin  and  undermined,  and  the  abscess  nearly  pointing, 
it  is  hopeless  to  avoid  leaving  an  open  wound ;  and  hence  the  condition  must 
be  treated  by  the  open  method.  The  cavity  is  freely  incised,  diseased  tissue 
scraped  away,  unhealthy  skin  removed,  and  the  cavity,  if  not  too  large  or 


SPECIFIC  INFECTIVE  DISEASES  187 

deep,  treated  with  pure  carbolic  acid  or  chloride  of  zinc  (gr.  xl.  ad  51.),  packed 
with  gauze  infiltrated  with  iodoform,  and  allowed  to  heal  from  the  bottom. 
Healing  is  often  slow,  if  sure;  but  a  tuberculous  abscess  ought  never  to  be 
allowed  to  reach  a  condition  in  which  it  is  necessary  to  leave  an  open  wound 
of  this  type. 

3.  When  a  chronic  abscess  is  situated  deeply  and  covered  with  healthy 
tissues,  treatment  consists  in  emptying  the  cavity  of  its  contents,  removing  as 
far  as  possible  the  tuberculous  lining  membrane,  and  closing  up  the  wound 
after  introducing  into  the  cavity  some  modifying  or  antiseptic  injection. 

In  many  cases  tapping  with  trocar  and  cannula  suffices  for  this  purpose. 
The  modus  operandi  is  as  follows:  The  skin  over  the  abscess  is  incised,  and  a 
large  trocar  and  cannula  introduced  obliquely  so  as  tc  allow  the  contents  to 
escape.  The  cavity  is  then  washed  out  with  sterilized  salt  solution  (3i.  ad 
Oi.)  at  a  temperature  of  105°  to  110°  F.,  and  the  abscess  wall  gently  kneaded 
from  the  outside  so  as  to  detach  cuidy  material  and  necrotic  pyogenic  mem- 
brane. This  is  continued  until  the  escaping  fluid  is  nearly  clear  or  only 
slightly  opalescent,  and  then  a  suitable  quantity  of  a  sterihzed  emulsion  of 
iodoform  in  glycerine  (10  per  cent.)  is  introduced,  and  the  opening  closed  by 
stitches.  In  this  way  it  is  often  possible  to  cure  a  chronic  abscess  at  one 
sitting.  The  treatment  is  most  likely  to  be  efficacious  when  all  active  bone 
or  joint  disease  has  disappeared,  and  residual  abscesses  are  the  most  favour- 
able of  all.  The  good  results  are  probably  due  in  part  to  the  liberation  of 
iodine  and  its  antiseptic  influence  over  the  tubercle  bacilli ;  but  the  stimulating 
effect  on  the  tissues  in  the  direction  of  leucocytosis  by  the  operative  manipu- 
lations and  the  injected  material  cannot  be  overlooked. 

Where  the  disease  is  more  active,  it  is  often  wiser  to  make  an  mcision  into 
the  abscess  sufhcientlv  large  to  introduce  the  finger.  Through  this  opening 
diseased  bone  can  pos'sibly  be  removed  and  the  lining  wall  scraped,  and  for 
this  purpose  a  Barker's  flushing  gouge  is  often  useful.  The  instrument  con- 
sists of  a  gouge  or  sharp  spoon  with  a  long  hollow  handle,  which  communicates 
by  a  tube  with  a  reservoir  of  fluid  placed  at  some  height  above  the  patient. 
During  its  application  the  constant  rush  of  w^ater  or  lotion  through  the  handle 
clears  the  gouge  and  removes  the  debris.  It  is  admirably  adapted  for  certain 
cases,  but  its  use  needs  considerable  care,  as  the  sharp  edge  can  readily  scrape 
through  an  abscess  wall  or  lay  open  a  vein.  If  much  bleeding  occurs,  the 
cavity  should  be  irrigated  with  hot  sterilized  salt  solution.  The  wounds  are 
subsequently  closed  after  injecting  the  iodoform  emulsion,  and  an  a,ttempt 
is  made  to  gain  immediate  healing  of  the  denuded  cavity  by  bringing  the 
sides  into  apposition  by  suitable  pressure. 

Not  uncommonly  the  cavity  refills  in  the  course  of  three  or  four  weeks,  and 
the  irrigation  may  then  have  to  be  repeated.  The  fluid  withdrawn  on  this 
occasion  is  often  blood-stained  serum,  perhaps  smelling  strongly  of  iodoform. 
It  is  possible  that  in  such  cases  a  sinus  develops  sooner  or  later,  and  has  to  be 
dealt  with  by  simple  drainage. 

It  is  often  a  matter  of  considerable  difficulty  to  secure  the  healing  of  a 
tuberculous  sinus,  owing  partly  to  the  existence  of  diseased  bone  or  other  trouble 
at  its  extremity,  partly  to  defective  drainage,  and  also  in  part  to  the  exist- 
ence of  tuberculous  tissue  in  its  wall;  the  added  presence  of  a  pyogenic  in- 
fection will  still  further  delay  healing.  Not  unfrequently  sinuses  of  this  type 
burrow  widely,  and  it  is  sometimes  difficult  to  ascertain  the  extent  of  the 
mischief  with  a  probe.  In  such  cases  help  may  be  obtained  by  injecting  the 
sinus  with  a  paste  consisting  of  bismuth  subnitrate  i  part  and  white  vaseline 
2  parts,  and  examining  the  extent  of  the  trouble  by  radiography.  This 
process  has  the  advantage  of  hastening  healing  of  the  sinus  owing  to  the 
chemotactic,  bactericidal,  and  astringent  influence  of  the  paste.  In  acute 
suppurative  lesions,  or  where  large  cavities  are  involved — e.g.,  in  empyema 
this  proceeding  should  not  be  employed,  as  toxic  effects  may  follow,  and  even 
cause  death ;  the  removal  of  the  bismuth  paste  for  toxic  troubles  is  hastened 
by  injecting  the  sinus  with  warm  oil.  Of  course,  all  ordinary  surgical  measures 
—e.g.,  removal  of  diseased  bone  or  foreign  bodies,  and  free  exit  for  discharges 
— must  be  provided  when  necessary. 


A   MANUAL  OF  SURGERY 


Glanders. 


Glanders  is  primarily  a  disease  of  the  horse,  ass,  or  mule,  which  is  trans- 
mitted to  men  by  direct  inoculation,  and  hence  is  usually  seen  only  in  stable 
attendants  and  those  brought  in  contact  with  such  animals.  The  disease  is  due 
to  a  definite  micro-organism,  the  Bacillus  mallei, -which  was  isolated  about  1882 
by  Schutz  and  Loffler,  ami  has  since  been  cultivated  outside  the  body ;  the  ex- 
perimental evidence  as  to  its  being  the  cause  of  the  malady  is  (juite  complete. 
In  Horses  and  other  animals  glanders  manifests  itself  by  a  formation  of  larger 
or  smaller  rounded  swellings  in  the  mucous  membrane  of  the  nose,  which  break 
down  and  ulcerate,  giving  rise  to  a  thin,  sero-purulent  discharge,  and  perhaps 
to  destruction  of  the  bones  and  cartilages.  Ihe  lymphatic  glands,  especially 
those  under  the  jaw,  early  become  enlarged,  constituting  the  '  farcy  buds  '  of 
farriers,  and  by  their  ulceration  may  leave  ragged,  foul,  sujipurating  sores. 
The  lymphatic  trunks  to  and  from  the  glands  are  involved  ('  corded  veins  '), 
whilst  the  lungs  and  internal  viscera  may  also  be  infected,  and  undergo 
destructive  changes.  The  disease  is  often  chronic,  lasting  perhaps  for  years; 
any  undue  strain  put  upon  the  animal  may  lead  to  an  acute  outbreak,  which 
is  fatal  in  six  to  twelve  days. 

In  Man,  glanders  generally  starts  about  the  hands  and  face,  but  occasionally 
in  the  nasal  mucous  membrane.  In  acute  cases  the  incubation  period  lasts 
from  three  to  five  days,  and  is  succeeded  by  the  occurrence  of  malaise  and 
febrile  disturbance,  followed  by  severe  pains  in  the  bones  and  joints.  The 
site  of  inoculation  becomes  swollen  and  angry,  whilst  the  lymphatics  leading 
from  this  to  the  nearest  glands  are  enlarged  and  infiamed.  An  eruption  of 
papules,  which  somewhat  resembles  those  of  small-pox,  occurs  around  the 
primary  lesion,  on  the  face,  and  in  other  parts  of  the  body;  but  each  papule, 
as  also  the  primary  lesion,  breaks  down  and  goes  on  to  the  formation  of  an 
ecthymatous-looking  ulcer.  It  is  not  an  uncommon  feature  of  these  sores, 
when  placed  over  a  bony  surface,  to  involve  the  periosteum  and  lay  bare  the 
subjacent  bone.  Similar  changes  occur  in  the  viscera,  muscles,  and  joints, 
and  these  being  associated  w-ith  high  fever  of  an  asthenic  type  may  suggest 
the  existence  of  pjsemia.  In  such  cases  death  may  ensue  in  seven  to  ten  days. 
In  chronic  glanders  similar  symptoms  are  met  with,  but  the  course  is  slower; 
there  is  little  or  no  fever ;  the  disease  is  less  extensive,  and  intermissions  are 
not  uncommon.  Total  recovery  is  stated  to  occur  in  50  per  cent,  of  the  cases. 
It  may  affect  the  nasal  mucosa,  leading  to  chronic  ulceration,  but  more  com- 
monly it  appears  in  the  shape  of  chronic  abscesses,  which  often  extend  deeply, 
even  down  to  the  bones,  and  are  very  difficult  to  deal  with.  In  one  case 
the  disease  gradually  spread  down  along  the  peronei  muscles,  and  in  spite  of 
repeated  scrapings  and  the  application  of  pure  carbolic  acid,  the  process  was 
only  arrested  at  the  point  where  the  peroneus  longus  disappears  into  the  foot. 
It  is  important  to  determine  the  Diagnosis  as  early  as  possible,  in  order  to 
undertaken  energetic  local  treatment.  The  local  lesions  are  distinguished  from 
small-pox  by  the  presence  of  the  characteristic  bacilli. in  the  discharge,  by  the 
fact  that  they  involve  the  subcutaneous  tissues  more  extensively,  and  by  the 
absence  of  umbilication.  Chronic  cases  resemble  syphilis  and  iuherculosis,  but 
the  history  of  exposure  to  infection  from  animals  suffering  from  the  disease  is 
most  important,  as  al.so  the  result  of  cultivations  made  from  the  discharge. 
When  the  bacilli  are  grown  on  potatoes,  a  colony  of  a  yellowish,  honey-like 
character  forms  in  two  or  three  days,  which  gradually  turns  to  a  chocolate- 
brown  colour.  Inoculation  of  the  peritoneal  cavity  of  a  guinea-pig  with  some 
of  the  secretion  leads  to  acute  orchitis  in  two  or  three  days,  the  testicles  being 
enlarged  and  the  skin  over  them  reddened;  the  affection  usually  runs  on  to 
suppuration.  Mallein,  a  sterilized  culture  of  the  organisms,  may  be  used  for 
diagnostic  purposes  in  animals,  the  injection  of  a  minute  dose  causing  a  sharp 
febrile  reaction  if  glanders  is  present;  but  it  is  of  no  use  for  diagnosis  or  treat- 
ment in  the  human  subject. 

Treatment  in  acute  cases  can  be  successful  only  when  undertaken  early,  and 
before  general  infection  has  ensued.     The  local  foci   should   be  thoroughly 


SPECIFIC  INFECTIVE  DISEASES  189 

extirpated,  either  by  the  knife,  or  by  scraping  and  applying  some  active 
cauterizing  agent.  The  same  treatment  must  be  adopted  m  chronic  cases, 
and  may  then  need  frequent  repetition. 

Leprosy. 

Leprosy  (syn.:  lepra,  or  elephantiasis  Grcscorum)  is  a  general  infective  disease 
due  to  the  Bacillus  Icprcs,  characterized  by  the  formation  of  granulation-hke 
neoplasms,  which  arise  primarily  in  connection  with  the  skm  and  nerves 

The  bacillus  of  leprosy  closely  resembles  that  of  tuberculosis,  and,  like  it, 
is  Gram-positive  and  strongly  acid-fast,  staining  by  Ziehl-Nielsen's  method. 
Leprosy  bacilli  are  usually  straighter  and  more  uniform  than  those  of  tubercle; 
and  when  seen  in  sections  of  leprous  material  they  are  often  present  in  far 
larger  numbers  than  are  the  tubercle  bacilli  in  tuberculous  tissues;  they  are 
usually  packed  together  hke  bundles  of  cigarettes  (Plate  III.,  Fig.  29) 
Numerous  attempts  have  been  made  to  cultivate  them,  and  a  few  doubttui 
successes  have  been  claimed.  All  attempts  to  inoculate  ammals  have  tailed, 
and  inoculation  constitutes  the  best  and  most  definite  test  between  the  two 

Leprosy,  though  formerly  common  in  this  country,  is  now  only  observed  in 
imported  cases.  In  Iceland,  Norway,  Russia,  and  the  East,  it  is  still  fre- 
quently met  with,  although  the  method  of  segregation  of  lepers  enforced  in 
Norway  has  greatly  diminished  the  number  in  that  country.  It  is  apparently 
very  slightly  contagious.  The  medical  attendants  and  nurses  in  leper  hos- 
pitals rarely  contract  the  disease,  and  inoculation  experiments  m  criminals 
have  led  to  negative  results.  The  late  Sir  Jonathan  Hutchinson  held  strong  y 
that  infection  only  takes  place  in  persons  who  eat  badly-cured  or  partially 
decomposing  fish.'  Opinions  diliEer  as  to  whether  the  disease  is  transmitted  to 
the  descendants,  but  probably  this  is  not  the  case. 

Symptoms.— Two  chief  varieties  of  leprosy  exist,  viz.,  the  tuberculated, 
and  the  anaesthetic  or  non-tuberculated;  but  the  two  are  often  associated.   _ 

Tuberculated  or  Cutaneous  Leprosy  is  the  form  most  commonly  seen  m 
Europe.  Nothing  may  be  noticed  for  months  or  years  after  exposure  to  tne 
contagion,  and  then,  after  a  period  of  malaise,  associated  with  d^^spepsia, 
diarrhcea,  and  drowsiness,  a  distinct  febrile  attack  is  noted,  lasting  for  da.ys 
or  weeks ;  it  may  be  ushered  in  by  a  rigor,  and  the  temperature  is  usually  of  a 
remittent  type.'  This  is  followed  by,  or  associated  with,  the  appearance  of 
shiny  red,  hvper^mic  spots,  which  are  from  the  first  infiltrated,  slightly  raised, 
and  hjTperjesthetic ;  they  are  usually  situated  on  the  forehead  or  cheeks  on 
the  outer  side  of  the  thighs,  or  on  the  front  of  the  forearms.  They  ma}-  fade 
away  and  disappear  entirely,  and  then  again  become  evident,  or  fresh  patches 
may  be  developed,  and  always  with  febrile  symptoms.  After  a  variable 
period  '  tuberculation  '  ensues:  numbers  of  httle  pink  nodules  form  over  the 
site  of  one  or  more  of  the  er\^hematous  patches,  and  these  gradually  increase 
in  size  and  coalesce,  until  possibly  thev  become  as  large  as  a  walnut  or  hen  s 
egg  and  are  then  of  a  brownish-yellow  colour.  Almost  any  part  of  the  surface 
of  the  body  may  be  invaded  in" this  manner,  but  the  face  is  especially  prone 
to  be  involved,'  and  the  resulting  disfigurement  is  very  marked  a  curious 
leonine  appearance  being  imparted  to  the  features  (Fig.  44).  The  nodules 
are  more  or  less  anaesthetic  from  the  pressure  of  the  infiltration  on  the  nerves, 
and  the  ultimate  result  of  the  process  may  vary  considerably;  resolution 
sometimes  occurs,  or  the  nodules  may  be  transformed  into  depressed  and 
pigmented  cicatrices,  or  ulceration  may  ensue.  Visceral  comphcations  and 
enlargement  of  the  lymphatic  glands  follow,  any  fresh  deposit  being  associated 
with  febrile  phenomena.  The  testes  atrophy,  and  sexual  power  is  lost  m 
both  sexes.  Death  is  usually  due  to  septic  phenomena,  larjmgeal  obstruction, 
or  disease  of  the  lungs  or  kidneys;  but  the  patient  may  live  for  many  years. 

The  nodules  consist  of  masses  of  granulation  tissue,  and  scattered  tfirougti 
them  are  numbers  of  large  cells,  containing  multitudes  of  bacilli. 

Ansesthetic  or  Non-tuberculated  Leprosy  is  the  most  common  form  met  ^^^.tn 
in  hot  climates .     The  earliest  phenomena  consist  in  a  certain  amount  ot  maiaise 


I  go  A   MANUAL  OF  SURGERY 

without  appreciable  lever,  together  with  sharp  tingling  or  lancinating  pains 
and  tenderness  along  the  course  of  certain  peripheral  nerves.  The  ulnar, 
median,  peroneal,  and  saphenous  nerves  are  those  most  often  affected.  This 
is  followed  by  muscular  weakness,  running  on  finall}'  to  paralysis,  various 
modifications  of  sensation,  and  trophic  phenomena,  involving  at  first  only 
the  skin,  but  later  on  attacking  bones,  joints,  and  muscles.  Circular  yel- 
lowish-white patches  are  observed  in  the  skin,  spreading  peripherally,  and 
tending  to  run  together,  forming  large  irregular  ovals;  the  border  is  often 


Fig.  44. — Leprosy.  (From  a  Photograph  kindly  lent  by  W.  Thelwall 
Thomas,  Esq.,  of  Liverpool.) 

The  patient  had  lived  as  a  sailor,  and  contracted  leprosy  abroad  many  years 
before.  The  facial  aspect  is  very  characteristic,  and  the  forearms  are 
enlarged  owing  to  leprous  deposits  in  the  subcutaneous  nerves. 

raised,  and  hypersensitive,  but  the  central  portions  become  atrophic,  dry, 
white,  and  anaesthetic.  The  anaesthesia  gradually  spreads,  and  serious  lesions, 
partly  due  to  trauma,  partly  arising  from  trophic  changes,  result.  The  muscles 
atrophy  and  contract,  and  give  rise  to  deformity,  the  hands  sometimes  be- 
coming markedly  '  clawed,'  as  in  ulnar  paralysis.  Interstitial  absorption  of 
the  bones  of  the  peripheral  portions  of  the  limbs  may  lead  the  fingers,  toes, 
and  other  portions  to  shrivel  and  disappear,  preceded  by  ankjdosis  of  the 
joints.     The  affected  nerves  can  usually  be  felt  distinctly  enlarged  and  tender. 


SPECIFIC  INFECTIVE  DISEASES 


191 


Visceral  lesions  arc  not  so  marked  in  this  as  in  the  other  form  of  the  disease, 
and  the  patient  may  retain  a  considerable  degree  of  health  and  strength, 
while  his  sexual  powers  are  not  much  interfered  with.  Finally  he  dies  from 
general  debility,  or  from  various  complications,  but  the  case  may  last  twenty 
or  more  years. 

The  Treatment  is  still  very  unsatisfactory.  Chaulmoogra  oil,  administered 
both  internally  and  externally,  is  the  drug  most  frequently  depended  on,  whilst 
intramuscular  injections  of  corrosive  sublimate  have  been  employed  with  some 
success.  Some  good  results  have  been  attributed  to  the  use  hypodermically  of 
Nastin  (Deycke),  a  neutral  fat  extracted  from  cultures  of  the  Streptothrix 
leproides,  obtained  from  leprous  nodules.  It  is  employed  in  combination  with 
benzoyl  chloride   (Nastin  B),  and  acts  by  withdrawing  fats  from  the  lepra 


'^ 


bacilli,  which  are  thereby  killed.  Hypodermic  injections  cause  a  reaction  of 
an  inflammatory  nature  and  necrosis  of  the  leprous  tissue.  Amputation  of 
extremities  is  sometimes  useful  in  late  stages  of  the  disease. 


Actinomycosis. 

Actinomycosis  is  a  disease  of  man  and  cattle,  due  to  infection  by  various 
types  of  a  group  of  streptothrices  called  Actinomyces  (ray  fungus).  The 
organisms  found  in  man  are  rarely  identical  with  those  present  in  the  bovine 
variety,  the  differences  being  mainly  in  the  staining  reactions. 

Actinomycosis  in  Cattle  is  usually  acquired  by  eating  infected  barley  or 
other  cereals,  fragments  of  which  are  sometimes  found  in  the  primary  lesion. 
It  most  commonly  affects  the  tongue  or  jaw,  and  causes  a  chronic  fibrosing 
inflammation  (the  wooden  tongue,  big  jaw,  or  '  osteo-sarcoma  '  of  cattle). 
These  often  suppurate  in  many  places,  producing  multiple  chronic  abscesses, 
which  discharge  externally  and  leave  a  diffuse  inflammatory  mass  riddled 
with  sinuses.  The  pus  from  such  abscesses  contains  small  yellow  or  brown 
gritty  bodies  (often  looking  like  grains  of  iodoform)  which  consist  of  colonies 
of  the  fupgi,  sometimes  undergoing  calcareous  changes.  The  structure  of 
these  colonies  may  be  made  out  by  crushing  the  particles  between  two  slides 


192 


A   MANUAL  OF  SURGERY 


and  staining  the  film  thus  produced,  but  is  better  seen  by  an  examination  of 
sections,  liat  h  colony  consists  of  a  tangled  mass  of  mycelium,  the  central 
portion  of  which  often  shows  the  presence  of  '  chain  sj)ores,'  whilst  the  peri- 
pheral part  has  a  definite  radial  arrangement,  from  which  the  organism  derives 
its  name.  The  mycelial  filaments  which  project  from  the  outer  portion  of 
the  colony  are  often  greatly  thickened,  and  appear  in  the  form  of  Indian  clubs, 
the  narrow  ends  being  pointed  inwards  (Fig.  45).  These  '  clubs  '  were  for- 
merly thought  to  be  rej^roductive  organs,  but  are  probably  caused  by  a 
degeneration  of  the  sheaths  of  the  filaments. 

In  Man  the  disease  is  very  similar  in  its  clinical  characters,  and  may  be  caused 
by  a  number  of  organisms  belonging  to  the  streptothrix  group,  so  that,  strictly 
speaking,  it  is  not  a  specific  disease.  The  organisms  form  colonies  in  the 
tissues  resembling  those  seen  in  cattle,  but  the  radially-arranged  clubs  at 
the  periphery  are  difficult  to  stain,  and  hence  usually  appear  to  be  absent 
(Fig.  46).  The  cultural  characters  in  different  cases  are  not  constant,  but 
all  the  .streptothrices  which  affect  man  stain  by  Gram's  method. 

Actinomycosis  is  found  to  be  not 
uncommon  when  a  systematic  ex- 
amination is  made  of  the  pus,  etc., 
from  all  patients  treated  ;  when  this 
is  not  done,  a  considerable  number 
are  diagnosed  as  tuberculosis  or  sy- 
philis. It  usually  occurs  in  farmers, 
millers,  and  others  who  are  brought 
in  contact  with  grain,  and  in  a  few 
cases  infection  from  these  materials 
may  be  definitely  traced.  In  many 
cases  the  fungus  enters  the  body 
from  a  carious  tooth  or  from  the 
tonsil,  and  the  primary  lesion  is 
usually  somewhere  in  the  region  of 
the  mouth.  Less  frequently  it  may 
occur  in  other  parts  of  the  alimen- 
tary canal,  especially  in  the  caecum, 
appendix  (causing  a  condition  which 
may  not  be  diagnosed  from  ordinary 
appendicitis  in  the  absence  of  a 
microscopic  examination),  or  in  the 
The  apparent  absence  of  the  radially-  liver,  giving  rise  to  a  very  character- 
arranged  clubs  '  is  very  obvious.         istic  reticulated  swelling,  in  which 

diffuse  suppuration  may  occur. 
Again,  it  may  be  primary  in  the  lung,  causing  lesions  similar  to  those  of 
tuberculosis,  and  often  giving  rise  to  localized  empyemata.  The  skin  may  also 
be  affected,  but  in  the  majority  of  cases  only  by  extension  from  the  deeper 
tissues.  Lastly,  a  few  cases  of  primary  actinomycosis  of  the  central  nervous 
system  have  been  recorded. 

The  structure  of  these  lesions  resembles  that  of  a  tubercle,  except  that  giant 
cells  are  perhaps  less  frecjuent  (the  disease  being  usually  more  rapid),  and  the 
centre  of  the  nodule  is  occupied  by  a  characteristic  colony  of  the  fungus.  At  a 
later  period  the  lesion  breaks  down  and  forms  pus,  containing  the  granular 
nodules  described  above.  The  disease  is  very  chronic,  and  has  a  tendency  to 
spread  locally ;  although  not  dangerous  in  itself,  it  may  become  so  by  attacking 
important  organs,  or  by  generalization,  giving  rise  to  pyaemic  abscesses  in  all 
parts  of  the  body. 

The  commonest  site  for  the  primary  lesion  is  close  to  the  angle  of  the  jaw, 
where  it  constitutes  a  cervico-facial  growth  of  tolerably  characteristic  appear- 
ance. At  first  the  mass  has  a  smooth,  regular,  and  even  surface,  and  merges 
gradually  into  the  surrounding  tissues;  the  skin  over  it  is  usually  hyperaemic. 
As  time  passes,  little  nodular  excrescences,  with  a  peculiar  yellowish  apex,  form 
here  and  there  on  the  surface  of  the  tumour,  and  these  finally  soften,  point,  and 
burst,  giving  exit  to  a  small  amount  of  glutinous  pus,  in  which  the  actino- 


FiG.  46. — Colony  of  Human  Actino- 
myces,   AS    SEEN    IN    Pus. 


SPECIFIC  INFECTIVE  DISEASES 


193 


myces  can  be  demonstrated.  When  all  the  mycelium  has  Deen  Uib- 
charged,  the  abscess  contracts  and  the  wound  closes.  The  cicatrization 
induced  by  the  constant  repetition  of  this  process  makes  the  surface  of  the 
mass  curiously  nodular  and  puckered  (Fig.  47),  and  this  appearance,  when 
present,  is  almost  pathognomonic.  At  other  times  sinuses  persist,  and  the 
affected  area  may  become  riddled  with  them.  Trismus  is  an  almost  constant 
symptom  in  the  cervico-facial  form  of  the  disease,  coming  on  early,  and  being 
apparently  independent  of  the  size  of  the  mass  or  its  involvement  of  nerve... 

Treatment  consists  in  the  administration  of  large  doses  of  iodide  of  potas- 
sium (grs.  20  to  30  three  times  a  day)  or  of  some  of  the  organic  preparations 
of  iodine,  which  seem  to  have  almost  as  great  an  influence  in  this  disease  as 
in  syphilis.  This  alone  may  suffice  when  there  is  no  open  wound  ;  but  if  open 
sores  are  present,  surgical  measures  must  also  be  employed.  Extirpation  of 
all  the  infiltrated  tissue,  either  by  the  knife  or  by  vigorous  scraping  after 
opening  up  sinuses,  should  be  undertaken,  and  the  part  fieely  cauterized; 


:^ 


Fig.  47. — Cervico-Facial  Actinomycosis.     (By  kind  Permission  of 
Sir  Malcom  Morris.) 

in  fact,  it  must  be  treated  in  exactly  the  same  way  as  a  diffuse  tuberculous 
mass.  This  can,  however,  only  be  carried  out  very  partially  in  the  visceral 
affections,  where  the  disease  may  prove  fatal,  n-ot  so  much  from  the  primary 
affection  as  from  associated  pyogenic  complications.        .  .  .  ^ 

Mycetoma  or  Madura  Foot  is  a  condition  somewhat  akin  to,  but  not  identical 
with,  actinomycosis.  It  occurs  in  natives  of  India  and  some  other  tropical 
countries,  and  is  induced  by  walking  bare-footed,  infection  following  some 
slight  abrasion  or  injury.  It  is  characterized  by  the  development  of  black 
or  yellow  nodules,  in  the  centre  of  an  indurated  inflamed  area  ;•  the  nodules 
break  down  and  give  exit  to  pus,  which  contains  blacMsh  nodules  constituted 
by  the  organism.  Gradually  these  abscesses  spread  throughout  the  foot., 
which  becomes  disorganized  and  distorted,  and  the  disease  may  even  encroach 
on  the  leg  if  neglected.  The  affection  is  extremely  chronic,  and  merely 
spreads  by  local  extension.  Treatment  consists  in  amputation  of  the  limb, 
if  limited  scraping  and  disinfection  are  insufficient.  The  administration  of 
iodides  is  useless. 


13 


CHAPTER  IX. 

TUMOURS  AND  CYSTS. 

Although  the  term  '  tumour  '  is  often  used  for  any  abnormal 
swelling  which  may  be  met  with  in  the  body,  yet  lor  scientific 
purposes  its  application  is  much  more  limited.  A  tumour  may  be 
defined  as  '  a  mass  of  new  formation  that  tends  to  grow  or  persist, 
without  fulfilling  any  physiological  function,  and  with  no  typical 
termination.'  The  fact  that  rt  has  no  typical  termination  dis- 
tinguishes it  from  inflammatory  overgrowths,  which  always  lead 
sooner  or  later  to  the  formation  of  fibro-cicatricial  tissue  or  some 
modification  of  it ;  inflammatory  growths,  moreover,  ma}'  disappear 
completely,  and  often  diminisli  in  size  temporarily.  Pure  hyper- 
trophies are  excluded  by  this  definition,  since  they  always  depend 
more  or  less  on  some  increased  physiological  function,  and  are 
composed  of  an  increased  development  of  normal  tissiies,  as,  for 
instance,  the  blacksmith's  biceps.  Congenital  overgrowth  of  a  limb 
or  portion  of  a  limb  also  occurs,  and  is  known  as  '  gigantism  ';  it 
cannot  be  considered  a  tumour,  being  merely  an  exaggerated 
development  of  normal  tissues. 

.etiology. — The  most  definite  fact  known  is  that  in  a  considerable 
number  of  cases  (variously  calculated  at  7  to  14  per  cent.)  they 
follow  some  injury  or  irritation,  which  determines  an  abnormal 
development  of  the  tissues  of  the  part.  Thus,  an  adenoma  of  the 
breast  is  often  attributed  to  a  blow,  and  tlie  irritation  of  a  clay 
pipe  may  produce  epithelioma  of  the  lip.  In  India  the  natives  of 
Kashmir  wear  under  their  robes  an  earthenware  pot  or  kangri, 
suspended  from  the  waist,  and  containing  smouldering  charcoal ;  the 
heat  of  this  leads  to  chronic  eczema  of  the  abdominal  wall,  and  this 
is  in  turn  frequently  followed  by  squamous-celled  carcinoma.  In 
some  cases  the  irritation  may  be  due  to  chemical  substances  such  as 
soot  (in  the  case  of  chimney-sweeps),  tar,  or  petroleum,  all  of  which 
occasionally  lead  to  the  production  of  epithelioma  in  persons  brought 
much  into  contact  with  them  ;  except  in  these  cases,  occupation  is 
not  known  to  exercise  any  influence  m  the  causation  of  tumours. 

The  question  of  heredity  as  a  predisposing  factor  is  still  unsettled. 
It  was  formerly  thought  to  be  of  considerable  importance,  but  recent 
observations  and  statistics  have  not  strengthened  this  \aew. 

19.1 


TUMOURS  AND  CYSTS  195 

The  geographical  distribution  of  tumours  has  only  been  inves- 
tigated in  the  case  of  cancer.  The  result  tends  to  show  that  the 
disease  is  most  common  in  low-lying,  damp,  well-wooded  areas, 
especially  if  they  are  liable  to  periodical  floods,  as,  for  example,  the 
Thames  Valley.  It  also  seems  proved  that  certain  houses  claim 
more  than  their  average  proportion  of  victims  from  cancer;  this  has 
been  taken  to  indicate  an  infectious  origin  for  the  disease,  but  other 
interpretations  are  possible. 

The  age-incidence  varies  with  the  type  of  tumour.  Most  innocent 
forms  may  occur  at  any  age,  though  to  this  rule  there  are  several 
interesting  exceptions — e.g.,  adenomata  of  the  breast  and  ftbro- 
myomata  of  the  uterus,  which  grow  only  during  the  period  of 
functional  activity;  and  certain  osteomata,  which  arise  from  ossi- 
fying cartilage  and  continue  their  growth  only  during  the  acti\nty 
of  that  structure.  In  the  malignant  tumours  the  age-incidence  is 
better  marked.  Sarcomata  occur  at  all  ages,  but  are  especially 
common  in  the  first  half  of  life,  whilst  carcinomata  are  rare  before 
the  age  of  thirty,  and  most  common  after  forty. 

The  effect  of  sex  on  the  incidence  of  the  innocent  tumours  and  the 
sarcomata  is  not  marked.  Women  are  more  liable  to  carcinomata 
than  males,  in  large  measure  owing  to  the  frequency  wth  which 
this  disease  attacks  the  uterus  and  breast ;  cancer  of  the  mouth  and 
other  portions  of  the  alimentary  canal  is  more  common  in  men. 

Many  theories  have  been  brought  forward  to  explain  the  patho- 
genesis of  tumours,  but  the  only  ones  that  need  be  mentioned  are  the 
three  following:  (i)  The  parasitic  theory  rests  mainly  on  analogy 
with  undoubtedly  infectious  diseases,  and  has  been  formulated 
chiefly  for  the  malignant  growths.  There  is  at  first  sight  a  close 
clinical  similarity  between  cancer  and  the  infective  granulomata, 
especially  tubercle;  in  each  there  is  a  primary  lesion  marked  by 
invasion  and  destruction  of  tissues,  followed  by  secondary  growths 
in  the  glands  or  internal  organs,  reproducing  the  structure  of  the 
primary  focus.  But  the  analog}^  is  only  superficial ;  the  secondary 
tubercles  are  due  to  the  carrying  of  the  infective  agents  (the  bacilli) 
in  the  blood  or  lymphatic  stream  to  distant  regions,  where  they  are 
deposited,  and  continue  to  grow  and  give  rise  to  an  inflammatory 
reaction.  The  secondary  nodules  of  cancer  are  caused  by  the 
transference  in  the  blood  or  lymph  of  actual  cancer  cells  derived 
from  the  primary  tum.our,  which  are  deposited  elsewhere,  and  con- 
tinue their  growth  undisturbed,  in  spite  of  their  change  of  en\dron- 
ment.  So-called  '  cancer  parasites  '  have  been  described  by  numer- 
ous pathologists,  but  are  now  generally  recognised  as  degenerated 
leucoc3^tes  or  red  corpuscles  within  the  cancer  cells,  or  as  portions 
of  nuclei,  etc.  A  few  investigators  claim  to  have  cultivated  blasto- 
mycetes  from  cancers,  and  to  have  produced  cancers  by  the  injection 
of  the  cultures  into  animals,  but  these  results  have  not  been  generally 
accepted. 

Recent  researches,  though  not  solving  the  problems  of  the  origin 
and  nature  of  cancer,  have  yielded  much  valuable  and  suggestive 


196  A   MANUAL  OF  SURGERY 

information.  Most  of  these  researches  have  been  carried  out  in  mice, 
the  tumours  of  which  (adeno-carcinoma  of  the  breast,  sarcoma, 
chondroma,  etc.)  are  inoculable  into  other  animals  of  the  same 
species.  The  mouse  is,  however,  the  only  animal  in  which  carcinoma 
has  been  successfully  propagated  (Bashford).  It  has  been  possible 
to  transfer  mouse-cancer  to  rats,  but  the  disease  quickly  dies  out. 

It  is  essential  that  living  cells  or  fragments  of  tissue  should  be 
inoculated  if  successful  results  are  to  follow.  The  fragment  con- 
tinues to  grow  in  its  new  host,  and,  since  the  transplantations  can  be 
carried  on  (as  far  as  is  known)  indeftnitely,  a  minute  portion  may 
continue  to  develop  in  one  animal  after  another  until  many  pounds' 
weight  of  cancer  has  been  produced.  It  would  appear,  therefore, 
that  the  essential  character  of  a  malignant  cell  is  its  power  of 
indehnite  growth  and  division  independently  of  the  surrounding 
tissues,  provided,  of  course,  that  these  are  of  suitable  nature.  The 
connective  tissue  of  the  graft  atrophies  and  disappears.  The  inocu- 
lation of  these  tumours  is  not  comparable  with  that  of  tubercle  or 
other  infective  diseases.  In  the  latter  case,  any  cehs  derived  from 
the  first  animal  soon  die,  but  the  micro-organism  continues  to  live 
and  produce  fresh  tissue  changes  in  the  new  host.  In  the  former, 
the  cells  themselves  five  and  divide,  and  do  not  induce  any  cancerous 
changes  in  the  cells  of  the  second  animal.  Hence  there  is  some 
analogy  between  these  cancer  cells  and  the  known  parasites,  which 
are  capable  of  indefinite  life  and  subdivision  in  suitable  hosts ;  more- 
over, if  cancer  is  actually  due  to  a  parasite  (which  appears  more  and 
more  improbable),  this  must  be  contained  within  the  malignant  cell. 
Inoculation  experiments  are  followed  by  a  comparatively  small 
proportion  of  successes,  indicating  that  conditions  must  be  present  in 
the  tissues  or  blood  of  the  host  which  are  favourable  to  the  growth 
of  the  tumour.  Some  tumours  are,  however,  highly  virulent,  yield- 
ing a  large  proportion  of  successes,  and  there  is  usually  an  increase 
in  virulence  brought  about  by  repeated  inoculations. 

The  question  of  immunity  has  also  been  raised.  That  natural 
immunity  exists  follows  from  the  facts  that  not  all  inoculations  are 
attended  by  success,  and  that  mice  from  different  localities  show 
very  different  degrees  of  susceptibihty  to  the  same  tumour.  That 
immunity  can  be  acquired  appears  from  the  observation  that  a  mouse 
unsuccessfully  inoculated  with  a  tumour  of  low  virulence  becomes 
refractory  to  tumours  of  great  infective  power  to  normal  mice. 

2.  The  theory  of  foetal  residues  was  originated  by  Virchow's  sug- 
gestion that  in  the  ossihcation  of  cartilage  small  islets  might  be  left, 
which  subsequently  grow  and  develop  into  chondromata;  the 
idea  was  at  a  later  date  expanded  by  Cohnheim  to  include  all 
tumours.  It  certainly  affords  an  explanation  of  some  varieties  of 
growth,  such,  for  instance,  as  the  dermoid  cysts,  which  originate  in 
portions  of  epidermic  structures  left  behind  during  embryonic 
development;  but  it  fails  to  explain  the  origin  of  most  tumours. 

3.  Ribbert's  theory  of  tissue  tension  is  especially  applicable  to 
the.  carcinomata,  and  attributes  the  initial  defect  to  a  weakness 
in  the  connective  tissues  in  proximity  to  the  epithelial  cells,  so  that 


TUMOURS  AND  CYSTS  197 

the  latter  are  allowed  to  proliferate  and  invade  the  surrounding 
structures.  The  balance  of  evidence  seems  decidedly  opposed  to 
this  theory,  although  it  affords  a  satisfactory  explanation  of  the 
frequency  of  carcinomata  in  advanced  life,  when  the  vitality  and 
resisting  power  of  the  tissues  may  be  assumed  to  be  lowered. 

Tumours  may  be  divided  into  two  great  classes  from  a  clinical 
standpoint,  viz.,  the  benign  and  the  mahgnant. 

Benign  or  Simple  Tumours  are  characterized  by  their  more  or  less 
exact  limitation,  being  frequently  encapsuled,  and  by  their  method 
of  growth.  The  surrounding  tissues  are  merely  pushed  aside  and 
compressed  by  the  increasing  growth  of  the  part ;  pain  and  atrophy 
are  sometimes  caused  by  this  pressure.  The  capsule  is  formed  by 
an  ensheathing  layer  of  fibro- cellular  tissue,  the  outcome  of  the 
chronic  irritation  and  inflammation  engendered  by  the  growth ; 
hence  enucleation  is  easy,  and  recurrence  uncommon.  They  are 
not  unfrequently  multiple,  and  may  be  hereditary ;  but  there  is  no 
tendency  to  produce  secondary  growths.  They  cause  no  cachexia 
and  do  not  threaten  hfe  unless  developing  in  or  upon  some  part 
whereby  the  vital  functions  are  impaired. 

Malignant  Tumours,  unless  removed  by  operation,  are  almost  in- 
variably fatal.  The  following  are  the  chief  characteristics  of 
mahgnancy:  (i)  The  primary  growth  is  usually  single,  rarely  multi- 
ple. (2)  It  progresses  steadily  and  constantly,  but  with  varying 
rapidity  in  different  cases.  (3)  The  local  development  is  charac- 
terized by  an  infiltration  of  the  surrounding  tissues,  which  are 
gradually  destroyed  and  replaced  by  the  tumour  substance.  A 
capsule  is  rarely  formed,  or,  if  at  all,  only  in  the  early  stages,  and 
thus  the  limits  of  the  growth  are  not  clearly  defined.  Moreover, 
many  varieties  spread  locally  along  the  efferent  lymphatics,  and 
hence,  although  the  growth  may  appear  to  have  been  completely 
excised,  recurrences  are  very  common,  owing  to  the  non-removal 
of  these  invisible  extensions  of  the  disease  into  apparently  normal 
tissue.  If  a  malignant  tumour  with  all  its  ramifications  is  com- 
pletely removed,  it  does  not  recur.  (4)  When  a  mahgnant  tumour 
invades  the  skin,  it  usually  leads  to  ulceration  and  is  very  Hable  to 
secondary  infection,  and  then  not  uncommonly  a  foul  fungating 
mass  results  (the  fungus  hcematodes  of  the  older  pathologists). 
(5)  Secondary  deposits  due  to  embohc  dissemination  of  the  cells  of 
the  growth  are  often  found  in  neighbouring  lymphatic  glands  or 
distant  viscera.  (6)  Cachexia  develops  injthe  later  stages,  partly 
due  to  the  pain,  partly  to  the  pressure  of  the  growth  on  important 
structures,  and  in  part  to  the  absorption  of  toxic  products  from  the 
tumour.  The  patient  becomes  thin  and  emaciated,  the  face  drawn 
and  with  an  expression  of  pain  on  it ;  the  appetite  is  impaired  and 
the  skin  often  sallow  and  earthy-looking.  Pyrexia  is  usually  absent 
unless  ulceration  of  the  growth  occurs,  as  is  usually  the  case  in  the 
stomach  or  intestine;  some  rapidly-growing  sarcomata  of  bones  are 
also  associated  with  fever.  (7)  Finally,  death  ends  the  scene,  after 
a  longer  or  shorter  period  of  suffering. 

The  degree  of  malignancy  varies  with    different  tumours.     In 


198  A   MANUAL  OF  SURGERY 

some  the  local  phenomena  predominate,  whilst  in  others  the  con- 
stitutional symptoms  are  the  more  important.  Thus,  rodent  ulcer 
is  slow  in  its  progress,  and  produces  no  visceral  deposits;  it  destroys 
life  merely  by  implication  of  vntal  parts.  Melanotic  sarcoma,  on  the 
other  hand,  may  produce  only  a  small  i)rimary  growth,  but  the  most 
extensively  diffused  secondary  deposits  may  form  in  the  viscera. 
The  sarcomata  are  usually  disseminated  by  the  blood-stream,  and 
hence  secondarv  growths  are  not  very  common  in  lymphatic  glands, 
whilst  the  carcinomata  spread  bv  means  of  the  lymphatics.  Even 
among  the  latter  considerable  differences  are  manifested;  thus,  in 
glandular  cancer  secondary  growths  occur  both  in  the  lymphatics 
and  the  viscera;  whilst  in  squamous  epithelioma  neighbouring 
lymphatics  are  affected,  but  the  viscera  usually  escape. 

As  a  general  rule  malignant  tumours  differ  structurally  from  the 
innocent  forms  in  deviating  more  widely  from  the  normal  histology 
of  the  region  in  which  they  develop ;  thus,  a  simple  adeno-fibroma  of 
the  breast  approaches  more  closely  to  the  structure  of  the  normal 
mammary  gland  than  does  an  adeno-carcinoma  of  the  same  region. 
This  deviation  from  the  normal  is  called  anaplasia,  and  in  general  the 
greater  the  degree  of  anaplasia  the  greater  the  malignancy.  It  is 
seen  in  the  structure  of  the  cells  as  well  as  in  their  arrangement,  and 
in  highly  malignant  tumours  the  constituent  cells  to  a  large  extent 
lose  their  distinctive  appearance  [e.g.,  prickle-cells  lose  their  prickles, 
etc.),  and  revert  to  more  simple  forms.  Highly  specialized  functions 
are  also  lost  or  badly  performed. 

Classification  of  Tumours. — The  following  is  a  practical  scheme  of 
classification,  based  partly  on  the  structure  of  the  tumour,  and  partly 
on  that  of  the  tissue  from  which  it  originates  : 

I.  Tumours  derived  from  the  Connective  Tissues  : 

{a)   Of  embryonic  tvpe :  Sarcoma. 

(b)  Of  adult  type:  Myxoma,  lipoma,  fibroma,  etc. 

II.  Tumours  composed  Wholly  or  Chiefly  of  Epithelium. — These 
may  resemble  papillse  or  glands,  or  may  infiltrate  the  connective  tissue 
in  a  wholly  irregular  way,  and  hence  may  be  subdivided  as  follows: 

(a)  ^Tumours  resembling  papillse: 

r  Squamous-celled. 
f  ,    '    I     Papilloma   \  Cuboidal-celled. 

[  Columnar-celled. 

{h)  Tumours  resembling  glands: 

A  1^     ™        rCuboidal-celled. 
Adenoma     ^  ^  ,  ,-.   . 

\  Columnar-celled. 

(c)  Atypical  tumours: 

{Squamous-celled  (epithelioma). 
Cuboidal-celled  (glandular  carcinoma). 
Columnar-celled. 

III.  Tumours  growing  from  Endothelium  : 

Endothelioma  and  perithelioma. 

IV.  Tumours  formed  by  the  Inclusion  of  Part  of  another  Embryo  ; 

Teratoma 


TUMOURS  AND  CYSTS  199 

I.  The  Connective-Tissue  Group  of  Tumours  :  (i)  Tumours 
composed  of  Embryonic  Connective  Tissue. 

Sarcoma  (  =  a  flesh-like  tumour;  Greek,  crap^,  flesh). — A  sarcoma 
is  a  mahgnant  tumour  which  consists  of  a  parenchyma,  formed  of 
cells  which  have  taken  on  the  power  of  continued  and  apparently 
limitless  growth,  and  of  a  more  or  less  inert  supporting  network  or 
stroma  consisting  of  fibrous  tissue,  bloodvessels,  etc.  It  is  charac- 
teristic of  the  sarcomata  that  these  two  elements  are  intimately 
mingled  together,  each  parench^nna  cell  being  separated  from  its 
neighbours  by  delicate  fibrilte  of  the  stroma;  in  the  carcinomata 
the  parenchvma  cells  occur  in  masses  or  alveoli  which  are  enclosed 
by,  and  sharply  marked  off  from,  the  stroma.  Sarcomata  are  of 
mesoblastic  origin,  and  the  parenchjana  cells  resemble  those  from 
which  the  connective  tissues  are  formed  in  the  embryo  both  in 
shape  and  in  their  capacity  for  continued  growth;  hence  they  are 
often  referred  to  as  embryonic  connective-tissue  cells.  Inflamma- 
tory new  formations  are  also  composed  of  mesoblastic  cells  which 
have  assumed  the  power  of  growth,  and  in  both  cases  these  em- 
bryonic cells  may  undergo  organization  into  more  mature  forms  of 
connective  tissue,  such  as  fibrous  tissue  or  bone.  There  is,  how- 
ever, this  marked  difference  between  the  two :  the  inflammatory  new- 
formations  arise  as  the  result  of  a  definite  irritant,  and  cease  to  spread 
when  that  irritant  ceases  to  act;  whereas  the  sarcomata  usually 
arise  without  apparent  cause,  and  continue  to  spread  indefinitely. 

A  sarcoma  may  at  first  be  well  defined  or  even  encapsulated ;  but 
many  forms  from  the  first,  and  all  later  on,  infiltrate  the  surrounding 
tissues,  replacing  them  with  their  own  particular  structure,  a  process 
which  can  be  well  observed  in  sarcomata  of  muscles.  The  blood- 
supply  is  very  abundant,  and,  indeed,  may  be  so  free  as  to  cause  the 
tumour  to  pulsate.  The  vessels  consist  of  spaces  or  clefts  within 
the  tumour  substance,  and  are  lined  merely  by  the  most  delicate 
endothelium ;  the  arteries  and  veins  in  the  neighbourhood  are  much 
dilated.  Interstitial  haemorrhage  is  frequent,  owing  to  the  thinness 
of  the  vessel  walls,  and  cysts  may  in  this  way  be  produced.  Dis- 
semination is  usually  dependent  on  the  relation  of  the  tumour  to  the 
veins.  As  already  stated,  the  veins  communicate  with  spaces 
hollowed  out  of  the  tumour  substance;  into  and  along  these  the 
sarcomatous  tissue  may  burrow,  until  the  apex  of  this  intravascular 
growth  projects  into  the  lumen  of  a  vessel  in  which  the  blood  is  freely 
circulating.  It  may  be  detached  by  some  shght  mechanical  injury, 
and  is  then  carried  away  as  a  malignant  embolus ;  if  a  large  portion 
is  set  free,  as  in  sarcoma  of  the  kidney,  it  may  lodge  in  the  right  side 
of  the  heart,  or  in  the  lungs,  and  cause  a  fatal  result.  Smaller  emboli 
are  either  detained  in  the  lungs,  or  pass  through  into  the  general 
circulation,  giving  rise  to  secondary  growths  wherever  they  are 
arrested ;  general  visceral  implication  is  often  secondary  to  the  pul- 
monary growths.  Occasionally  dissemination  by  way  of  the  lym- 
phatic glands  is  met  with,  especially  in  melanotic  sarcoma  of  the 
skin,  lympho-sarcoma,  and  sarcoma  of  the  tonsil,  testis,  and  thyroid 


200  A   MANUAL  OF  SURGERY 

body,  and  tliis  in  spite  of  the  fact  that  lyni})liatics  are  not  known 
to  be  present  in  sarcomata. 

The  various  forms  of  sarcoma  described  ])elo\v  liavc  a  tendency 
to  become  organized  into  tissues  which  ])ear  a  close  resemblance  to 
the  normal  connective  tissues,  and  tumours  in  which  this  process 
has  taken  place  to  a  marked  extent  often  receive  special  names — e.g., 
fibro-sarcoma,  in  which  the  parench^ona  cells  become  organized  into 
fibrous  tissue;  osteo-sarcoma,  in  which  they  develop  into  bone; 
chondro-sarcoma;  and  lipo-sarcoma.  The  secondar}-  deposits 
usuallv  resemble  closely  the  parent  tumour;  thus  masses  of  osteoid 

,,  _,^^  _  -,^.^    :•  ■..-,-  tissue   may  develop  in 

>^c5^*^'i*^^"U^^''^"^--W     -    •''-'      *^^     ^^"Ss     when    the 


^'^:&*f,>^'''^^:.'a'^:T^  - -;^        '-^^v^sS?^  primary   growth   is   an 

Y^^i:.r:W-^^^'i^^  '•'.'.  '  -  A    '**--'^-^--;*'^"-»  osteo-sarcoma. 
tjg'-"  .j'^^y'ri  .> ''S****;  — *4"-:  ^"iv'-'ri'^-  IS  y'        Degenerative  changes 

'^^"^^p*,t^^"   "^V--^  /'^'^'ir"-^^-'^"'''  of    a   fattv   or   mucoid 

older  por- 

coma, 

cystic 

malig- 

tumour 

affected. 

is  frequent 

er  varieties, 

ion  is  not 

the  more 


X^^K^^^^Z^^^^^'^^'W^MB'^        On  naked-eye  exam- 

-^-    ,  .:^>j^.>^.*i*;>^':^,^.^<!-^r^%^£:    ination,  a  sarcoma  pre- 

I-iG.    4,-..  ^  Small    Round -celled    Sarcoma,     gg^ts     a    more    or    less 

SHOWING  THE  ADVANCING  Edge  OF  THE    hon^Q^gneous   appear- 

Growth  infiltrating  Muscle  and  Sali-  9,  ,         rV_ 

VARY  Gland.    (xi2o.)  ance,  the  colour  varying 

with  the  amount  of  the 
blood-supply,  from  a  grayish-white  in  the  fibro-sarcoma  to  a  deep 
red  in  the  small  round-celled.  Its  consistencv,  whether  hard  or  soft, 
depends  on  the  amount  of  stroma  present;  the  more  malignant  are 
usually  soft  and  mav  pulsate  visibly ;  the  more  chronic  are  often  hmier. 
Sarcoma  occurs  most  commonly  in  young  and  middle-aged 
people,  especially  affecting  the  first  and  fourth  decades  of  life;  it 
may  also  be  congenital.  The  degree  of  malignancy  varies  con- 
siderably, some  forms  being  almost  benign,  or,  at  any  rate,  only 
locally  malignant,  w^hilst  others  are  exceedingly  virulent  in  nature. 
Sarcomata  are  divided  artificially  into  the  following  groups, 
depending  on  the  size,  shape,  arrangement,  and  character  of  the 
constituent  cells : 

{a)  Round-celled  Sarcomata  (Fig.  48)  usually  consist  of  a  mass  of 
small  round  cells  containing  a  very  definite  circular  or  oval  nucleus; 
the  intercellular  substance  is  slight  in  amount,  and  often  homo- 


TUMOURS  AND  CYSTS 


geneous  in  character.  The  mass  is  very  vascular,  and  may  even 
pulsate;  it  is  soft,  like  granulation  tissue,  and  usually  grows  rapidly. 
It  is  extremely  malignant,  infiltrating  surrounding  parts,  and  early 
giving  rise  to  secondary  deposits;  lymphatic  glands  are  not  unfre- 
quently  affected  in  this  variety.  The  small  size  of  the  cells  is  thought 
to  be  an  indication  of  the  rapidity  of  development,  since  they  divide 
before  growing  to  a  large  size.  Any  part  of  the  body  may  be 
involved,  and  it  may  be  met  with  at  any  age.  Lympho- sarcoma  is 
a  variety  of  this  type  in  which  the  intercellular  substance  is  of  a 
delicate  reticular  nature,  corresponding  to  the  retiform  tissue  met 
with    in    lymphatic 


glands.  It  grows 
rapidly,  and  is  ex- 
ceedingly malignant ; 
it  usuall}/  starts  in 
l5nnphatic  glands,  or  in 
the  lymphoid  tissue  of 
mucous  membranes, 
and  is  disseminated  by 
means  of  the  lym- 
phatics. For  the 
clinical  characters  of 
lympho-sarcomata,  see 
Chapter  XV. 

The  large  rotmd-celled 
sarcoma  is  an  un- 
common variety  made 
up  of  larger  cells,  which 
contain  one  or  two  large 
oval  nuclei  with  an 
abundant  protoplasm 
around.  A  well-marked 
stroma  is  interspersed 
between  the  cells,  and 
an  alveolar  arrangement  is  sometimes  present ;  it  occurs  in  the  same 
position  as  the  former,  but  is  rather  less  malignant. 

(b)  Spindle-celled  Sarcomata  (Fig.  49)  consist  of  large  or  small 
spindle  cells,  which  are  often  arranged  in  a  somewhat  fasciculated 
manner  with  a  greater  or  less  amount  of  intercellular  substance. 
When  consisting  of  small  cells,  the  tumour  grows  rapidly,  and  is  firmer 
and  less  succulent  than  the  round-celled  variety.  They  may  originate 
in  any  part  of  the  body,  but  more  especially  from  aponeuroses, 
fasciae,  tendons,  etc.,  constituting  localized  growths,  which  are  at 
first  tolerably  well  defined,  but  later  on  invade  and  infiltrate  sur- 
rounding parts.  When  growing  rapidly,  the  cells  become  less  fusi- 
form in  shape,  and  may  even  approach  to  the  round  cell  in  character, 
after  passing  through  a  stage  known  as  the  oval  or  oat-shaped 
sarcoma.  A  few  giant  cells  are  often  seen  in  these  cases.  These 
^umours,  consisting  of  small  spindle  cells,  are  usually  very  malignant. 


Fig.  49. 


Some  of  the  fibres  are  running  in  longitudinal 
bundles ;  others  are  cut  transversely. 


202  A   MANUAL  01-   SUliGERY 

In  some  icw  cases  the  cells  undergo  organization  into  well-formed 
librous  tissue,  and  the  tumour  closely  resembles  a  simple  hbroma, 
being  well  defined.  These  tumours  are  known  as  fibro-sarcomata 
('  recurrent  fibroid  '  tumours  of  Paget),  and  are  not  uncommon  in 
the  subcutaneous  tissues.  They  are  on  the  border-line  of  malig- 
nancy, since  they  rarely  form  secondary  growths,  and  often  do  not 
return  for  two  or  three  years  after  removal.  After  each  operation, 
however,  they  usually  recur  more  rapidly,  and  show  signs  of  greater 
malignancv,  until,  after  perhaps  being  removed  a  dozen  times,  they 
recur  with  all  the  characters  of  an  ordinary  spindle-celled  sarcoma. 

The  large  spindle-celled  sarcomata  arc  softer  and  of  a  deeper  colour 
than  the  former.  They  grow  from  the  fibroiis  tissues,  and  not 
uncommonly  from  the  viscera.  The  congenital  sarcoma  of  the 
kidney  is  of  this  nature,  though  some  of  the  cells  become  transversely 
striated,  looking  like  muscle  fibres;  such  tumours  are  sometimes 
called  '  mvo-sarcomata.' 

(c)  Alveolar  Sarcoma  is  a  variety  in  which  the  cells  are  grouped 
together  in  alveoli,  separated  by  a  distinct  fibrous  stroma.  On 
microscopic  examination  the  section  closely  resembles  cancer;  but 
on  carefully  pencilling  it  with  a  camel's-hair  brush,  it  will  be  found 
that  the  stroma  sends  delicate  prolongations  between  each  of  the 
cells.  It  is  quite  possible  that  the  majority  of  these  tumours  are  in 
reality  endotheliomata.  They  are  most  commonly  found  growing 
from  the  skin,  are  occasionally  of  a  melanotic  nature,  and  often  very 
malignant. 

((/)  Melanotic  Sarcoma  is  the  most  virulent  of  all  this  group  of 
tumours,  because  of  the  early  date  at  which  it  forms  secondary 
deposits  in  lymphatic  glands  and  internal  organs.  It  grows  from 
those  portions  of  the  body  which  are  naturally  pigmented,  especially 
the  choroid  coat  of  the  eye  and  the  skin.  Those  growing  from  the 
former  situation  are  usually  composed  of  spindle  cells,  all  of  which 
contain  granules  of  melanin;  these  choroidal  tumours  are  true 
sarcomata,  and  have  a  special  tendency  to  form  secondary  deposits 
in  the  liver.  The  melanomata  of  the  skin  most  frequently  develop 
from  pigmented  moles  (Plate  IV.,  Fig.  i).  They  have  an  alveolar 
structure,  and  were  formerly  regarded  as  alveolar  sarcomata,  but 
most  pathologists  now  follow  Unna  in  regarding  the  tumour  cells  as 
being  derived  from  downgrowths  of  the  surface  epithelium,  and 
classify  the  tumours  themselves  as  carcinomata.  The  pigment 
granules  in  this  form  are  very  unevenly  distributed,  some  lying  in 
the  stroma  between  the  alveoli,  whilst  others  are  contained  in  the 
cells;  some  portions  of  the  primary  tumour  are  often  quite  free  from 
pigment,  and  some  of  the  secondary  growths  are  often  colourless, 
whilst  adjacent  growths  may  be  absolutely  black.  The  nature  of 
the  pigment  (melanin)  is  still  uncertain,  but  the  fact  that  it  does  not. 
contain  iron  seems  to  indicate  that  it  is  not  derived  from  haemoglobin. 
It  may  be  deposited  in  the  skin  of  the  patient  apart  from  the  tumours 
(melanosis),  or  may  be  excreted  in  the  urine. 

If  the  primary  tumour  is  not  removed  very  early,  the  nearest 


I'LATE   IV. 


:s^ 


Fis[.   i.^Melanotic  Sarcoma  of  Buttock,  with  secondary  coloured  nodules  in  the 
line  of  the  lymphatics  between  the  growth  and  the  inoperable  inguinal  glands. 


Fig.  2. — Fungating  Carcinoma  of  outer  side  of  the  right  Breast  (Fungus 
Hi^matodes)  with  dissemination  through  skin  between  the  growth  and  the  nipple,  and 
around  the  nipple,  constituting  an  eczematous-looking  patch,  somewhat  akin  to 
Paget's  disease. 

\To  face  page  202. 


TUMOURS  AND  CYSTS  203 

lymphatic  glands  are  soon  affected,  and  secondary  deposits  in  the 
viscera  follow.  The  original  tumour  is  often  not  very  large,  and  the 
secondary  deposits  are  frequently  characterized  by  their  number 
rather  than  by  their  size,  scarcely  an  organ  in  the  body  being  free. 

Of  late  years  a  more  benign  type  of  cutaneous  melanosis  has  been  described, 
and  is  now  well  recognised  by  dermatologists.  It  usually  spreads  from  a  con- 
genital  mole  as  a  deeply  pigmented  patch,  which  may  extend  over  an  area  of 
several  square  inches,  and  presents  at  first  no  sign  of  induration  or  infiltration ; 
in  this  stage  microscopic  examination  reveals  no  change  in  texture  except 
pigmentation  of  the  deeper  layers  of  the  cutis  vera.  Sooner  or  later,  a  tumour 
develops  in  the  centre  of  this  patch ;  it  is  not  very  rapid  in  its  coui'se,  but  if  left 
alone  will  finally  become  disseminated.  In  treating  this  type  of  melanosis,  it  is 
essential  to  remove  every  portion  of  pigmented  tissue  as  well  as  the  tumour. 

The  Treatment  of  sarcoma  consists  in  its  removal  as  early  and 
completely  as  possible.  This  may  be  a  simple  matter  in  cases  where 
the  tumour  is  encapsuled,  but  even  then  recurrence  is  very  hkely  to 
follow  unless  the  capsule  is  also  taken  away,  and  a  considerable 
margin  of  tissue  beyond  it.  Where,  however,  the  growth  is  more 
diffuse,  the  only  hope  hes  in  cutting  widely,  so  as  to  get  beyond  its 
furthest  hmits,  and  it  may  be  advisable  to  remove  the  skin  over  it 
and  the  lymphatic  area  leading  from  it ;  the  prognosis  of  such  cases 
is  very  bad. 

In  cases  where,  owing  to  the  position  of  the  growth  or  its  extent, 
complete  removal  is  impossible,  a  partial  operation  may  be  feasible, 
scraping  or  cutting  away  part  of  the  tumour,  and  stopping  the 
haemorrhage  by  the  cautery  or  by  packing.  Radio-therapy  may 
then  be  employed,  sometimes  with  distinct  advantage,  in  the  form 
either  of  X  rays  or  of  radium.  In  the  former  case  the  rays  are 
applied  two  or  three  times  a  week  for  an  hour  or  so  at  a  sitting, 
but  care  is  taken  that  the  same  area  is  not  exposed  unduly,  so  as 
to  prevent  X-ray  burns.  In  the  latter  the  radium  may  advisably 
be  buried  in  the  tumour  substance  for  twenty-four  hours  or  more, 
and  then  removed  (p.  57). 

In  hopelessly  inoperable  cases  somewhat  similar  measures  have 
been  employed  as  for  the  similar  stage  of  cancer  {vide  p.  226). 
Many  cures  have  been  recorded  from  th-e  use  of  Coley's  fluid,  which 
consists  of  a  sterihzed  culture  of  the  Streptococcus  pyogenes  and 
Micrococctts  prodigiosus  in  bouillon.  This  fluid  is  intensely  toxic, 
and  the  injections,  commencing  with  doses  of  half  a  minim,  are 
gradually  increased  up  to  7  or  8  minims  or  more;  severe  reaction 
usually  follows,  and  the  surgeon  should  aim  at  obtaining  two  or 
three  such  effects  each  week.  The  fluid  is  introduced  partly  into 
the  abdominal  wall,  and  partly  into  or  around  the  tumour.  If  it 
is  going  to  do  any  good,  the  improvement  is  manifest  in  a  few  days, 
and  as  the  course  of  treatment  proceeds  the  growth  gradually 
dwindles.  The  patient  is  treated  for  three  or  four  weeks  at  a 
time,  and  then  given  a  rest,  as  the  repeated  reactions  are  very 
trying,  and  to  persist  in  this  treatment  requires  much  pluck  and 
patience.  The  results  obtained  in  this  country  hitherto  have  been 
very  disappointing,  possibly  owing  to  the  ineffective  character  of 


204 


A   MANUAL  OF  SURGERY 


the  Colcy's  fluid  available;  but  the  author  has  certainly  kept  one 
tumour  in  check  for  years  by  this  means.  The  growth  is  probably 
a  chondro-sarcoma  of  the  ilium,  and  from  time  to  time  the  patient 
comes  up  to  have  a  short  course  of  treatment  on  account  of  a  re- 
currence of  the  pain,  and  hitherto  improvement  has  consistently 
followed  the  injections. 

(2)  Tumours  consisting  of  Connective  Tissue  of  Adult  Type. 

Myxoma. — A  myxoma  is  a  tumour  consisting  of  connective- 
tissue  cells,  surrounded  by  and  separated  from  each  other  by  an 
intercellular  substance  of  a  mucoid  character;  a  similar  type  of 
material  occurs  normally  in  the  substance  of  the  umbilical  cord. 
The  cells  are  usually  polygonal  in  shape,  and  present  long  branched 
processes  which  interlace  with  those  from  adjacent  cells.  The 
intercellular  substance  is  homogeneous  and  translucent,  containing 
wandering  connective-tissue  corpuscles,  and  traversed  by  blood- 
vessels; the  density  of  the  tumour  varies  inversely  with  the  amount 
of  intercellular  substance.  It  is  not  uncommon  for  this  form  of 
growth  to  be  associated  with  sarcoma,  and  hence  a  thorough  and 
early  removal  of  the  mass  is  always  advisable. 

Myxomata  occur  as  rounded  tumours,  perhaps  lobulated,  in  the 
neighbourhood  of  mucous  membranes — e.g.,  the  face,  intestine,  and 
bladder;  they  also  grow  in  the  sheaths  of  nerves,  and  are  the  com- 
monest form  of  simple  tumour  of  the  spinal  cord. 

Lipoma. — A  fatty  tumour  is  an  overgrowth  of  fibro-cellular  tissue 
infiltrated  with  fat.     On  microscopical  examination  it  differs  in  no 

respect  from  ordinary  adipose 
tissue,  and  is  not  very  freely 
supplied  with  bloodvessels. 

When  localized  (Fig.  50)  it 
forms  a  tumour,  soft  and  semi- 
fluctuating  in  consistence,  roun- 
ded and  lobulated  in  outline, 
and  if  occurring  in  the  sub- 
cutaneous tissues,  the  skin  be- 
comes dimpled  on  moving  it 
from  side  to  side,  owing  to  the 
fact  that  fibrous  trabeculae  pass 
from  the  capsule  to  the  skin. 
The  growth  is  usually  encap- 
suled  and  freely  moveable ;  but  if 
exposed  to  pressure  or  friction, 
as  when  situated  on  a  man's 
shoulder  and  rubbed  by  the 
braces,  it  becomes  firmly  ad- 
herent to  surrounding  structures.  Such  growths  are  either  single 
or  multiple,  in  the  latter  case  perhaps  occurring  in  hundreds,  and 
are  most  commonly  found  about  the  trunk  or  the  upper  extremities. 


Fig.  50. — Lipoma,  showing  Charac- 
teristic Lobulated  Outline. 
(From    King's    College    Hospital 

Museum.) 


TUMOURS  AND  CYSTS  205 

Occasionally  subcutaneous  tumours  become  pedunculated  and  pen- 
dulous, especially  about  the  upper  part  of  the  thigh. 

The  diagnosis  of  a  subcutaneous  lipoma  from  a  chronic  abscess  is 
made  by  noting  that  in  the  former  there  is  a  defined  outhne  of  a 
lobulated  character,  that  the  edge  shps  away  on  making  pressure 
over  it,  and  that  the  skin  dimples  on  moving  the  growth  from  side 
to  side.  In  a  chronic  abscess  the  swelhng  is  less  defined  in  outhne, 
has  a  shelving  margin,  and  the  skin  is  either  quite  free  or  adherent 
over  a  considerable  area.  Fluctuation  is  present  in  both,  since  fat 
at  the  temperature  of  the  body  is  fluid. 

Deep  intermuscular  lipomata  occur,  and  the  diagnosis  is  often 
uncertain,  since  their  mobility  and  lobulated  outline  are  masked  by 
the  superjacent  tissues;  they  have  even  been  mistaken  for  sarcom- 
atous growths.  Still  more  difficult  of  recognition  are  those  known 
as  Parosteal  Lipomata,  growing  from  the  outer  surface  of  the  peri- 
osteum. They  are  often  congenital,  and  appear  as  soft  swellings, 
lying  beneath  the  muscles  in  close  proximity  to  a  bone  and  suggesting 
the  presence  of  a  chronic  abscess. 

A  painful  lipoma  of  the  foot*  has  been  described- (Tubby)  as  occur- 
ring on  the  inner  side  of  the  sole,  causing  great  pain  on  walking  and 
simulating  flat-foot.  Removal  by  operation  is  necessary,  and  must 
be  very  thorough,  if  recurrence  is  ,to  be  avoided. 

Pericranial  Lipoma  is  of  a  somewhat  similar  nature.  It  is  usually 
congenital  in  origin,  and  the  cranium  may  be  hollowed  out  beneath 
it.  An  angiomatous  element  is  sometimes  present  in  these  growths 
(nsevo-hpoma). 

Locahzed  overgrowths  are  often  met  with  in  the  subperitoneal 
fatty  tissue,  constituting  Subserous  Lipomata.  They  occur  not  un- 
frequently  in  the  lower  part  of  the  abdomen,  and  may  extend  into 
the  inguinal  and  crural  canals.  By  their  traction  a  process  of  peri- 
toneum may  eventually  be  drawn  down,  and  a  true  hernia  produced- 
A  similar  condition  occurs  in  the  anterior  abdominal  wall,  small 
pedunculated  masses  of  fat  projecting  through  congenital  or  ac- 
quired openings  in  the  hnea  alba  or  hnea  semilunaris;  these  are 
known  as  Fatty  Hernia  of  the  Linea  Alba,  and  are  often  painful. 

Occasionally  the  connective-tissue  basis  of  a  hpoma  undergoes 
modifications;  e.g.,  it  may  become  increased  in  amount,  and  fibrous 
in  character;  it  may  be  associated  with  a  myxomatous  element,  or 
even  become  sarcomatous.     For  navo-lipoma,  see  p.  355. 

By  the  term  Diffuse  Lipoma  (Fig.  51)  is  meant  a  fatty  infiltration 
of  the  subcutaneous  tissues  of  some  region  of  the  body,  particularly 
beneath  the  chin  and  at  the  back  of  the  neck,  and  more  rarely  in  the 
pubic  region.  These  growths  are  often  multiple  and  almost  always 
symmetrical.  They  usually  occur  in  men  who  drink  beer  freely  and 
take  but  little  exercise.  Their  size  sometimes  diminishes  on  hmiting 
the  amount  of  alcohol  and  making  the  patient  do  physical  work. 

In  some  of  these  cases  the  term  '  diffuse  '  is  not  strictly  merited,  as 
the  growths  are  in  reahty  hmited,  but  the  hmitations  are  difficult  to 
*  American  Journal  of  OrthopcBdic  Surgery,  Ma3^  1909. 


2o6 


A   MANUAL  OF  SURGERY 


dcrme  in  the  midst  of  the  surrounding  fat.  Tln'X'  have  a  consider- 
able tendency  to  burrow,  and  by  their  pressure  on  important  organs 
may  sometimes  lead  to  serious  symptoms. 

A  somewhat  different  type  of  fatty  overgrowth  is  met  with 
generally  in  women  about  the  climacteric,  in  whom  masses  of  fat 
accumulate  in  various  parts  of  the  body,  associated  with,  and 
perhaps  preceded  by,  severe  jxiin  of  a  neuralgic  type,  constituting 
the  condition  known  as  Adiposis  dolorosa  (l)ercum's  disease).  There 
is  but  little  doubt  that  the  affection  is  a  manifestation  of  hypo- 
thyroidism, since  the  th\-roid  body  is  xisually  delicient  and  the 
mental  state  dull,  whilst  the  administration  of  thyroid  extract  is 

beneficial.  Somewhat 
akin  to  this  is  the 
deposition  of  subcu- 
taneous fat  together 
with  loss  of  function 
or  atrophy  of  the  geni- 
tal organs  associated 
with  absence  or  de- 
struction of  the  pitui- 
tary body. 

The  Treatment  of 
lipomata  consists  in 
their  removal.  When 
they  are  loosely  en- 
capsuled,  this  is  a  very 
simple  matter,  all  that 
is  required  in  many 
cases  being  to  squeeze 
the  mass  forwards  be- 
tween the  thumb  and 
finger,  making  the  skin 
tense  over  it,  and  then 
to  incise  the  capsule 
freely,  when  the  tumour  almost  jumps  out;  but  if  there  are  many 
adhesions  it  may  not  be  so  easy.  In  the  diffuse  forms  dietetic  and 
hygienic  measures  should  first  be  tried,  and  possibly  the  prolonged 
administration  of  thyroid  extract  (grs.  5  every  night)  will  suffice  to 
diminish  their  bulk.  Should  an  operation  be  required,  it  is  well  to' 
cut  through  the  whole  thickness  of  the  tumour  at  once,  and  deal  with 
each  half  separately,  dissecting  it  away  from  its  deep  attachments. 


Fig.  51. — Diffuse  Lipoma. 


Fibromata  consist  of  overgrowths  of  fibrous  tissue;  they  were 
formerly  divided  into  two  groups,  the  hard  and  the  soft,  and  although 
there  is  no  essential  difference,  it  is  a  useful  clinical  distinction. 

The  Hard  Fibroma  is  composed  of  firm  dense  tissue,  which  creaks 
on  section  with  the  knife,  the  exposed  surface  showing  numerous 
trabecule  of  glistening  fibres,  similar  in  character  to  those  met  with 
in  a  tendon  (Fig.  52).     Microscopically,  interlacing  fibrillar  are  seen, 


TUMOURS  AND  CYSTS  207 

which  are  sometimes  arranged  concentrically  around  the  blood- 
vessels; there  are  but  few  nucleated  cells  in  the  mcjre  slowly  growing 
tumours.  The  vascular  supply  is  somewhat  defective,  although 
dilated  veins  are  often  present  in  the  capsule,  and  sometimes  in  the 
substance  of  the  mass;  these,  if  opened  by  ulceration,  may  lead  to 
profuse  haemorrhage.  Hard  fibromata  are  met  with  in  the  form  of 
epulis,  keloid,  fibrous  polypus  of  the  naso-pharynx,  and  not  un- 
commonly in  the  sheaths  of  nerves. 

Soft  Fibromata  develop  as  localized  overgrowths  of  the  subcu- 
taneous fibro-cellular  tissues,  and  may  be  rapid  in  their  onset,  and 
then  somewhat  resemble  a  sarcoma,  or  slow  in  their  growth,  ap- 


FiG.  52. — -Section  of  Hard  Fibroma.     (Royal  College  of  Surgeons' 

Museum.) 

proximating  more  to  the  type  of  a  hpoma.  Sometimes  they  become 
more  or  less  pedunculated,  constituting  what  is  known  as  a  molhis- 
cum  fibrosum,  and  then  may  appear  as  rounded  smooth-topped 
nodules,  or  may  be  pink  in  colour  and  covered  with  somewhat 
corrugated  skin,  looking  like  a  nipple,  or  may  develop  into  large 
pendulous  folds.  '  In  the  latter  instance  the  condition  is  usually 
a  manifestation  of  neuro-fibromatosis  (p.  213). 

Chondroma. — Cartilaginous  tumours  grow  in  connection  with 
either  bone  or  cartilage.  They  consist  of  hyaHne  cartilage,  which 
instead  of  being  uniform  in  texture  and  devoid  of  vessels,  as  at  the 
articular  ends  of  bones,  occurs  in  the  form  of  pellets  or  nodules  of 
varying  size,  held  together  by  vascular  connective  tissue,  which  may 


2o8 


A   MANUAL  OF  SURGERY 


even  penetrate  into  its  substance.  The  cells  are  also  less  regular  in 
shape  than  is  the  case  with  normal  cartilage,  and  are  not  arranged 
according  to  any  definite  plan. 

Chondromata  are  liable  to  become  calcified,  and  even  ossified. 
When  large,  the  central  parts  may  undergo  a  mucoid  change,  giving 
rise  to  a  cavity  which,  if  infection  is  admitted,  becomes  exceedingly 
foul.  They  are  not  uncommonly  accompanied  in  their  growth  by 
sarcomatous  and  other  elements. 

Chondromata  of  the  smaller  bones  are  not  uncommon,  be'ng 
usually  seen  in  the  hands  of  young  people,  and  are  frequently 
multiple  (Fig.  53).  The  growth  commences  in  the  interior,  close 
to  the  epiphyseal  cartilage,  and  results  in  expansion  of  the  bone, 

the  hand  becoming  thereby  deformed. 
Treatment  consists  inincising  the  cap- 
sule, and  scooping  out  the  cartilaginous 
tissue,  a  proceeding  which  may  result 
in  defective  growth  and  subsequent 
deformity.  In  the  later  stages,  how- 
ever, amputation  is  inevitable. 

When  growing  from  the  long  bones, 
chondromata  usually  start  from  be- 
neath the  periosteum,  and  are  inde- 
pendent of  the  epiphyseal  cartilage, 
although  it  was  suggested  by  Virchow 
that  they  originate  from  a  nodule  of 
cartilage  displaced  from  its  usual  situa- 
tion during  an  attack  of  rickets.  They 
constitute  firm  lobulated  encapsuled 
tumours,  and  give  rise  to  no  pain, 
except  when  they  encroach  on  neigh- 
bouring nerves.  They  often  attain  a 
great  size.  The  growth  may  extend 
secondarily  into  the  medullary  canal, 
and  thus  cause  expansion  of  the  bone ; 
or  it  may  erode  the  compact  tissue,  and 
lead  to  spontaneous  fracture.  Amputation  of  the  limb  will  probably 
be  necessary,  unless  the  case  comes  under  observation  in 'the  early 
stages,  when  the  tumour  can  be  gouged  or  scraped  away. 

Overgrowths  of  cartilage,  known  as  Ecchondroses,  occur  around 
the  articular  cartilages  in  connection  with  osteo-arthritis;  they  also 
arise  from  the  cartilages  and  septum  of  the  nose,  and  from  the 
laryngeal  cartilages.  Some  of  the  loose  bodies  which  form  in  joints 
are  of  a  similar  nature. 


Fig.  53. — Multiple  Chondro 

MATA    OF    THE    FiNGERS. 


Osteoma.- — Bony  tumours  are  of  two  chief  forms:  the  cancellous 
and  the  ivory. 

Cancellous  Osteomata  are  usually  met  with  growing  near  the 
articular  end  of  a  bone,  being  derived  originally,  from  some  isolated 
portion  of  the  epiphyseal  cartilage,  which  has  perhaps  been  separated 


TUMOURS  AND  CYSTS 


209 


from  its  original  connection  after  an  attack  of  rickets.  If  such  an 
island  be  placed  near  the  periphery  of  the  bone,  it  is  easy  to  under- 
stand its  development  into  a  tumour,  which  consists  of  cancellous 
bone,  capped  by  a  layer  of  hyaline  cartilage,  from  which  it  grows 
(Figs.  54  and  55).  It  is  pedunculated  or  sessile,  and  may  attain  to  a 
large  size,  leading  to  considerable  deformity.  It  necessarily  de- 
velops in  young  people,  and  may  be  congenital.  As  the  individual 
grows,  the  basis  of  attachment  may  become  separated  from  the 
epiphysis  to  an  extent  corresponding  to  the  amount  of  growth 
which  has  taken  place  at  that  spot,  or  it  may  still  remain  attached 
to  the  epiphyseal  line.  As  a  rule  its  growth  and  development  cease 
at  maturity,  when  the  cartilage  covering  it,  as  well  as  the  epiphyseal 
cartilage,    ossifies.     A    bursa    occasionally    forms    over    the    most 


Fig.  54. — Cancellous  Osteoma 
OF  Lower  End  of  Femur 
(Semi-diagrammatic,  from  a 
Skiagram). 


Fig.  55. — The  Same,  with  Oste- 
oma DIVIDED  Longitudinally 
TO  show  the  Extent  of  the 
Investing  Cartilage. 


prominent  part  of  these  tumours  as  a  result  of  friction  or  pressure, 
giving  rise  to  the  condition  known  as  exostosis  hursata  ;  this  cavity 
may  communicate  with  the  j  oint.  An  effusion  of  blood  or  serum  into 
the  bursa  may  be  the  first  evidence  of  the  existence  of  such  a  growth. 
Multiple  exostoses  are  not  unfrequently  met  with,  and  are  then  often 
inherited.  The  most  common  situation  for  such  a  tumour  is  the 
inner  condyle  of  the  femur,  close  to  the  adductor  tubercle  (Fig.  54), 
and  it  may  cause  discomfort  there  by  its  size,  especially  when  ridmg. 
The  upper  end  of  the  tibia  is  sometimes  affected,  and  when  the 
growth  develops  on  the  inner  side,  trouble  may  arise  from  hitching 
of  the  tendons  there  inserted  over  the  neck  of  the  growth,  causing 
painful  locking  of  the  knee.  The  suhungual  exostosis  (Fig.  56) 
develops  as  a  rounded,  cherry-hke  swelling  under  the  nail  of  the 
great  toe.     It  is  very  painful,  and  should  be  treated  by  removing 


A   MANUAL  OF  SURGERY 


the  nail,  incising  the  tissues  over  it  down  to  the  bone,  and  cutting 
it  away  with  pliers  or  gouge. 

Ivory  Exostoses  develop  most  frequently  on  the  inner  or  outer 
aspect  of  the  cranial  bones,  especially 
affecting  the  orbit,  external  auditory 
meatus,  antrum,  and  frontal  sinus  (Fig. 
57).  They  consist  of  masses  of  very 
dense  compact  tissue,  covered  by  peri- 
osteum, from  which  they  grow.  They  are 
usually  lobulated,  and  when  situated  in 
the  frontal  sinus,  or  growing  from  the 
under  surface  of  the  skull,  may  give  rise 
to  serious  symptoms  from  irritation  or 
compression  of  the  brain  or  its  mem- 
branes. In  a  few  cases  necrosis  has 
resulted,  and  they  have  sloughed  out. 
Fig.  56.— Subungual  Exos-  thus  bringing  about  a  spontaneous  cure. 
Tosis.     (Bland  Sutton.)  Occasionally  diffuse  overgrowths  of  the 

bones  of  the  skull  (Hyperostoses)  are  met 
with,  affecting  either  the  calvarium  alone,  being  then  probably 
syphilitic  in  nature,  or  the  facial  and  cranial  bones,  as  in  leontiasis 
ossea.     New   formation  of   bone  also  occurs  in  the   substance   of 


Fig.  57. — Ivory  Exostosis  growing  from  Frontal  Sinus,  and  encroaching 

BOTH  ON  the  Orbit  and  the  Cranial  Cavity. 

(From  Specimen  in  the  College  of  Surgeons'  MiLseum.) 

muscles  and  tendons  which  are  exposed  to  irritation  or  excessive 
action — e.g.,  the  tendon  of  the  adductor  longus  in  riders,  producing 
what  is  known  as  '  the  rider's  bone  '  (Chapter  XVIIL). 
The   Treatment  of  osteomata  consists  in   their   removal   when 


TUMOURS  AND  CYSTS 


necessary.  This  may  be  simple  in  the  case  of  the  cancellous  osteo- 
mata  of  the  limbs,  but  is  sometimes  a  formidable  proceeding  when 
deahng  with  compact  exostoses  of  the  calvarium.  The  fact  that 
cancellous  osteomata  cease  to  grow  when  the  patient  reaches 
maturity  explains  the  rule  of  surgery  that  they  do  not  need  to  be 
removed  unless  causing  pain  or  mechanical  inconvenience  by  their 
size.  After  careful  purification  a  suitable  incision  is  made,  the 
tumour  exposed,  and  its  limits  defined.  It  is  chiselled  or  sawn  away 
from  its  attachment  to  the  bone,  special  attention  being  directed  to 
the  total  removal  of  the  covering  cartilage,  since  growth  continues 
unless  this  is  completely  excised. 

Compact  osteomata  of  the  cranium  may  be  set  free  and  removed  by 
chiselling  away  the  bone  around  them,  but  occasionally  a  burr  driven 
by  electricity  is  required  in  order  to  divide  their  attachments ;  they 
should  not,  however,  be  touched  unless  causing  obvious  symptoms. 

Myeloma. — This  tumour,  which  was  formerly  described  as  a 
myeloid  sarcoma,  is  in  reality  derived  from  the  bone  marrow,  and 
is  benign  in  its  nature. 
It  is  characterized  by 
the  presence  of  large 
numbers  of  multi- 
nucleated giant  cells 
{myeloplaxes)  .imbedded 
in  a  considerable  quan- 
tity of  round  or  spindle 
cells,  the  intercellular 
substance  being  usually 
of  a  gelatinous  nature 
(Fig.  58).  The  myeloid 
cells  vary  a  good  deal 
in  size,  but  always  con- 
tain many  nuclei,  which 
are    not    distributed 

regularly  in  the  peri-  ,  .  ,,  ^  ►»  i-H-r-^.i-^m 
phery  of  the  cell,  as  in  ^A;5:?^<'^"!|x|>tTS^ 
"of     ^^H,'*^^"*^!'    Ji^^ 


the  giant  cells 

tubercle;  they  may  be 

regular    in    OutUne,    or     Fig.    58.— Myeloma,     showing     the    Multi- 

°  1  J      •      +  rv,  NUCLEATED     MYELOID     CeLLS     (MyELOPLAXES) 

proiongea  mto   numer-         lying      amongst      the     More     Abundant 
OUS    interlacing    pro-         Round  and  Spindle  Cells,    (x  100.) 
cesses,    although   these 

latter  are  usually  not  very  evident.  There  is  also  no  definite 
arrangement  of  cells  around  them,  as  in  the  tubercular  giant-cell 
systems.  These  tumours  are  soft  in  consistency,  and  on  scraping  a 
slimy  fluid  is  obtained.  They  are  very  vascular,  and  may  pulsate. 
Haemorrhage  into  their  substance  is  common,  giving  rise  to  cysts, 
filled  with  serum  and  a  yellowish  fibrinous  clot.  When  fresh,  the 
growing  edge  is  of  a][dark  maroon  colour  on  section,  and  has  been 


212  A   MANUAL  OF  SURGERY 

likened  to  the  appearance  of  a  pomegranate;  when  preserved  in 
spirit,  these  tumours  are  always  of  a  characteristic  brown  colour, 
owing  to  the  formation  of  haematin.  They  never  give  rise  to  secon- 
dary deposits.  Their  growth  is  tolerably  rapid,  and  they  may 
attain  enormous  dimensions.  For  particulars  as  to  tlunr  clinical 
characters,  see  Chapter  XXI. 

Diffuse  Myelomatosis,  or  myelojmthic  albumosuria,  is  a  condition  in  which 
the  manovv  oi  t\\v  vi^rtebrae,  sternum,  and  ribs,  and  occasionally  of  the 
long  bones,  is  transformed  into  a  structure  closely  resembling  that  of  the 
myelomata.  The  bony  tissue  is  absorbed,  and  deformity  or  spontaneous 
fracture  may  result.  It  is  associated  with  the  presence  in  the  urine  of 
albumosc,  which  is  precipitated  at  a  comparatively  low  temperature,  and 
redissolved  on  boiling. 

Myoma. — Myomata  almost  always  consist  of  tinstriped  muscle 
fibres  (Leiomyoma  or  fibromyoma),  forming  rounded  and  often 
encapsuled  tumours,  the  cells  of  which  are  long  and  fusiform,  and 
contain  a  rod-like  nucleus.  Bundles  of  these  cells  are  grouped 
together  into  fasciculi,  which  are  arranged  more  or  less  regularly. 
The  tumours  themselves  are  not  very  vascular,  but  vessels  of  con- 
siderable size  are  found  in  the  capsule.  It  is  often  difficult  to  dis- 
tinguish these  tumours  microscopically  from  fibromata  on  the  one 
hand,  and  from  fibro-sarcomata  on  the  other.  From  the  former 
they  are  known  by  the  fact  that  individual  cells  can  be  recognised, 
and  by  the  absence  of  wavy  tendinous  fibrillge;  from  the  latter  the 
distinction  depends  on  the  facts  that  other  types  of  tissue  may 
occur  in  the  sarcoma,  and  that  the  growing  edge  is  usually  more  or 
less  embryonic  in  character,  whilst  a  myoma  is  of  the  same  structure 
throughout.  Again,  in  a  myoma  the  bloodvessels  have  distinct  and 
definite  walls,  and  in  a  sarcoma  they  are  simply  clefts  or  passages 
in  the  tumour  substance. 

Myomata  are  met  with  in  the  uterus,  occasionally  in  the  prostate, 
and  more  rarely  in  the  walls  of  the  alimentary  canal  or  in  the  ovary. 
Secondary  changes  sometimes  occur — e.g.,  mucoid  softening,  calcifi- 
cation, ulceration  with  profuse  haemorrhage,  and  possibly  consequent 
inflammation,  whilst  malignant  disease  may  supervene. 

Tumours  consisting  of  striped  muscle  fibres  (Rhabdomyoma)  have 
been  described,  but  are  exceedingly  rare. 

Neuroma. — True  Neuroma  is  seldom  met  with,  only  five  undoubted 
cases  being  on  record.  It  consists  of  a  mass  of  newly-formed 
ganglion  cells  and  nerve  fibres,  which  may  be  medullatcd  or  not. 
It  affects  children  or  young  people,  and  usually  involves  the  sympa- 
thetic system.  The  tumours  may  attain  considerable  dimensions,  are 
often  multiple,  and  may  be  quite  soft,  like  a  lipoma,  or  firm.  They 
are  insensitive  and  innocent,  and  may  be  freely  removed  if  necessary. 

False  Neuromata,  or  those  developing  in  connection  with  the 
sheaths  of  nerves,  are  more  common,  and  may  be  described  under 
three  headings : 

I.  Localized  Pseudo-Neuroma,  which  may  be  innocent  or  malig- 
nant, the  former  being  a  fibroma  or  myxoma,  the  latter  usually  a 


TUMOURS  AND  CYSTS  213 

sarcoma.  It  may  project  from  one  side  of  the  nerve,  or  more 
frequently  the  nerve  fibres  are  spread  out  over  it.  It  moves  more 
freely  at  right  angles  to  the  axis  of  the  nerve  than  along  its  course. 
When  developing  from  a  small  nameless  subcutaneous  twig,  it  is 
termed  a  painful  subcutaneous  nodule,  and  gives  rise  to  intense 
radiating  neuralgic  pain,  especially  when  compressed  or  irritated, 
or  when  exposed  to  cold.  A  false  neuroma  growing  from  a  larger 
mixed  nerve  [trunk  neuroma)  is  less  painful,  because  there  are  rel- 
atively fewer  nerve  fibrillae,  and  the  mass  is  less  exposed.  A  growth 
on  a  pure  motor  nerve,  though  sensitive,  is  not  associated  with 
radiation  of  pain.  It  is  uncommon  for  tumours  of  this  type  to 
cause  complete  paralysis  or  anaesthesia,  unless  they  are  of  a  mahg- 
nant  nature.  They  occur  most  frequently  in  healthy  adults,  and 
in  women  a  little  more  commonly  than  in  men. 

Treatment. — A  neuroma,  if  painful,  should  be  removed,  care  being 
taken,  if  possible,  not  to  interfere  with  the  continuity  of  the  nerve 
fibrillce,  the  section  of  the  sheath  being  made  in  the  long  axis.  If 
this  cannot  be  accomplished,  the  nerve  must  be  divided,  the  growth 
removed,  and  the  ends  subsequently  sutured  together.  In  remov- 
ing a  pamful  subcutaneous  nodule  it  is  unnecessary  to  endeavour 
to  save  the  nerve. 

The  malignant  pseudo-neuroma,  as  already  stated,  is  sarcomatous 
in  character,  and  develops  at  first  in  the  sheath  of  the  nerve,  spread- 
ing longitudinally,  but  subsequently  involves  the  tissues  around. 
Chnically,  it  presents  at  first  the  phenomena  of  a  simple  growth,  but 
its  course  is  more  rapid  and  painful,  and  if  involving  a  motor  nerve 
paralysis  is  induced.  The  main  nerve  trunks  are  usually  affected, 
and  it  may  be  possible  to  treat  the  case  by  amputation ;  failing  that, 
nerve  section  above  the  growth  may  be  required  to  relieve  the  pain. 

2.  Diffuse  or  Generalized  Neuro-Fibromatosis. — This  consists  of 
a  diffuse  thickening  of  the  nerve  sheaths,  causing  multiple  elliptic  or 
spherical  tumours,  or  a  generalized  enlargement.  The  growths  may 
be  encapsuled  and  limited,  or  not;  they  may  be  few  in  number, 
or  hundreds  may  be  present,  and  they  are  usually  whitish  and  firm 
in  texture.  They  originate  from  the  endoneurium  of  the  primary 
nerve  bundles.  Any  part  of  the  peripheral  nervous  system  may  be 
affected,  including  the  sympathetics,  but  it  is  most  common  in  con- 
nection with  the  cranial  nerves  and  the  large  plexuses  of  the  trunk. 
The  actual  symptoms  are  sometimes  very  slight,  but  the  tumours 
may  be  sensitive  to  pressure,  and  some  of  them,  more  exposed 
than  the  others,  may  be  exquisitely  tender.  Motor  phenomena  are 
rare,  and  paralysis  is  usually  due  to  involvement  of  the  nerve 
roots  in  the  spinal  canal,  or  to  the  supervention  of  sarcoma,  which 
is  a  not  uncommon  termination.  The  disease  may  start  at  any  time 
during  life,  and,  although  progressing  slowly,  sooner  or  later  ter- 
minates fatally.  No  known  treatment  is  of  any  avail,  but  should 
any  particular  tumour  become  large  and  tender,  it  may  be  removed. 

A  Plexiform  Neuroma  is  a  special  modification  of  this  process, 
occurring  congenitally  or  in  young  people,  and  usually  involving  the 


214 


A   MANUAL  OF  SURGERY 


trigeminal  or  superficial  cervical  nerves;  it  may  be  associated  with 
the  former  condition.  The  overgrowth  is  of  a  softer,  more  gelatinous 
type  (myxo-hbromatous),  and  the  resulting  tumour  consists  of  a 
plexus  of  thickened,  tortuous,  venuiform  strands,  of  soft  consistence, 
held  together  by  loose  connective  tissue,  but  easily  se})arable  into 
their  constituent  elements,  which  are  of  a  nodulated  character,  so 
that  the  dissected  mass  looks  '  not  unlike  grains  of  boiled  tapioca  on 
a  string  '  (Alexis  Thomson).  The  plexiform  neuroma  is  almost 
always  subcutaneous,  but  often  dips  deeply  between  and  into  the 
substance  of  muscles.     When  limited  in  extent,  the  growth  may  be 

dissected  out,  and  this 
is  usually  required  for 
cosmetic  purposes.  The 
final  prognosis  is  rather 
better  than  in  the  former 
condition,  as  secondary 
sarcomatous  changes  are 
rare. 

In  this  affection  one 
not  unfrequently  ob- 
serves a  large  develop- 
ment of  fibrous  growths 
of  the  skin,  similar  to 
what  we  have  already 
described  as  molluscum 
ftbrosum.  On  careful 
microscopical  examina- 
tion of  specimens  stained 
by  Weigert's  method, 
the  presence  of  nerve 
fibrilke  can  be  demon- 
_>^  ^^^^^S^'  strated  in  these  growths, 

^K^^i-  Hh^  '  showing    that   they   are 

really  ncuro-fibromatous 
in  origin.  So  excessive 
does  this  overgrowth 
occasionally  become 
that  a  form  of  elephan- 
tiasis is  produced — e.g., 
the  irregular  hyperplasia  of  the  scalp  tissues  known  as  a  pachy- 
dermatocele. The  association  of  molluscous  tumours  with  neuro- 
fibromatous  changes  in  the  nerves  and  cutaneous  pigmentation 
constitutes  the  affection  known  as  Recklinghausen's  disease  (Fig.  59). 
3.  The  bulb  formed  upon  the  proximal  end  of  a  nerve  after  its 
division  is  sometimes  described  as  a  neuroma  (Traumatic  Neuroma). 
It  consists  of  a  mass  of  fibro-cicatricial  tissue  containing  spaces, 
within  which  are  numbers  of  newly-formed  axis  cylinders  (p.  372). 


Fig.  59.  —  Multiple  Molluscous  1  umouks 
AND  Pigmentation  of  Skin  (A)  in  a 
Case  of  Recklinghausen's  Disease. 

(For  the  loan  of  this  block  we  are  indebted  to 
Dr.  F.  Parkes  Weber.) 


Gliomata  are  tumours  arising  from  the  neuroglia  of  the  brain 
and    spinal    cbrd,  and    occasionally   in    the   retina.     Most    of   the 


TUMOURS  AND  CYSTS  215 

growths  occurring  in  the  retina,  and  supposed  to  be  ghomata,  are 
in  reahty  round-celled  sarcomata;  the  distinction  is  one  of  some 
importance,  since  true  gliomata  are  never  followed  by  secondary 
growths.  They  consist  of  cells  (which  may  be  round,  spider-shaped, 
or  spindle-shaped)  and  of  fibres;  these  occur  in  varying  proportions 
in  different  cases,  giving  rise  to  the  hard  and  soft  var'eties.  Their 
colour  often  closely  resembles  that  of  the  brain  itself,  and  there  is 
usually  no  shaip  line  of  distinction  between  the  tumour  and  the 
surrounding  tissue.  They  vary  greatly  in  rapidity  of  growth  and  in 
vascularity,  but  are  always  benign  in  nature. 

Angioma  is  the  term  applied  to  conditions  in  which  a  new  forma- 
tion of  bloodvessels  occurs ;  aneurisms  and  varicose  veins  are,  obvi- 
ously, not  included  in  this  category.     For  a  description  see  p.  352. 

Lymphadenoma  and  Lymphangioma. — The  primiary  tumours  de- 
veloping in  connection  with  lymphatic  glands  and  vessels  are 
described  at  p.  368. 

Odontoma. — Timiours  originating  from  somxC  abnormal  condition 
of  the  teeth  or  teeth-germs  are  known  as  '  odontomes.'  Bland 
Sutton,  in  h"s  work  on  tumours,*  has  described  seven  different 
varieties,  several  of  which  are,  however,  rarely  m.et  with  in  man. 
The  more  important  of  these  are  as  follows:  (i)  Epithelial  Odon- 
tome.  In  this  condition,  also  known  as  '  fibro-cystic  disease  of  the 
jaw,'  the  mandible  is  most  commonly  affected.  A  tumour  forms, 
consisting  of  spaces  lined  by  epithelium,  which  are  developed  as 
irregular  outgrowths  from  the  enam^el  organ.  It  occurs  most  fre- 
quently in  young  adults,  and  may  give  rise  to  a  growth  of  enormous 
size.  (2)  Follicular  Odontomes,  or,  as  they  are  often  termed, 
*  dentigerous  cysts,'  are  produced  by  the  developm^ent  of  a  cavity 
around  a  misplaced  or  ill-developed  tooth  of  the  peraianent  set, 
which  often  lies  horizontally,  so  that  its  eruption  is  impossible. 
(3)  Fibrous  Odontomes  are  the  result  of  a  thickening  and  condensa- 
tion of  the  connective  tissue  around  a  tooth  sac.  They  are  most 
frequently  observed  in  the  lower  animals,  but  are  also  said  to  occur 
in  rickety  children.  (4)  Radicular  Odontome  is  the  term  applied 
to  a  tumour  composed  of  cement,  developing  at  the  root  of  a  tooth. 
It  gives  rise  to  severe  pain,  and  may  cause  suppuration  in  the  sur- 
rounding bone.  (5)  Composite  Odontomata  consist  of  a  conglomiera- 
tion  of  the  various  forms  of  tissue  entering  into  the  formation  of  a 
tooth,  and  developing  in  the  neighbourhood  of  the  jaw.  They  may 
be  very  large,  and  probably  some  of  the  bony  tumours  described  as 
osteomata  of  the  antrum  are  of  this  nature.  (See  also  Chapter 
XXVIII.) 

II.  Tumours  of  Epithelial  Origin. 

The  various  tumours  grouped  under  this  heading  are  composed 
mainly  of  epithelium,  with  a  variable  admixture  of  connective  tissue. 
They  are  derived  from  pre-existing  epithehal  structures,  and  vary  in 

*  Bland  Sutton,  '  Tumours  and  Cysts.'     Cassell  and  Co. 


2l6 


A   MANUAL  Ol-  SURGERY 


the  arrant,a'im'nt  and  character  of  the  ei)itheHum  witli  the  site  of 
origin.  Ki)itheUal  cells  can  practically  be  of  onlv  three  tvpes: 
(a)  The  spheroidal  or  cuboidal,  in  which  the  three  diameters  are 
more  or  less  equal ;  (/;)  the  Hat  or  squamous,  in  which  two  diameters 
are  long  and  one  very  short;  and  (c)  the  colunmar,  in  which  one 
diameter  is  long  and  two  are  short.  These  three  forms  of  cells  are 
found  in  most  of  the  groups  of  epithelial  tumours.  In  some  the 
structure  conforms  more  or  less  to  the  normal  type,  and  then  the 
growth  is  probably  of  an  innocent  nature,  as  in  the  papillomata  and 
adenomata;  but  when  the  structure  becomes  atypical,  the  tumour 
is  likely  to  be  malignant  and  of  a  cancerous  nature. 

Papilloma. — This  term  ought   really  to  be  limited  to  tumours 
formed  by  an  overgrowth  of  papilla;,  and  since  papillae  are  confined 

to    regions    covered    with 


-i^> 


epithelium  of  epiblastic 
origin,  they  are,  strictly 
speaking,  only  found  in 
the  skin  and  the  so-called 
'mucous  membranes,' 
which  are  morphologically 
of  the  same  nature — i.e., 
that  lining  the  mouth, 
vagina,  larynx,  anus,  etc. 
They  consist  of  the  same 
structures  as  a  normal 
papilla,  there  being  a  cen- 
tral core  of  mesoblastic 
tissue  (connective  tissues, 
vessels,  etc.)  covered  by 
squamous  epithelium, 
which  may  or  may  not 
undergo  excessive  horny 
development,  and,  like  the 
normal  papilla;,  of  which 
they  are  an  exaggeration,  they  project  outwards  from  the  general 
surface  of  the  body,  and  never  invade  the  subcutaneous  or  sub- 
mucous tissues  (Fig.  60). 

The  term  is,  however,  often  used  loosely  to  indicate  a  growth 
composed  of  a  mesoblastic  core  with  an  investment  of  epithelium; 
thus,  we  speak  of  papillomata  of  the  large  intestine,  although  in  this 
region  true  papilhe  do  not  occur.  Hence  it  becomes  convenient  to 
classify  the  papillomata  according  to  the  nature  of  the  epithelium 
with  which  they  are  covered. 

(i)  Those  covered  by  squamous  epithelium  occur  in  the  skin, 
mouth,  larynx,  etc.,  and  consist  of  bundles  of  papilhe,  which  undergo 
extensive  proliferation  and  frequently  branch,  forming  secondary 
papillae.  If  the  epithelium  undergoes  keratinization,  as  in  the 
common  warts,  they  become  hard,  and  may  constitute  horn-like 
outgrowths.     When  they  occur  in  moist  situations — e.g.,  between 


Fig.  60. — Section  of  a  Warty  Papilloma 
to  show  the  arrangement  of  the 
Epithelium. 

The  normal  skin  is  seen  on  each  side  running 
into  the  hypertrophied  papillae,  over  which 
is  heaped  up  a  mass  of  thickened  keratinized 
cuticle.  There  is  no  invasion  of  the  sub- 
cutaneous tissues,  as  in  an  epithelioma 
(cf.  Fig.  62). 


TUMOURS  AND  CYSTS 


T.l'J 


the  toes,  on  the  prepuce,  or  growing  from  mucous  membranes 
(except  that  covering  the  vocal  cords) — this  formation  of  horny 
substance  is  usually  very  imperfect,  and  the  papillomata  remain 
soft.  It  must  be  pointed  out  that  many  of  the  squamous  papillo- 
mata are  of  infective  origin,  and  not  true  tumours  at  all — e.g.,  the 
venereal  warts,  condylomata,  and  mucous  tubercles.  There  are 
also  some  reasons  for  thinking  that  warts  may  be  infective  and  due 
to  the  action  of  a  micro-organism.  Not  unfrequently  a  papilloma 
which  has  become  irritated  may  take  on  malignant  action  and  be 
transformed  into  an  epithelioma,  a  change  which  would  be  charac- 
terized clinically  by  the  base  becoming  infiltrated. 

The  papillomata  which  develop  in  the  bladder  and  pelvis  of  the 
kidney  are  covered  by  many-layered  transitional  epithelium,  and 
usually  form  long 
slender  fimbriated  tufts 
containing  dehcate 
bloodvessels,  which 
readily  give  way  and 
may  lead  to  consider- 
able haemorrhage.  Not 
unfrequently  they 
occur  in  conjunction 
with  malignant 
growths. 

(2)  Papillomata 
covered  by  ciihoidal  or 
spheroidal  epithelium 
occur  in  glandular 
structures,  especially 
in  the  breast,  kidney, 
etc. 

(3)  Papillomata 
covered  by  columnar 
epithelium  are  some- 
times found  projecting 
into  cystic  cavities  in 
other  tumours,  as  in  the  prohferous  ovarian  cysts  and  in  duct  carci- 
noma of  the  breast,  as  also  into  dilatations  of  other  ducts.  The  '  papil- 
lomata '  of  the  intestine  are  usually  either  adenomata  or  fibromata. 

Adenomata  consist  of  new  growths  arising  in  connection 
with  secreting  glands,  and  in  structure  simulating  somewhat 
closely  the  organs  from  which  they  rise  (Fig.  61).  They  differ 
from  them,  however,  in  that  they  are  incapable  of  producing 
the  character  istic  secretion,  that  they  are  devoid  of  ducts, 
and  that  the  mimicry  is  incomplete,  since  the  alveoli  are  less 
perfectly  developed,  and  may  be  entirely  occupied  by  several 
layers  of  epithelial  cells.  The  epithelium,  which  from  the  nature 
of  the  case  is  spheroidal,  cuboidal,  or  columnar  in  shape,  does 
not   pass    beyond    the   basement   membrane   into   the  connective 


Fig.  61.- 


-FlBRO-ADENOMA    OF    THE    BREAST. 
(X30.) 


2i8  A   MANUAL  OF  SURGERY 

tissue,  and  by  this  lack  of  inliltration  they  are  distin/^uished 
from  cancerous  tumours.  A  variable  amount  of  connective  tissue 
is  always  present,  and  may  be  normal  in  texture,  or  may  manifest 
various  modiiications.  Adenomata  are  single  or  multiple,  and 
usually  encapsuled,  being  merely  connected  with  the  original  gland 
by  a  pedicle,  through  which  the  vessels  enter.  When  growing 
from  mucous  membranes,  they  sometimes  become  pedunculated, 
as  in  the  so-called  polypus  recti.  The  alveoli  in  some  cases 
become  distended  with  effusion,  giving  rise  to  a  cysto-adenoma  or 
adenocele,  and  sometimes  the  tumour  projects  into  these,  consti- 
tuting intracystic  growths.  They  are  free  from  malignancy,  except 
that  occas'onally  the  connective  tissue  undergoes  a  sarcomatous 
change;  more  rarely  carcinoma  supervenes,  especially  in  the  breast. 
When  of  large  size,  they  may  cause  trouble  by  compression  of  im- 
portant structures.  Any  glandular  organs  may  become  affected 
with  adenoma — e.g.,  the  breast,  thyroid  body,  prostate,  testis,  etc. 
They  are  also  found  as  congenital  tumours  in  connection  with  the 
thyroid  body,  post-anal  gut,  and  possibly  the  kidney. 

Carcinoma, — The  malignant  forms  of  epithelial  new  growth  are 
known  as  '  cancers  '  or  '  carcinomata,'  and  are  characterized  by  the 
appearance  of  a  primary  growth,  which,  by  its  continued  develop- 
ment, infiltrates  and  destroys  the  neighbouring  tissues,  incorporating 
them  into  its  substance.  If  superficial,  the  growth  undergoes  necrotic 
changes,  resulting  in  ulceration,  which  frequently  becomes  horribly 
offensive  owing  to  the  supervention  of  a  mixed  infection.  The  disease 
spreads  along  the  lymphatics,  and  involves  neighbouring  lymphatic 
glands,  which  may  also  break  down,  or  suppurate,  and  ulcerate ;  and 
finally  general  dissemination  to  the  viscera  may  occur,  the  lungs, 
liver,  brain,  and  bone-marrow  being  specially  liable  to  invasion. 

Any  epithelial  surface  or  organ  may  be  affected  by  cancer,  but 
it  is  most  frequently  seen  in  parts  which  are  exposed  to  injury  or 
chronic  irritation.  In  the  male,  the  stomach  is  the  organ  most 
frequently  affected,  and  then  follow  in  order  the  intestines,  tongue 
and  mouth,  etc.  Eighty  per  cent,  of  all  cancers  in  the  male  sex 
affect  the  intestinal  canal;  in  the  female,  cancer  of  the  uterus,  sexual 
organs,  and  breast,  account  for  nearly  80  per  cent,  of  all  cases  of 
the  disease.  It  is  not  very  common  in  early  life,  but  increases  in 
frequency  after  thirty  years,  and  reaches  its  maximum  incidence 
between  forty  and  fifty-five  years  of  age. 

Cancers  are  classified  as  epithelioma,  columnar  cancer,  or 
spheroidal-celled  cancer,  according  to  whether  the  epithelium 
from  which  the  tumour  is  derived  is  of  the  squamous,  columnar, 
or  spheroidal  type.  The  term  '  celloid  cancer  '  is  used  to  indicate 
a  degenerative  change  occurring  in  some  forais. 

The  essential  character  of  a  cancerous  growth  consists  in  an 
unlimited  multiplication  of  the  epithelial  cells  in  the  organ  or  tissue 
attacked.  The  cells  thus  affected  lose  to  a  greater  or  less  extent 
that  interrelation  which  normally  makes  them  grow  into  glands 
or  other  structures,  so  that  in  the  mahgnant  tumours  the  epithelial 


TUMOURS  AND  CYSTS  219 

cells  form  masses  which  show  a  varying  degree  of  resemblance  to 
the  glands,  etc.,  of  the  normal  part:  in  general,  the  greater  the 
malignancy,  the  greater  the  anaplasia,  until  in  the  most  malignant 
forms  the  epithelium  is  arranged  in  masses  or  alveoh,  bearing  not 
the  slightest  resemblance  to  the  structure  from  which  it  springs. 
There  is  also  an  alteration  of  the  mutual  relations  between  the 
epithehal  cells  and  the  connective  tissue  of  the  part.  The  former 
take  on  unlimited  powers  of  growth,  but  are  not  (as  is  the  case  in 
innocent  tumours  and  in  epithelial  proliferation  due  to  irritants  or 
other  causes)  limited  by  normal  basement-membranes  and  other 
mesoblastic  elements,  but  burst  through  these,  producing  infiltra- 
tion of  surrounding  tissues.  Columns  of  epithehal  cells  can  be  seen 
to  penetrate  into  the  tissues  (Fig.  62),  following  the  Hues  of  least 
resistance,  and  usually  extending  deeply  along  the  lymph-clefts. 
There  is  thus  no  longer  a  sharp  and  definite  fine  of  demarcation 
between  the  epi- 
thelial and  con- 
nective-t  i's[s  u  e 
portions    of    the 


tumour,  but  the 
two  are  inextric- 
ably blended.    The 

epithelial  cells  ^ 

themselves  are  also  F^^-  62.-Section  of  an  Epithelioma. 

anaplastic  losing  The  normal  skin  is  seen  oh  each  side  running  into  the 
thpir  morp  ^npHal  growth,   which   dips    down   into    and   invades   the 

their  more  special-  Underlying  tissues  This  diagram  should  be  com- 
1  Z  e  d       characters,  pg,red  carefully  with  Fig.  60. 

and    reverting    to 

simple  masses  of  protoplasm  which  have  lost  all  powers  except  that 
of  growth  and  subdi\'ision.  They  often  differ  greatly  among  them- 
selves in  size,  character  of  nuclei,  etc.,  and  in  rapidly-growing 
carcinomata  numerous  mitoses  (which  may  be  irregular,  tripolar, 
or  multipolar)  may  be  seen. 

Marked  changes  occur  in  the  connective  tissues  around  the  cancer ; 
they  are  irritated  by  the  growth,  and  become  infiltrated  with  small 
round  cells  (IjTnphocytes)  and  plasma  cells,  which  undergo  a  greater 
or  less  degree  of  organization,  leading  to  the  development  of  a  stroma 
of  variable  density  and  vascularity  around  the  epithelial  columns. 
In  chronic  cases  the  stroma  is  usually  fibro-cicatricial  in  type,  and 
contains  few  bloodvessels;  in  the  more  actively  growing  parts  and 
in  acute  cases  the  stroma  is  comparatively  small  in  quantity,  more 
cellular,  and  decidedly  vascular.  When  ulceration  has  occurred, 
polynuclear  leucocytes  are  usually  abundant,  and  other  inflamma- 
tory manifestations  may  be  seen ;  pyogenic  bacteria  may  sometimes 
be  detected  in  the  growth. 

Cancerous  tumours  are  not  necessarily  tender  to  the  touch,  but  a 
considerable  degree  of  pain,  usually  of  a  neuralgic  type,  is  often 
complained  of,  especially  in  the  harder  forms,  when  tissues  get 
dragged  upon  by  the  contracting  stroma. 


A   MANUAL  OF  SURGI'RY 


The  enlaigoinent  of  the  neighbouring  lyni])hatic  ghmds  is  usually 
an  early  and  important  sign,  l)ut  it  must  be  remembered  that,  when 
the  primary  growth  has  a  dirty  ulcerating  surface,  the  enlargement 
may  be  largely  due  to  the  absorjition  of  toxins,  and  treatment 
directed  to  cleansing  the  surface  of  the  sore  may  lead  to  a  disap- 
pearance of  the  enlargement. 

T.  Epithelioma  {syii.  :  Squamous  Epithelioma,  Epithelial  Cancer). 
— By  this  term  is  meant  a  cancerous  tumourgnnving  from  skin  or  from 

those  portions  of  the  mucous 
membranes  which  are  covered 
with  squamous  epithelium. 

Epithelioma  is  usually  met 
with  in  middle-aged  or  elderly 
individuals,  occasionally  in 
young  adult  life.  Any  part  of 
the  skin  may  be  the  site  of  this 
tumour,  as  also  the  mucous  mem- 
brane of  the  mouth,  pharynx, 
and  oesophagus,  and  that  lining 
the  genito-urinary  tract.  It  com- 
monly results  from  some  long- 
continued  irritation,  as  in  the  lip 
or  tongue,  wliilst  upon  the  penis 
it  is  always  associated  with  a 
long  foreskin.  Old  scars,  espe- 
cially if  they  become  ulcerated, 
are  likely  to  be  invaded,  and  the 
disease  may  supervene  on  in- 
FiG.  63. — Typical  Epitheliomatous  tractable  lupus. 
Ulcer,  showing  Heaped-up  Mar-       Clinically,  epithelioma  may  be 

looked  upon  as  a  malignant  wart, 
which  not  only  grows  outwards 
from  the  surface,  but  also  bur- 
rows deeply  into  adjacent  tissues  (Fig.  62) ;  sooner  or  later  ulceration 
follows.  Several  characteristic  forms  are  described:  (a)  It  may 
occur  as  a  nodular  indurated  mass,  with  hard  everted  edges  and 
central  ulceration,  giving  rise  to  a  somewhat  crateriform  ulcer 
(Fig.  63).  (b)  The  destructive  process  may  extend  equally  with  the 
new  formation,  leading  to  the  appearance  of  a  depressed  sore,  with 
sharply-cut  edges,  closely  resembling  a  rodent  ulcer,  (c)  Occasion- 
ally the  superficial  outgrowth  is  excessive,  and  the  destructive  pro- 
cess limited,  giving  rise  to  a  projecting  caulifiower-like  mass,  which 
is  soft  and  easily  bleeds  {malignant  papilloma),  {d)  A  chronic  epi- 
thelioma is  sometimes  seen,  in  which  the  fibrous  stroma  contracts 
and  compresses  the  columns  of  epithelial  cells;  the  surface  is  then 
indurated  and  wart-like,  with  but  little  ulceration,  whilst  the  base 
is  very  hard,  and  the  progress  of  the  case  much  less  rapid  than  in 
other  forms.     This  form  is  not  uncommon  in  the  lip. 

The  disease,  as  a  rule,  early  infects  neighbouring  lymphatic  glands. 


GINS  AND  Deep  Central  Crateri- 
form Excavation.  (College  of 
Surgeons'  Museum.) 


TUMOURS  AND  CYSTS  221 

which  become  the  seat  of  a  similar  growth,  and,  if  superficial,  sooner 
or  later  involve  the  skin  and  give  rise  to  characteristic  ulceration. 
As  the  disease  progresses,  more  distant  groups  of  lymphatic  glands 
are  attacked;  it  is  unusual  to  find  this  form  of  cancer  disseminated 


Fig.  64. — Epithelioma  of  Lip. 
The  epitheliumjat  the;.left-hand  margin  of  the  figure  is  normal,  whilst  at  A  the 
altered  appearance  of  the  cells  indicates  that  they  have  become  malignant; 
at  B,  C,  D,  they  are  growing  down  into  the  stroma  in  irregular  columns;' 
B  indicates  a  small  cell-nest,  and  C  passes  through  one  half  an  inch  from 
its  extremity.  The  connective-tissue  stroma  is  inflamed.  This  is  most 
marked  at  F. 

through  the  internal  viscera.  The  glands  sometimes  become  cystic, 
especially  in  the  neck,  and  on  cutting  into  them  a  thin,  turbid"'fluid 
hke  sero-pus  escapes,  mixed  perhaps  with  white  masses  of  epithelial 
debris;  from  time  to  time  similar  material  is  discharged  through  the 
resulting  sinuses.     Ulceration  into  the  main  vessels  of  the  neck  may 


222  A   MANUAL  OF  SURGERY 

also  follow,  and  cause  death  from  haemorrhage;  otherwise  the  fatal 
event  is  due  to  cachexia  and  exhaustion. 

Microscopically,  an  epithelioma  consists  of  columns  of  epithelial 
cells  (Fig.  64),  ramifying  in  the  subcutaneous  tissues,  and  interlacing 
freely  with  each  other,  so  as  to  produce  an  irregular  network,  the 
meshes  of  which  are  occupied  by  a  fibro-cellular  stroma,  which  is 
frequently  infiltrated  by  an  inflammatory  exudate  of  small  round 
cells  (largely  lymphocytes  or  plasma  cells).  The  true  cancer  cells 
are  derived  from  the  prickle-cell  layer  of  the  epidermis,  but  in  some 
rapidly-growing  cases  the  cells  undergo  so  much  alteration  that  the 
prickles  are  difficult  to  find.  The  cells  in  contact  with  the  stroma 
are  usually  regular,  and  resemble  the  basal  layer  of  normal  skin; 

A 


Fig.  65. — Epithelial  Cell-nest,  from  an  Epithelioma  of  the  Mouth. 

A,  Stroma,  with  collections  of  small  round  cells;  B,  layer  of  basal  epithelial 
cells ;  C,  prickle  cells,  which  at  D  have  become  flattened  ;  E  and  F  show  the 
final  stage,  the  cells  being  transformed  into  badly-formed  keratinous 
scales. 


the  cells  next  to  this  are  polygonal  in  shape,  and  in  the  deepest 
layers  may  become  flattened  and  undergo  imperfect  keratinization. 
This  differentiation  is  best  seen  in  the  cell-nests  (Fig.  65)  which 
develop  in  the  substance  of  the  columns;  they  are  most  common  in 
comparatively  chronic  cases,  and  may  be  absent  in  the  rapidly- 
growing  forms. 

2.  Spheroidal-celled  Cancer  usually  develops  in  connection  with 
glands,  and  may  be  looked  on  as  a  malignant  form  of  adenoma,  bear- 
ing the  same  relation  to  the  latter  as  does  an  epithelioma  to  a  benign 
papilloma.  The  epithelium  of  the  glandular  acini,  from  which  it 
originates,  is  not  retained  by  the  basement  membrane,  but  travels 


TUMOURS  AND  CYSTS  223 

beyond  it  along  the  lymphatics  into  surrounding  parts,  which  are 
transformed  into  the  tumour  substance  by  a  process  already  de- 
scribed. The  amount  of  stroma  varies  considerably,  and  according 
to  whether  it  is  abundant  or  small  in  quantity,  the  tumour  is  hard 
or  soft  in  consistence,  and  slow  or  rapid  in  growth.  To  the  former 
type  the  term  Scirrhus  is  apphed ;  to  the  latter,  Encephaloid. 

Scirrhtis  is  met  with  most  frequently  in  the  breast,  but  also  occurs 
m  the  prostate,  pancreas,  and  pyloric  end  of  the  stomach.  On 
naked-eye  examination  a  scirrhous  tumour  appears  as  a  hard  nodular 
mass,  the  hmits  of  which  are  imperfectly  defined.  When  cut  across, 
it  creaks  under  the  knife,  and  presents  a  yellowish- white  surface,' 
which  rapidly  becomes  concave  owing  to  the  contraction  of  the 
nbrous  stroma.  It  has 
often  been  compared  to 


the  section  of  an  unripe 
pear  or  turnip,  both  on 
account  of  the  grating 
sensation  imparted  to 
the  knife  and  from  its 
appearance.  On  scra- 
ping the  cut  surface  'i*?5?^i^J- iriv  ^*"'^'^ 
with  the  blade  of  a  t^^^^A'^'''^','^^'"'^^^ 
knife,   a  typical  cancer     :^' :l'??i^ ^^I^SC >  **^((^ %  '^.^  A.  •<! 

juice  is  obtained,  con-     '^  "    '      ^       -^ -.-.-..-   --     -    

sisting  of  epithehal  cells 
and  debris. 

On  microscopical  ex- 
amination, the  tumour 
is  found  to  consist  of 
an  abundant  and  well- 
marked  stroma  of  a 
definite  fibrous  nature, 

the  acini  of  which  are  t:-       ^^r     o 

f^^^a.A         uu  -ir-  ?-}\  Fig.  66,— Scirrhus  Mamm^.       x  120.) 

filled     with     epithehal  /a  i^k  i      f  ,  x.       .   ■  ^"^    ^  ■) 

cells   fFiff    66^       Tn  th^  ^     lobule  of  normal  breast  tissue  is  seen  at  the 

,    ^    P'.      '\  "*^  lower  margin.) 

centre  fatty  degenera- 

tion  is  often  present,  small  cysts  being  occasionally  produced  in 
tnis  way.  At  the  periphery  the  growth  may  be  seen  extending  in 
all  directions  along  the  lymphatics,  whilst  a  round-celled  infiltration 
ot  the  surrounding  tissues  is  also  evident. 

•  J^^.^^e^^the  stroma  is  very  excessive,  the  cell  elements,  and, 
maeed,  the  whole  tumour,  may  undergo  atrophy,  owing  to  com- 
pression of  the  nutrient  vessels,  constituting  the  variety  known  as 
atrophic  scirrhus. 

Encephaloid,  Medullary,  or  Acute  Cancer  is  a  term  given  to  a 
growth  of  a  similar  nature,  in  which  the  stroma  is  much  less  abun- 
dant than  the  cell  elements.  It  constitutes  a  rapidly-growing 
tumour,  not  so  hard  as  a  scirrhus,  abundantly  supplied  with  blood- 
vessels, and  very  early  infiltrating  surrounding  parts  and  affecting 


224 


A   MANUAL  OF  SURGERY 


noii^hboiiring  lymphatic  glands.  Tlic  skin  over  such  a  tumour  is 
stretched,  and  dilated  blue  veins  can  be  seen  through  it.  Ulcera- 
tion occurs  early,  and  from  this  surface  a  foul,  bleeding,  fungating 
mass  sprouts  up,  formerly  known  as  a  '  fungus  luematodes  ' 
(Plate  IV.,  Fig.  2).  Encephaloid  cancer  is  met  with  in  the  breast, 
testis,  kidney,  and  a  few  other  glandular  organs. 

On  section  it  is  found  to  be  composed  of  a  soft  whitish  mass, 
somewhat  resembling  brain  substance.  It  is  usually  very  vascular, 
perhaps  pulsating,  and  haemorrhagic  extravasation  into  its  tissues 
is  not  uncommon.  An  abundant  juice  is  obtained  on  scraping. 
Under  the  microscope  large  groups  of  spheroidal  epithelial  cells 
are  seen,  held  together  by  a  scanty  fibro-cellular  stroma. 

3.  Columnar  Carcinoma. — This  affection  is  in  the  majority  of 
cases  a  true  glandular  cancer,  originating  most  frequently  in  the 

alimentary  canal  from 
any  portion  of  it  in 
which  columnar  epithe- 
lium occurs,  and  usu- 
ally as  an  overgrowth 
of  Lieberkiihn's  folhcles 
(Fig.  67).  It  forms  a 
projecting  growth  from 
the  surface,  and  also 
y  into 
s  and 
The 
deep  processes  retain 
an  imperfect  alveolar 
arrangement,  and  be- 
tween them  is  found  a 
certain  amount  of 
stroma,  varying  with 
the  character  of  the 
tumour.  In  the  more 
chronic  forms  the 
stroma  is  abundant,  and 
fibro-cicatricial  in 
quality ;  in  the  softer  and 
more  rapidly  growing  forms  the  stroma  is  less  abundant,  and  fibro- 
cellular  in  nature.  It  is  usually  easy  to  distinguish  the  growth 
from  a  simple  adenoma  of  Lieberkiihn's  follicles,  since  in  the  latter 
the  alveoli  are  complete  and  regularly  lined  with  a  layer  of  columnar 
epithehum,  whilst  in  cancer  the  alveoli  vary  in  shape,  and  the 
epithelial  elements  are  less  regularly  arranged..  The  distinction  is 
well  seen  in  Fig.  67.  If  a  large  section,  including  the  whole  thick- 
ness of  the  intestinal  wall,  is  examined,  the  extension  of  the  glan- 
dular tissue  into  and  between  the  muscular  fasciculi  (Fig.  68)  at  once 
indicates  the  malignant  nature  of  the  case.  Ulceration  usually 
occurs,  giving  rise  to  a  typical  sore,  surrounded  in  the  more  chronic 


Fig.  67. COLUMNAK-CELLED    CARCINOMA    OF 

THE  Intestine,     (x   16.) 

(Normal  mucous  membrane  is  shown  at  the  left 
hand  side.) 


TUMOURS  AND  CYSTS 


225 


forms  by  indurated  and  everted  edges.  Neighbouring  lymphatic 
glands  are  implicated,  as  in  the  case  of  all  cancers,  whilst  later  on 
the  disease  spreads  to  the  viscera,  and  maybe  generally  disseminated. 
A  similar  type  of  growth  occurs  in  the  cervical  portion  of  the  uterus, 
and  occasionally  in  the  ducts  of  glands,  such  as  the  liver  and  breast. 
It  is  also  met  with  in  the  superioi 
maxilla,  originating  m  the  tubular 
glands  of  the  mucous  membrane 
lining  the  antrum. 

4.  Colloid  Cancer  results  from  a  de- 
generation of  the  epithehal  cells  of  a 
glandular     or 


columnar  cancer. 
Its  most  fre- 
quent site  is 
within  the  ab- 
dominal cavity, 
in  connection 
with  cancers 
arising  from  the 
stomach,  intes- 
tine, or  omen- 
tum. To  the 
naked  eye  it  pre- 
sents an  alveolar 
texture,  the 
spaces  being 
filled  with  trans- 
lucent gelatinous 
material  of  vary- 
ing density. 
Microscopically, 
the  epithelial 
cells  are  rarely 
distinguishable, 
being  replaced 

by  a  structureless  colloid  substance.  Towards  the  growing  margin, 
however,  the  cells  may  be  seen  in  process  of  degeneration,  globules  of 
the  material  forming  within  them  and  pressing  the  nucleus  to  one  side. 

The  Treatment  of  Cancer  has  made  considerable  strides  in  recent 
years.  Unfortunately,  cases  too  often  come  under  observation  at 
such  a  late  stage  that  only  a  small  percentage  of  cures  is  possible; 
but  the  old  position  of  hopeless  and  helpless  expectation  of  a  fatal 
issue  in  all  cases  may  now  be  abandoned,  and  a  cure  looked  for  in 
many.  The  main  reliance  is  still  in  operation,  but  experience  of 
radio-therapy  has  shown  that  in  it  we  have  a  valuable  adjunct,  and 
in  suitable  cases  an  effective  alternative. 

Operative  treatment  consists  in  the  removal  of  the  tumour,  together 
with  a  wide  margin  of  healthy  tissue  around  it,  or  in  some  cases  of 

15 


Fig.   68. — -Section    through    Advancing    Margin    of 
Columnar  Cancer  of  Stomach,      x  25.     (Ziegler.) 

a,  Mucosa;  6,  submucosa ;  c,  muscularis;  ^,  serosa;  e  neo- 
plasm which,  starting  from  the  mucosa,  has  invaded 
the  other  layers.  Small-celled  infiltration  has  accom- 
panied here  and  there  the  formation  of  the  neoplastic 
tubules. 


i-zb  A   MANUAL  OF  SURGliRY 

the  whole  organ  affected,  as  well  as  of  the  lymphatic  area  concerned, 
and,  if  practicable,  in  one  mass,  so  as  not  to  cut  across  the  lymphatic 
vessels  passing  from  the  growth  to  the  glands.  The  wide  area  of 
permeation  by  the  cancer  cells,  and  the  impossibility  of  recognising 
their  existence  in  the  tissues,  explains  the  extensive  scope  of  such 
operations,  and  the  only  too  frequent  recurrence  locally  or  in  the 
course  of  the  lymph-stream.  In  spite  of  this,  however,  better 
results  are  being  obtained,  thanks  in  part  to  our  increasing  know- 
ledge of  the  anatomy  of  tlie  lymphatics,  and  in  part  to  the  improve- 
ment in  our  surgical  technique,  which  justihes  more  extensive  opera- 
tions. That  surgeons  can  now  report  17  to  50  per  cent,  of  their 
patients  operated  on  for  cancer  of  the  breast  as  alive  and  free  from 
recurrence  at  periods  varying  from  six  to  thirteen  years  is  indeed 
a  matter  for  congratulation ;  237  operations  for  cancer  of  the  uterus 
showed  38  per  cent,  of  the  patients  free  from  recurrence  after  an 
interval  of  five  years;  of  114  cases  of  cancer  of  the  lip,  53  per  cent, 
were  alive  and  well,  or  dead  from  some  other  disease,  more  than 
three  years  after  operation  (Gottingen  clinique).  Results  such  as 
these,  which  could  be  easily  added  to,  prove  that  cancer  is  curable 
by  operation  if  it  be  seen  early  enough,  but  it  is  from  early  diagnosis 
that  we  can  alone  hope  for  better  results 

The  non-operative  treatment  of  cancer  is  only  required  in  cases 
where  the  disease  is  very  superficial — e.g.,  rodent  ulcer,  and  some 
forms  of  epithelioma,  or  where  it  is  impossible  to  remove  it  com- 
pletely by  operation. 

The  introduction  of  radio-therapy  has  placed  at  the  surgeon's 
disposal  an  active  and  valuable  remedy,  which  in  suitable  cases  can 
be  effective.  Its  method  of  use,  value,  and  limitations,  have  been 
already  discussed  (p.  55). 

Apart  from  such  measures,  there  are  no  certain  cures  for  cancer. 
Many  substances  have  been  vaunted  in  this  direction,  but  careful 
tiials  under  trained  observers  have  always  resulted  in  disappoint- 
ment. In  some  few  instances  the  growth  of  the  tumour  has  been 
hindered  by  tying  the  nutrient  vessels — e.g.,  the  external  carotid 
and  its  branches  in  cancers  of  the  head^ — and  pain  has  been  relieved 
by  division  of  sensory  nerves.  In  ulcerating  cases,  the  adoption  of 
careful  aseptic  methods  and  the  use  of  a  staphylococcic  vaccine 
may  reduce  the  inflammatory  reaction,  and  cause  temporary  im- 
provement. In  the  final  stages,  morphia  or  heroin  can  alone  be 
depended  upon  to  give  some  relief  to  the  patient's  pain. 

In  conclusion,  one  must  point  out  that  ma  very  small  percentage 
of  cases  a  natural  cure  is  possible,  the  tumour  shrinking  and  gradu- 
ally disappearing.  Unfortunately,  nothing  definite  is  known  as  to 
the  conditions  which  favour  such  a  happy  issue. 

III.   Tumours  of  Endothelial  Origin. 

The  Endotheliomata  form  a  large  and  important  group  of  tumours. 
They  are  by  no  means  rare,  and  as  a  class  are  much  less  malignant 
than  the  sarcomata  or  carcinomata,  to  which  they  often  have  a  close 


TUMOURS  AND  CYSTS 


227 


structural  resemblance;  they  are  slow  in  their  development,  but 
often  recur  locally  after  removal,  and  may,  after  a  time,  affect  glands 
or  forni  secondary  deposits  in  internal  organs.  Their  most  frequent 
seat    is    in    the    parotid 


gland,  where  they  form 
the  mixed  parotid  tiDiioiir 
of  the  older  surgeons, 
but  they  are  common  in 
other  parts  in  the  neigh- 
bourhood of  the  mouth 
and  in  the  meninges  of 
the  brain  and  cord ;  they 
may  occur,  however,  in 
any   part   of  the  bod} 


The  cells  constituting  an 
endothelioma  are  de- 
rived from  the  pre- 
existing endothelium  of 
the  region,  and  they  be- 
come spherical,  cuboidal, 
or  even  columnar  in 
shape,  and  take  on  inde- 
pendent gro\vth.  The 
tumour  may  start  in  the 
lymphatic  clefts,   w^hich 


Fig. 


69. — Endothelioma  of  the  Parotid 
Gland,     (x  120.) 


-Perithelioma,     (x  120.) 
this    may    especially    involve    those 


then  appear  to  be  in- 
jected \\dth  cuboidal 
cells,  and  form  a  cellular 
network  having  a  general 
resemblance  to  a  carci- 
noma. The  stroma  be- 
tween these  columns  is 
profoundly  altered,  usu- 
ally becoming  mucoid 
or  converted  into  a 
hyaline  tissue  resembhng 
cartilage  (Fig.  6g) ;  fat  is 
often  deposited  in  it,  and 
cystic  degeneration  may 
take  place,  the  tumour 
thus  formed  being  of  ex- 
traordinary complexity. 
In  some  cases  the  cells 
affected  are  those  lining 
the  smaller  lymphatic 
vessels,  and  in  others 
occurring    in    the    vascular 


sheaths,  forming  a  cellular  investment  to  the  smaller  vessels — pen- 
thelioma  or  perithelial  sarcoma  (Fig.  70).     In  a  third  group  the  endo- 


228  A   MANUAL  OF  SURGERY 

thcliuiu  which  takes  on  morbid  growth  is  that  which  hnes  the  l)lood- 
vesscls  themselves.  In  this  case  it  is  common  for  the  cylinders  of 
cells  thus  formed  to  undergo  a  hyaline  degeneration  {cylindroma). 

The  endotheliomata  which  occur  in  the  brain  are  usually  com- 
posed of  spindle-shaped  cells,  which  have  a  tendency  to  organize 
into  fibrous  tissue,  and  have  a  curious  arrangement  in  wdiorls,  some- 
thing like  those  of  a  cell-nest.  The  central  portions  of  these  masses 
frequently  undergo  conversion  into  a  material  resembling  amyloid 
substance,  and  subsequently  become  calcified.  These  tumours  are 
called  Psammomata.  Endotheliomata  of  tlie  brain  are  not  un- 
common, and  are  generally  superficial,  readily  shelled  out,  and  do 
not  usually  recur  after  operation. 

IV.  Tumours  formed  by  Inclusion  of  Part  of  another  Embryo. 

Teratomata  arc  tumours  derived  from  included  embryos,  or  from 
portions  of  a  second  embryo,  which  are  formed  by  dichotomy,  but 
which  have  remained  rudimentary,  and  partially  or  completely 
buried  in  the  tissues  of  the  host.  The  commonest  example  is  the 
so-called  dermoid  of  the  ovary,  which  is  usually  unilocular  and  often 
of  large  size.  Its  lining  wall  is  more  or  less  obviously  cutaneous  in 
nature,  and  from  it  an  abundant  development  of  cutaneous  appen- 
dages— hair,  nails,  teeth,  nipples,  mamnice,  etc. — is  sometimes  ob- 
served. Most  commonly  the  cyst  is  filled  with  greasy  sebaceous 
material  and  with  an  abundance  of  hair,  which  is  said  to  be  influenced 
in  the  same  way  as  that  on  the  scalp,  becoming  gray  or  being  shed 
at  the  same  time.  Sometimes  the  tumour  becomes  more  complex, 
containing  structures  such  as  bone,  muscle,  gland  tissue,  etc.,  which 
are  formed  from  all  three  layers  of  the  embryo;  in  some  rare  cases 
large  portions  of  an  embryo  (such  as  a  limb)  are  recognisable. 
Similar  dermoids  are  found  in  the  testis  and  in  other  portions  of 
the  body,  though  very  unfrequently.  Teratomata  of  complex  struc- 
ture are  often  found  in  the  sacral  region,  where  they  are  probably 
due  to  posterior  dichotomy,  the  smaller  portion  of  the  embryo 
remaining  rudimentary  and  attached  to  the  larger  twin  in  the 
region  of  the  sacrum. 

Cysts. 

By  a  cyst  is  usually  meant  a  more  or  less  rounded  cavity,  with  a 
distinct  lining  membrane,  distended  with  some  fluid  or  semi-solid 
material.  The  term  is  used  very  loosely,  being  applied  to  a  variety 
of  manifestations  which  it  is  difficult  to  classify,  owing  to  the  fact 
that  conditions  which  are  pathologically  similar  in  origin  are  some- 
times termed  cysts  in  one  part  of  the  body,  and  not  so  in  another. 
For  practical  purposes,  however,  they  may  be  grouped  as  follows : 

I.  Cysts  of  embryonic  origin,  or  arising  in  connection  with  em- 
bryonic remains. 

II.  Cysts  arising  from  the  distension  of  pre-existing  spaces  (dis- 
tension cysts). 

III.  Cysts  of  new  formation.. 

IV.  Cysts  of  degeneration. 


TUMOURS  AND  CYSTS 


229 


I.  Cysts  of  Embryonic  Origin,  or  arising  in  Connection  with 
Embryonic  Remains. 

I.  Dermoids  are  characterized  by  the  existence  in  abnormal  situa- 
tions of  cavities  hned  with  epithehum,  from  which  may  be  developed 
such  cutaneous  appendages  as  hairs  and  nails,  whilst  the  space  is 
usually  occupied  by  sebaceous  contents.  The  structure  of  the  lining 
wall  is  very  similar  in  nature  to  skin  or  mucous  membrane,  con- 
sisting of  stratified  epithelium,  from  which  a  considerable  growth 
of  sebaceous  glands  and  hair  folhcles  often  takes  place.  If  teeth 
or  more  complex  tissues,  such  as  bony  alveoh,  mammary  glands, 
nipples,  etc.,  develop  in  such  a 
cavity,  it  should  probably  be 
looked  on  as  a  teratoma. 

Several  varieties  of  dermoids 
are  described: 

(a)  Sequestration  Dermoids  are 
cj^sts  arising  from  the  incomplete 
disappearance  of  surface  epithe- 
lium in  situations  where,  during 
embryonic  life,  fleshy  segments 
coalesce.  Thus,  in  almost  any 
part  of  the  middle  line  of  the 
body  such  tumours  may  develop, 
owing  to  the  fact  that  there  is 
here  a  union  of  two  lateral  seg- 
ments. Similarly,  they  are  not 
uncommon  about  the  face  and 
neck,  occurring  along  the  lines  of 
the  facial  and  branchial  clefts. 
Perhaps  the  most  common  posi- 
tion for  them  in  this  region  is  the 
upper  portion  of  the  orbito-nasal 
cleft,  behind,  and  to  the  outer 
side    of   the   eye   (Fig.    71).     It 

is  not  unusual  to  find  the  skull  defective  beneath  them 
pedicle  extending  from  the  deep  side,  connecting  them  with  the 
dura  mater.  Sequestration  dermoids  appear  as  rounded,  definitely 
hmited  tumours,  firm  and  elastic  to  the  touch,  over  which  the  skin 
ghdes  freely,  but  are  usually  somewhat  adherent  to  the  deeper  parts. 
This  form  of  dermoid  may  be  removed  without  difficulty,  but  in 
those  occurring  about  the  scalp,  with  the  bone  hollowed  out  beneath 
them,  it  is  perhaps  advisable  to  delay  operation  till  adult  fife,  unless 
the  tumours  are  rapidly  increasing  in  size.  The  reason  for  this  is 
that  the  bone  gradually  grows  up  around  the  pedicle,  and  thus 
closes  the  communication  with  the  cranial  cavity.  In  some  cases 
it  may  be  difficult  to  remove  the  whole  of  the  hning  membrane  by 
dissection,  and  under  these  circumstances  the  portion  left  behind 
should  be  destroyed  by  cairtery  or  caustics:  otherwise,  recurrence 
is  almost  certain  to  follow. 


Fig.  71. — Dermoid  Cyst,  growing  at 
THE  Outer  Angle  of  the  Orbit. 
(Bland  Sutton.) 


and  a 


230 


A   MANUAL  OF  SURGERY 


Hydatid  ol 
Morgagni. 


{!))  Tubulo-Dermoids  arise  in  connection  with  embryonic  canals 
and  passages,  such  as  the  thyro-glossal  duct  and  the  post-anal 
gut  (q.v.). 

{c)  For  Ovarian  Dermoids,  see  p.  228. 

2.  Cysts  occasionally  arise  in  connection  with  the  formation  of 
the  teeth  ;  such  have  been  already  alluded  to  under  the  terms 
follicular  and  epithelial  odontomes  (p.  215),  the  former  being  also 
known  as  dentigerous  cysts,  the  latter  as  fibro-cystic  disease  of 
the  jaw. 

3.  Various  cysts  develop  in  connection  with  the  remains  of  the 
Wolffian  body,  as  also  from  its  tubules  and  duct.  It  must  be  remem- 
bered that  this  body  (the  mesonephros)  arises  in  the  posterior  ab- 
dominal wall,  together  with  the  kidney  and  testis,  and  that  part 

of  it  enters  into  the  formation 

Paradidymis  or      ^^   ^^^    j^^^^^^.    j^^^^^^    ^^^^    -^    ^^^ 

sui"prised  to  find  that  its  remains 
are  closely  associated  with  that 
organ  in  the  scrotum. 

In  the  male  (Fig.  72)  the 
Wolffian  body  atrophies  almost 
completely,  being  represented 
by  a  few  blind  tubules,  situated 
close  to  the  epidichniis,  and 
known  as  the  paradidymis,  or 
organ  of  Giraldes.  Fibro-cystic 
disease  of  the  testis  {adenoma 
testis)  is  said  to  arise  from  this 
structure.  The  majority  of  the 
ducts  of  the  Wolffian  body  form 
the  vasa  efferentia  testis;  a  few 
of  the  upper  ones,  however, 
contract  no  attachment  to  the 
gland,  and  their  free  ends  (known 
as  Kobelt's  tubes)  may  become 
dilated,  and  form  small  cysts, 
situated  close  to  the  hydatid  of 
Morgagni,  which  structure  represents  the  remains  of  the  Miillerian 
body  and  duct.  It  is  possible  that  an  encysted  hydrocele  of  the 
epididymis  sometimes  arises  from  one  of  these  unobliterated  tubules. 
The  main  duct  of  the  Wolffian  body  forms  the  lower  portions  of  the 
epididymis  and  vas  deferens. 

In  the  female  (Fig.  73)  the  remains  of  the  Wolffian  body  are 
sometimes  met  with  as  a  series  of  closed  tubes  (paroophoron)  in  the 
neighbourhood  of  the  ovary.  Paroophoritic  Cysts  may  arise  in  con- 
nection with  this  structure,  and  are  chiefly  characterized  by  their 
inner  walls  being  the  seat  of  proliferating  papillomata.  The  Wolffian 
tubules  can  almost  always  be  recognised  in  the  broad  hgament, 
constituting  the  parovarium,  or  organ  of  Rosenmiiller.  Parovarian 
Cysts  formed  from  the  chstension  of  this  structure  are  usually  uni- 


FiG,  72. — Diagram  of  Adult  Tes- 
ticle, TO  SHOW  Relation  of 
Mesonephros  and  its  Ducts. 
(Bland  Sutton.) 


TUMOURS  AND  CYSTS 


231 


locular,  and  filled  with  a  clear  limpid  serous  fluid;  they  have  no 
definite  pedicle,  and  strip  up  the  layers  of  the  broad  ligament.  Some 
of  the  terminal  lubes  may  be  converted  into  small  cysts  which 
project  from  the  fimbriated  ends  of  the  Fallopian  tube,  and  are 
known  as  cysts  of  Kobelt's  tubes.  The  main  Wolffian  duct  generally 
atrophies,  but  occasionally  runs  down  between  the  layers  of  the 
broad  ligament  close  to  the  uterus,  to  open  in  the  vagina  near  the 
urethral  orifice,  being 
then  known  as  Gartner's 
duct.  Cysts  may  occa- 
sionally arise  in  connec- 
tion ^^dth  this  structure, 
projecting  into  the 
lateral  fornix  of  the 
vagina. 

4.  The  processus 
vaginalis,  or  funicular 
process,  is  the  term 
applied  to  the  pro- 
trusion of  peritoneum 
which  precedes  the 
testis  to  form  the  tunica 
vaginalis,  and  which  in 
the  female  accompanies 
the  round  ligament 
{canal  of  Ntick).  Nor- 
mally it  becomes  ob- 
literated, but  sometimes 
portions  remain  patent, 
and  are  distended  wath 
a  clear  straw-coloured  serous  fluid,  constituting  in  the  male  an 
encysted  hydrocele  of  the  cord,  and  in  the  female  a  hydrocele  of 
the  round  ligament. 

5.  Cysts  arise  occasionally  in  connection  \rith  some  irregular  de- 
velopment of  the  l\Tnphatic  spaces;  thus,  in  the  neck  the  so-called 
cystic  hygroma  is  in  reality  a  congenital  cavernous  lymphangiectasis. 


Fig.  73. — Diagram  to  represent  the  Cyst 
Regions  of  the  Ovary.     (Bland  Sutton.) 

A,  Oophoron,  or  ovarian  tissue;  B,  paroopho- 
ron, or  tissue  of  the  hilus;  C,  parovarium; 
K,  Kobelt's  tubes;  G,  Gartner's  duct  (  =  niain 
Wolffian  duct) . 


IL  Cysts  due  to  the  Pistension  of  Pre-existing  Spaces. 

{a)  Exudation  Cysts  arise  from  the  distension  of  cavities  which  are 
unpro\aded  ^rith  excretory  ducts,  and  are  frequently  of  inflammatory 
origin.  Such  spaces  may  be  fined  \\dth  epithefium  or  endothelium. 
As  illustrations  of  epithelial  cysts  may  be  mentioned  those  which 
arise  in  connection  with  the  thyroid  body,  as  also  conditions  due  to 
the  distension  of  the  central  canal  of  the  nervous  system  (syringo- 
myelocele), and  those  forms  of  ovarian  cyst  which  arise  from 
distension  of  Graafian  follicles. 

Exudation  cysts  lined  by  an  endothelial  wall  are  much  more 
numerous.     Enlargements    of    bursge,    hydroceles    of    the    tunica 


232  A   MANUAL  OF  SURGERY 

vaginalis  or  funicular  process,  and  sonic  forms  of  ganglia,  are  of 
this  nature.  Diverticula  or  hernial  protrusions  of  the  synovial 
membrane  of  joints  are  known  as  Baker's  cysts. 

A  Serous  Cyst  is  supposed  to  arise  from  the  distension  of  lymph 
spaces,  giving  rise  to  uni-  or  multi-locular  cavities,  lined  witli  endo- 
tlielium,  and  containing  a  limpid  straw-coloured  fluid.  They  are 
seen  most  commonly  in  the  neck,  axilla,  or  breast,  and  in  the  latter 
structure  may  be  surrounded  by  dense  fibrous  tissue.  They  may 
be  looked  on  as  cavernous  lymphangiomata. 

Adventitious  Bur  see  arise  as  a  result  of  repeated  irritation,  and  are 
dealt  with  elsewhere. 

{h)  When  a  collection  of  blood  forms  in  a  pre-existing  cavity,  a 
so-called  Cyst  of  Extravasation  is  produced.  Such  is  met  with  in 
the  pelvis  or  tunica  vaginalis  (hctmatocele),  and  also  occasionally 
on  the  surface  of  the  brain,  constituting  an  arachnoid  cyst. 

(c)  Retention  Cysts  always  arise  from  obstruction  to  the  escape  of 
some  natural  secretion  from  a  gland  duct  or  tubule.  The  cavity 
thus  formed  is  lined  with  epithelium,  whilst,  o\ving  to  the  irritation 
produced  by  the  tension,  a  fibro-cicatricial  wall  of  variable  thickness 
is  developed  outside.  There  is  sometimes  a  considerable  formation 
of  intrac^'Stic  growths,  especially  in  the  breast,  whilst  the  contents 
generally  consist  of  the  inspissated  secretion,  perhaps  mixed  with 
blood. 

Retention  cysts  may  develop  in  connection  with  any  glandular 
tissue.  The  majority  are  described  under  the  appropriate  headings 
— viz.,  mammary  cysts,  renal  cysts,  pancreatic  cysts,  etc. 

III.  Cysts  of  New  Formation  are  such  as  occur  apart  from  any 
embryonic  condition  or  pre-existing  cavity.  The  following  varieties 
may  be  described : 

{a)  An  Implantation  Cyst  is  one  which  arises  from  the  accidental 
intrusion  into  the  subcutaneous  or  submucous  tissues  of  epithelial 
cells  which  retain  their  vitality,  and  are  enabled  to  develop  a  cyst 
very  similar  in  nature  to  a  dermoid;  in  fact,  it  may  be  looked  upon 
as  an  Acquired  or  Traumatic  Dermoid.  Such  an  occurrence  is  usually- 
brought  about  as  the  result  of  an  injury,  especially  from  punctured 
wounds;  thus,  cysts  of  this  nature  have  been  met  with  in  the  fingers 
or  palm  of  the  hand  as  a  consequence  of  the  penetration  of  some 
sharp  instrument,  whilst  they  are  atso  occasionally  seen  in  the 
anterior  chamber  of  the  eye,  following  an  iridectomy.  They  are, 
moreover,  observed  in  the  axillae  of  cattle,  as  a  result  of  goading 
them  with  a  sharp  implement.  The  clinical  signs  and  treatment 
are  similar  to  those  of  a  dermoid  cyst. 

{h)  Cysts  may  form  around  foreign  bodies,  which  thus  become 
encapsuled.  They  are  lined  with  granulation  tissue  or  endothelium, 
surroimded  h\  a  variable  amount  of  fibro-cicatricial  tissue. 

(c)  Blood  Cysts  are  of  variable  origin.  Some  certainly  arise  from 
extravasation  of  blood,  and  are  then  filled  with  coagulated  blood, 
or  a  thin  serous  fluid  with  a  varying  amount  of  laminated  fibrin. 


TUMOURS  AND  CYSTS 


233 


In  many  cases  a  so-called  blood  cyst  is  really  a  soft  sarcoma,  into 
which  hcemorrhage  has  occurred;  but  a  few  instances  are  on  record 
in  which  a  thin-walled  cavity  existed,  occupied  by  blood,  and 
readily  relilling  after  it  had  been  tapped,  and  with  no  evidence  of 
any  growth.  Such  conditions  have  been  most  frequently  observed 
in  the  neck  (see  Chapter  XXXII.). 

(d)  Parasitic  Cysts  are  produced  by  the  irritation  caused  by  the 
growth  wthin  the  tissues  of  certain  living  organisms.  Thus,  in  the 
disease  known  as  trichinosis,  derived  from  eating 
unsound  pork,  the  Trichina  spiralis,  a  small  round 
worm,  develops  in  large  numbers  in  the  voluntary 
muscles,  and  becomes  surrounded  by  a  capsule 
which  is  subsequently  calcified. 

The  most  important  of  these  parasitic  cysts  is 
that  caused  by  the  development  within  the  body  of 
the  scolex  stage  of  the  Tcenia  echinococcus,  giving 
rise  to  what  are  known  as  Hydatid  Cysts.  This 
disease  is  much  more  common  in  Australia  than 
in  this  country.  The  Tcenia  echinococcus  (Fig.  74) 
is  a  minute  tapeworm,  less  than  half  an  inch  in 
length,  which  inhabits  the  intestinal  canal  of  dogs ; 
it  consists  of  four  segments,  the  posterior  one  being 
larger  than  the  rest  of  the  body,  and  containing 
the  genital  organs.  When  mature,  this  last  segment 
becomes  filled  with  ova,  which  are  discharged,  and 
these  find  their  way  into  the  human  stomach  by  the 
media  of  water  or  uncooked  vegetables,  such  as 
watercress,  which  have  been  contaminated  with  the 
dog's  excreta.  The  process  of  digestion  sets  the 
embryo  free,  and  by  means  of  a  crown  of  little 
hooks  which  it  possesses,  as  well  as  four  suckers,  it 
is  enabled  to  bore  its  way  through  the  walls  of  the 
stomach,  and  thence  travels  by  the  bloodvessels  to 
the  liver  or  some  other  part  of  the  body.  As  a 
result  of  the  irritation  caused  by  its  presence,  a  sac 
forms,  which  originally  consists  of  three  layers 
(Fig.  75) ;  externally,  a  fibro-cicatricial  layer,  then 
an  intermediate  lamellated  layer  of  chitinous 
material  (true  ectocyst),  and  finally  the  cyst  is  lined  -^iq 
by  a  protoplasmic  germinal  layer  {endocyst),  from  - 
which  may  be  developed  solitary  tsenia  heads  or 
scolices,  also  provided  with  four  suckers  and  a  circlet 
of  hooks,  whilst  sometimes  groups  of  them,  known  as  brood-capsules, 
may  arise  in  the  same  way  (Fig.  76).  Daughter-cysts  are  not  unfre- 
quently  formed  from  the  scolices,  and  they  in  their  turn  may  pass 
through  the  same  changes,  although  as  a  rule  they  are  barren. 
Occasionally  even  the  main  cyst  may  be  sterile  (acephalocyst),  and 
in  such  cases  the  walls  become  very  definiteh'  laminated.  The 
fluid  contained  in  the  cyst  varies  much  in  amount,  but  is  always 


tef- 


ik'S 


'f^^ 


-T^NIA 

Echinococcus. 
'x  ABOUT  20.) 


234 


A   MANUAL  OF  SURGERY 


of  low  specific  gravity,  not  more  than  1007;  it  is  colourless,  but 
slightly  opalescent,  limpid,  and  contains  but  a  trace  of  allnmien, 
although  a  considerable  amount  of  chloride  of  sodium  is  present. 


Fig.   75. — Diagrammatic  Section  of  Wall  of  Cyst. 

a,  Fibro-cellular  capsule,  here  somewhat  exaggerated ;  b,  lamcllated  chitinous 
layer,  or  ectocyst;  c,  brood-capsules  developing  from  the  protoplasmic 
layer,  or  endocyst;  d,  scolex,  or  separate  head,  enlarged 


Fig.  76. — Hydatid  Cyst  (Diagrammatic),  showing  Daughter-Cysts  and 
Brood-Capsules  growing  from  the  Walls.     (After  Bland  Sutton.) 

On  examining  the  fluid  microscopically,  the  characteristic  booklets 
are  observed.  The  organs  usually  affected  by  hydatid  disease  are 
the  liver,  kidneys,  and  brain,  but  any  part  of  the  body  may  be 


TUMOURS  AND  CYSTS  235 

attacked.  Occasionally  in  the  liver,  and  usually  in  bone,  multiple 
C3'Sts  develop  quite  distinct  from  each  other,  and  with  no  general 
cyst-wall  {exogoioits  multiplication).  This  can  only  occur  when  the 
ectocyst  is  thin,  allowing  the  scolices,  which  always  have  a  retractile 
neck,  to  push  through  and  '  swarm  off  '  into  surrounding  tissues. 

Hydatid  cysts  give  rise  to  no  special  symptoms,  except  those 
caused  by  their  size  and  situation,  and  they  are  likely  to  go  on  grow- 
ing until  operative  treatment  becomes  imperative  on  account  of 
some  complication,  or  from  the  size  of  the  mass.  At  any  time  the 
cyst  may  rupture,  either  spontaneously  or  as  the  result  of  some 
injury;  if  into  a  serous  ca\aty,  such  as  the  peritoneal  or  pleural,  this 
becomes  infected,  and  an  abundant  development  of  scolices  and  cysts 
ensues,  giving  rise  to  considerable  locaUzed  inflammatory  reaction ; 
moreover,  the  escape  of  the  cyst  fluid  may  cause  serious  toxsemia, 
or,  at  any  rate,  urticaria,  owing  to  the  presence  therein  of  some 
toxic  substance. 

Occasionally  the  organism  dies  spontaneously,  and  then  the  cyst 
shrivels  up,  and  the  laminated  walls  and  daughter-cysts  form  a  firm 
leathery  mass,  perhaps  infiltrated  with  hme  salts  and  of  the  con- 
sistency of  wet  mortar ;  a  thick  fibro-cicatricial  capsule  encloses  the 
whole.  At  other  times  suppuration  takes  place  within  the  cyst,  and 
an  abscess  results.  If  acute,  it  bursts  either  externally,  or  may  open 
into  some  serous  ca\dty  or  hollow  viscus;  in  the  last  case,  the  cyst 
may  evacuate  itself,  and  a  spontaneous  cure  result.  Sometimes  the 
abscess  becomes  chronic  and  encapsuled,  and  may  then  remain 
quiescent  for  years. 

For  the  diagnosis  and  treatment  of  hydatid  cyst  of  the  liver,  see 
Chapter  XXXV.  In  other  regions,  if  the  tumour  cannot  be  removed 
by  dissection,  reliance  must  be  placed  on  drainage,  where  the  situa- 
tion of  the  growth  renders  this  practicable,  or  aspiration,  since  it  is 
usually  found  that  removal  of  the  fluid  contents  causes  death  of  the 
organism,  probably  by  altering  the  intracystic  tension. 

IV.  Cysts  of  Degeneration  arise  in  connection  with  tumours,  espe- 
cially those  where  the  blood-supply  is  not  very  abundant.  Thus, 
mucoid  degeneration  is  not  uncommon  in  fibromata,  fibro-myomata, 
chondromata,  and  even  in  the  harder  forms  of  cancer.  Occasionally 
cysts  form  in  the  sarcomata  from  this  cause,  but  more  frequently  as 
a  result  of  hemorrhage. 


CHAPTER  X. 
WOUNDS. 

A  WOUND  has  been  defined  as  the  forcible  solution  of  continuity  of 
any  of  the  tissues  of  the  body;  but  the  term  is  more  commonly 
limited  to  injuries  of  the  soft  parts,  involving  the  skin  or  mucous 
membranes.  Lesions  in  which  the  skin  does  not  participate,  and 
in  which  the  deeper  structures,  such  as  bones,  ligaments,  etc.,  are 
not  involved,  are  spoken  of  as  contusions. 

A  Contusion  is  any  subcutaneous  wound  or  injury  due  to  the 
agenc}'  of  external  violence,  causing  laceration  of  the  cellular  tissue, 
without  necessarily  involving  such  deeper  structures  as  muscles, 
tendons,  nerves,  or  bones.  The  signs  are  usually  very  obvious,  viz., 
pain,  bruising,  or  discoloration  of  the  part,  and  swelling.  These  are 
readily  explained  by  the  injury  inflicted  on  the  subcutaneous  tissues, 
which  in  the  worst  cases  may  be  entirely  disorganized  and  separated 
from  the  skin.  The  amount  of  bruising  varies  with  the  part  injured 
and  the  severity  of  the  lesion;  thus,  in  the  eyeUds,  scrotum,  and 
vulva,  where  the  tissues  are  lax,  the  ecchymosis  will  be  very  exten- 
sive and  of  a  black  colour;  on  the  scalp  there  is,  on  the  other  hand, 
but  little  swelling,  if  the  injury  does  not  include  bleeding  beneath 
the  aponeurosis  of  the  occipito-frontalis.  Again,  the  condition  of  the 
patient's  general  health  influences  the  amount  of  blood  effused; 
a  strong  man  in  good  training  does  not  bruise  nearly  as  much  as 
those  of  a  languid  temperament  and  relaxed  tissues.  Blebs  and 
bullae  may  form  over  the  injured  spot,  especially  in  connection  with 
fractures.  The  changes  that  occur  in  a  bruise  are  well  known,  the 
colour  passing  from  a  blackish-purple  through  various  shades  of 
brown  and  green  to  a  yellow,  which  gradually  fades  and  disappears; 
this  is  due  to  the  disintegration  of  the  red  corpuscles,  and  staining  of 
the  tissues  by  the  haemoglobin  thus  set  free,  or  by  the  products 
formed  during  its  removal.  When  haemorrhage  has  taken  place 
into  the  deeper  parts  or  under  dense  fascire,  it  is  often  some  days 
before  the  bruise  '  comes  out,'  and  this  may  occur  at  some  distant 
spot,  e.g.,  in  the  eyelids  after  a  blow  on  the  scalp,  whilst  it  may 
travel  along  the  muscular  and  fascial  planes  under  the  influence  of 
gravity. 

236 


WOUNDS  237 

In  a  bruise  or  ecchymosis,  the  tissues  are,  as  a  rule,  merely  infil- 
trated with  blood,  but  occasionally  the  extravasation  is  more 
localized,  collecting  in  a  cavity  formed  by  the  laceration  of  the 
tissues,  and  remaining  as  a  fluid  swelling,  or  Hsematoma.  It  some- 
what resembles  an  abscess  to  the  touch,  but  differs  from  it  in 'its 
history,  having  supervened  immediately  after  an  injury,  and  having 
appeared  without  any  heat  or  other  sign  of  inflammation ;  moreover, 
though  at  first  fluid  and  soft,  it  soon  becomes  harder,  whereas  an 
abscess  is  preceded  by  a  stage  of  brawny  infiltration,  and  the 
softening  occurs  later.  The  subsequent  history  of  a  hematoma 
varies  somewhat  according  to  circumstances,  {a)  Fibrin  may  be 
deposited  peripherally,  leaving  for  a  time  a  fluid  centre,  which 
gradually  disappears,  and  the  whole  is  finally  absorbed.  This  is  well 
exemplified  in  a  subpericranial  cephalhaematoma,  where  the  contrast 
between  the  peripheral  fibrinous  deposit  and  the  fluid  centre,  through 
which  the  skull  can  be  felt,  is  sometimes  so  accentuated  as  to  give 
the  sensation  of  a  depressed  fracture.  (&)  The  fluid  portion  of  the 
blood  may  be  absorbed  almost  entirely,  and  the  solid  fibrinous 
residuum  may  become  organized  into  a  firm  fibroid  tumour  which 
persists  indefinitely;  the  mass  is  more  or  less  laminated,  and  not 
unfrequently  pigmented,  (c)  The  fibrin  may  be  entirely  absorbed, 
and  a  slightly  pigmented  fibrous  capsule  formed  containing  serous 
fluid,  and  constituting  a  definite  cyst ;  this  is  best  seen  in  connection 
with  the  cerebral  tunics  {arachnoid  cyst) .  {d)  Suppuration  may  ensue 
owing  to  auto-infection  from  within  the  body,  or  from  an  invasion  of 
organisms  through  abraded  skin. 

In  forming  an  opinion  as  to  the  gravity  of  a  subcutaneous  injury, 
one  must  be  guided  by  the  character  and  extent  of  tissue  involved, 
the  amount  of  blood  extravasated,  and  the  age  and  vitality  of  the 
individual.  In  the  less  severe  cases,  though  there  may  be  much 
bruising,  recovery  will  ensue,  but  in  unfavourable  conditions  slough- 
ing and  death  of  the  injured  tissues  may  result. 

The  Treatment  of  a  bruise  usually  consists  in  keeping  the  part  at 
rest,  and  applying  cold  or  evaporating  lotions.  The  effusion  of 
blood  may  be  hindered,  if  the  case  is  seen  early,  by  firm  bandaging 
of  the  part  over  a  compress  of  cotton-wool.  In  the  later  stages 
absorption  of  the  blood  may  be  hastened  by  massage.  In  the  severer 
cases,  where  blebs  or  bullae  have  formed  or  there  is  a  hkelihood  of 
the  skin  sloughing,  it  must  be  carefully  washed  and  rendered  aseptic, 
and,  if  need  be,  wrapped  in  an  aseptic  dressing .  When  a  tense  and 
pamful  hsematoma  exists,  as  under  the  fascia  lata  of  the  thigh, 
recovery  can  be  hastened  and  pain  reheved  by  an  aseptic  puncture, 
followed  by  careful  compression.  In  general  bruising  of  the  body 
from  a  fall  or  extensive  injury,  pain  can  often  be  relieved  by  applying 
fomentations  or  by  a  hot  bath.  There  is  usually  a  certain  amount 
of  fever  and  constitutional  disturbance  for  a  few  days,  and  these  are 
dealt  with  by  purgatives  and  a  suitable  limitation  of  diet. 


238  A   MANUAL  OF  SURGERY 

Open  Wounds. 
An  open  wound  may  be  detined  as  a  solution  of  continuity  of  any 
superiicial  part  of  the  body,  including  skin  or  mucous  membrane. 
Various  kinds  of  wounds  are  described,  such  as  the  incised,  lacerated, 
contused,  punctured,  poisoned,  and  gunshot;  but,  of  course,  the 
most  important  distinction  to  draw  is  between  the  infected  and  the 
non-infected. 

I.  Incised  Wounds. — An  incised  wound  is  one  made  by  any  sharp 
cutting  instrument,  but  occasionally  one  not  produced  in  this  manner 
may  be  characterized  by  similar  appearances;  e.g.,  the  skin  of  the 
knee  or  elbow  may  be  cleanly  split  open  from  falling  on  it  with  the 
limb  flexed,  and  occasionally  a  policeman's  truncheon  will  lay  open 
the  scalp  almost  as  evenly  as  if  a  knife  had  been  employed. 

1  he  special  features  of  an  incised  w'ound  are  as  follows : 

1.  The  hsemorrhage  is  free,  from  the  fact  that  the  vessels  are 
cleanly  divided.  The  amount  necessarily  depends  on  the  size  of 
the  vessels  involved,  and  the  vascularity  of  the  part;  its  continu- 
ance, upon  the  density  of  the  structures  allowing  or  not  of  con- 
traction and  retraction  of  the  severed  ends. 

2.  Separation  of  the  lips  of  the  wound  also  occurs,  the  amount 
depending  upon  the  elasticity  and  character  of  the  part  involved  and 
the  degree  of  tension  to  which  it  is  exposed. 

3.  Bruising  of  the  margins  of  the  incision  is  absent,  so  that  under 
ordinary  circumstances  rapid  healing  (by  first  intention)  should 
obtain.  The  surfaces,  to  begin  with,  are  Hned  by  a  microscopic 
layer  of  damaged  tissue,  some  of  which  may  be  actually  dead ;  but 
if  suitable  precautions  are  taken,  this  is  absorbed,  and  in  no  way 
interferes  with  satisfactory  union. 

The  chief  dangers  of  an  incised  wound  are:  (i)  Haemorrhage; 
(2)  injury  to  subcutaneous  structures,  such  as  nerves,  tendons, 
muscles,  etc.;  and  (3)  the  risks  involved  from  infection. 

Treatment  of  Incised  Wounds. — Seven  essentials  must  be  attended 
to  if  healing  bv  first  intention  is  to  be  obtained,  viz.  : 

(i.)  The  Arrest  of  all  Bleeding. — General  oozing  may  be  stayed  by 
exposure  to  the  air  or  the  pressure  of  an  aseptic  swab.  Arteries  and 
veins  will  need  a  ligature,  but  if  situated  close  to  the  skin,  they  may 
sometimes  be  secured  by  passing  under  the  bleeding  spot  the  needle 
used  for  the  suture.  The  importance  of  complete  hcemostasis  in 
limiting  or  hindering  bacterial  developments  has  been  already 
alluded  to  (p.  4). 

(ii.)  Sterilization  of  the  Wound  and  its  Surroundings. — In  casualty 
work  asepsis  cannot  be  always  assured,  as  the  wound,  though 
cleanly  cut,  is  made  through  dirty  skin,  and  portions  of  clothing, 
dirt,  and  splinters  of  wood  or  glass  may  be  carried  in.  Under  these 
circumstances  the  wound  and  its  surroundings  must  be  thoroughly 
purified,  according  to  the  rules  given  on  p.  278,  and  a  careful  search 
made  for  foreign  bodies. 


WOUNDS  239 

(iii.)  The  coaptation  of  the  opposed  surfaces  by  means  of  sutures 
may  now  be  undertaken.  Many  substances  are  employed  for  this 
purpose,  but  amongst  the  best  are  fine  silver  wire,  silk,  horsehair, 
silkworm  gut  and  catgut.  In  casualty  work,  and  for  parts  of  the 
body  where  but  little  scar  is  subsequently  desirable,  as  in  the  face, 
horsehair  and  silkworm  gut,  being  non-absorbent,  are  perhaps  the 
best  materials  to  employ ;  but  in  ordinary  operative  work,  which  will 
be  more  certainly  aseptic,  and  where  the  after-treatment  is  more 
efficient,  fine  catgut  or  silk  may  be  used.  There  are  three  chief 
varieties  of  sutures,  viz.,  the  buried,  the  deep,  and  the  superficial. 

B  lined  sutures  are  now  largely  employed,  smce  a  foreign  body  may 
be  safely  inserted  into  the  tissues,  if  both  it  and  the  wound  are 
aseptic.  Some  discrimination  must  be  employed  in  the  selection  of 
the  material  chosen  for  a  buried  stitch,  according  to  whether  or  not 
it  is  desirable  that  it  should  persist  or  be  absorbed.  If  a  part  is  not 
very  strong  and  the  cicatrix  is  exposed  to  a  certain  amount  of  ten- 
sion, as  in  the  abdominal  wall  after  a  laparotomy,  non-absorbent 
material  such  as  silk  or  silkworm-gut  may  be  employed,  and  the  in- 
corporation of  the  suture  in  the  cicatrix  will  prove  a  source  of 
strength.  At  the  same  time  it  must  be  remeraibered  that,  if  drawn 
too  tight,  the  tissues  within  its  grasp  may  be  strangled,  and  suppura- 
tion at  a  later  date  determined  even  apart  from  external  infection. 
In  other  cases  all  that  is  required  of  a  buried  stitch  is  to  hold  certain 
tissues  in  contact  until  a  natural  bond  of  union  has  developed,  and 
then  the  sooner  the  stitch  disappears  the  better — e.g.,  in  building  up 
the  tissues  of  the  neck  after  the  removal  of  a.goitre  or  in  re-uniting 
a  divided  nerve ;  for  such  a  purpose  fine  catgut  slightly  chromicized 
answers  admirably. 

Deep  stitches,  or  sutures  of  relaxation,  are  required  in  cases  where 
there  is  difficulty  in  bringing  the  edges  of  the  wound  together,  in 
order  to  transfer  the  tension  from  the  healing  margin  to  tissues 
further  away,  the  edges  being  thereby  relaxed.  For  this  purpose 
thick  silk  or  catgut  may  be  employed,  inserted  i  or  i|  inches  from 
the  margins,  or  silver  wire  may  be  used,  lead  buttons  being  inter- 
posed next  to  the  skin,  and  the  ends  of  the  wire  fastened  round  the 
projecting  edges.  Deep  stitches  are  generally  removed  at  the  end 
of  two  or  three  days. 

Superficial  stitches,  or  sutures  of  coaptation,  must  be  so  inserted  as 
to  brmg  the  edges  of  the  wound  into  contact  without  undue  pressure, 
and  without  any  folding  in  of  the  skin.  Various  methods  are  em- 
ployed, viz.:  I.  The  interrupted  suture  (Fig.  77,  A),  in  which  each 
stitch  is  separately  finished  off,  the  knot  lying  well  to  one  side  of  the 
incision.  This  is  generally  utilized  for  wounds  which  are  of  irregular 
shape  or  in  which  there  is  tension.  2.  The  continuous  glover's 
stitch  (Fig.  jy,  B)  is  not  to  be  recommended.  3.  The  blanket  or 
buttonhole  stitch  (Fig.  77,  C)  is  the  form  of  continuous  suture  which 
should  be  employed  for  extensive  wounds  or  incisions.  In  it  the 
needle,  after  traversing  the  lips  of  the  wound,  is  carried  under  the 
slack  of  the  thread,  so  that  the  loop'  of'  each  stitch,  as  it  is  tightened. 


240 


A   MANUAL  OF  SURGERY 


is  maintained  at  right  angles  to  the  edge  of  the  wound,  whilst  the 
intermediate  portion  lies  parallel  to  it.  4.  Halstead's  ihitrcidcrmic  or 
subcit/icHlar  stitch  (Fig.  77,  D)  may  be  employed  when  very  exact 
coaptation  is  desirable,  and  a  minimum  of  visible  scar  required,  as 
in  the  face  or  neck.  The  deeper  tissues  must  first  be  carefully  built 
up  by  a  series  of  buried  sutures,  so  that  the  margins  of  the  wound 
are  nearly  in  apposition.  Fine  silkworm-gut  or  silver  wire  is  em- 
ployed, and  a  short  straight  needle.  The  needle  is  introduced  in 
the"  substance  of  the  skin  beneath  the  cuticle  and  passed  parallel 
with  the  surface,  to  emerge  on  the  same  level  less  than  a  centimetre 


Fig.   77. — Various  Forms  of  Suture. 

A,  Interrupted  suture;  B,  continuous  suture;  C,  blanket  stitch.  At  the  lower 
end  the  needle  has  just  been  passed,  and  the  way  in  which  it  catches  up 
the  loop  is  indicated.  At  tfie  upper  end  the  method  of  finishing  off 
(originally  suggested  by  the  late  ]\Ir.  Maunsell)  is  shown;  viz.,  the  needle 
is  passed  in  the  opposite  direction  to  all  the  other  stitches,  the  free  end 
being  left  long,  so  as  to  enable  it  to  be  tied  into  a  knot  with  the  double 
thread  which  the  needle  has  carried  through;  D,  Halstead's  intradermic 
or  subcuticular  stitch. 


from  the  point  of  introduction,  thereby  taking  up  a  semicircle 
of  tissue;  it  is  then  introduced  in  a  similar  way  on  the  opposite  side 
of  the  incision,  and  the  process  is  repeated  from  one  end  of  the 
wound  to  the  other.  Ihe  suture  is  finally  pulled  tight  at  each  end; 
and  left  long.  To  remove  it,  one  end  is  cut  short,  and  then  a  steady 
pull  on  the  other  end  draws  out  the  remainder  quickly  and  without 
pain.  5.  Metalhc  clips  (e.g.,  Michel's)  are  used  by  some  surgeons 
instead  of  sutures,  but  they  have  no  real  advantage. 

Adhesive  plaster  is  sometimes  employed,  but  tlie  wounds  must  be 


WOUNDS 


241 


very  small  and  insignificant  which  only  require  such  treatment.  A 
fine  aseptic  suture  is  in  most  cases  preferable. 

(iv.)  Drainage  must,  if  necessary,  be  provided,  in  order  to  guard 
against  the  irritation  and  tension  caused  by  retained  blood  or  exuda- 
tions. In  casualty  wounds,  where  there  is  doubt  as  to  the  complete- 
ness of  the  asepsis  or  ha?mostasis,  or  where  there  has  been  much 
tearing  or  laceration  of  tissues,  it  is  often  wise  to  insert  a  tube  for 
twenty-four  or  forty-eight  hours. 

When  drainage  is  required,  the  indiarubber  tube  introduced  by 
Chassaignac  answers  well;  the  end  should  be  cut  flush  with  the 
surface,  and  stitched  to  the  edges  of  the  wound,  so  as  to  prevent  it 
slipping  in  or  out.  For  small  wounds,  a  strand  of  horsehair  or  a 
strip  of  gauze  or  protective  will  usually  suffice. 

(v.)  All  fresh  sources  of  irritation  and  infection  of  the  wound  must 
be  excluded  by  some  form  of  antiseptic  or  aseptic  dressing. 

(vi.)  Rest  to  the  injured  part  must  be  secured  by  such  an  arrange- 
ment of  splints,  slings,  .or  bandages  as  may  be  necessary. 

(vii.)  The  general  health  of  the  patient  is  a  most  important  item 
to  attend  to.  In  an  operation  case  the  bowels  should,  if  possible, 
be  previously  opened,  and  the  patient's  diet  carefully  regulated;  in 
casualty  work  a  good  purge  should  be  administered  as  soon  as 
convenient,  and  the  food  and  drink  limited. 

Under  ordinary  circumstances  an  aseptic  incised  wound  heals  in 
about  five  to  seven  days,  but  the  actual  time  when  it  is  safe  to 
remove  the  stitches  varies  with  the  age  and  vigour  of  the  individual, 
the  part  of  the  body,  and  the  amount  of  tension  required  to 
draw  the  lips  of  the  wound  together.  In  ordinary  aseptic  opera- 
tion wounds  one  usually  removes  the  stitches  on  the  eighth  day ;  but 
ill  the  face  it  is  often  possible  and  advisable  to  take  them  out 
earlier,  partly  because  the  healing  process  is  quickly  accomplished  in 
such  a  vascular  region,  partly  in  order  to  minimize  the  amount  of 
scarring. 

Many  conditions  may  arise  to  prevent  the  healing  of  an  incised 
wound  by  first  intention,  and  they  may  be  epitomized  as  essentially 
the  reverse  of  the  seven  conditions  mentioned  above — ^viz.,  (i.)  Non- 
arrest  of  the  bleeding,  causing  separation  of  the  lips  ,  or  deeper 
portions  of  the  wound;  (ii.)  the  presence  of  impure  foreign  bodies  or 
failure  of  the  antiseptic  precautions;  (iii.)  the  edges  not  being 
brought  into  contact;  (iv.)  imperfect  drainage,  leading  to  tension 
on  the  stitches;  (v.)  late  infection  of  the  wound  from  various  causes; 
(vi.)  lack  of  rest  to  the  part;  and  (vii.)  constitutional  conditions,  such 
as  deficient  general  vitality  from  disease  or  other  causes. 

When  blood  collects  in  the  deeper  parts  of  the  wound,  the  skin 
incision  may  heal  satisfactorily,  but  there  may  be  some  local  tender- 
ness, and  a  little  swelling,  and  some  slight  fever,  the  temperature 
running  up  at  night  to  about  100°.  In  such  cases  it  usually  suffices 
partially  to  open  the  incision,  squeeze  or  press  out  the  fluid,  and 
insert  a  small  tube   or  gauze   drain.     (For  Wound  Infection,  see 

p.  90.) 

16 


242  A   MANUAL  OF  SURGERY 

II.  Lacerated  or  Contused  Wounds. — Such  injuries  are  caused  by 
blvint  instriiiui'iits,  by  macliinciy,  missiles,  the  wheels  of  a  vehicle, 
etc.     They  are  characterized  by  the  following  signs: 

1.  The  haemorrhage  is,  as  a  rule,  but  slight,  since  the  vessels  are 
torn  across  irregularly,  and  not  cut  cleanly;  the  middle  and  inner 
coats,  which  give  way  first,  are  curled  up  within  the  contorted 
outer  coat,  forming  a  barrier  sufficient  to  prevent  loss  of  blood. 
The  vessels,  being  elastic,  may  be  pulled  out  of  their  sheaths,  and  are 
sometimes  seen  pulsating  upon  the  surface. 

2.  The  amount  of  damage  inflicted  varies  with  the  character  of 
the  injury,  but  is  often  so  considerable  as  to  involve  the  death,  at 
once  or  subsequently,  of  considerable  portions  of  tissue.  The  skin 
is  irregularly  torn,  and  may  be  extensively  stripped  from  under- 
lying parts;  muscles  and  tendons  may  be  laid  bare,  or  torn  from 
their  attachments;  nerves  may  be  lacerated;  bones  crushed  and 
comminuted;  joints  laid  open;  and  all  these  damaged  tissues  may 
be  hopelessly  infected  by  the  dust  and  dirt  which  accumulates  on 
greasy  machinery,  or  on  the  roadway.  Some  of  the  injuries  inflicted 
by  heavy  motor  vehicles  are  horribly  severe.  When  a  limb  is  torn 
completely  off,  the  tendons  are  often  left  long,  and  the  muscular  bellies 
project  from  their  fascial  sheaths  as  flabby  congested  masses,  since 
the  skin  gives  way  at  a  higher  point  than  the  subjacent  structures. 

The  Progress  of  the  case  depends  largely  upon  the  question 
whether  or  not  the  wound  can  be  rendered  aseptic. 

In  an  Aseptic  lacerated  wound  it  may  be  possible  to  bring  the 
edges  together  by  suture  or  otherwise,  and,  even  though  they  are  a 
little  bruised,  heahng  by  a  slightly  delayed  first  intention  is  possible 
if  drainage  is  provided.  When  the  wound  remains  open,  the  dead 
tissue  is  absorbed  or  separated,  and  an  aseptic  granulating  surface 
results.  There  may  be  some  simple  traumatic  fever  for  a  day  or 
two,  but  it  is  of  little  consequence. 

If  the  wound  is  Infected,  however,  inflammatory  phenomena 
supervene,  as  a  result  of  which  bruised  and  dead  tissues  have  to  be 
absorbed  or  cast  off  b}^  a  process  of  suppuration,  which  finally  leaves 
a  granulating  surface.  1  hree  stages  may  be  described  in  the  course 
of  the  case,  viz.: 

{a)  The  stage  of  injury,  resulting  in  shock,  which  may  be  very 
severe  if  large  nerve  trunks  have  been  crushed. 

(fo)  Ihe  stage  of  inflammation  and  sloughing,  which  lasts  a  week, 
ten  days,  or  more,  according  to  circumstances,  and  during  this 
period  the  patient  is  liable  to  various  forms  of  infective  trouble, 
including  secondary  hemorrhage,  toxaemia,  pyaemia,  tetanus,  and 
traumatic  gangrene. 

(c)  The  stage  of  repair  by  granulation,  or  prolonged  suppuration, 
with  exhaustion  and  hectic  fever  in  the  worst  cases. 

The  results  of  the  healing  of  injuries  such  as  these  may  be  quite 
satisfactory,  or  considerable  trouble  may  be  experienced  at  a  later 
date  from  the  implication  of  nerves  in  the  cicatrix,  or  their  paralysis ; 
from  the  adhesions  or  cicatricial  contraction  of  muscles  and  tendons, 


WOUNDS  243 

impairing  the  free  mobility  of  the  part;  or  from  the  deformity 
caused  bv  the  contraction  of  the  scar. 

The  Treatment  of  contused  and  lacerated  wounds  varies  with 
their  character,  and  no  absolute  rule  of  practice  can  be  laid  down 
to  suit  all  cases.     The  following  routine  is  that  usually  adopted: 

(rt)  Immediate  Treatment.— The  great  desideratum  in  all  these 
cases  is  to  render  the  wound  aseptic.  To  accomplish  this  in  severe 
injuries,  it  is  wise  to  anaesthetize  the  patient,  and  then,  after 
shaving'  and  purifying  the  skin,  the  wound  is  thoroughly  irrigated 
with  some  effective  antiseptic,  such  as  carbolic  lotion  (i  in  20), 
or  with  salt  solution  and  peroxide  of  hydrogen.  Foreign  bodies 
are  removed,  and  dead  or  doubtful  tissues  cut  away,  if  unimportant, 
whilst  bleeding  vessels  are  secured  by  hgature;  it  may  be  advisable 
to  enlarge  the  wound  in  order  to  deal  effectively  with  it.  Ample 
provision  must  be  made  for  drainage,  since  the  antiseptic  irrigation 
of  itself  causes  much  exudation ;  occasionally  it  is  desirable  to  make 
a  counter-opening  for  this  purpose.  Ragged  or  torn  fragments 
of  skin  are  removed  bv  knife  or  scissors,  and  then,  if  sufficient 
tissue  remains,  the  wound  may  be  loosely  closed  by  a  few  interrupted 
sutures,  and  an  antiseptic  dressing  of  the  usual  type  apphed.  If, 
liowever,  the  skin  is  scanty  and  asepsis  not  assured,  it  is  better  to 
leave  the  wound  open,  or,  at  any  rate,  only  to  close  it  partially, 
packing  it  carefully  with  gauze  impregnated  with  iodoform.  One 
cannot  lay  too  much  stress  upon  the  danger  of  accurately  suturing 
up  badly  lacerated  ivonnds  where  asepsis  is  not  assured. 

{b)  Subsequent  Treatment  depends  on  whether  or  not  the  measures 
adopted  to  obtain  asepsis  have  been  successful.  If  the  wound 
remains  free  from  infection,  nothing  special  is  required.  If  in- 
fection occurs,  cellulitis,  associated  with  a  certain  degree  of  sloughing, 
will  follow,  and  necessitate  opening  the  wound  freely,  and  following 
up  any  burrowing  suppuration  by  free  incisions.  Fomentations, 
baths,  etc.,  will  be  required  as  long  as  the  inflammatory  process 
lasts.'  When  the  suppuration  has  ceased  and  the  sloughs  have 
separated,  heahng  by  granulation  wih  occur.  It  must  be  remem- 
bered that  secondary  haemorrhage  may  occur  when  the  dead  tissues 
are  finaUy  detached.  During  this  period  inflammatory  fever  con- 
tinues, and  the  patient's  general  health  must  be  closely  watched. 
When'once  a  clean  granulating  surface  is  obtained,  it  is  treated  m 
the  same  way  as  any  healing  wound,  skin-grafting  possibly  being 
needed  in  the  more  extensive  cases. 

The  question  of  Amputation  will  necessarily  arise  m  deahng  with 
the  graver  forms  of  lacerated  wounds,  although  many  limbs  are 
now  saved  which  would  inevitably  in  former  days  have  been  sacri- 
ficed. Hard-and-fast  rules  cannot  be  laid  down  as  to  when  to 
amputate  and  when  not  to  do  so ;  each  case  must  be  treated  on  its 
own  merits.  The  following  general  points  must  first  be  carefully 
considered:  [a)  The  age  and  vitality  of  the  patient.  An  old  person 
has  less  recuperative  power  than  a  young  one,  and  hence  a  damaged 
limb  mav  often  be  left  in  a  youth  which  one  would  certainly  remove 


244  A   MANUAL  OF  SURGERY 

in  an  elderly  person.  The  vitality  of  the  individual  is  perhaps  even 
more  important  than  the  age,  for  some  men  at  sixty  are  in  a  much 
more  healthy  and  resistant  state  than  others  at  forty.  The  habits, 
as  to  temperance,  etc.,  must  also  be  taken  into  consideration,  and 
the  existence  of  general  diseases,  such  as  diabetes  or  albuminuria, 
might  induce  one  to  resort  to  radical  rather  than  conservative 
measures,  {b)  The  vitality  of  the  extremity  injured.  A  leg  has 
to  be  sacrificed  more  frequently  than  an  ajm,  since  the  vitality 
and  reparative  power  of  the  latter  are  so  nluch  greater,  [c]  The 
presence  or  not  of  infection  is  of  the  greatest  significance,  since,  if 
infection  can  be  prevented,  the  chances  of  preserving  the  limb  are 
greatly  improved. 

1  he  local  conditions  which  suggest  or  determine  the  performance 
of  an  amputation,  may  be  conveniently  divided  into  two  groups — 
viz.,  where  amputation  is  essential,  or  where  it  is  doubtful. 

A.  Amputation  is  certainly  called  for — 

1.  To  trim  up  the  stump  of  a  limb  torn  off  by  machinery,  or  cutoff 
by  a  railway  train,  or  blown  off  in  an  explosion. 

2.  When  the  whole  limb  or  one  complete  segment  of  it  has  been 
totally  disorganized,  or  crushed  to  pulp,  though  still  retaining  its 
connection  with  the  body. 

3.  In  cases  where  gangrene  is  imminent  or  has  superv'ened, 
especially  if  it  is  of  the  spreading  type. 

4.  WTien  severe  infective  symptoms  develop  in  a  case  where  an 
attempt  is  being  made  to  save  a  limb,  the  retention  of  which  was 
from  the  first  doubtful;  or  when  exhaustion  supervenes  from  pro- 
longed suppuration. 

5.  In  severe  compound  lacerations  of  the  foot  in  old  people,  in- 
volving the  bones  and  laying  open  the  common  synovial  cavnty. 
Infection  is  likely  to  result  in  disease  of  the  bones  and  joints,  whilst 
the  distance  of  the  foot  from  the  centre  of  the  circulation  increases 
the  likelihood  of  gangrene. 

B.  Amputation  is  doubtful  in  the  following  conditions: 

1.  Compound  comminuted  fractures  in  parts  other  than  the  foot 
do  not  per  se  require  amputation  unless  verv  extensive.  By  care- 
ful attention  to  antisepsis,  free  drainage,  and  the  removal  of  detached 
fragments  of  bone  and  foreign  bodies,  which  should  usually  be 
accomplished  under  an  anesthetic,  limbs  which  would  have  formerly- 
been  condemned  to  amputation  can  not  only  be  preserved,  but  also 
restored  to  a  considerable  degree  of  functional  usefulness.  Ihe 
final  decision  will  largely  depend  on  the  age,  condition,  and  previous 
habits  of  the  individual. 

2.  When  the  soft  parts  have  borne  the  brunt  of  the  injury,  and 
have  been  extensively  stripped  from  the  bones — e.g.,  when  the 
muscles  of  the  forearm  have  been  torn  up  in  a  machine  accident — 
amputation  is  by  no  means  an  essential,  provided  that  they  can  be 
restored  to  their  original  position,  that  there  is  a  reasonable  prob- 
ability of  their  vitality  being  maintained,  and  that  the  utility  of  the 
limb  will  not  be  hopelessly  impaired,  as  a  result  of  lesions  to  the 


WOUNDS  245 

nerves,  after  the  wound  has  healed.  The  surgeon  has  here  to 
balance  carefully  the  risk  run  if  an  attempt  is  made  to  save  the  limb, 
and  the  value  that  the  limb  if  saved  wll  subsequently  be  to  the 

patient. 

_].  Laceration  of  the  main  artery  of  a  limb  need  not  in  itself 
determine  amputation ;  but  if  in  addition  to  this  the  bones,  veins,  or 
nerves  are  hopelesslv  injured,  and  especially  in  the  lower  extremities 
of  old  people,  amputation  should  be  undertaken  without  delay.  In 
this  connection  it  may  be  pointed  out  that  in  all  probability  tissue- 
grafting  will  be  more  extensively  used  in  the  future  than  it  has  been 
hitherto,  and  that  alread\-  some  astonishing  results  of  this  process 
have  been  attained. 

III.  Punctured  Wounds  and  Stabs. — These  may  be  brought  about 
b}'  any  form  of  penetrating  instrument,  from  a  pin  or  needle  to  a 
sword^  bavonet,  or  pickaxe.  The  external  opening  may  be  in  itself 
insignificant,  the  chief  danger  arising  from  the  damage  to  deep 
structures — bloodvessels  or  nerves  being  di^-ided,  and  serous  ca\'ities 
or  \-iscera  opened,  or  even  the  skull  penetrated.  The  subsequent 
s^Tiiptoms  depend  almost  entirely  upon  the  question  of  infection; 
there  is  alwavs  considerable  difficulty  in  draining  effectively  the 
depths  of  a  long  and  narrow  wound,  and  therefore  collections  of  pus 
readily  fomi  and  may  burrow  in  all  directions. 

Wounds  resulting  from  the  modern  sword-bayonet,  though  very 
serious  from  their  size  and  depth,  are  not  so  difticult  to  heal  as  those 
inflicted  by  the  old  triangular  blade.  They  should  be  effectively 
purified,  well  drained,  and  the  skin  opening  not  allowed  to  close 
until  all  discharge  has  ceased;  if  necessary,  a  counter-opening  is 
made  at  a  dependent  spot.  Serious  haemorrhage  or  paralysis  calls 
for  immediate  opening  up  of  the  wound,  so  as  to  expose  and  deal 
with  injured  vessels  or  nerves. 

Needles  are  frequently  broken  off  short  in  the  body,  especially 
in  the  hands,  feet,  knees,  or  nates.  If  seen  soon  after  the  injury, 
it  is  ad\-isable  to  undertake  their  immediate  removal,  a  proceeding 
sometimes  verv  simple,  but  occasionally  necessitating  a  deep  and 
difficult  dissection.  Should  the  needle'  not  be  removed,  it  may 
travel  about  the  bodv  along  the  muscular  and  fascial  planes,  and 
there  is  no  knowing  where  it  may  lodge  or  come  to  the  surface,  or 
how  long  it  may  remain  in  the  body ;  it  has  been  known  to  consti- 
tute the  nucleus  of  a  renal  calculus. 

One  of  the  most  troublesome  and  painful  forms  of  penetratiiig 
wound  is  that  caused  by  a  fish-hook,  since  the  barbed  end  catches  in 
the  tissues,  and  it  is  impossible  to  withdraw  it  without  increasing  the 
size  of  the  wound  considerably.  The  simplest  plan  of  treatment  is 
to  push  on  the  hook  and  make  it  protrude  through  the  skin  else- 
where to  such  an  extent  as  to  enable  the  barb  to  be  cut  away,  when 
the  remainder  of  the  hook  \^-ill  be  set  free. 

For  the  detection  of  penetrating  foreign  bodies  of  a  metaUic 
nature,  or  of  splinters  of  glass  or  stone,  the  X  rays  are  exceedingly 


246 


A   MANUAL  OF  SURGERY 


valuable  (Figs.  78,  79),  but  one  need  scarcely  point  ont  that  such 
plates  are  useless  as  means  of  localizing  the  foreign  body;  thus  one 
could  not  even  say  on  which  side  of  the  bones  (dorsal  or  palmar) 
the  substance  is  located.  It  is,  therefore,  always  necessary  to  take 
the  skiagram  from  two  directions,  and  if  the  antero-posterior  one 
is  taken  stereoscopically,  so  much  the  better.  Even  with  this 
assistance,  it  is  often  difficult  to  find  a  foreign  body,  such  as  a 
needle,  and  it  is  advisable  to  undertake  the  operation  for  its  removal 
under  the  rays  with  the  assistance  of  a  screen.  These  are  now 
made  in  a  sterilizable  form,  so  that  full  asepsis  can  be  maintained. 

The  employment  of  complicated  methods  of  localizing  foreign 
bodies — e.g.,  the  cross-thread  localizer — are  not  necessary  except  in 
oj)hthalmic  work. 

IV.  Gunshot  Wounds. — The  character  of  a  gunshot  wound  varies 
according  to  the  nature  of  the  projectile,  the  arm  employed,  the 


Fig.  78. — Skiagram  of  Wrist  with  Fig.  79. — Skiagram  of  Hand  with 

Portion   of  Needle    embedded  Splinters    of  Glass   embedded 

IN  Palmar  Aspect.  Close  to  the  Metacarpal  Bone 

OF  THE  Index  Finger. 

It  will  be  noted  that  the  glass  casts 
quite  as  dense  a  shadow  as  the 
bone. 

velocity  of  the  missile,  the  distance  from  the  body  at  which  the  fire- 
arm was  discharged,  the  part  of  the  body  struck,  and  the  direction 
of  the  shot. 

The  wounds  inflicted  by  the  modern  small-bore  rifle  {e.g.,  the  Lee- 
Enfield,  Mauser,  or  Krag-Jorgenson)  are  very  different  to  those 
produced  by  the  old-fashioned  guns  of  former  days.  The  modern 
rifle  has  been  designed  to  secure  great  muzzle  velocity,  a  low  tra- 
jectory, and  clean  and  hard  hitting.  To  this  end  the  barrel  is 
rifled  so  as  to  cause  the  bullet  to  rotate  on  its  own  longitudinal  axis 
(without  such   rifling  the  bullet  would  rotate  on  its  short  axis), 


WOUNDS 


247 


and  the  bullet  has  been  greatly  modified,  whilst  gunpowder  has 
given  way  to  more  highly  explosive  substances. 

The  modern  bullet  of  the  British  Army  is  a  long,  thin,  conical 
body,  consisting  of  a  core  of  lead  hardened  by  the  addition  of 
2  per  cent,  of  antimony,  enclosed  in  a  cover,  jacket  or  mantle  made 
of  a  copper-nickel  alloy.  The  muzzle- velocity  is  very  high,  amount- 
ing to  2,000  feet  per  second  for  a  Lee-Enfield  rifle,  and  2,380  feet 
per  second  for  a  Mauser.  The  trajectory  is  nearly  flat;  anything 
within  500  yards  may  be  fired  at  point-blank,  whilst  in  a  range  of 
2,000  yards  the  bullet  only  rises  194  feet,  as  compared  with  866 
feet  with  the  Snider  bullet. 

The  effect  of  these  arms  varies  to  some  extent  with  the  range; 
the  worst  wounds  are  usually  produced  at  a  short  distance,  say 
500  or  750  yards,  yet  quite  simple  wounds  with  no  disruptive 
phenomena  may  also  be  caused  at  a  similar  range.  One  of  the  best- 
marked  features  of  these  wounds  is  that  the  bullet  travels  straight 
and  direct,  without  lateral  deviation  or  deflection,  as  was  so 
commonly  the  case  in  the  old  days.  Simple  flesh  wounds  are  of 
no  great  importance  per  se,  granted  that  important  vessels  and 
nerves  are  not  injured.  The  aperture  of  entry  is  small,  and  looks 
somewhat  '  like  a  bug-bite  '  (Treves) ;  the  aperture  of  exit  is  slightly 
larger,  and  tends  to  be  a  little  more  slit-like.  A  certain  amount  of 
extravasation  occurs  into  the  tissues  around  the  track,  but  the 
external  bleeding  is  often  shght.  There  is  but  little  tendency 
to  carry  in  portions  of  clothing  or  septic  material,  and  the  bullet 
usually  escapes;  the  wound  heals  by  first  intention  if  reasonable 
precautions  are  taken.  The  external  cicatrices  finally  look  very 
similar  to  those  produced  by  bad  acne  pustules.  Vessels  and  nerves 
are  not  likely  to  be  injured  unless  they  are  actually  in  the  line  of  the 
bullet ;  the  accurate  limitation  of  the  damage  to  this  line  is  evident 
when  one  hears  of  a  bullet  passing  between  the  abdominal  aorta  and 
the  vena  cava  without  either  being  injured.  If  a  large  artery  is 
cleanly  hit,  the  patient  bleeds  freely,  and  may  die  of  haemorrhage, 
unless  it  can  be  controlled  by  a  tourniquet.  If  the  artery  is 
button-holed,  a  traumatic  aneurism  may  result;  arterio-venous 
wounds  have  been  common  in  recent  campaigns.  There  has 
been  some  difference  of  opinion  as  to  the  character  of  the  injuries 
to  bones;  that  large  masses  of  cancellous  tissue  {e.g.,  the  lower  end 
of  the  femur)  can  be  drilled  cleanly  without  fracture  is  certain ;  but 
such  wounds  are  sometimes  associated  with  much  splintering  and 
involvement  of  neighbouring  joints,  possibly  as  a  result  of  a  short 
range,  or  of  expansion  of  the  bullet  from  the  tearing  down  of  the 
mantle.  If  a  bullet  hits  cleanly  the  compact  shaft  of  a  long  bone, 
it  may  smash  the  whole  bone  into  small  fragments,  or  the  force 
may  be  more  localized  in  its  action,  though  always  severe.  Such 
comminuted  fractures  are  very  likely  to  become  infected,  if  there 
is  a  long  transport  to  the  field  hospital,  and  then  fragments  undergo 
necrosis  and  serious  inflammatory  phenomena  follow. 

Head  wounds  are  much  less  fatal  than  might  be  imagined  from 


248  A   MANUAL  OF  SURGERY 

the  experimental  work  that  has  been  undertaken.  At  close  range 
frightful  disruptive  effects  are  produced  which  are  almost  certain 
to  be  fatal;  at  a  longer  range  comparatively  little  mischief  is  done, 
except  along  the  line  of  the  missile.  The  inner  table  is  always  more 
splintered  than  the  outer,  and  of  course  a  certain  amount  of  brain 
substance  may  escape.  Abdominal  wounds  are  also  much  less 
serious  than  formerly,  a  mortality  of  go  per  cent.  (American  Civil 
War)  being  replaced  by  one  of  40  per  cent,  in  the  South  African 
campaign,  and  that  without  operation  (Treves).  The  mere  penetra- 
tion of  one  or  more  coils  of  intestine  is  not  sufficient  to  cause  general 
peritonitis;  the  wound  is  very  small,  and  peristalsis  seems  to  come 
to  an  end  entirely  as  soon  as  the  patient  is  struck,  so  that  neighbour- 
ing coils  of  intestine  or  the  omentum  sulftce  to  prevent  faecal 
extravasation;  indeed,  many  of  the  patients  suffer  but  little  con- 
stitutional or  local  disturbance.  Of  course  an  empty  intestinal  canal 
is  a  favourable  condition,  and  this  is  not  unfrequently  present  on  the 
field  of  battle.  Bloodvessels  may  be  wounded  in  the  mesentery, 
and  death  result  from  haemorrhage;  solid  viscera,  such  as  the  liver 
or  spleen,  are  often  damaged  but  little,  granting  a  fairly  long  range. 

On  the  whole,  the  effect  of  these  modern  billlets  is  comparatively 
shght,  unless  a  vital  part  or  a  long  bone  is  struck,  and  hence  their 
'  stopping  '  power  is  defective,  especially  in  dealing  with  the  mad 
rushes  of  savages  or  fanatics.  Modifications  are  in  progress,  so 
as  to  secure  a  more  effective  disabling  of  a  man  when  hit  without 
resorting  to  such  contrivances  as  soft-nosed  bullets. 

Soft-nosed  Bullets  {e.g.,  the  Dum-Dum)  are  characterized  by  the 
mantle  being  absent  at  the  top,  whilst  the  lead  core  is  usually  free 
from  antimony.  The  result  of  this  is  that  as  soon  as  the  bullet 
strikes,  the  lead  core  mushrooms  out,  and  terrible  mutilation  or 
destruction  of  surrounding  tissues  ensues,  whilst  bones  are  com- 
minuted and  sohd  viscera  pulped.  A  similar  result  follows  from 
rubbing  or  cutting  off  the  top  of  the  Lee-Enfield  or  Mauser  bullet, 
or  even  from  incising  the  cover  in  two  or  three  places.  These 
bullets  are  'expanding'  and  not  'explosive'  in  character;  the 
latter  property  can  only  be  secured  by  including  some  substance 
which  detonates  on  impact. 

Martini-Henry  and  Snider  Bullets  produce  wounds  which  are  inter- 
mediate in  their  severity  between  the  preceding  two.  The  aperture 
of  entry  is  usually  small,  that  of  exit  large  and  with  everted  edges. 
Portions  of  clothing  are  frequently  carried  in  by  these  missiles,  and 
add  to  the  risks  of  infection. 

Shell  Wounds  have  no  special  peculiarities  beyond  their  severity 
and  the  ghastly  nature  of  the  injuries  which  may  be  inflicted  by 
them,  depending  on  the  irregular  shape  of  the  fragments  into  which 
the  shell  bursts. 

Revolver  Wounds  are  more  likely  to  be  seen  in  civil  practice  than 
any  other  form  of  gunshot  injury.  They  may  be  suicidal  or  acci- 
dental in  origin.  Suicidal  wounds  are  usually  directed  to  the  temple, 
the  base  of  the  skull  through  the  mouth,  or  the  heart.     In  the 


WOUNDS 


249 


temporal  region  (right  side  for  right-handed  individuals)  there  is 
usually  a  small  wound,  surrounded  by  an  area  in  which  the  skin  and 
hair  are  singed,  and  perhaps  stained  by  the  powder.  The  bullet 
pierces  the  bone  and  traverses  the  brain,  but  in  the  majority  of  cases 
does  not  emerge  from  or  even  fracture  the  other  side.  It  may  be 
found  either  embedded  in  the  brain  substance  or  loose  under  the 
dura  mater.  Death  is  not  always  instantaneous,  as  no  large  vessel 
may  be  torn.  When  the  revolver  is  discharged  upwards  through 
the  mouth,  the  base  of  the  skull  is  penetrated,  and  death  is  more 
hkely  to  be  instantaneous;  the  bullet  in  some  cases  may  dislodge 
a  portion  of  the  top  of  the  cranium,  but  without  penetration.  Acci- 
dental revolver  wounds  may  present  any  variety  of  lesion,  but  the 
apertures  of  entr}"  and  exit  are  distinctly  recognisable  as  a  rule. 

Dangerous  wounds  may  be  inflicted  by  small  shot,  as,  for  instance, 
when  one  of  the  pellets  enters  the  eye,  whilst  the  wads  or  other 
portions  of  the  cartridge  may  also  be  carried  into  the  body ;  a  horse- 
hair wad  may  produce  tetanus.  A  blank  cartridge,  if  discharged  at 
a  short  distance,  mav  produce  a  severe  wound  or  even  death,  and 
under  such  circumstances  the  skin  around  is  likely  to  be  burned  and 
blackened,  leaving  a  permanent  bluish-black  tattooing  of  the  tissues. 

The  Treatment  of  gunshot  wounds  is  conducted  in  accordance 
with  general  surgical  principles,  although  it  may  have  to  be  some- 
what modified  b}'  the  patient's  environment  and  by  the  fact  that 
after  a  battle  the  pressure  of  work  may  be  such  that  all  lengthy 
operative  procedures  have  to  be  discarded.  The  first  essential  is  to 
protect  the  wound  from  infection,  and  for  this  purpose  the  small 
packet  of  antiseptic  dressing  carried  by  all  our  soldiers  is  admirable. 
Bleeding  is  controlled  by  a  tourniquet,  and  splints  must  be  impro- 
\ased  for  broken  limbs.  As  soon  as  the  wounded  man  reaches  the 
field  hospital,  the  wound  is  more  thoroughly  explored  and  cleansed; 
foreign  bodies  are  removed,  bleeding-points  secured,  and  if  the  bullet 
has  not  escaped  and  can  be  readil}-  detected,  it  should  be  extracted. 
When  lodged  deeply,  its  position  may  be  determined  by  skiagraphy, 
or  by  such  appliances  as  Nelaton's  porcelain-ended  probe,  or  more 
complicated  electrical  contrivances,  such  as  the  telephone  probe. 
Comminuted  fractures  are  carefully  investigated,  detached  frag- 
ments of  bone  are  removed,  and  if  an  attempt  is  made  to  save  the 
Hmb,  splints,  etc.,  are  carefully  applied.  Primary  amputations  for 
bullet  wounds  are  not  very  common  at  the  present  day,  except  when 
great  comminution  of  bone  or  hopeless  involvement  of  vessels  and 
ner\'es  has  occurred.  Wounds  of  the  skull  alwaj-s  demand  the 
most  careful  attention,  even  when  the  bullet  has  penetrated  cleanly 
and  escaped;  each  opening  must  be  trephined  so  as  to  allow  of  the 
removal  of  depressed  splinters  of  the  inner  table.  This  rule  holds 
good  even  when  a  bullet  has  merely  ploughed  a  groo\'e  or  track 
along  the  calvarium  without  penetration. 

The  treatment  of  abdominal  wounds  produced  by  small-bore  rifle 
fire  is  generalh'  one  of  expectancy.  It  has  now  been  abundantly 
proved  that  patients  can  recover  in  the  most  astonishing  fashion 


250  A   MANUAL  OF  SURGERY 

from  bullet  wounds  which  have  traversed  the  alxlomcn  from  side 
to  side  or  from  front  to  back,  and  therefore  unless  there  is  some 
very  clear  indication,  operation  is  better  avoided.  Moreover,  the 
practical  difficulties  connected  with  abdominal  sections,  the  frequent 
lack  of  sterilized  water,  of  towels,  and  the  dirty  condition  of  the 
patient,  together  with  the  length  of  time  that  such  an  operation 
takes^ — all  these  constitute  reasons  for  not  interfering  unnecessarily 
Abdominal  chstension  from  haemorrhage  is  one  of  the  chief  indica- 
tions for  laparotomy. 

For  revolver  wounds  very  similar  rules  of  treatment  hold  good. 
As  a  general  rule,  careful  antisepsis  to  the  external  wound  is  all  that 
is  required;  the  bullet  may  be  disregarded,  and  there  is  no  need 
to  attempt  its  removal,  unless  it  is  superficial  or  doing  some  mis- 
cheif.  Wounds  in  the  limbs  should  not  be  explored  unless  vessels 
or  nerves  have  been  injured.  On  the  other  hand,  cranial  injuries 
always  demand  exploration  of  the  aperture  of  entry  and  a  limited 
search  for  the  bullet.  Abdominal  wounds  should  also  be  opened 
up  and  investigated,  if  it  is  thought  likely  that  some  hollow  viscus 
has  been  injured  or  internal  hccmorrhage  is  proceeding. 

V.  Poisoned  Wounds. — The  great  majority  of  poisoned  wounds 
are  due  to  some  definite  micro-organism,  and  have  been  discussed 
elsewhere.     A  few  only  remain  to  be  dealt  with  here. 

Stings  of  Insects,  such  as  bees  and  wasps,  are  exceedingly  painful, 
but  not  dangerous,  unless  some  local  complication,  such  as  erysipelas, 
supervenes,  or  the  stings  are  very  numerous,  as  when  a  swarm  of 
angry  bees  settles  on  a  person,  or  the  part  involved  is  such  as  to 
lead  to  serious  swelling,  as  in  the  pharynx  or  tongue,  oedema  of 
the  glottis  possibly  arising  under  such  circumstances.  All  that  is 
usually  needed  is  the  application  of  a  weak  alkaline  lotion,  whilst 
a  common  and  efficient  domestic  remedy  is  a  freshly  sliced  onion 
applied  to  the  part.  Care  must  also  be  exercised  to  ascertain  that 
the  sting  and  poison  sac  are  not  left  in  the  body. 

Some  varieties  of  flies  and  spiders  are  also  extremely  virulent,  and 
the  former  play  an  active  part  in  the  transmission  of  many  types 
of  disease.  Thus  various  forms  of  infective  cellulitis  or  lymphan- 
gitis niav  be  caused  by  the  bite  of  a  fly  that  has  been  feeding  on 
putrid  carrion,  whilst  the  epidemic  diarrhoea  of  children  in  summer 
is  largely  due  to  the  infection  of  their  food  by  flies.  The  tsetse 
fly  in  vSouth  and  East  Africa  is  the  carrier  of  the  virus  of  sleeping- 
sickness.  Mosquitoes  and  midge  bites  are  exceedingly  irritating; 
one  variety,  the  female  of  the  Anopheles,  is  the  active  agent  in 
transmitting  the  virus  of  malaria,  and  another  is  responsible  for 
the  development  of  filariasis.  Fleas  carry  the  5.  pestis  from  infected 
rats  to  the  human  subject,  giving  rise  to  plague,  and  it  is  probable 
that  bed-bugs  are  similarly  harmful. 

Chigoe,  or  the  jigger,  occurs  in  many  parts  of  the  tropics  as  a  result  of  the 
activity  of  the  sand-flea  [Pulex  penetrans) .  The  female,  when  impregnated,  fixes 
herself  by  the  head  to  some  portion  of  the  skin,  preferably  of  the  sole  of  the  foot. 


WOUNDS  251 

or  under  the  nails  and  proceeds  to  burrow  between  the  dermis  and  the  epidermis, 
protlucint>  thereby  a  peculiar  stinging  pain,  which  is  very  characteristic  Ihe 
head  remains  fixed  in  the  deeper  part  of  the  pocket,  whilst  the  abdomen 
becomes  greatlv  distended  in  the  course  of  a  few  days,  constituting  a  sac, 
containincr  a  lars^e  number  of  eggs.  Great  irritation  is  caused  thereby,  and 
inflammatory  phenomena,  with  perhaps  swelling  of  lymphatic  glands,  especially 
if  the  sac  is  crushed  or  burst.  Left  to  itself,  the  ova  are  set  free,  and  escape 
externally  to  develop  into  vermiform  larvae.  Treatment  consists  m  enlarging 
the  burrow  bv  means  of  a  blunt  needle  or  probe,  and  digging  out  the  jigger 
complete,  taking  care  not  to  burst  the  sac.  The  small  opening  is  touched  with 
tincture  of  iodine,  but  if  suppuration  is  present,  fomentations  will  be  required. 

Snake-bites  require  but  little  notice  here,  as  they  are  exceedingly 
rare  in  this  country,  the  common  adder  [Pehas  bents)  bemg  the  only 
venomous  one  likely  to  be  met  wdth,  and  even  with  this  the  poison 
is  not  sufficiently  virulent  to  do  much  hann  unless  the  individual 
attacked  is  a  child  or  a  person  in  a  very  bad  state  of  health.  Ihe 
poison  is  conveyed  to  the  wound  from  the  glands  and  poison  sac 
situated  on  either  side  of  the  upper  jaw  through  fine  canals  m  the 
speciahzed  teeth,  which  open  at  their  apices;  these  teeth  are  so 
delicate  in  some  snakes  that  it  mav  be  difficult  to  find  the  wounds 
produced  by  them.  The  effects  of  an  adder's  bite  are  not,  as  a  rule, 
noticed  immediately,  but  come  on  in  the  course  of  an  hour  or  so ; 
extreme  prostration  supervenes,  with  a  weak  pulse,  cold  clammy 
perspiration,  dilatation  of  the  pupils,  and  perhaps  delirium  m  bad 
cases,  merging  into  coma. 

The  Treatment  consists  in  preventing  the  absorption  of  the  virus 
by  tying  a  hgature  firmly  above  the  wound,  which  should  then  be 
laid  open  so  as  to  allow  of  free  bleeding,  and  the  surface  excised  or 
cauterized.  The  collapse  resulting  from  absorption  of  the  poison  is 
best  remedied  by  the  administration  of  stimulants  or  the  hypodermic 
injection  of  strychnine. 

In  India  and  other  countries  many  varieties  of  poisonous  snakes 
are  met  with,  and  wounds  are  frequently  fatal;  indeed,  in  India  it 
is  stated  that  12,000  individuals  are  yearly  destroyed  m  this  way. 
1  he  s\Tnptoms  come  on  rapidly,  and  are  extremely  severe,  although 
they  are  modified  according  to  the  variety  of  snake.  Treatment 
consists  in  the  immediate  apphcation  of  a  hgature  round  the  limb 
above  the  wound,  which  is  excised,  or  squeezed  and  sucked  after 
incising,  so  as  to  encourage  bleeding.  The  wound  is  then  packed 
with  crystals  of  permanganate  of  potash,  or  soaked  m  a  concen- 
trated solution  of  the  same  or  of  peroxide  of  hydrogen.  If  the 
patient  sur\dve,  the  ligature  is  removed  from  the  hmb  after  a  few 
hours.*  Strychnine  and  stimulants  are  required  to  counteract 
the  depressing  effects  of  the  poison,  and  Calmette's  antivenene,  if 
obtainable,  may  also  be  employed;  it  consists  of  the  blood-serum 
of  a  horse  that  has  been  immunized  by  the  injection  of  graduaUy 
increasing  doses  of  cobra  venom.  The  dose  required  vanes  with 
the  size  of  the  snake— from  10  to  40  c.c.  or  more— and  to  be  bene- 
ficial must  be  injected  Nvithin  an  hour  of  the  bite. 

The  Anatomical  Tubercle,  or  Butcher's  Wart  {Veniica  necrogenica), 

*  Leonard  Rogers,  Brit.  Med.  Jour.,  November  11,  1905- 


252  A   MANUAL  OF  SURGERY 

consists  in  a  papillomatous  dev^elopment  usually  on  the  knuckles  or 
wrists  of  those  who  are  exposed  to  wounds  either  in  the  deadhouse 
or  slaughter-house.  It  is  in  all  probability  a  manifestation  of  tuber- 
culous infection,  and,  indeed,  resembles  somewhat  closely  the  appear- 
ance of  lupus  when  it  develops  on  the  hands.  Treatment  consists 
in  the  application  of  a  powerful  caustic,  whilst  in  bad  cases  it  is 
necessar\-  to  scrape  the  surface  before  cauterizing. 

Poisoned  Wounds  of  the  Fingers  are  not  uncommon,  arising  from 
the  infection  ol  pricks,  scratches,  and  abrasions,  and  sometimes 
giving  rise  to  serious  consequences,  and  especially  when  the  patient's 
occupation  brings  his  hands  into  contact  with  infective  material. 
The  dissecting-room  used  to  be  a  fertile  source  of  infected  fingers, 
but  the  care  now  taken  in  the  preparation  of  the  cadaver  has  almost 
abolished  this  form  of  trouble.  Pathologists  and  the  attendants 
in  the  post-mortem  rooms  are  liable  to  infection  of  this  kind  in 
spite  of  the  use  of  rubber  gloves;  surgeons  operating  on  cases  of 
septic  peritonitis,  or  nurses,  especially  when  attending  patients 
suffering  from  puerperal  fever,  may  also  be  infected  by  pricking 
the  finger  with  a  needle  or  pin.  The  resulting  lesions  vary  much 
in  their  character,  from  a  mild  suppurative  foUicuHtis  to  various 
forms  of  inflammation  of  the  nail  m^atrix  or  subcutaneous  tissues 
(constituting  a  whitlow),  whilst  the  worst  cases  may  develop  a 
grave  cellulitis,  with  perhaps  suppuration  of  the  axillary  glands 
and  septicremia.  ]\Iost  of  these  conditions  are  described  elsewhere, 
but  it  will  be  convenient  to  deal  here  with  the  subject  of  whitlow, 
(For  Affections  of  the  Xail  Matrix,  see  p.  407.) 

A  Whitlow  {Paronychia  or  Panaritium)  occurs  in  four  different 
forms,  of  which  one  is  a  localized  inflammation  of  the  skin,  another 
a  true  cellulitis,  a  third  is  a  teno-synovitis,  and  the  fourth  involves 
the  terminal  phalanx. 

[a)  The  Subcuticular  whitlow  (or  purulent  blister)  consists  merely 
in  a  development  of  pus  beneath  the  cuticle  which  separates  it 
from  the  cutis  vera.  It  is  painful,  but  otherwise  of  little  importance. 
A  boracic  fomentation,  preceded  by  the  removal  of  the  loose  cuticle, 
is  all  that  is  needed  in  its  treatment. 

{h)  The  Subcutaneous  whitlow  is  a  true  cellulitis,  commencing  in 
the  pulp  of  a  finger,  but  often  spreading  upwards  to  involve  the 
palm.  The  finger  becomes  swollen  and  painful,  the  pain  being 
increased  by  pressure  or  by  hanging  do\\Ti  the  arm.  Gradually 
both  these  symptoms  increase  in  amount,  the  back  of  the  finger 
becoming  oedematous,  and  the  pulp  more  or  less  red.  The  swelhng 
is  at  first  hard  and  brawnv,  and  even  when  pus  is  present  it  may 
be  difficult  to  detect  fluctuation  unless  the  abscess  is  nearly  pointing. 
Constitutional  sjonptoms  are  not,  as  a  rule,  very  severe,  though  the 
intensity  of  the  pain  mav  exhaust  the  patient.  The  hand  should 
be  elevated,  and  the  finger  fomented  or  poulticed,  or  treated  by 
Klapp's  suction-balls.  When  pus  has  formed,  a  free  longitudinal 
incision  in  the  middle  fine  should  be  early  adopted;  but,  though 


WOUNDS 


253 


free,  it  must  not  extend  too  deeply,  or  the  tendon  sheath  may  be 
opened  and  infected.  Occasionally  the  pus  forms  at  one  or  other 
side  of  the  ftnger,  and  the  incisions  must  then  be  suitably  modified. 
Antiseptic  fomentations  constantly  changed  and  baths  must  be 
utilized  after  such  an  incision,  the  constant  moisture  adding  greatly 
to  the  patient's  comfort.  Bier's  plan  of  treatment  may  advisably 
be  repeated  after  incision. 

(c)  The  Thecal  form  of  whitlow  is  really  a  suppurative  teno- 
synovitis of  the  flexor  sheaths.  The  signs  are  much  the  same  as 
in  the  former  variety,  only  more  severe,  because  the  process  is  often 
more  extensive.  As  special  features  may  be  mentioned,  the  in- 
abihty  of  the  patient  to  bend  the  finger,  and  the  extreme  pain  caused 
on  attempting  to  extend  it,  owing  to  the  involvement  of  the'tendon 
and  its  sheath.  The  swelling  also  is  more 
marked,  and  often  extends  to  the  dorsum  of 
the  finger,  where  localized  collections  of  pus 
form  a  communication  with  the  sheaths  by  a 
narrow  neck;  these  are  due  to  the  yielding  of 
weak  spots  in  the  postero-lateral  aspects  of  the 
sheath.  Infection  of  the  inter-phalangeal  joints, 
or  even  of  the  bones,  resulting  in  caries  or 
necrosis,  may  occasionally  follow. 

Extension  to  the  palm,  and  even  to  the  fore- 
arm, is  very  likely  to  occur,  owing  to  the  arrange- 
ment of  the  tendon  sheaths  (Fig.  80) ;  this  is 
almost  always  the  case  when  the  little  finger 
and  thumb  are  involved,  as  the  sheaths  run 
along  the  tendons  under  the  annular  hgament. 
(In  the  little  finger,  however,  there  is  sometimes 
a  short  break  in  the  continuity,  which  is  easily 
overstepped.)  With  the  other  fingers  there  is 
a  definite  gap  between  the  tendon  sheaths  and 
the  main  palmar  sheath  (or  bursa),  and  hence 
extension  upwards  is  due  to  a  proximal  rupture 
of  the  sheath  and  infection  of  the  connective 
tissue  space  in  the  palm,  where  it  may  be  hmited,  or  whence  infection 
may  spread  to  the  palmar  bursa  or  directly  into  the  forearm  under 
the  annular  hgament.  Involvement  of  the  palm  is  recognised  by 
the  part  becoming  swollen  and  tender,  whilst  the  general  symptoms 
are  aggravated.  The  intercarpal  articulations  may  be  secondarily 
affected,  and  necrosis  or  caries  of  carpal  bones,  especially  of  the  os 
magnum,  may  follow. 

Extension  to  the  forearm  is  usually  due  to  infection  of  the  tendon 
sheaths,  but  may  spread  along  the  connective  tissue  planes.  The 
annular  ligament  constitutes  an  unyielding  barrier,  above  which  the 
forearm  becomes  swollen,  hard,  and  brawny.  The  pus  usually  follows  a 
definite  course,  being  placed  between  the  tendons  of  the  flexor  profun- 
dus and  the  pronator  quadratus,  and  then  travels  up  in  close  proximity 
to  the  interosseous  septum  along  the  median  nerve  or  ulnar  vessels. 


Fig.  80. — Diagram  of 
Synovial  Sheaths 
OF  Flexor  Ten- 
dons OF  Hand. 


254 


A   MANUAL  OF  SURGERY 


Lymphatic  infection  may  be  associated  with  any  of  these  mani- 
festations, in  the  form  either  of  an  acute  lymphangitis  or  acute 
inflammation  of  the  epicondyloid  or  axillary  glands,  in  the  lattei 
instance  being  perhaps  associated  with  an  axillary  celluhtis.  Natur- 
ally the  constitutional  results  will  be  greatly  increased  by  these 
complications. 

Free  and  early  incisions  are  required  either  in  the  middle  line  or 
on  either  side  of  the  finger  in  order  to  secure  effective  drainage  of 
the  sheath,  and  thereby  to  prevent  as  far  as  possible  the  formation 
of  adhesions,  or  to  keep  the  tendons  from  sloughing.  It  may  sufhce 
to  limit  the  incisions  to  the  interarticular  segments  of  the  fingers, 
but  frequently  it  will  be  necessary  to  make  an  incision  the  whole 

length  of  the  finger.  Extensions  to  the 
dorsum  must  be  treated  by  counter- 
openings.  If  the  connective  tissue  space 
of  the  palm  is  involved  by  extension 
from  the  index,  middle,  or  ring  fingers, 
the  incisions  employed  in  dealing  with 
these  sheaths  must  be  carried  up  into  the 
palm,  but  precautions  must  be  taken  not 
to  infect  the  sheaths  of  the  thumb  and 
little  finger.  As  a  rule  this  palmar  in- 
cision need  not  encroach  on  the  superficial 
palmar  arch,  but  even  if  it  does  it  is  of 
little  consequence,  as  the  vessel  is  easily 
secured.  Involvement  of  the  thumb  and 
little  finger  will  require  more  extensive  in- 
cisions for  satisfactory  drainage  (Fig.  8i), 
whilst  extension  to  the  forearm  will  in- 
volve opening  up  the  deep  space  between 
the  flexor  profundus  and  the  pronator 
quadratus,  and  this  is  best  accomplished 
by  lateral  and  not  by  central  incisions, 
the  more  superficial  tendons  being  drawn 
forwards.  In  addition  to  effective  drain- 
age, fomentations  will  be  required,  as 
also  immersion  from  time  to  time  in  hot  baths;  and  when  the  dis- 
charge of  pus  is  lessening.  Bier's  hypera?mia  induced  by  the  appli- 
cation of  a  rubber  bandage  above  the  elbow  will  be  most  beneficial. 
The  iisual  constitutional  treatment  for  an  infective  disease  will 
be  needed,  and  the  patients  usually  require  much  improvement  of 
their  general  health. 

Unfortunately,  however,  patients  often  come  under  observation 
late  in  the  case,  and  the  mischief  often  extends  in  such  a  manner 
and  to  such  an  extent  as  to  render  amputation  the  only  feasible 
method  of  treatment. 

{d)  The  Subperiosteal  whitlow  may  be  merely  a  complication  of 
the  thecal  variety;  but  it  occasionally  starts  as  an  acute  necrosis 
of  the  terminal  phalanx,  arising  either  idiopathically  or  as  a  result 


Fig.  8i.  —  Incisions  for 
dealing  with  various 
Forms  of  Whitlow  and 
THEIR  Extensions  into 
THE  Hand  or  Forearm. 


WOUNDS  255 

of  infection  from  the  nail  matrix.  The  inflammation  may  be  limited 
to  the  end  of  the  finger,  or  may  spread  to  the  palm.  Free  incisions, 
and  the  removal  of  the  bone,  if  dead,  are  necessary,  followed  by 
antiseptic  fomentations  or  baths. 

Repair  of  Wounds. 

When  any  of  the  tissues  or  solid  organs  have  been  divided  or 
injured,  the  reparative  activities  of  the  body  early  assert  themselves 
in  order  to  make  good  the  defect,  unless  they  are  for  a  time  diverted 
by  the  necessity  of  overcoming  an  invasion  of  bacteria,  and  even 
then  the  means  employed  by  Nature  to  conquer  the  microbes  are 
useful  in  determining  the  early  stages  of  repair.  It  matters  little 
what  tissue  of  the  body  is  involved,  for  in  all  the  reparative  process 
is  the  same,  although  modified  somewhat  by  the  local  conditions 
In  the  majority  of  cases  the  ultimate  result  is  a  production  of  cica- 
tricial or  scar  tissue,  which  serves  as  the  bond  of  union  between  the 
divided  structures,  and  varies  in  amount  with  the  closeness  of 
approximation,  the  maintenance  or  not  of  rest  to  the  part,  and  the 
degree  of  inflammatory  disturbance  in  the  wound.  In  a  few  tissues 
a  further  stage — viz.,  that  of  regeneration  of  the  injured  parts — is 
reached;  in  this  there  is  a  preliminary  formation  of  granulation 
tissue,  which  is  subsequently  invaded  and  replaced  by  a  develop- 
ment from  the  parenchjnna  of  the  affected  tissue  or  organ,  but  this 
can  only  occur  when  the  parts  are  accurately  brought  together 
and  perfect  asepsis  is  present.  Striped  muscle,  bone,  tendon, 
nerves,  and  some  glandular  structures  may  thus  be  regenerated; 
the  skin  and  subcutaneous  tissues,  rarely;  the  spinal  cord,  never. 

The  general  facts  as  to  the  process  of  repair  may  be  stated  as 
follows:  The  margins  of  the  wound  are  always  bounded  by  an  area 
of  tissue  in  a  state  of  lowered  vitality,  even  if  no  bruising  or  sloughing 
of  the  parts  is  present.  The  divided  vessels  are  in  a  condition  of 
thrombosis  as  far  as  the  next  patent  branches,  which  in  their  turn 
are  slightly  dilated,  partly  as  a  result  of  this  obstruction  and  partly 
from  the  reflex  irritation  of  the  injury.  The  surface  of  the  wound 
is  generally  covered  with  a  film  of  lymph  or  blood-clot,  whilst  any 
spaces  left  in  the  interstices  of  the  tissues  are  similarly  occupied. 

{a)  The  first  stage  in  the  process  consists  in  an  abundant  exudation 
of  small  round  cells,  presumably  leucocytes,  whose  function  is  to 
remove  all  dead  or  damaged  tissue,  as  well  as  to  break  up,  disin- 
tegrate, and  finally  absorb,  any  blood-clot  which  is  present.  After 
their  work  is  completed,  they  disappear,  either  finding  their  way 
back  into  the  circulation,  or  being  destroyed  by  the  fibroblasts. 
These  cells  are  derived  from  the  surrounding  vessels,  and  are  accom- 
panied by  a  certain  amount  of  plasma,  so  that  the  early  manifesta- 
tions of  a  slight  inflammatory  reaction  are  simulated,  and  this,  if 
it  does  not  extend  beyond  certain  limits,  is  a  beneficial  proceeding. 
If  much  tissue  has  to  be  absorbed,  or  when  a  foreign  body  such  as 
a  suture  is  buried,  giant  cells  are  likely  to  make  their  appearance. 


2.56 


A   MANUAL  OF  SURGERY 


{b)  The  exudation  of  leucocytes  is  soon  followed  by  the  appear- 
ance of  a  number  of  large  oval  cells  with  abundant  protoplasm 
and  large  vesicular  nuclei,  known  as  fibroblasts.  These  cells  are 
mainly  derived  from  those  composing  the  tissues  of  the  part, 
either  from  the  connective-tissue  corpuscles  or  the  endothelial  cells 
lining  the  capillaries,  lymphatics,  or  lymph-spaces.  The  ingenious 
researches  of  Zeigler  and  his  school,  who  inserted  into  the  peritoneal 
cavity  glass  chambers  composed  of  two  pieces  of  thin  cover-glass, 
cemented  a  short  distance  apart,  and  watched  the  process  of  organi- 
zation in  this  narrow  space,  have  shown  definitely  that  some  at 
least  of  the  fibroblasts  are  wandering  cells  derived  from  the  blood: 
it  is  possible  that  these  cells  are  in  their  turn  derived  from  the 
endothelium,  and  that  the  endothelial  cell  is  the  fibroblastic  cell 


Fig.  82.— Granulation  Tissue  from  the  Base  of  ax   L'lcer.     (x  60.) 

par  excellence.  Whatever  their  origin,  they  soon  form  a  layer  of 
cellular  tissue  which  lies  upon  the  surface  or  between  the  lips  of  the 
wound,  whilst  the  pre\aously  effused  leucocytes  disappear. 

[c]  The  vascularization  of  this  cellular  layer  forms  the  next  stage 
in  the  process.  This  is  brought  about  by  the  outgrowth  from  the 
walls  of  the  nearest  capillaries  of  solid  rods  of  protoplasm  (Fig.  83,  a), 
which  appear  first  as  minute  buds,  but  rapidly  increase  in  length, 
and  may  be  single  or  double.  They  soon  bend  over  to  unite  with 
similar  threads  growing  out  from  other  capillaries,  or  with  the  wall 
of  another  vessel  (Fig.  83,  h),  or  occasionally  they  unite  with  the 
vessel  from  which  they  started.  After  a  time  these  protoplasmic 
threads  become  canalized  (Fig.  83,  c),  and  a  communication  is 
established  between  them  and  the  mother  vessel,  so  that  blood 
passes  into  them.     The  new  capillary  wall,  at  first  homogeneous, 


WOUNDS 


257 


soon  becomes  lined  with  definite  endothelial  cells,  and  strengthened 
by  connective  tissue  derived  from  the  fibroblasts  around.  By  this 
means  a  soft  vascular  tissue  is  produced,  known  as  granulation 
tissue  (Fig.  82),  consisting  of  loops  of  capillaries  supported  by 
large  nucleated  cells  with  a  varying  amount  of  intercellular  substance, 
which  becomes  fibrihated  in  texture.  The  capillary  loops  arise  in 
leashes  from  small  terminal  arterioles,  and  it  is  to  this  arrange- 
ment that  the  granular  appearance  of  the  developing  tissue  is  due; 
each  granulation,  as  it  arises,  is  about  the  size  of  a  pin's  head. 

{d)  The  transformation  of  this  granulation  tissue  into  fibro-cica- 
tricial  tissue  is  next  proceeded  with.  The  fibroblasts  become  spindle- 
shaped,  and  finally  long  and  narrow,  with  pointed  extremities,  which 
often  branch  (Fig.  84);  the  nuclei  also  become  long  and  narrow. 


Fig.   83. — New  Vessel  Formation.     (After  Tillmanns.) 

a,  A  small  bud-like  projection  from  the  wall  of  a  capillary;  b,  the  union  of  such 
buds  one  with  another;  c,  the  canalization  of  these  processes. 

and  lose  their  vesicular  appearance.  Around  them  is  developed 
a  fibrillated  structure  of  a  collagenous  material,  which  is  finally 
transformed  into  the  fibrous  tissue  of  the  scar ;  the  actual  arrange- ' 
ment  of  this  material  varies  with  the  physical  characters  and 
condition  of  the  wound.  By  the  contraction  of  these  fibres  the 
fibroblastic  cells  become  flattened  out  and  compressed,  and  the 
newly-formed  vessels  constricted,  so  that  as  time  passes  the  scar 
tissue  becomes  less  and  less  vascular,  and  consequently  firmer  and 
denser,  as  well  as  smaller. 

{e)  Whilst  this  last  stage  is  in  progress,  the  surface  of  the  wound 
is  covered  over  with  cuticle,  which  spreads  inwards  from  healthy 
epithehum  in  the  neighbourhood  of  the  wound,  and  especially  from 
the  deeper  layers  of  the  rete  Malpighii. 

17 


258 


A   MANUAL  OF  SURGERY 


As  alread}?  stated,  the  general  process  of  repair  sketched  above 
is  modified  according  to  the  character  and  condition  of  the  wound. 
The  following  modifications  are  met  with  in  surgery: 


w 

-».  ^ 

\ 

% 

w       .*  .  - 

% 

'*■'■■  .• 
•  * 

9^  m 

^*    " 

• 

\y. 

• 

< 

^ 

^  '$^ 

r 

^^   '^  '■• 

f. 

^  ^ 

'•'^..^**?:^.* 

% 

Fig.   84. — Granulation   Tissue   in   Process   of  Organization.     (  x  250.) 

I.  Healing  by  First  Intention  or  Primary  Union  occurs  in  cleanly- 
cut    aseptic   wounds   where   the   lips   are   unbruised   and   brought 


^f^' 


r: 


Fig.  85. — Diagram  of  Healing  by  First  Intention.     (After  Billroth.) 
The  wound  is  occupied  by  a  fibro-cellular  growth,  into  which  loops  of  capil- 
laries extend,  constituting  granulation  tissue,  whilst  the  epithelium  has 
united  across  the  surface. 

together,   so   that   no  extensive  collection   of   blood  or  discharge 
between  them  is  possible.     A  thin  layer  of  blood-clot  hes  between 


WOUNDS 


259 


the  surfaces  of  the  wound  and  penetrates  into  their  irregularities, 
and  the  contraction  of  this  clot  is  at  first  the  chief  means  of  keeping 
the  deeper  parts  in  apposition.  There  is  but  a  microscopic  hne  of 
damaged  tissue,  which,  together  with  the  blood-clot,  is  easily 
absorbed,  and  the  process  runs  a  typical  course,  as  sketched  out 
above,  union  being  effected  in  five  to  seven  days.  (See  Figs.  85 
and  86.) 

2.  Healing  by  Granulation,  or  Second  Intention,  as  it  used  to  be 
termed,  is  met  with  [a)  in  cases  where  there  has  been  definite  loss 
of  substance,  so  that  the  hps  of  the  wound  are  not,  or  cannot  be. 


Fig.  86. — Section  of  a  Wound  Healed  by  First  Intention  Ten  Days 
AFTER  its  Infliction. 

The  epithelium  is  drawn  in  to  form  a  V-shaped  notch,  and  beneath  is  a  mass  of 
fibro-cicatricial  tissue  with  comparatively  few  cells  or  vessels  evident. 

approximated ;  as  also  (6)  when  the  surface  of  the  wound  is  bruised 
or  damaged  so  that  portions  of  tissue  have  to  separate  by  sloughing ; 
or  (c)  when  the  advent  of  infection  has  prevented  the  occurrence  of 
primary  union. 

When  a  small  amount  of  aseptic  dead  tissue  is  present,  it  is 
removed,  as  previously  described  (p.  109),  by  an  invasion  of  leuco- 
cytes from  the  surrounding  vessels,  which  disintegrate  and  gradually 
absorb  it.  These  are  followed  by  the  fibroblasts,  which  form  a 
layer  of  granulation  tissue  on  the  surface  of  the  wound  (Fig.  87). 
If  there  is  much  slough  to  be  dealt  with,  the  vitahty  of  the  granula- 
tion tissue  cannot  be  maintained  beyond  a  certain  distance  from 


26o 


A   MANUAL  OF  SURGERY 


its  source  of  nutrition,  and  so  by  a  process  of  simple  anamic  ulcera- 
tion the  unabsorbed  dead  portion  is  cast  off  and  a  granulating 
surface  remains.  If  bacteria  are  present  in  the  slough,  inflammation 
occurs  in  the  adjacent  living  tissue,  and  this  brings  about  a  similar 
result,  though  accompanied  by  suppuration  and  fever. 

When,  however,  there  is  a  simple  loss, of  substance,  with  no  bruis- 
ing or  infection  of  the  tissues,  the  course  of  events  is  as  follows:  The 
blood-stream  in  the  superficial  capillaries  having  been  arrested, 
adjacent  vessels  become  dilated,  and  from  these  an  exudation  of 
plasma  and  leucocytes  results.  The  plasma  coagulates  on  the  sur- 
face and  forms  a  layer  of  fibrin,  entangled  in  the  meshes  of  which 
arc  a  number  of  white  corpuscles,  so  that  the  wound  becomes 
covered  with  a  film  of  whitish-yellow  material  known  as  lymph. 
This  gradually  increases  in  amount  and  thickness,  and  is  vascu- 


^.■9 


Fig.  87. — Diagrammatic  Representation  of  Healing  by  Granulation. 
(After  Billroth.) 

larized  from  below  into  granulation  tissue,  this  process  occupying 
from  four  to  seven  days. 

The  heahng  of  a  granulating  wound  is  brought  about  by  the 
conversion  of  the  granulations  into  fibro-cicatricial  tissue,  and  by 
the  surface  becoming  covered  with  cuticle.  The  contractile  ten- 
dency inherent  m  all  cicatricial  tissue  produces  two  results  from  its 
presence  in  ihe  base  of  the  wound  beneath  the  superficial  layer  of 
granulations:  (i.)  The  surface  area  of  the  wound  is  diminished  in  all 
directions,  a  most  important  element  in  the  healing  process,  since  if 
the  base  is  adherent  to  some  dense  resisting  structure  repair  is  slow 
and  difficult.  When  the  granulating  surface  is  very  extensive, 
contraction  may  proceed  to  such  a  degree  as  to  obliterate  many  of 
the  vascular  channels,  and  by  thus  depriving  the  superficial  tissues 
of  their  adequate  nutrition,  the  healing  process  mav  be  indefinitely 
prolonged,  (ii.)  The  depth  of  the  wound  is  diminished,  partly  by 
the  continuous  growth  of  granulation  tissue  from  below  upwards, 
but  mainly  by  the  contractile  base  lifting  the  deeper  structures  to 


WOUNDS 


261 


the  surface.  If  the  base  of  the  wound  cannot  be  raised,  the  super- 
ficial parts  are  drawn  down,  and  the  cicatrix  is  usually  depressed 
and  adherent  to  the  underlying  parts. 

During  the  process  of  repair  the  wound  takes  on  the  appearances 
already  described  as  characteristic  of  a  healing  ulcer  (p.  105). 

It  is  sometimes  possible  to  hasten  the  healing  of  an  extensive 
granulating  wound  by  drawing  together  the  two  margins  so  that 
the  two  surfaces  are  brought  into  apposition.  Exudated  lymph 
sticks  the  surfaces  together  in  the  first  place,  and  subsequently 
granulations  develop  and  bridge  the  gap.  This  union  of  granu- 
lating surfaces  is  often  helpful  in  the  closure  of  abdominal  wounds 
left  by  the  drainage  of  deep  abscesses. 


c 


Fig.  88. — Scar  from 


Recently  Healed  Superficial  Wound. 
(Low  Power.) 

The  epithelial  surface  is  regular  and  devoid  of  papillae;  the  scar  tissue  has  an 
abundance  of  cells  scattered  through  it,  as  well  as  some  very  obvious 
vessels,  which  would  almost  entirely  disappear  at  a  later  date. 

3.  Healing  under  a  Scab  is  a  proceeding  that  can  only  take  place 
in  very  small  wounds,  such  as  superficial  grazes  and  abrasions,  and 
is  practically  identical  with  the  granulating  process,  except  that, 
instead  of  an  artificial  dressing  applied  by  the  surgeon,  the  lesion  is 
covered  by  a  scab  which  consists  of  clotted  blood  or  dried  exudation. 
Should  infection  be  present,  pus  is  likely  to  accumulate  beneath  the 
scab  and  may  cause  trouble. 

4.  Healing  by  Organization  of  Blood-clot  can  only  be  watched  in 
strictl}'  aseptic  wounds  where  there  is  definite  loss  of  substance,  as 
in  the  deep  channels  sometimes  made  in  the  treatment  of  bones 


262  A   MANUAL  OF  SURGERY 

thickened  bv  chronic  osteitis,  but  of  course  it  occurs  in  all  subcu- 
taneous wounds  where  there  is  effusion  of  blood.  The  dark 
coaguluni  shows  no  trace  of  change  for  some  days,  but  gradually 
the  peripheral  portions  become  granular  and  yellowish-white  in 
colour;  granulations  appear  in  this  peripheral  portion,  and  in 
time  spread  through  the  whole  mass  from  periphery  to  centre,  and 
then  repair  occurs  as  described  above.  The  clot  is  absolutely 
passive  in  this  process,  being  infiltrated  by  leucocytes  and  removed 
by  degrees,  and  thus  merely  serves  as  a  basis  of  support  or  scaffolding 
for  the  building  up  of  the  granulation  tissue  which  replaces  it.  A 
similar  result  may  be  obtained  by  filling  a  cavity  with  grafts  of 
sterile  sponge  or  decalcified  bone. 

5.  Healing  of  a  Detached  Portion  of  the  Body  is  not  unfrequently 
seen  when  parts  of  the  nose,  external  ear,  or  finger-tip,  are  separated. 
The  loose  portion  is  carefully  cleansed,  reapplied  accurately,  and 
fixed  firmly,  though  gently,  into  position.  If  it  lives,  union  occurs 
by  first  intention;  if  it  dies,  but  remains  aseptic,  it  constitutes  a 
cover  or  scab,  under  which  healing  by  granulation  occurs. 

A  Scar  is  a  mass  of  fibroid  tissue  covered  by  epithelium,  which 
has  been  formed  in  the  repair  of  a  wound  (Figs.  86  and  88).  It  is 
at  first  vascular,  and  contains  cells  of  the  connective-tissue  type; 
but  after  a  time,  as  contraction  continues,  the  cell  elements  become 
flattened  out,  fewer  in  number  and  less  obvious,  the  intercellular 
fibrous  tissue  more  abundant,  and  the  vessels  constricted,  so  that 
finally  a  scar  becomes  well-nigh  bloodless.  Where  superficial,  its 
colour  changes  from  red  to  white,  and  if  of  small  size  it  may  almost 
disappear,  but  never  absolutely,  unless  the  subcutaneous  tissue  has 
not  been  involved.  When  the  parts  around  become  injected  by  any 
cause,  such  as  sharp  friction,  the  anaemic  scar  tissue  again  becomes 
evident  by  contrast.  L3nnphatics,  nerves,  hairs,  and  cutaneous 
glands  are  all  absent,  except  perhaps  at  the  periphery,  and  the 
epithelial  covering  itself  is  merely  a  uniform  laj-er  without  papillae. 
The  Pathological  Phenomena  connected  with  scars  are  as  follows: 
I.  Excessive  Contraction,  which  may  lead  to  great  deformity, 
especially  when  the  wound  has  occurred  in  the  flexure  of  any  of 
the  joints.  A  w^eb-like  mass  of  fibroid  tissue  then  forms,  hmiting 
movement,  and  requiring  operative  interference.  A  seriously 
burned  hand  may  by  cicatricial  contraction  be  fused  into  an  un- 
sightly mass,  rendering  the  fingers  of  little  use;  similarly,  the  chin 
may  be  drawn  down  and  practically  fixed  to  the  sternum,  and  the 
lower  lip  everted,  as  the  result  of  a  burn  on  the  front  of  the  neck, 
ihe  Treatment  of  such  conditions  consists  in  dividing  or  excising 
the  cicatrix,  and  thus  freeing  the  parts,  during  which  process  it 
must  be  remembered  that  deeper  structures  of  importance,  such  as 
the  main  vessels  and  nerves,  may  be  adherent  to  the  under  surface, 
and  thus  be  endangered.  When  once  the  scar  has  been  divided, 
there  is  often  no  difficulty  in  restoring  the  parts  to  their  normal 
positions,  although  when  the  contraction  has  existed  for  any  length 


WOUNDS  263 

of  time  it  may  be  advisable  to  do  this  slowly,  even  by  gradual 
extension  with  a  weight  and  pulley,  so  as  to  avoid  the  risk  of 
lacerating  the  deeper  parts,  which  are  usually  contracted  second- 
arily. The  raw  surface  thus  produced  is  covered  with  epithelium 
by  Thiersch's  method  or  Wolfe  grafts. 

Of  recent  years  it  has  been  proposed  to  treat  such  cases  by  in- 
jections of  thiosinamin  or  fibrolysin,*  administered  hypodermically. 
A  solution  of  10  parts  of  the  drug  in  20  parts  of  glycerine  and  70  of 
distilled  water,  is  apparently  the  best,  and  in  the  adult  the  dose  may 
range  upwards  from  |  c.c.  Interesting  results  have  been  published 
of  cures  of  many  different  conditions  due  to  developments  of  scar 
tissue,  and  it  is  supposed  that  they  are  due  to  an  active  leucocytosis 
induced  by  the  drug.  Possibly  the  internal  administration  of 
iodolysin  (an  ethyl-iodide  of  thiosinamin)  may  be  even  more  useful. 
Care  must  be  taken  in  the  use  of  this  remedy  in  old  people,  as  it 
is  impossible  to  limit  its  action  to  the  scar  that  it  is  desired  to 
soften.  Cases  have  been  known  in  which  the  walls  of  arteries  in  a 
condition  of  arterio-sclerosis  have  been  acted  upon,  and  the  patient's 
death  resulted  from  purpura  or  cerebral  haemorrhage. 

2.  Overgrowth  of  the  scar  tissue  is  sometimes  met  with,  con- 
stituting what  is  known  as  the  false  or  Alibert's  Keloid  (Plate  II., 
Fig.  2).  This  most  frequently  occurs  in  the  scars  of  burns  or  of 
wounds  in  tuberculous  patients,  but  may  arise  from  any  cicatrix, 
presenting  itself  as  a  fibroid  indurated  mass  of  a  dusky  red  colour, 
with  perhaps  a  number  of  dilated  vessels  coursing  over  it,  which 
occupies  the  region  of  the  old  scar,  and  may  possibly  send  claw-like 
processes  into  neighbouring  healthy  structures.  It  consists  merely 
of  a  hyperplasia  of  the  scar  tissue,  but  as  to  its  aetiology  nothing  is 
known.  With  the  exception  of  somewhat  severe  pruritus  or  itching, 
its  presence  entails  no  inconvenience,  although  if  it  occurs  on  exposed 
parts  it  may  be  very  disfiguring.  Removal  is  useless,  since  the 
keloid  almost  always  recurs  in  the  new  cicatrix  and  in  the  stitch 
holes.  After  a  longer  or  shorter  interval  it  often  disappears  spon- 
taneously. Exposure  to  X  rays  or  to  radium  is  beneficial  in  these 
cases,  although  the  treatment  may  be  of  long  duration. 

3.  Ulceration  of  Scars  is  usually  an  evidence  of  defective  nutrition, 
or  of  local  irritation.  It  is  always  chronic  and  difficult  to  heal. 
Local  protection  and  stimulating  appHcations,  together  with  general 
tonic  treatment,  are  required. 

4.  Painful  Scars  arise  from  either  the  imphcation  of  a  nerve  ter- 
minal in  the  cicatrix,  or  the  pressure  of  a  contracting  scar  upon  the 
bulbous  end  of  a  divided  nerve,  as  in  amputation  stumps.  The 
pain  is  often  very  persistent  and  wearing,  and  may  radiate  widely. 
Operation  is  usually  necessary  in  order  to  free  the  nerve  from  the 
scar  tissue  or  to  excise  it. 

5.  Malignant  Disease  of  Scars,  or  of  old  chronic  sores  but  partially 
healed,  is  of  an  epitheUomatous  type,  and  appears  as  a  hard  ulcerated 

*  Thiosinamin  is  prepared  by  warming  oil  of  mustard  with  an  alcoholic  solu- 
tion of  ammonia.    Fibrolysin  is  a  mixture  of  thiosinamin  with  salicylate  of  soda. 


264  A   MANUAL  OF  SURGERY 

tumour  with  everted  edges  and  a  thickened  base  [Marjolin's  ulcer). 
The  progress  is  very  slow,  since  the  vascularity  of  the  tissue  is 
slight.  It  is  painless,  from  the  absence  of  nerves,  and  as  long  as 
the  disease  is  limited  to  the  scar,  no  Ij'mphatic  implication  will  be 
noted.  As  soon,  however,  as  the  malignant  growth  invades  healthy 
tissues,  the  usual  phenomena  show  themselves.  The  diseased 
tissues,  which  are  often  very  dirty  and  offensive  at  first,  may  be 
freely  dissected  out,  having  regard  to  subjacent  structures,  and  the 
wound  closed  by  some  plastic  method,  or  amputation  may  be 
required. 

General  Conditions  connected  with  Wounds. 

I.  Shock. — By  the  term  '  shock  '  is  meant  a  general  depressed 
condition  of  the  system  associated  with  a  marked  fall  of  blood- 
pressure,  resulting  from  the  transmission  of  some  energetic  stimulus 
to  the  vital  centres  in  the  medulla,  either  from  the  peripheral  sensory 
or  sympathetic  nerves  of  an  injured  part,  or  from  the  emotional 
centres.  Local  Shock  is  a  curious  condition  of  insensibility  to  pain 
on  handling,  which  is  sometimes  present  after  severe  injuries,  and 
is  especiall}^  seen  in  gunshot  wounds.  Possibly  it  is  due  to  some 
temporary  paralysis  of  the  sensory  nerves. 

The  term  coUapse  is  applied  to  a  condition  ver}^  similar  in  nature  to  shock, 
but  differing  from  it  mainly  in  its  onset,  which  is  gradual,  and  often  preceded 
by  some  exhausting  disease,  and  by  the  fact  that  muscular  relaxation  is  more 
complete.  The  collapse  of  cholera  is  one  of  the  most  typical  manifestations, 
but  any  condition  associated  with  loss  or  derivation  of  fluids  from  the  vessels 
may  give  rise  to  it — e.g.,  prolonged  vomiting  or  serious  haemorrhage.  If  at 
the  same  time  toxic  absorption  is  taking  place,  the  sj^mptoms  are  still  more 
marked;  thus  in  acute  peritonitis  the  two  factors,  removal  of  fluid  from  the 
circulation  and  toxaemia,  are  proceeding  concurrently.  Shock  usually  tends 
to  recovery,  unless  the  lesion  is  of  a  serious  nature,  and  then  collapse  may 
supervene  and  prove  fatal;  thus,  after  rupture  of  the  intestine  the  immediate 
symptoms  are  the  result  of  shock,  but  they  are  quickly  followed  by  the  col- 
lapse due  to  acute  peritonitis. 

Our  knowledge  of  this  subject  has  been  largely  increased  of  late 
years  by  the  researches  of  Crile  in  America,  and  J.  D.  Malcolm 
in  this  country,  and  it  is  now  clearly  recognised  that  the  essential 
cause  of  shock  is  the  division  of,  or  injury  to,  the  sensory  or  sympa- 
thetic nerves.  Experimentally  it  is  easy  to  demonstrate  that  a 
marked  fall  of  blood-pressure  results  from  dividing  or  crushing  a 
sensory  or  mixed  nerve,  and  that  clean  division  is  less  harmful  than 
bruising  or  crushing. 

It  is  therefore  obvious  that  the  degree  of  shock  will  vary  with  the 
abundance  or  not  of  the  supply  of  sensory  nerves  to  the  injured 
parts;  organs  like  the  testis,  hand,  small  intestine,  etc.,  will  be 
productive  of  much  shock  when  injured.  Cceteris  paribus,  deep 
wounds  are  more  productive  of  shock  than  superficial,  but  a  very 
extensive  superficial  lesion  may  be  more  harmful  than  a  limited 
deep  one.  Thus,  a  scorch  or  burn  involving  half  the  surface  of  the 
body  is  more  productive  of  shock  than  the  complete  incineration 


WOUNDS  265 

of  a  liaud  ur  foot.  Operations  on  the  head  or  the  brain  arc  followed 
by  comparatively  little  shock,  whilst  the  upper  part  of  the  abdomen 
is  more  susceptible  to  depressing  influences  than  the  lower.  Opera- 
tions on  the  kidneys  and  urinary  passages  are  associated  with  little 
shock. 

Ihe  charactev  of  the  injury,  whether  clean-cutting  or  crushing,  is 
also  important.  Surgical  operations  which  involve  traction  on 
important  nerve  trunks  or  centres  are  followed  by  a  greater  degree 
of  shock  than  when  nerves  are  simply  divided ;  hence  clean  manipu- 
lations and  the  avoidance  of  rough  bungUng  handiwork  are  pre- 
ventives of  shock. 

Shock  is  also  increased  by  anything  that  lowers  the  general  tone 
of  the  body,  such  as  loss  of  blood,  exposure  to  cold,  want  of  food, 
or  toxic  absorption. 

The  nervous  susceptibility  of  the  patient  and  the  expectation  or 
not  of  the  injury  are  most  important  factors  in  the  production  of 
shock,  for  the  more  highly  organized  the  nervous  system,  the 
greater  is  the  amount  of  shock  experienced,  and  vice  versa.  When 
the  whole  nervous  system  is  maintained  in  a  state  of  tension, 
anxiously  expecting  the  receipt  of  some  painful  impression,  the 
effect  produced  will  naturally  be  increased,"  whilst  if  the  attention 
is  diverted,  and  interest  actively  aroused  in  other  things,  the  shock 
at  the  time  is  much  diminished,  though  its  effects  maj^  be  subse- 
quently greater.  Thus,  in  the  keen  excitement  and  nervous  tension 
of  a  battle,  soldiers  have  often  been  wounded  severely,  and  yet  not 
known  it  at  the  time;  whilst  the  pain  of  the  most  trifling  cut  may 
produce  deep  shock  when  the  patient  is  in  a  state  of  dread  and 
anticipation. 

The  Symptoms  vary  with  the  injury  inflicted,  from  a  shght 
momentary  giddiness  and  faintness  (closely  simulating  an  attack  of 
syncope  or  a  fainting  fit)  to  immediate  and  complete  prostration, 
insensibiht3^  and  even  death.  The  pulse,  at  first  small  and  weak, 
soon  becomes  irregular,  extremely  rapid,  and  often  imperceptible; 
the  countenance  is  pallid  and  shrunken,  and  the  brow  covered  with 
cold  sweat;  the  respirations  are  slow  and  shallow,  whilst  the  tem- 
perature is  usually  subnormal. 

After  an  interval,  the  length  of  which  depends  on  the  severity  of 
the  lesion  and  the  treatment  adopted,  reaction  occurs,  being  intro- 
duced by  increased  depth  and  frequency  of  the  respirations;  the 
pulse  becomes  slower  and  fuller,  the  surface  warmer,  whilst  con- 
sciousness and  muscular  power  are  gradually  restored.  During 
this  period  it  is  not  unusual  for  an  attack  of  vomiting  to  supervene. 

Sometimes  reaction  is  accompanied  by  irritability,  either  of  the 
mental  or  muscular  sj/stems,  in  the  one  case  leading  to  traumatic 
dehrium,  which  is  always  of  grave  import,  and  in  the  other  to  intense 
restlessness,  as  in  the  shock  which  follows  extensive  burns.  It  is 
probable  that  both  these  conditions  are  largely  due  to  toxaemia. 
The  term  erethitic  shock  is  sometimes  applied  to  these  manifesta- 
tions. 


266  A    MANUAL  OF  SURGERY 

Occasionally  the  evidences  of  shock  are  tlelayed  in  their  appear- 
ance for  some  time  after  the  injury,  and  come  on  graduall3^  Especi- 
ally is  this  the  case  after  railway  accidents  when  no  great  injury 
has  been  experienced;  for  a  time  the  anxiety  and  excitement  are 
such  that  no  depression  is  noticed,  but  as  the  mental  perturbation 
passes  off,  the  individual  experiences  symptoms  very  similar  to 
the  above,  but  probably  rather  of  the  nature  of  neurasthenia  than 
of  real  shock  (see  Chapter  XXIV.).  When  an  accident  occurs  to 
a  person  in  a  state  of  intoxication,  it  is  not  unusual  for  the  phenomena 
of  shock  to  be  delayed  for  some  time,  only  showing  themselves  when 
the  effect  of  the  alcohol  has  passed  away. 

Pathology. — The  post-mortem  evidences  are  not  at  all  character- 
istic, and  consist  merely  in  anaemia  of  the  brain  and  superficial  parts 
of  the  body,  and  enormous  engorgement  of  the  abdominal  viscera, 
lungs,  and  great  venous  trunks;  the  heart  contains  practically  no 
blood,  although  it  is  probable  that  the  right  side  is  much  distended 
at  the  time  of  death,  especially  when  due  to  sudden  injury,  and 
subsequently  empties  itself  by  post-mortem  contraction.  The  ex- 
planation of  the  phenomena  of  shock  is  by  no  means  simple,  and 
several  factors  are  probably  needed  to  produce  the  complex  result. 
I.  Reflex  inhibition  of  the  heart's  action  through  the  cardio-inhibi- 
tory  centre  in  the  medulla  explains  the  early  syncope  with  slow 
pulse.  It  is  well  known  that  if  a  frog's  abdomen  is  opened  and  the 
exposed  intestine  sharply  struck,  the  heart  stops  in  a  condition  of 
diastole,  whilst  if  the  vagi  are  previously  divided,  no  effect  is  pro- 
duced. Any  severe  peripheral  injury  may  lead  to  such  a  result, 
especially  those  directed  to  the  great  sympathetic  centres  in  the 
abdomen  which  are  closely  connected  with  the  vital  centres  in  the 
medulla.  In  this  way  sudden  death  may  be  produced  by  a  severe 
blow  in  the  epigastrium,  or  by  drinking  a  glass  of  very  cold  water, 
when  hot ;  but,  as  a  rule,  this  inhibition  of  the  heart's  action  is  never 
prolonged  in  mammals.  2.  The  causation  of  the  shock  which 
follows  lengthy  operations  is  still  a  matter  of  discussion.  Crile,* 
who  has  studied  this  subject  experimentally,  shows  that  stimulation 
of  the  central  end  of  a  divided  sensory  nerve  causes  a  rise  of  blood- 
pressure  at  first ;  but  if  the  stimulation  is  repeated  often,  this  rise 
gradually  diminishes,  disappears,  and  in  time  is  represented  by  a 
fall.  This  he  attributes  to  exhaustion  of  the  vasomotor  centre  in 
the  medulla;  the  blood  collects  in  the  splanchnic  area  as  a  result  of 
paralytic  distension,  and  hence  the  supply  to  the  brain  and  surface 
of  the  body  is  diminished  to  a  dangerous  degree.  Obviously,  any 
considerable  haemorrhage  will  aggravate  the  symptoms.  In  con- 
firmation of  this  idea  is  the  fact  that  pre\aous  cocainization  of  the 
nerve  hinders  the  rise  or  fall  of  blood-pressure,  evidently  by  blocking 
the  upward  extension  of  the  stimuli.  Crile's  explanation  has  been 
recently  questioned  by  Malcolm,  j  who  points  out  that  in  lengthy 

*  '  An  Experimental  Research  into  Surgical  Shock,'  by  G.  W.  Crile.  J.  B. 
Lippincott  Co.,  1899. 

t   '  Remarks  on  Shock,'  Brit.  Med.  Journ.,  December  9,  1905. 


WOUNDS  267 

abdominal  operations  with  much  shock  this  portal  engorgement 
does  not  become  obvious,  and  suggests  that  the  cause  of  the  shock 
is  not  paralysis  or  exhaustion  of  the  vasomotor  mechanism,  but  a 
gradually  ascending  contraction  of  the  arteries  from  the  surface 
towards" the  centre,  which  keeps  the  blood  more  and  more  in  the 
central  parts  of  the  body,  and  deprives  the  periphery,  and,  finally, 
the  brain  itself,  of  its  necessary  blood-supply. 

Diagnosis. — i.  From  the  general  results  of  hceynorrhage.  Rest- 
lessness and  thirst  are  then  prominent  signs,  together  with  a  sense 
of  d\'spncea,  causing  rapid  respiratory  efforts;  the  mental  condition, 
moreover,  is  less  affected,  and  the  patient  is  generally  sensible;  the 
surface  is  exceedinglv  blanched,  and  the  pulse  may  have  a  marked 
hc-emorrhagic  wave.  "  2.  In  concussion  of  the  brain  there  are  super- 
added to  the  s\-mptoms  of  shock  those  more  particularly  connected  . 
wth  the  region  affected,  i  e.,  the  intellectual  centres,  so  that  un- 
consciousness is  the  predominant  feature,  whilst  loss  of  memory 
of  the  accident  and  of  the  events  which  followed  is  often  noticed. 
3.  When  vomiting  is  approaching  under  the  influence  of  an  ancBsthetic, 
the  patient's  pulse  usuallv  becomes  weak  and  rapid,  and  the  coun- 
tenance pale.  This  condition  closely  simulates  shock,  and  is  often 
distinguished  from  it  only  by  the  progress  of  the  case.  Under  such 
circumstances,  if  vomiting  is  plainly  imminent,  it  is  sometimes  wise 
to  increase  the  amount  of  anaesthetic,  as  the  patient  is  usually  not 
fullv  under  its  influence. 

Treatment. — In  shght  cases  very  httle  is  needed  beyond  resting 
quietly  for  a  few  minutes,  or  the  exhibition  of  some  aromatic  stimu- 
lant to  the  nostrils,  such  as  ammonia  or  smeUing-salts.  In  the 
more  severe  cases  the  patient  is  laid  recumbent,  with  the  head  low; 
hot  bottles,  well  protected,  and  blankets  are  applied  to  the  trunk 
and  extremities  to  maintain  and  increase  the  bodily  temperature. 
A  very  simple,  but  successful,  plan  of  raising  the  bodily  temperature 
is  to  place  under  the  bedclothes,  which  are  supported  on  a  cradle, 
one  or  more  electric  lamps  of  such  strength  as  to  bring  the  tempera- 
ture of  the  air  around  the  body  to  100°  to  105°  F.  This  has  proved 
of  much  value  in  combating  "the  severe  shock  following  burns  in 
children. 

The  injection  of  hot  saUne  fluid  (i  drachm  of  chloride  of  sodium  to 
I  pint  of  water)  into  a  superficial  vein,  the  rectum,  or  the  subcu- 
taneous tissues  (submammary  or  gluteal,  for  choice),  has  been 
employed  with  considerable  success  of  recent  years.  The  modus 
operandi  of  intravenous  or  intrarectal  infusion  is  described  else- 
where; the  fluid  should  be  introduced  at  a  temperature  between 
105°  and  110°  F.  Where  there  has  been  much  loss  of  blood,  the 
intravenous  infusion  of  2  or  3  pints  may  be  useful  to  begin  with, 
but  as  a  rule  rectal  infusion  is  sufficient. 

According  to  Crile,  a  most  valuable  remedy  for  shock  is  the  intra- 
venous injection  of  a  solution  of  adrenahn  (i  in  50,000  or  100,000 
parts  of  normal  sahne  solution),  a  few  cubic  centimetres  being 
allowed  to  enter  the  circulation  each  minute.     Pituitary  extract 


268  A   MANUAL  OF  SURGERY 

also  has  a  powerful  effect  in  raising  the  blood-pressure,  and  slowing 
the  too  rapid  action  of  the  heart  in  shock.  Drugs,  such  as  strychnine 
or  digitalin,  are  not  of  much  use,  but  a  small  enema  of  hot  strong 
coffee  is  sometimes  very  valuable  in  tiding  the  patient  over  the 
period  of  depression.     Alcohol  is  usually  undesirable. 

An  important  question  is  often  raised  as  to  the  advisabiUty  of 
performing  an  operation  during  shock.  As  a  general  rule,  it  may 
be  stated  that  operation  should  be  deferred  until  reaction  has  come 
on,  unless  the  presence  of  the  injured  organ,  such  as  a  badly  crushed 
limb,  is  e\'idently  prolonging  the  condition.  Under  these  circum- 
stances a  hypodermic  injection  of  morphia  may  improve  matters 
by  relieving  pain;  otherwise  the  local  lesion  should  be  at  once  dealt 
with,  and  it  will  be  often  found  that,  as  the  patient  passes  under  the 
influence  of  the  antesthetic,  the  pulse  improves,  and  the  state  of 
shock  disappears,  the  ansesthetic  shielding  the  medullary  centres 
from  the  painful  afferent  stimuli. 

Shock  may  to  a  large  extent  be  prevented  during  operation  by  a 
careful  attention  to  such  details  as  not  purging  or  starving  the 
patient  unduly  beforehand,  keeping  him  well  covered  and  as  warm 
as  possible,  by  maintaining  the  temperature  of  the  operating-room 
at  not  less  than  70°  F.,  by  minimizing  haemorrhage,  and  by  rapidity 
and  cleanness  of  execution.  A  hypodermic  injection  of  strychnine, 
or  a  brandy  and  beef-tea  enema,  given  just  before  the  operation, 
is  also  useful;  and  in  nervous  patients  a  dose  of  morphia  will  often 
blunt  their  nervous  susceptibilities  and  protect  them  from  shock. 
It  must  also  be  remembered  that  incomplete  anaesthesia  tends  to 
increase  the  shock  rather  than  to  prevent  its  occurrence,  although 
as  little  anesthetic  should  be  administered  as  possible,  and  in  bad 
cases  ether  rather  than  chloroform.  In  any  operation,  where  shock 
is  likely  to  be  severe,  its  development  may  often  be  prevented  by 
commencing  intravenous  infusion  before  the  operation  begins,  and 
continuing  it  slowly  throughout,  or  by  administering  ether  in  con- 
junction with  the  sahne  solution.  Spinal  anaesthesia,  when  avail- 
able, is  useful  in  preventing  shock,  since  it  protects  the  medullary 
centres  from  afferent  stimuli ;  but  the  question  of  the  mental  effect 
of  the  operation  on  the  patient  must  also  be  considered;  the  aboli- 
tion of  consciousness  is  in  many  cases  a  most  desirable  condition. 
The  recently  introduced  plan  of  inducing  anesthesia  by  the  so-called 
anoci-associaiion  method,  described  in  Chapter  XLV.,  holds  out 
hopeful  prospects  of  eliminating  largely  the  element  of  operation- 
shock. 

II.  Traumatic  Fever. — Traumatic  fever  is  that  which  follows  the 
receipt  of  an  injury,  whether  simple  or  compound,  or  after  an  opera- 
tion.    Two  main  varieties  are  described: 

(a)  Aseptic  Traumatic  Fever  occurs  after  subcutaneous  injuries, 
such  as  sprains,  contusions,  fractures,  etc.,  and  after  aseptic  operation 
wounds  or  compound  injuries,  where  micro-organisms  are  absent  or 
impotent.     The  cause  is  the  absorption  of  fibrin  ferment  or  some 


WOUNDS  269 

other  chemical  substance,  which  has  a  stimulating  effect  upon  the 
thermogenic  centres.  Probably  the  use  of  irritating  antiseptics  in 
the  wound,  the  retention  of  serous  discharges,  and  the  accumulation 
of  blood,  are  the  chief  causes  of  the  pyrexia.  Occasionally  fever  is 
observed  in  cases  where  we  have  no"  grounds  for  supposing  that 
absorption  is  taking  place ;  it  may  then  be  due  to  some  peripheral 
irritation,  e.g.,  a  badly-fitting  sphnt,  and  disappears  immediately  on 
the  removal  of  the  cause. 

The  symptoms  are  those  of  shght  pyrexia,  reaching  100°  or  101°  F. 
within  twenty-four  or  forty-eight  hours  of  the  injury,  with  coated 
tongue,  loss  of  appetite,  etc.,  gradually  passing  off  in  three  or  four 
days.     If  thus  hmited,  it  is  of  no  prognostic  importance. 

{b)  Symptomatic  Traumatic  Fever  is  caused  either  by  the  absorp- 
tion of  the  products  of  putrefaction,  resulting  from  the  vital  activity 
of  organisms  in  discharges,  blood-clot,  or  dead  tisue;  or  from  the 
absorption  of  the  toxins  connected  with  a  development  of  parasitic 
organisms  in  the  wound  or  its  surroundings ;  or  from  the  superven- 
tion of  some  general  infective  disorder.  All  these  different  con- 
ditions have  been  dealt  with  elsewhere  (p.  91). 

III.  Traumatic  Delirium.—Although  dehrium  is  merely  a  symp- 
tom, it  is  occasionally  of  so  pronounced  a  character  as  to  demand 
special  attention.     Three  forms  are  described : 

[a)  The  Active  Delirium  w^hich  accompanies  severe  injuries,  par- 
ticularly in  plethoric,  and  often  in  previously  healthy  individuals, 
whose  environment  has  been  suddenly  changed  from  that  of  every- 
day hfe  to  a  sick-bed  in  a  hospital  ward.  Infection  of  the  wound 
is  usually  present,  and  the  dehrious  state  is  associated  and  runs  a 
parallel  course  with  the  fever.  It  is  not  usually  of  a  violent  type, 
although  the  patient  may  be  irrational  and  restless ;  he  moves  the 
injured  part  without  any  evident  appreciation  of  the  pain  which, 
if  conscious,  he  must  suffer,  but  he  is  easily  restrained  by  the  ex- 
hibition of  firmness  and  tact  on  the  part  of  the  attendant.  The 
symptoms  are  most  marked  at  night,  and  commence  at  the  end  of 
forty-eight  hours,  lasting,  as  a  rule,  for  two  or  three  days.  There 
is  a  distaste  for  food,  which,  however,  can  be  overcome  by  gentle 
persuasion. 

Treatment, — Patients  in  this  condition  must  never  be  left ;  the  diet 
should  be  fight,  but  nourishing ;  the  bowels  are  thoroughly  opened, 
and  an  icebag  to  the  head  may  be  useful.     The  wound  should  be 
•  freed  from  any  purulent  accumulation. 

[b]  Delirium  of  a  Low  Muttering  Type  is  met  with  in  individuals 
of  low  \dtafity,  exhausted  by  dissipation,  drink,  disease,  or  faulty 
hygienic  surroundings.  It  is  commonly  associated  with  fever  of  an 
asthenic  type,  such  as  is  seen  towards  the  end  of  infective  diseases. 
The  patient  usuaUy  lies  on  his  back,  staring  vacantly  upwards,  is 
incoherent,  takes  no  notice  of  surrounding  objects,  and  is  observed 
to  pick  at  the  bedclothes  and  mutter  to  himself  unintelfigibly. 
There  is  often,  in  addition,  an  involuntary  escape  of  urine  or  faeces. 


270  A   MANUAL  OF  SURGERY 

The  mouth  is  generally  open,  the  tongue  dry,  brown  and  cracked, 
and  viscid  mucus  collects  about  the  teeth  (sordes). 

The  Treatment  should  be  directed  to  careful  nursing  and  feeding, 
as  by  that  means  alone  can  the  patient  be  saved. 

(c)  Delirium  Tremens  is  observed  in  individuals  who,  previously 
of  intemperate  habits,  have  suffered  some  serious  injury,  such  as  a 
compound  fracture.  The  violent  symptoms  do  not  set  in  till  about 
the  third  day,  but  are  usually  preceded  by  some  amount  of  sleep- 
lessness and  wandering  at  night,  or  the  patient  ma}-  have  short 
snatches  of  sleep,  from  which  he  awakes  semi-delirious,  ihis 
gradually  increases,  and  is  followed  by  violent  delirium,  in  which 
the  patient  is  haunted  by  terrifying  visions  of  reptiles,  horrible 
insects,  and  the  like,  from  which  he  tries  in  vain  to  escape.  During 
this  stage  of  exitement  he  is  with  difficulty  restrained  from  jumping 
out  of  bed ;  in  many  instances  these  patients  are  remarkably  cunning, 
and,  managing  to  elude  the  vigilance  of  their  attendants,  will  succeed 
in  escaping  from  the  room  by  the  door  or  window,  and  may  inflict 
serious,  and  even  fatal,  injuries  upon  themselves  or  others.  There 
is  always  a  tremulous  condition  of  the  extremities  and  of  the  tongue, 
which  is  white  and  coated,  whilst  the  bowels  are  obstinately  con- 
fined. The  pulse  and  temperature  vary  considerably,  and  the  skin 
is  often  moist  and  clammy.  The  violent  stage  is  always  followed  by 
profound  exhaustion,  in  which  the  patient  may  gradually  sink  into 
a  state  of  coma  and  die.  In  the  case  of  a  fractured  leg,  the  struggles 
of  the  patient  will  cause  considerable  displacement  of  the  limb,  and 
necessitate  constant  attention  to  prevent  further  mischief.  The 
limb  should  never  be  fixed  to  the  bed,  but  slung  in  a  Salter's  swing 
or  immobilized  in  plaster  of  Paris. 

Treatment. — In  cases  where  an  attack  of  delirium  tremens  is  con- 
sidered imminent,  either  from  the  previous  history  of  the  patient,  the 
tremulous  state  of  his  hands  and  tongue,  or  his  sleeplessness,  the 
best  treatment  to  adopt  is  to  support  the  strength  by  suitable, 
easily  digested  food,  combined  with  free  purging  and,  if  need  be, 
soporifics,  such  as  chloral,  bromide,  paraldehyde,  or  morphia. 
Paraldehyde  is  perhaps  the  safest,  whilst  morphia  must  be  ad- 
ministered cautiously;  under  such  a  regimen  the  symptoms  usually 
soon  disappear.  In  the  acute  maniacal  attacks  the  patient  must 
be  fully  controlled  and  guarded,  but  with  as  little  manifestation  of 
retraint  as  possible ;  faihng  other  drugs,  hyoscin  in  doses  of  tt^  to 
j-^o  grain  will  sometimes  succeed  in  quieting  the  patient,  but  must 
be  used  with  great  care,  as  it  is  a  severe  depressant.  Nourishing 
food  of  a  fluid  type  should  be  administered  during  the  quiet  intervals, 
and  free  purging  is  of  course  essential.  The  patient  usually  re- 
covers from  a  first  attack,  but  in  the  later  ones  may  die  of  heart 
failure  or  exhaustion. 


CHAPTER  XI. 

THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY. 

No  one  who  has  been  brought  up  in  the  modern  school  of  antiseptic 
or  aseptic  surgery  can  have  any  idea  of  the  horrors  that  were  per- 
petrated under  the  name  of  surgery  by  our  ancestors.  Aneesthesia 
was  unknowm,  and  perhaps  this  was  an  advantage  rather  than  other- 
wise, as  it  hmited  the  number  and  the  scope  of  operations.  Patients 
had  to  be  forcibly  restrained  during  the  procedure;  haemostatic 
forceps  were  not  in  existence,  and  the  operating  theatre  was  not  the 
quietly  decorous  spot  that  it  now  is,  but  rather  resembled  the 
shambles.  The  wards  were  a  hotbed  of  surgical  fever,  and  erysipelas, 
pyaemia,  and  other  manifestations  of  pyogenic  infection  led  to  an 
appalhng  post-operative  death-rate.  Hospital  gangrene,  wound 
phagedena,  and  other  affections  now  happily  extinct,  were  common 
enough,  and  not  unfrequently  wards  had  to  be  entirely  closed  in 
order  to  hmit  the  ravages  of  such  diseases.  The  almost  synchronous 
discovery  of  anaesthesia  and  antisepsis  has  transformed  surgery,  and 
from  being  an  art  dangerous,  barbarous,  and  almost  repulsive,  it  has 
been  changed  into  a  scientific  procedure,  beautiful  in  its  details  and 
beneficent  in  its  results.  In  this  connection  the  names  of  Simpson, 
who  fought  the  battle  of  anaesthesia,  of  Spencer  Wells,  who  popu- 
larized the  use  of  haemostatic  forceps,  and  of  Lister,  who  first  appHed 
to  surgery  the  principles  that  were  being  taught  by  Pasteur  as  to 
the  microbic  origin  of  disease,  will  ever  stand  out  as  three  of  the 
greatest  benefactors  of  the  human  race. 

The  Antiseptic  plan  of  treating  wounds,  as  originally  introduced 
by  Lord  Lister,  is  an  outcome  of  the  germ  theory  of  putrefaction. 
It  has  for  its  object  the  prevention  of  bacterial  development  in 
wounds  bv  the  use  of  chemical  agents,  some  of  which  are  true  germi- 
cides, capable  of  destroying  the  bacteria,  whilst  others  merely  pre- 
vent or  inhibit  their  growth.  Amongst  the  multifarious  antiseptic 
agents  which  have  been  used,  the  most  prominent  are  carbolic  acid, 
corrosive  sublimate,  biniodide  of  mercury,  iodine,  iodoform,  formahn, 
boric  acid,  salicylic  acid,  etc. 

Carbolic  Acid,  the  first  antiseptic  employed  by  Lister,  has  a  direct  germicidal 
action  in  strong  solutions,  and  an  inhibitory  effect  in  weaker  ones.  The 
crystals,  when  heated  with   lo  per   cent,   of  water,  constitute  an  oily  fluid 

271 


272  A   MANUAL  OF  SURGERY 

known  as  pure  or  liquefied  carbolic  acid,  which  is  a  powerful  though  super- 
ficial caustic,  and  may  be  applied  without  much  fear  to  infected  living  tissues 
— e.g.,  to  tuberculous  sinuses  or  wounds — after  scraping  them,  in  order  to 
destroy  any  portions  of  tuberculous  material  which  may  have  escaped  the 
spoon.  Excess  of  the  acid  may  be  washed  away  with  absolute  alcohol,  which 
quickly  dissolves  it.  The  liquid  carbolic  dissolves  in  water  on  the  application 
of  warmth,  and  the  i  in  20  and  i  in  40  solutions  are  those  mainly  employed; 
the  former  is  an  efficient  and  potent  antiseptic,  but  must  be  used  carefully  on 
delicate  skins.  It  is  most  important  to  ensure  the  complete  solution  of  the 
acid,  as  otherwise  globules  of  it  may  be  deposited  on  the  hands  or  in  the  wound, 
and  may  do  much  harm.  Carbolic  acid  is  frequently  somewhat  crude  and 
impure,  and  many  of  the  irritative  and  toxic  phenomena  are  due  to  cresylic 
acid  and  other  substances  which  should  not  be  present.  General  absorption 
of  this  reagent  leads  to  darkening  of  the  urine,  which  may  become  olive- 
green  or  even  black  in  colour,  and  this  carboluria  is  often  associated  with 
giddiness,  nausea,  and  vomiting,  in  bad  cases  progressing  to  a  condition  of 
collapse;  diseased  kidneys  may  be  seriously  affected.  Weaker  solutions  are 
more  readily  absorbed  than  the  liquefied  or  pure  acid.  It  must  be  remembered 
that  children  and  some  adults  are  peculiarly  susceptible  to  its  action,  and 
its  application  to  large  wounded  surfaces,  e.g.,  burns,  is  inadvisable.  On  the 
other  hand,  its  great  affinity  for  all  greasy  and  oily  substances  renders  it  a 
valuable  antiseptic  for  emergency  work,  as  it  penetrates  into  the  skin  more 
readily  than  other  agents.  A  solution  in  olive  oil  (i  in  20)  or  vaseline  is  some- 
times used  as  a  lubricant  for  catheters,  etc.,  but  is  not  very  satisfactory. 

Corrosive  Sublimate  is  usually  employed  in  solutions  of  i  in  2,000,  i  in  1,000, 
or  I  in  500.  Occasionally  the  last  of  these  three  solutions  has  5  per  cent,  of 
carbolic  acid  added  to  it,  constituting  what  is  known  as  Lister's  strong  mixture. 
Sublimate  solutions  are  inhibitory  in  action  rather  than  germicidal,  but  are 
potent  and  reliable,  especially  in  purifying  the  skin;  when  mixed  with  albu- 
minous fluids,  such  as  blood,  an  insoluble  albuminate  of  mercury  forms, 
which  is  ineffective  as  an  antiseptic.  They  have  less  power  of  penetration  than 
carbolic  acid,  and  have  less  hardening  or  roughening  influence  on  the  skin.  If, 
however,  a  dressing  soaked  in  a  sublimate  solution  (i  in  2,000)  is  kept  for  long  in 
contact  with  the  skin,  it  acts  as  a  direct  irritant,  and  may  lead  to  an  abundant 
formation  of  pustules,  owing  to  the  activity  of  the  germs  in  the  deeper  parts 
ot  the  cutis  which  have  not  been  destroyed  by  the  antiseptic.  Instruments 
should  not  be  placed  in  sublimate  solutions,  as,  even  if  plated,  they  soon  lose 
their  bright  appearance.  It  must  be  remembered  that  individuals  very 
sensitive  to  the  action  of  mercury  may  be  salivated  by  this  agent,  and  espe- 
cially when  used  frequently  for  irrigating  cavities  to  which  a  free  exit  is  not 
provided.  Symptoms  of  acute  intestinal  irritation,  cramps,  vomiting,  and 
blood-stained  diarrhoea,  may  also  be  caused. 

Biniodide  of  Mercury  is  a  potent  antiseptic,  which  has  been  chiefly  employed 
in  the  form  of  a  i  in  500  solution  in  70  per  cent,  methylated  spirit  for  the 
purification  of  the  hands  or  of  the  skin  of  the  patient.  It  is,  of  course,  extremely 
toxic.  A  I  in  2,000  aqueous  solution  is  also  employed  for  the  hands,  and  is 
less  harmful  to  instruments  than  the  perchloride. 

Boric  or  Boracic  Acid  is  a  mild  and  weak  antiseptic,  which  may  be  utilized 
when  stronger  remedies  might  prove  harmful — e.g.,  in  plastic  operations  and  for 
infants.  It  is  also  useful  when  antiseptic  fomentations  are  required  in  treating 
inflammatory  phenomena,  and  in  ophthalmic  surgery. 

Iodine  is  a  most  valuable  antiseptic,  and  at  the  present  time  is  largely 
employed  to  sterilize  the  skin  before  operations  in  alcoholic  solutions,  varying 
from  2  to  5  per  cent.  To  be  effective  it  is  essential  that  the  skin  be  pre- 
viously freed  from  moisture  or  grease.  In  weaker  solutions  iodine  is  useful 
to  irrigate  suppurating  cavities,  or  may  be  employed  as  a  bath  in  which  to 
immerse  inflamed  parts. 

Iodoform  is  a  yellow  powder  of  characteristic  and  unpleasant  odour,  which 
probably  acts  by  being  decomposed  in  the  tissues  and  slowly  giving  off  iodine. 
Commercial  iodoform  is  usually  contaminated  with  a  variety  of  germs;  it  is 
therefore  wise  to  wash  the  iodoform  before  use  in  i  in  20  carbolic  lotion.     Its 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY    273 

chiol'  value  is  in  foul  or  tuberculous  wounds,  and,  indeed,  it  seems  to  have  a 
specific  inhibitory  action  upon  the  development  of  the  B.  tuberculosis.  It 
may  be  suspended  in  glycerine  (10  per  cent.),  ami  after  sterilization  by  im- 
mersing the  vessel  in  which  it  is  contained  in  boiling  water  for  half  an  hour, 
this  can  be  injected  into  tuberculous  tissues,  joints,  or  abscesses;  or  if  open 
wounds  exist,  gauze  soaked  in  this  emulsion,  as  it  is  incorrectly  termed,  may  be 
packed  into  them  with  advantage.  Toxic  effects  of  very  variable  type  may 
follow  from  undue  absorption  of  the  drug.  Gastro-intestinal  disturbances, 
vomiting,  diarrhoea,  colic,  etc.,  may  be  the  chief  symptoms,  but  delirium  and 
collapse  often  supervene.  There  is  alwavs  an  abundance  of  iodine  in  the  urine. 
Various  substitutes  have  been  proposed  in  order  to  avoid  the  unpleasant  smell 
— e.g..  aristol.  orthoform,  etc. — but  they  are  of  doubtful  value. 

Chinosol  is  a  yellow  substance,  harmless  and  free  from  toxic  qualities;  it  is 
easily  soluble  in  water,  and  possesses  powerful  antiseptic  properties. 

Lysol  is  another  useful  antiseptic  derivative  of  coal-tar.  It  is  freely  soluble 
in  water,  and  as  a  2  per  cent,  solution  may  be  used  in  syringing  out  cavities, 
such  as  the  vagina,  external  ear,  etc.  Its  solution  is  somewhat  soapy,  and 
tends  to  cling  to  the  tissues  and  prolong  its  action. 

Permanganate  of  Potash,  Sanitas,  and  Peroxide  of  Hydrogen,  all  act  in  the 
same  way  as  oxidizing  agents;  the^^  are  necessarily  unstable  and  cannot  be 
utilized  for  dressings,  and  are  therefore  chiefly  employed  in  the  disinfection  of 
cavities  or  wounds  already  contaminated.  The  most  potent  of  these  is  per- 
oxide of  hydrogen,  which  is  sold  as  a  fluid  capable  of  setting  free  10  to  20  times 
its  volume  of  nascent  oxygen.  It  is  quite  unirritating,  and  may  be  poured 
directly  into  an  infected  wound,  or  even  into  the  peritoneal  cavity;  forthwith 
it  commences  to  effervesce,  liberating  its  oxygen,  and  forming  a  frothy  foam, 
which  is  likely  to  bring  to  the  surface  any  loose  sloughs  or  foreign  bodies.  Its 
use  is  particularly  indicated  in  the  treatment  of  dirty  ulcers,  carbuncles,  sloughy 
abscess  cavities,  and  the  like.  Sanitas  and  permanganate  of  potash  are  used 
in  solutions  of  varying  strength,  and  act  more  slowly;  the  latter  has  the  dis- 
advantage of  staining  the  tissues  with  which  it  is  brought  in  contact. 

Formalin  is  a  powerful  antiseptic,  and  consists  of  a  40  per  cent,  aqueous 
solution  of  formic  aldehyde.  It  is  decidedly  toxic,  even  in  a  i  per  cent, 
solution.  It  blackens  steel  instruments,  gives  off  an  irritating  vapour,  and 
hardens  the  skin  to  an  unpleasant  degree. 

The  Aseptic  Method  of  treating  wounds  consists  in  the  elimination 
of  chemical  antiseptics  as  far  as  possible,  and  the  substitution  of 
heat,  drv  or  moist,  as  a  steiilizing  agent.  Every  efficient  antiseptic 
is  more  or  less  toxic  and  irritating,  and  there  can  be  no  question  that, 
from  an  ideal  standpoint,  the  less  they  are  introduced  into  wounds, 
the  better.  No  more  satisfactory  germicide  can  be  imagined  than 
heat,  in  the  form  either  of  boiling  water  or  of  steam  under  pressure, 
and  it  is  claimed  that  if  e\'er3i:hing  brought  in  contact  with  the 
wound  is  aseptic,  then  no  antiseptics  need  be  employed.  Dressings, 
swabs,  towels,  aprons  or  coats,  and  caps,  are  sterilized  in  drums  or 
kettles  b\^  means  of  steam  at  ordinary  pressure,  or  by  superheated 
steam  at  high  pressure.  The  latter,  of  course,  is  the  more  satisfac- 
tory, o\ving  to  its  greater  penetrative  power,  but  the  former  can  be 
effective  if  the  drums  are  so  constructed  as  to  permit  a  free  passage 
of  steam  through  the  articles  to  be  sterilized,  and  if  the  latter  are 
packed  loosely  and  not  tightlv.  The  drum  is  first  lined  wdth  a  layer 
of  lint  or  gauze,  and  a  similar  covering  must  be  placed  over  the 
contents  beneath  the  lid.  A  shding  shutter,  or  some  suitable  con- 
trivance, allows  the  entrance  of  steam  into  the  drum.  \Mien  the 
drum  is  removed  from  the  sterihzer,  this  shutter  is  closed,  and  the 


274  A   MANUAL  OF  SURGERY 

contents  may  be  expected  to  remain  sterile  for  a  day  or  two,  but 
not  for  long  unless  hermetically  sealed.  For  small  establishments 
a  Schimmelbusch's  low-pressure  dressing  steriHzer  or  a  small  high- 
pressure  (from  5  to  15  pounds)  steam  sterilizer  answers  excellently; 
but  for  large  hospitals  an  extensive  and  expensive  plant  must  be 
installed,  and  probably  some  variety  of  the  Washington-Lyon 
sterilizer  is  the  best.  For  private  practice  suppHes  of  effectively 
sterihzed  articles  in  hermetically  sealed  tins  or  drums  can  now  be 
obtained  from  many  instrument  makers  and  chemists. 

Of  course,  there  are  two  elements  in  an  operation  which  can  never 
be  sterilized  apart  from  chemical  antiseptics- — viz.,  the  skin  of  the 
patient  and  the  surgeon's  and  assistants'  hands — and  thus  the  most 
complete  aseptic  precautions  can  never  entirel}'  eliminate  chemical 
agents.  Moreover,  it  must  not  be  forgotten  that  the  air  itself  holds 
numberless  germs  which  cannot  be  excluded  from  the  wound,  and 
that  such  germs  are  more  numerous  in  crowded  cities  and  in  places 
where  sick  people  are  likely  to  congregate.  To  obviate  this,  most 
elaborate  precautions  have  often  been  taken  in  order  to  filter  the  air 
admitted  to  the  operating  theatre,  and  also  as  to  the  cleanliness  and 
dress  of  the  surgeon  ancl  his  assistants.  Unsterilized  persons,  and 
therefore  students,  are  frequently  banished  from  the  operating 
theatre,  or  placed  behind  a  glass  screen,  as  every  additional  onlooker 
must  increase  the  risk  in  purely  aseptic  conditions.  Then,  too,  the 
surgeon  ought  to  be  able  to  rely  on  assistants  and  nurses  who  are  not 
changing  every  six  or  twelve  months,  as  there  is  no  second  line  of 
defence  in  the  presence  of  antiseptics  to  make  good  errors  in  tech- 
nique. Moreover,  away  from  hospital,  surgeons  are  not  always  able 
to  command  aseptic  conditions,  but  may  have  to  operate  in  very 
unsuitable  surroundings.  Hence,  in  a  large  teaching  hospital,  de- 
voted to  the  training  of  students  and  nurses  (and  such,  we  believe, 
can  only  be  carried  out  effectively  by  their  active  participation  in 
the  work),  it  is  quite  a  question  whether  it  is  desirable  to  maintain 
a  purely  aseptic  chnique. 

The  actual  details  of  operative  technique  vary  somewhat  with 
different  surgeons,  but  the  main  principles  which  govern  modern 
operative  surgery  are  much  the  same  in  all,  and  the  following  sketch 
of  the  preparations  required  and  of  the  routine  usually  practised  in 
undertaking  an  operation  may  be  considered  more  or  less  typical  of 
modern  methods: 

I.  The  Operating  Theatre  or  Room. — The  arrangement  of  this 
necessarily  depends  upon  considerations  of  space  and  finance.  It 
should  not  be  unnecessarily  large,  and  the  old-fashioned  theatre  with 
tiers  of  seats  overlooking  the  central  area  is  not  desirable.  On- 
lookers should  have  a  low  gallery  provided  for  them,  but  little  raised 
above  the  floor-space  and  shut  off  from  it  not  merely  by  a  rail,  but 
by  an  effective  barrier  breast-high.  It  may  with  advantage  be 
placed  between  the  operating  area  and  the  source  of  light,  but  clear 
of  the  window,  or  to  one  side,  and  should  be  entered  by  a  separate 
passage  and  not  through  the  theatre.     A  north  light  is  desirable. 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY     275 

and  it  should  come,  not  from  the  top,  but  from  the  side,  in  the  form 
of  what  is  known  as  a  '  studio  hght.'  The  walls  should  be  free  from 
ledges  on  which  dust  may  accumulate,  and  hned  with  white  tiles  or 
glazed  bricks,  or,  better  still,  present  a  smooth  surface  painted  with 
white  enamel,  which  can  be  washed  down  with  a  hose;  of  course  all 
corners  should  be  rounded.  The  floor  must  be  impermeable,  and 
slope  towards  an  open  channel  on  one  side  of  the  theatre,  so  as  to 
allow  of  suitable  flushing  with  a  hose.  All  shelves  must  be  made  of 
glass,  but  the  fewer  fixtures  in  the  actual  theatre  the  better.  The 
heating  arrangements  should  be  such  that  the  temperature  can  be 
raised,  if  necessary,  to  75°  or  80°  F.  Attached  to  the  theatre  should 
be  a  suitable  series  of  smaller  rooms  for  the  anaesthetist,  for  sterilizing 
purposes,  etc. 

In  a  private  house  the  room  must,  if  possible,  be  carefully  pre- 
pared beforehand.  The  carpet  should  be  taken  up  and  curtains 
removed.  The  walls  should  be  wiped  over  with  an  antiseptic  solu- 
tion, and  the  floor  thoroughly  scrubbed ;  all  unnecessary  furniture  is 
removed.  Should  the  operation  be  an  emergency  one,  without  time 
for  such  complete  preparation,  it  is  often  wiser  to  leave  things 
alone,  and  not  stir  up  dust  and  dirt  by  a  hurried  attempt  to  make 
the  place  look  a  httle  better  than  it  really  is.  A  suitable  supply 
of  hot  and  cold  boiled  water  must  be  secured  beforehand,  and  basins 
and  dishes,  etc.,  should,  if  possible,  be  previously  boiled. 

2.  Ihe  Surgeon  must  remember  the  very  grave  responsibiUty 
that  rests  upon  him  in  undertaking  many  of  the  modern  operations, 
and  he  must  be  wilUng  and  ready  to  submit  himself  to  the  strictest 
regime.  In  a  general  hospital  the  surgeon  will  probably  lay  aside 
his  outdoor  clothes  and  boots,  and  don  an  operating  suit  consisting 
of  a  soft  white  shirt,  white  '  drill '  trousers,  and  a  pair  of  clean  shoe? ; 
he  will  then  proceed  to  purify  his  hands  and  arms,  and  finally  puts 
on  a  sterilized  gown  reaching  lo  the  wrists,  a  sterihzed  cap  and  mask 
covering  the  whole  face  except  the  eyes,  and  sterihzed  gloves  reach- 
ing over  the  lower  end  of  the  sleeves.  The  assistants  will  be  simi- 
larly prepared.  Where  such  a  complete  change  is  impossible,  the 
shirt-sleeves  must  be  turned  up  well  above  the  elbow'S,  and  other 
preparations  made  as  before.  During  the  operation  unnecessary 
talking  is  forbidden,  and  if  one  has  to  cough  or  sneeze  the  head  is 
turned  completely  aside. 

Similar  rules  hold  good  in  regard  to  the  nurses,  whose  arms 
should  be  bare  to  the  elbows,  and  who  should  wear  sterihzed  coats ; 
the  hair  must  be  covered  by  a  sterihzed  cap,  even  if  a  mask  is  not 
considered  necessary. 

1  he  hands  and  arms  must  be  as  thoroughly  and  effectively  puri- 
fied as  if  no  aseptic  coverings  were  available.  They  are  scrubbed 
thoroughly  with  soft  or  ether  soap  and  hot  water:  the  nails  are  cut 
if  need  be,  special  attention  being  directed  to  the  semilunar  folds 
of  skin  at  the  base,  where  infected  material  is  apt  to  collect.  For 
this  purpose  a  purified  nail-brush  is  employed  with  advantage,  and 
if  a  runninsf  stream  of  hot  w^ater  can  be  obtained,  so  much  the  better. 


276  A   MANUAL  OF  SURGERY 

The  hands  and  arms  are  tlien  bathed  in  an  efficient  antiseptic  solu- 
tion-— e.g.,  a  I  in  500  solution  of  iodide  of  mercury  in  70  per  cent, 
methylated  spirit  for  one  minute,  and  then  in  a  i  in  2,000  sublimate 
solution.  The  hands  and  arms,  once  purified,  should  not  be  dried 
except  on  a  sterilized  towel.  It  is  possible  that  complete  steriliza- 
tion of  the  hands  is  not  effected  in  this  way,  but  the  surgeon  must 
always  aim  at  obtaining  it.  On  several  occasions  when  our  hands 
and  those  of  our  assistants  were  tested  bacteriologically  after  this 
method  of  preparation,  they  were  found  to  be  sterile,  even  scrapings 
from  beneath  the  nails  giving  no  reaction. 

The  majority  of  surgeons  nowadays  use  thin  rubber  gloves,  which 
can  be  sterilized  by  dry  heat,  or  boiled  in  water  without  soda;  if 
dry,  they  can  be  easily  shpped  on  after  dusting  them  inside  with 
a  sterilized  powder,  such  as  boracic  acid  or  French  chalk ;  the  hands 
must,  of  course,  be  dried  previously.  Boiled  gloves  are  best  put 
on  by  everting  them,  and  thoroughly  anointing  the  interior  with 
steriUzed  glycerine;  or  the  hand  may  be  immersed  in  methylated 
spirit,  and  the  gloves  then  slip  on  easily.  They  are  made  so  thin 
that  the  delicacy  of  touch  is  but  little  impaired,  especially  when  the 
use  of  such  gloves  has  become  habitual.  They  can  be  slightly 
roughened  on  the  exterior,  so  that  even  slippery  structures,  such  as 
intestine,  can  be  held.  They  should  fit  accurately  and  extend  well 
above  the  wrist.  Care  must  of  course  be  taken  to  ensure  that  the 
fingers  of  the  gloves  are  not  punctured.  Cotton  gloves  are  used  by 
some  surgeons,  and  several  pairs  may  be  required  during  a  single 
operation ;  they  do  not  appear  to  be  so  satisfactory  as  the  former. 

Assistants  and  nurses  taking  any  part  in  the  operation  should  also 
wear  gloves,  especially  if  the  handling  and  wringing  out  of  swabs  is 
entrusted  to  them. 

Much  of  the  success  of  an  operative  clinique  depends  upon  the 
methodical  and  effective  organization  of  the  same.  It  is  desirable 
that  all  unnecessary  hands  should  be  eliminated,  and  therefore 
everything  likely  to  be  needed  should  be  laid  out  within  reach  of  the 
surgeon  and  his  assistants  on  suitable  side-tables,  so  that  they  may 
be  able  to  take  up  instruments,  figatures,  and  sutures,  etc.,  without 
being  touched  by  others. 

3.  Instruments  are  sterilized  by  boiling  in  a  weak  solution  of 
bicarbonate  of  soda  (i  per  cent.)  for  five  or  ten  minutes,  or  more  if 
they  have  been  previously  used  for  a  dirty  case.  To  prevent  them 
from  rusting,  they  should  be  carefully  plated,  and  the  water  ought 
to  boil  for  some  minutes  before  they  are  immersed,  in  order  that 
the  suspended  air  may  be  driven  off.  After  boiling  they  may  be  laid 
out  on  a  sterihzed  dry  towel  and  covered  over  with  a  similar  towel 
till  they  are  required,  or  kept  in  a  weak  antiseptic  solution — e.g., 
carbolic  lotion,  i  in  60.  Mercurial  solutions  should  be  avoided,  as 
they  spoil  the  instniments.  If  during  an  operation  an  instrument 
which  has  not  been  previously  sterilized  is  required,  it  may  be 
quickly  purified  by  immersing  it  for  half  a  minute  in  liquefied  car- 
bolic acid,  the  excess  of  which  is  removed  by  washing  thoroughly  in 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY     277 

alcohol  or  hot  sterilized  water.  The  same  process  or  re-boiling  must 
be  adopted  for  any  instrument  which  falls  on  the  floor  or  becomes 
otherwise  soiled.  Special  care  must  be  chrected  towards  the  forceps, 
to  see  that  the  serrations  are  freed  from  dried  blood-clot  and  other 
dirt.     H.nemostatic  forceps  should  be  opened  before  boiling. 

4.  Swabs  have  now  so  completely  taken  the  place  of  sponges  in 
surgery  that  it  is  unnecessary  to  consider  the  preparation  of  the 
latter.  Swabs  are  made  of  absorbent  wool  wrapped  in  a  single 
square  layer  of  gauze  the  corners  of  which  are  tied  across  and  tucked 
in ;  or  they  may  be  composed  of  gauze  alone,  folded  over,  and  perhaps 
stitched  so  as  to  leave  no  free  edge  which  may  fray  out ;  or  they  may 
be  formed  of  larger  squares  of  absorbent  material,  such  as  Gamgee 
tissue.  A  sufftciency  of  these,  suited  in  size  and  shape  to  the  re- 
quirements of  the  case,  is  provided  before  the  operation.  They  are 
sterilized  in  a  suitable  autoclave  or  sterilizer,  and  kept  in  the  drum 
until  required,  when  they  are  removed  by  sterile  hands  or  instru- 
ments to  a  sterile  receptacle,  being  used  dry  or  after  immersion  in 
lotion.  In  case  of  need,  where  a  sterilizer  is  not  available,  they  may 
be  boiled  and  then  kept  either  in  boiled  water,  covered  over  till 
required  with  a  steriHzed  cloth,  or  in  an  antiseptic  solution ;  or  maj^ 
be  dried  in  an  oven  after  being  enclosed  in  a  suitable  cloth. 

Cloths  and  gauze  strips  for  abdominal  operations  are  prepared  in 
a  similar  manner.  In  these  cases  a  careful  record  must  be  kept  of 
the  numbers  used,  so  that  all  may  be  accounted  for  afterwards; 
indeed,  it  is  wise  always  to  have  swabs,  etc.,  done  up  in  packets  or 
bags  containing  a  known  number,  such  as  a  dozen. 

5.  The  Ligatures  and  Sutures  demand  very  thorough  purification, 
which  varies  with  the  material  used.  Silkworm-gut,  horsehair,  and 
silver  wire,  which  do  not  imbibe  fluids  or  become  absorbed,  merely 
require  to  be  boiled,  but  silk  and  catgut  need  much  more  care  if 
stitch  suppuration  is  to  be  avoided.  Silk  must  be  boiled  for  twenty 
or  thirty  minutes,  and  should  be  wound  loosely  on  reels  or  winders, 
so  that  the  deeper  strands  may  become  sterile  as  well  as  the  super- 
ficial. It  may  be  used  at  once  or  after  being  kept  in  spirit  or  in  some 
antiseptic  lotion,  such  as  a  solution  of  subhmate  (i  in  1,000),  for 
a  week  or  until  required,  so  that  its  strands  may  become  well  impreg- 
nated with  the  salt.  An  important  precaution  in  the  use  of  silk  is 
to  soak  it  in  sterilized  water  before  use,  especially  if  it  has  been  kept 
in  spirit;  the  object  of  this  is  to  protect  the  tissues  from  the  caustic 
action  of  the  latter,  and  thereby  hinder  stitch  suppuration.  More- 
over, silk  should  never  be  used  with  ungloved  hands  ;  the  strands  cut 
through  the  epidermis  and  become  contaminated  by  germs  lying  in 
the  deeper  layers  of  the  skin,  and  stitch  suppuration  may  result. 

Catgut  is  still  more  difficult  to  purify,  inasmuch  as  boiling  in  water 
is  out  of  the  question.  Lord  Lister  claimed  that  catgut,  prepared 
according  to  his  directions  (p.  290),  remains  actively  antiseptic  for 
an  indefinite  period,  and  that  it  suffices  before  use  to  immerse  it  in 
a  I  in  20  solution  of  carbohc  acid  for  a  quarter  of  an  hour.  The 
majority  of  surgeons,  however,  prefer  to  sterihze  it  before  use,  and 


278  A   MANUAL  OF  SURGERY 

especially  so  if  they  used  non-chromicized  gut  or  catgut  which  has  been 
hardened  in  a  5  per  cent,  solution  of  formalin  for  twenty-four  hours. 
Many  different  processes  have  been  recommended,  but  perhaps  the 
simplest  and  most  effective  is  that  known  as  the  '  iodine '  method. 
The  catgut  is  wound  loosely  on  a  glass  spool  or  winder,  and  immersed 
in  a  solution  containing  iocline,  i  part  ;  iodide  of  potassium,  i  part; 
and  distilled  water,  100  parts.  It  is  kept  thus  in  the  dark  for  seven 
to  ten  days,  and  then  removed  and  kept  dry,  wrapped  in  sterile  gauze. 
Before  use  it  is  placed  for  a  few  minutes  in  spirit  (rectified  or  methy- 
lated), so  as  to  dissolve  out  a  little  of  the  excess  of  iodine  present. 
Catgut  so  prepared  is  not  only  aseptic,  but  also  actively  antiseptic, 
and  rarely  causes  trouble  in  the  tissues  (except,  perhaps,  in  delicate 
children).  An  extensive  experience  of  this  material  for  some  years 
has  proved  its  reliability  and  value.  Various  instrument-makers 
provide  sterilized  catgut  in  sealed  glass  tubes,  which  can  usually  be 
trusted. 

6.  The  skin  of  the  patient  is  carefully  prepared  before  operation, 
the  length  of  such  treatment  depending  on  the  cleanliness  or  not  of 
the  part  and  the  urgency  of  the  case.  The  skin  is  first  shaved,  if 
necessary,  and  washed  with  soft  or  ether  soap  and  hot  sublimate  lotion 
(i  in  2,000) ;  acetone  or  turpentine  may  be  used  to  remove  grease 
and  excessive  dirt.  It  is  then  flushed  with  biniodide  of  mercury  in 
spirit  (i  in  500),  or  with  carbolic  lotion  (i  in  20),  and  afterwards  the 
stronger  antiseptic  is  washed  away  with  a  weaker  solution  either  of 
carbolic  acid  or  subhmate.  The  part  is  finally  wrapped  up  in  an  anti- 
septic compress — i.e.,  of  gauze  or  lint,  soaked  in  i  in  40  carbolic  or 
I  in  2,000  sublimate  solution.  At  the  time  of  operation  the  same  pro- 
cess may  be  repeated.  It  must  not  be  forgotten  that  a  very  vigorous 
use  of  carbolic  acid  may  be  followed  by  local  irritation,  as  well  as  by  its 
absorption  into  the  blood-stream,  especially  in  protracted  operations 
and  in  children.  Care  must  also  be  taken  that  the  patient  does  not 
lie  in  a  pool  of  antiseptic  lotion  which  has  run  down  during  the 
washing  and  collected  under  the  sacrum ;  many  a  bad  antiseptic  burn 
has  resulted  therefrom.  Again,  not  only  does  the  quality  of  the  skin 
vary  in  different  individuals  (as  may  be  illustrated  by  contrasting 
that  of  a  coal-heaver,  who  possibly  bathes  once  a  year,  with  that  of  a 
child  or  lady,  which  is  soft,  clean,  and  dehcate),  but  it  also  differs  in 
various  regions  of  the  body,  and  hence  the  process  of  purification 
must  be  modified  according  to  the  character  and  thickness  of  the 
integument .  Any  part  where  dirt  may  accumulate  demands  scrupu- 
lous attention — e.g.,  the  umbilicus,  external  ear,  toes,  or  corona 
glandis  in  persons  with  long  foreskins.  A  word  of  warning  is  also 
needed  as  to  the  too  vigorous  use  of  a  nail-brush  leading  to  a  trau- 
matic dermatitis,  or  even  waking  up  into  activity  germs  which  other- 
wise would  have  lain  dormant  in  the  deeper  layers  of  the  uninjured 
skin.  It  may  be  again  mentioned  that  in  cases  of  emergency  it  is 
wiser  to  trust  in  carbohc  lotion  than  in  sublimate,  as  the  former  unites 
freely  with  the  grease  of  the  skin,  and  hence  penetrates  more  deeply. 

This  method  of  preparing  the  patient  has,  however,  been  largely 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY     279 

displaced  by  the  discovery  of  the  penetrating  antiseptic  properties 
oi  iodine,  to  which  Mr.  Waterhouse  drew  attention  {Lancet,  April  16, 
1910).  The  all-essential  element  in  the  use  of  this  agent  is  that  the 
skin  to  which  it  is  appUed  must  be  quite  dry;  moisture  causes  the 
cells  of  the  prickle-celled  layer  to  swell  up,  and  hinders  the  action. 
It  may  therefore  be  employed  directly  in  casualty  work  to  a  dirty 
skin  without  washing.  In  operative  work  the  part  to  be  purified 
should  be  shaved  and  washed  twelve  hours  before,  and  wrapped  in  a 
sterihzed  towel ;  the  iodine  is  painted  over  two  hours  before  opera- 
tion, and  the  sterile  covering  replaced ;  and  finally  on  the  operating 
table  the  parts  are  painted  once  again.  The  solution  employed 
should  be  one  containing  2  or  2*5  per  cent,  of  iodine  in  rectified,  not 
methylated,  spirit ;  the  latter  causes  intolerable  irritation  of  the  eyes. 
The  iodine  method  is  quite  rehable,  if  the  precautions  noted  above 
are  taken,  but  occasionally  it  causes  some  irritation  of  dehcate  and 
sensitive  skins. 

7.  The  area  of  operation  is  surrounded  by  mackintoshes,  which 
should  always  be  purified  or  sterihzed,  and  these  in  turn  are  covered 
with  dry  sterihzed  towels,  fixed  to  the  skin  by  suitable  towel-chps. 
FaiHng  dry  sterihzation,  the  towels  may  be  boiled,  and  subsequently 
dried  by  baking  in  an  oven,  or  soaked  in  an  antiseptic  solution. 
During  an  operation  irrigation  or  flushing  is  unnecessary,  unless  the 
proceedings  are  prolonged,  and  then  hot  sterihzed  salt  solution 
should  be  employed  for  the  purpose ;  but  a  final  flushing  with  carbohc 
lotion  (i  in  40)  or  with  sublimate  (i  in  2,000)  is  somerimes  useful, 
especially  when  operating  under  conditions  which  are  not  ideal  as 
to  surroundings  and  technique.  The  objection  to  such  flushing  is 
that  the  lorion  is  more  or  less  of  an  irritant,  and  determines  a  certain 
amount  of  subsequent  oozing  and  effusion,  which  will  necessitate 
drainage.  More  particularly,  when  deahng  with  the  peritoneal 
cavity  or  interior  of  a  joint,  the  less  one  employs  antiseptics  the 
better ;  they  lead  to  a  desquamation  of  the  dehcate  endothehal  Uning 
which  it  is  so  important  to  maintain  intact. 

8.  Before  closing  the  wound  absolute  hsemostasis  should  be 
secured,  and  then  the  wound  may  usually  be  stitched  up  completely 
and  without  drainage.  It  is  important  to  build  up  again  the  divided 
tissues  of  the  part  by  suitable  buried  sutures,  so  as  not  only  to 
secure  more  perfect  apposition,  but  also  to  obhterate  '  dead  spaces  ' 
in  which  blood-clot  or  effusion  may  collect.  In  this  way  wounds 
through  fleshy  and  vascular  structures — e.g.,  an  amputation  through 
the  thigh— may  sometimes  be  completely  closed  up  without  drainage. 
On  the  other  hand,  where  accurate  apposition  of  tissues  and  ob- 
Uteration  of  cavities  cannot  be  obtained,  as  after  clearing  out  the 
axilla,  and  where  some  amount  of  oozing  may  be  expected,  it  is 
advisable  to  insert  a  suitable  drainage-tube,  and  stitch  it  flush  with 
the  surface.  It  is  removed  at  the  end  of  forty-eight  hours  at  most ; 
in  such  cases  the  removal  of  the  discharge  and  the  changing  of  the 
soaked  and  perhaps  stiffened  dressings  add  materially  to  the  comfort 
of  the  patient. 


28o  A   MANUAL  OF  SURGERY 

When  the  operation  has  been  completed,  the  skin  around  is 
cleansed  with  lotion,  but  only  after  a  piece  of  dressing  has  been  placed  as 
a  protection  over  the  wound.  This  cleansing  should  always  be  accom- 
plished by  wiping  peripherally  away  from  the  wound,  and  any  swab 
utilized  for  this  purpose  should  not  again  l)e  allowed  to  touch  it. 

9.  Finally,  a  carefully  arranged  Dressing  is  applied,  and  the  part 
bandaged  and  placed  at  rest  on  a  splint  or  in  a  sling,  if  such  is 
indicated  by  the  requirements  of  the  case;  absolute  rest  and  quiet 
are  essential  if  rapid  healing  is  to  be  obtained. 

Lord  Lister  pointed  out  some  years  back  that  the  main  essentials 
of  a  good  dressing  consisted  in  its  containing  some  trustworthy  anti- 
septic ingredient;  in  this  agent  being  so  stored  up  that  it  cannot  be 
dissipated  before  the  next  dressing;  in  its  being  entirely  unirritating; 
and  in  the  capacity  of  the  fabric  readily  to  absorb  blood  or  serum 
that  may  ooze  from  the  wound.  The  original  antiseptic  dressings — 
viz.,  the  carbolic  and  eucalj^ptus  gauzes,  and  even  the  alembroth 
gauze  and  wool — failed  to  fulfil  these  requirements ;  but  in  the  double 
cyanide  of  mercury  and  zinc  gauze  we  have  a  material  which  is  to 
all  intents  and  purposes  perfect.  It  should  be  soaked  for  some  hours 
in  carbolic  lotion  (i  in  20),  and  applied  to  the  wound  without  fear 
after  wringing  it  out  of  a  i  in  40  solution;  or  it  may  be  sterilized 
and  applied  dry.  A  sufficiency  of  this  is  employed  so  as  to  cover  in 
a  wide  margin  of  skin  all  round  the  wound,  and,  finally,  over  all  a 
liberal  covering  of  sterilized  or  antiseptic  wool,  so  as  to  diffuse  the 
pressure,  which  is  applied  by  means  of  careful  bandaging.  1  he  best 
material  for  bandages  is  butter-cloth,  since  it  is  light  and  adapts 
itself  easily  to  the  outUnes  of  the  part.  Other  dressings,  such  as 
boric  lint,  iodoform  gauze,  etc.,  are  occasionally  employed,  but  they 
are  not  so  satisfactory  for  general  use  as  the  cyanide  gauze. 

Many  surgeons  employ  simple  sterilized  gauze  without  any  anti- 
septic ingredients,  and  where  complete  asepsis  has  been  maintained 
and  no  great  amount  of  discharge  is  expected,  this  will  suffice  ad- 
mirably. An  antiseptic  dressing  is,  however,  an  extra  safeguard 
that  may  be  wisely  adopted,  and  especially  in  cases  where  a  good 
deal  of  post-operative  oozing  is  likely  to  occur.  Thus  in  a  case  of 
excision  of  the  astragalus,  where  by  an  oversight  the  dressing, 
though  badly  soiled,  had  been  left  untouched  for  a  week,  the  bandage 
and  aseptic  wool  soaked  with  a  blood-stained  discharge  stank;  but 
on  removing  them  and  taking  off  the  underlying  cyanide  gauze,  the 
foetor  gradually  diminished,  and  the  wound  was  found  to  be  un- 
infected, and  ran  an  ordinary  course  to  repair.  The  bacteria,  which 
were  attacking  the  parts  from  without,  were  unable  to  penetrate  the 
cyanide  gauze,  which  probably  saved  the  boy  from  losing  his  foot. 

10.  After-Treatment. — If  no  drainage-tube  has  been  employed, 
and  the  dressing  is  not  soaked  through,  it  may  be  left  untouched  for 
seven  or  eight  days,  at  the  conclusion  of  which  period  it  is  removed, 
the  stitches  are  taken  out,  and  in  all  probability  the  wound  will  be 
completely  healed.  When  a  drainage-tube  has  been  inserted,  it  is 
usual  to  take  it  out  at  the  end  of  twenty-four  or  forty-eight  hours ; 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY      281 

there  is  no  advantage  in  retaining  it  longer,  since  it  is  only  required 
for  the  removal  of  "the  sero -sanguineous  fluid  which  exudes  imme- 
diately after  the  operation.  Should  this  early  discharge  be  very 
abundant  and  soak  through  the  dressings,  there  is  no  actual  need  to 
remove  them  and  re-dress  during  the  first  twenty-four  hours,  if 
cyanide  gauze  has  been  employed ;  all  that  should  be  done  is  to  damp 
the  stained  external  bandages  with  i  in  20  carbolic  lotion,  and  then 
pack  on  some  more  gauze  or  wool.  This  may  even,  if  necessary,  be 
be  repeated  a  second  time.  But  where  merely  sterile  gauze  has 
been  used,  it  is  wise  to  redress  the  wound  completely. 

The  after-dressings  of  the  wound  need  to  be  conducted  with 
the  same  precautions  as  to  asepsis  of  hands,  instruments,  etc.,  as  the 
original  operation,  and  not  a  few  instances  of  infection  at  the  first 
dre'ssing  occur.  It  is  essenrial  that  everything  hkely  to  be  required 
should  be  prepared  before  the  dressings  are  removed,  so  that  ex- 
posure to  the  air  may  last  as  short  a  rime  as  possible.  If  the  first 
dressing  is  undertaken  after  twenty-four  or  forty-eight  hours,  and  all 
is  going  on  sarisfactorilv,  the  tube  is  removed,  and  the  wound  re- 
dressed in  exactlv  the  same  way  as  formeriy,  though  probably  much 
less  gauze  will  be  required.  If  the  case  is  left  for  eight  da^^s,  the 
sritches  can  probably  be  taken  out,  and  the  skm  mcision  will  then  be 
found  united.  A  small  dressing  of  cyanide  gauze  is  apphed,  fitring 
closely  to  the  scar,  and  sealed  down  with  flexile  collodion,  which  wall 
not  only  prevent  the  gauze  from  sHpping,  but  will  also  by  its  con- 
traction serve  to  steady  the  parts.  This  should  be  covered  with 
wool  and  a  bandage,  so' as  to  support  the  parts,  and  may  be  finally 
removed  at  the  end  of  another  week. 

An  open  method  of  treating  certain  operation  wounds  has  been 
recently  adopted  with  considerable  advantage.  Absolute  haemostasis 
is  the  first  essential,  and  the  wound  must  be  completely  closed  wath- 
out  drainage.  It  is  carefully  dried  and  painted  over  with  2  per  cent, 
solution  of  iodine  in  spirit.  'A  sterilized  towel  may  be  placed  around 
the  part  for  the  first  twenty-four  hours ;  but  this  may  be  discarded 
after^vards,  and  the  wound  is  left  uncovered,  and  merely  painted  wth 
the  iodine  solution  daily.  In  the  case  of  children  some  arrangement 
of  the  bed-clothes  must  be  devised  to  keep  their  fingers  away  from 
the  part.  Hernia  operations  and  similar  wounds  do  excellently  under 
this  regime. 


CHAPTER  XII. 

H  ^  M|0  R  R  H  A  G  E. 

By  the  term  hemorrhage  is  meant  any  escape  of  blood  from  the 
vessels,  whether  insignificant  and  immediately  arrested  by  natural 
means,  or  more  excessive  and  requiring  treatment  to  prevent  its 
continuance.  Although  most  commonly  due  to  some  injury, 
whether  subcutaneous  or  inflicted  through  the  skin,  it  may  be  pre- 
disposed to  by  weakness  of  the  vascular  tissues,  especially  if  asso- 
ciated with  increased  blood-pressure.  Certain  diseases,  such  as 
purpura  and  scurvy,  are  characterized  by  a  tendency  to  bleeding, 
and  there  is  one  congenital  condition,  haemophilia,  in  which  it  is 
difficult  to  stop  the  flow  of  blood  when  started. 

The  character  of  the  bleeding  differs  according  to  the  vessel  from 
which  the  blood  escapes.  Arterial  Haemorrhage  consists  in  a  flow 
of  bright  red  blood,  which  escapes  at  first  per  saltum — i.e.,  in  jets 
synchronous  with  the  heart's  beat,  and  may  be  derived,  not  only 
from  the  proximal,  but  also  from  the  distal  end  of  the  divided  vessel, 
if  the  collateral  circulation  is  sufficiently  abundant.  If,  however,  it 
is  derived  from  a  deep  artery,  the  blood  may  well  up  from  the  depths 
of  the  wound  and  not  escape  in  gushes.  In  Venous  Haemorrhage 
the  flow  is  usually  continuous,  and  the  blood  of  a  dark  red  or  almost 
black  colour.  If,  however,  a  large  vein  is  wounded,  such  as  the 
internal  jugular,  the  blood  may  escape  with  a  very  definite  spurt, 
owing  to  respiratory  or  other  influences.  Capillary  Haemorrhage  is 
marked  by  general  oozing  from  a  raw  surface,  the  blood  trickling 
down  into  a  wound,  if  present,  and  filling  it  from  below  upwards. 
By  Extravasation  of  Blood  is  meant  the  pouring  out  of  blood  from  a 
wounded  vessel  or  vessels  into  the  lax  areolar  planes  immediately 
adjacent,  which  become  swollen  and  boggy.  The  usual  constitutional 
signs  may  be  manifested  as  a  result  of  such  extravasation,  and, 
indeed,  fatal  haemorrhage  may  occur  in  this  way  without  any  escape 
upon  the  surface  of  the  body.  Subcutaneous  or  submucous  hccmor- 
rhage  is  also  met  with  in  the  form  of  small  localized  petechise,  arising 
from  injuries,  or  from  changes  in  the  blood  or  vessel  walls  (as  in 
purpura,  scurvy,  and  septicaemia).  Epistaxis  is  the  term  given  to 
bleeding  from  the  nose.  By  Haematemesis  is  meant  the  vomiting 
of  blood;  it  may  either  have  been  swallowed,  as  in  some  cases  of 
fractured  base  of  the  skull,  where  the  pharyngeal  mucous  membrane 

282 


HEMORRHAGE  283 

has  been  torn,  or  it  may  have  originated  from  the  upper  part  of  the 
intestinal  traet.  If  it  has  remained  in  the  stomach  any  length  of 
time,  the  blood  becomes  curdled  and  brownish  in  colour,  somewhat 
resembling  coffee-grounds,  from  the  action  of  the  gastric  juice  upon 
it.  When  gastric  hcemorrhagc  is  more  active,  the  blood  is  bright 
red  in  colour,  and  may  be  vomited  in  the  form  of  large  clots 
Haemoptysis  is  the  title  given  to  the  escape  of  blood  from  the  air 
passages,  whether  it  results  from  injury  or  disease.  The  characters 
vary  with  the  quantity  lost;  in  the  milder  cases  it  is  usually  bright 
red  and  frothy  from  admixture  with  air ;  in  graver  cases,  when  larger 
vessels  are  involved,  the  blood  may  escape  unaltered,  and  be  so 
abundant  as  to  asph^^xiate  the  patient.  Hsematuria  [q-v.)  is  a  con- 
dition in  which  blood  is  passed  in  the  urine.  By  Melsena  is  meant 
the  passage  of  dark  tarry  blood  with  the  faeces;  it  is  always  an 
e\ndence  of  disease  or  injury  of  the  intestinal  canal  sufficiently  far 
from  the  anus  to  allow  the  blood  to  become  altered  in  character  by 
the  action  of  the  intestinal  juices.  Blood  derived  from  the  rectal 
mucous  membrane  usually  retains  its  bright  red  colour. 

Constitutional  Efiecls. — If  the  haemorrhage  is  severe,  as  from 
division  of  a  large  artery,  death  results  from  syncope.  The  surface 
of  the  body  becomes  cold,  clammy,  and  pale;  the  hps,  ears,  and 
eyehds  are  livid;  the  patient  gasps,  his  respirations  become  quick 
and  sighing,  and  death  ensues  after  perhaps  a  few  convulsive 
twitches  of  the  Hmbs. 

If  the  haemorrhage  is  not  so  great  as  to  kill  immediately,  the 
patient  faints,  and  on  recovery  is  in  a  condition  of  severe  collapse 
and  weakness,  which  continues  for  some  time;  he  is  also  liable  to 
recurrent  attacks  of  syncope,  especially  if  the  bleeding  recurs. 

If  the  haemorrhage  is  concealed  and  of  moderate  severity,  as  from 
ulceration  of  the  stomach  or  duodenum,  or  by  shpping  of  a  ligature 
after  an  abdominal  operation,  the  patient  rapidly  becomes  pro- 
foundly anaemic,  and  his  face  shrunken  and  drawn  as  a  result  of  the 
dehydration  of  the  tissues  of  the  cheeks.  The  organs  of  the  body 
generally  suffer  from  want  of  oxygen,  and  hence  the  patient  feels  as 
if  he  were  being  suffocated,  and  is  extremely  restless,  tossing 
about  in  bed,  and  clamouring  for  open  windows  and  more  air  {air- 
himger).  Any  sudden  exertion,  or  even  sometimes  the  attempt  to 
sit  up,  is  followed  by  a  sensation  of  faintness  or  actual  syncope; 
noises  are  heard  in  the  ears,  the  sight  becomes  dim,  or  is  even  tem- 
porarily lost  (amblyopia),  and  severe  headache  may  be  complained 
of,  all  arising  from  cerebral  anaemia.  The  pulse  often  becomes  what 
is  known  as  hemorrhagic  in  character — i.e.,  frequent — and  com- 
pressible, but  collapsing  entirely  between  the  beats,  and  markedly 
dicrotic.  These  pecuUar  features  are  due  to  the  sudden  passage  of  a 
small  amount  of  blood  through  a  vessel  which  is  practically  empty. 
From  the  defective  vis  a  tergo,  oedema  of  the  extremities  may  result. 
During  the  continuance  of  haemorrhage  the  blood-pressure  neces- 
sarily falls;  but  unless  the  loss  is  great,  it  quickly  rises  again  to  the 
normal  after  the  bleeding  has  ceased.     This  rise  in  blood-pressure  is 


284  A   MANUAL  OF  SURGERY 

partly  due  to  a  diminution  in  the  size  of  the  vascular  area,  owing 
to  vasomotor  contraction  of  the  peripheral  arterioles  and  of  the 
splanchnic  area,  but  is  also  caused  by  an  increased  flow  of  lymph  into 
the  circulation.  For  the  changes  that  occur  in  the  blood  as  a  result 
of  h.'emorrhage,  see  p.  58.  The  ha:-moglobin  is  gradually  restored, 
and  an  increase  of  i  per  cent,  daily  is  about  the  normal  rate  (Emery). 

Children  and  elderly  people  alike  bear  the  loss  of  blood  badly;  but 
whereas  children  rapidly  recover  from  the  immediate  effects,  elderly 
people  do  not. 

General  Treatment. — When  the  loss  of  blood  has  been  severe,  the 
patient  must  be  kept  quiet  with  the  head  low,  whether  syncope  is 
present  or  not.  Ihc  foot  of  the  bed  or  couch  should  be  placed  on 
blocks  or  on  chairs,  so  as  to  assist  in  the  maintenance  of  the  circula- 
tion to  the  medullary  centres.  Stimulants  may  be  necessary  to 
maintain  the  heart's  action,  but  should  never  be  given  iMtil  the 
bleeding  has  been  effectively  controlled,  as  otherwise  they  may  increase 
or  re-start  it.  If  death  appears  to  be  imminent,  the  arms  and  legs 
should  be  bandaged,  or  the  abdominal  aorta  compressed,  in  order 
to  confine  the  blood  as  much  as  possible  to  the  head  and  trunk. 

'  No  patient  should  be  allowed  to  die  of  haemorrhage.'  Such  was 
the  dictum  of  the  late  Mr.  Wooldridge,  of  Guy's  Hospital,  based  on 
a  knowledge  of  the  value  of  transfusion  and  infusion.  By  Trans- 
fusion is  meant  the  transference  of  blood  from  one  individual  to 
another;  it  has  now,  however,  been  recognised  that  the  success  of 
this  proceeding  depends  on  the  introduction  of  a  sufficient  quantity  of 
fluid  as  a  temporary  substitute  for  the  blood  which  has  been  lost, 
rather  thdn  on  its  quality  ;  for  it  has  been  proved  that  the  transfused 
blood  of  another  person  is  rapidly  destroyed  and  eliminated.  Hence 
transfusion  has  now  been  replaced  by  the  Infusion  of  some  bland  fluid, 
isotonic  with  blood-plasma,  into  the  vessels,  and  by  this  means 
greatly  improved  results  have  been  obtained.  The  apparatus  re- 
quired is  a  metal  or  glass  cannula,  the  end  of  which  is  bulbous,  blunt, 
and  bevelled,  which  can  be  inserted  into  a  vein,  and  connected  by 
means  of  a  rubber  tube  with  a  reservoir  containing  the  fluid  (Fig.  89) . 
A  vein — e.g.,  the  median  basilic  or  internal  saphena — should  be  ex- 
posed, tied  below,  and  opened  by  a  longitudinal  or  oblique  incision; 
the  cannula,  filled  with  lotion  so  as  to  exclude  air,  is  then  inserted, 
and  a  ligature  placed  round  the  vessel,  so  that  on  withdrawal  it  can 
be  tightened.  The  amount  injected  varies  with  the  circumstances 
and  the  effects  produced,  but,  to  be  efficacious,  some  2  or  3  pints 
are  usually  needed;  this  may  be  repeated,  if  necessary,  but  rectal 
infusion  will  often  suffice  in  the  later  stages. 

As  to  the  material,  a  warm  saline  solution  is  the  best,  consisting 
of  a  drachm  of  chloride  of  soda  to  a  pint  of  sterilized  water  (or  about 
0-6  per  cent.),  at  a  temperature  of  105°  to  110°  F.  Tabloids  or 
tablets  of  the  dried  salt  are  dissolved  in  a  small  quantity  of  boiling 
water,  and  this  is  then  diluted  to  the  required  bulk  and  temperature. 
Of  course,  the  apparatus  is  carefully  sterilized  by  boiling,  and  no  air 
must  be  admitted.     The  injection  is  made  slowly,  so  that  the  solu- 


HAEMORRHAGE 


285 


tion  may  be  mixed  gradually  with  the  blood.  It  has  been  found  by 
experiment  that  after  an  infusion  following  hiiemorrhage  the  specific 
gravity  of  the  blood  is  only  lowered  for  a  very  short  period,  and 
rapidly  rises  to  a  normal  level,  or  may  even  be  raised  above  the 
normal.  This  suggests  that  the  increased  amount  of  fluid  is  ab- 
sorbed into  the  tissues,  and  explains  why  it  is  sometimes  necessary 
to  repeat  the  injection  more  than  once. 

In  the  later  stages  of  recovery  from  hemorrhage  and  in  cases  of 
shock  the  introduction  of  warm  sahne  solution  into  the  rectum  {proc- 
toclysis), or  through  an  exploring  needle  connected  with  a  tube  and 


Fig. 


-Infusion  into  Vein  of  Forearm. 


Above,  a  useful  form  of  metal  cannula  is  represented ;  below,  the  arrangement 
of  the  ligatures  on  the  vein. 

funnel  into  the  loose  connective  tissues  of  the  buttock,  abdomen,  or 
submammary  region  [hypodermoclysis] ,  is  exceedingly  valuable.  In 
the  latter  case  the  funnel  or  receiver  must  be  held  at  some  height 
(5  or  6  feet),  in  order  to  gain  sufficient  pressure,  and  by  this  means 
a  pint  or  more  may  be  slowly  injected;  a  carefully  steriHzed  syringe 
and  a  large  needle  may  be  employed  for  the  same  purpose.  During 
the  injection  the  part  should  be  gently  rubbed  so  as  to  distribute 
the  fluid.     For  method  of  proctoclysis,  see  Chapter  XXXV.). 

Natural  Arrest  of  Hsemorrhage. 

The  process  is  much  the  same  for  arteries,  veins,  or  capillaries; 
but  since  the  arrest  of  arterial  haemorrhage  has  been  more  thoroughly 
investigated,  and  is  the  most  important,  we  shall  deal  mainly  with  it. 


286 


A   MANUAL  OF  SURGERY 


The  Temporary  arrest  of  arterial  hitmorrhage  is  brought  aljout  by 
three  principal  factors: 

(i)  The  coagulation  of  the  blood,  which  occurs  in  and  around  the 
vessel,  and  without  which  death  would  ensue  from  the  merest 
scratch.  The  coagulability  of  the  blood  varies  in  different  subjects, 
and  is  influenced  by  various  conditions — e.g.,  the  amount  of  calcium 
salts  present.  In  hcemophilia  the  blood  coagulates  with  difficulty, 
and  therefore  hiemorrhage  is  always  a  serious  phenomenon  in  this 
affection.  Loss  of  blood  increases  the  coagulability  to  a  certain 
degree. 

(2)  Diminution  in  the  force  of  the  heart's  action  always  follows 
haemorrhage   from    ana-mia   of   the  cerebral    centres — a  beneficent 

provision   whereby    coagulation    is 

facilitated  and   the  flow  of  blood 

checked.     Un,til  the  vessel  has  been 

-'""KCj^sN-it  ■ »  -  -  efficicntlv  secured,  stimulants  should 

'^■J^/.^v^A  'y^^^  '      therefore  he  carefully  avoided. 

Kr"  ^^''"\.*»^V<*  (3)  Changes  in  and  around   the 

[{f'^MB^.  »»r  "l^^\\^"'  -        '1^  ^^^       vessel  play  a  most  important  part 

fifHHI^''^   ""^"i'^'S^    '\i»l  •'!,'      in   completing  the   process.     They 

consist  in  the  retraction  of  the 
artery  within  its  sheath  by  reason 
of  its  inherent  longitudinal  elas- 
ticity ;  if,  however,  it  is  only 
divided  partially  (or,  as  it  is  called, 
'  buttondioled  '),  this  condition  can- 
not obtain,  and  the  haemorrhage 
is  more  likely  to  continue.  As  a 
result  of  this  retraction,  the  rough 
and  uneven  inner  lining  of  the 
sheath  is  exposed,  and  upon  this 
the  blood  coagulates  as  it  flows, 
thus  gradually  producing  what  is 
known  as  the  external  coagulum. 
At  the  same  time  the  transverse 
muscular  and  elastic  fibres  in  the 
vessel  wall  cause  contraction  of  the 
open  mouth,  and  thus  the  external 
coagulum  is  able  to  increase  in  size  by  fresh  deposits  of  fibrin,  until 
at  last  its  resistance  is  too  great  for  the  chminishcd  cardiac  impulse 
to  overcome,  and  the  sheath  is  filled  with  clot,  which  extends  to  the 
divided  mouth  of  the  vessel.  From  this  an  internal  coagulum  next 
develops,  which  sometimes  extends  upwards  as  far  the  neaiest  patent 
branch.  Thus  the  haemorrhage  is  arrested  for  the  time  being,  and 
preparation  made  for — 

The  Permanent  closure  of  the  wound  in  the  artery,  which  merely 
consists  in  a  modification  of  the  general  process  of  repair.  Ihe 
vessel  wall  contracts  upon  the  internal  coagulum,  with  which,  how- 
ever, it  does  not  unite,  except  at  and  near  its  base.     As  a  result  of 


Fig.  90. — Organized  Thrombus 
IN  Vessel,  showing  the  Newly- 
formed  Connective  Tissue  oc- 
cupying the  Lumen  of  the 
Vessel,  and  Vascularized 
from  the  Vasa  Vasorum. 
(Tillmanns.) 

Two   giant  cells  arc   seen    in    the 
centre. 


HEMORRHAGE 


287 


the  injuiy,  a  simple  plastic  arteritis  is  set  up,  evidenced  by  a  hyper- 
semic  condition  of  the  vessel  wall  and  its  infiltration  with  leucocytes, 
which  also  in\'ade  the  coagulum  and  cause  its  base  to  become 
decolorized.  The  leucocytes  break  up  the  clot,  traversing  the 
natural  lines  of  cleavage  which  result  from  its  contraction,  and 
gradually  remove  it,  a  few  giant  cells  occasionally  assisting  in  this 
process  (Fig.  90).  The  tunica  intima  proliferates  concurrently, 
causing  a  secondary  infiltration  with  the  larger  fibroblastic  cells  in 
that  part  of  the  thrombus  which  is  adherent  to  the  vessel  wall  (Fig.  gi) ; 
whilst  a  growth  of  granulations  springs  up  in  those  parts  of  the  vessel 
wall  where  the  apex  of  the 
clot  lies  free  and  unadherent, 
new  vessels  being  derived 
from  the  vasa  vasorum.  The 
free  conical  extremity  of  the 
clot  contracts,  and  is  gradu- 
ally removed,  partly?  by  the 
activity  of  leucocytes  which 
infiltrate  it  from  the  base, 
partly  by  the  erosive  action 
of  the  surrounding  granula- 
tion tissue.  A  similar  set  of 
changes  occurs  at  the  distal 
side  of  the  hgature  in  an 
artery  tied  in  its  continuity. 
The  ligature  itself  may  be 
infiltrated  by  leucocytes, 
and  replaced  by  granulation 
tissue,  or  may  be  encapsuled. 
A  rod  of  granulation  tissue 
is  thus  developed,  blocking 
the  vessel,  and  this,  by  the 
usual  process  of  repair,  is 
transformed  into  a  firm  cica- 
tricial cord  in  the  course  of 
a  few  months  (Fig.  go).  It 
must  be  clearly  understood, 
however,  that  the  presence 

of  a  coagulum  is  by  no  means  essential  to  the  obliteration  of  an 
artery.  Thus,  if  the  walls  are  merely  brought  into  close  and  accurate 
apposition  by  a  ligature  without  dividing  the  inner  or  middle  coats,  a 
proliferative  endarteritis  without  any  clot  formation  results  which  is 
quite  sufficient  for  the  occlusion  of  the  vessel. 

The  arrest  of  haemorrhage  from  veins  and  capillaries  is  more  easily 
accomphshed,  the  collapse  of  the  walls,  and  the  absence  of  blood- 
pressure  facilitating  the  process.  The  later  steps  are  similar  to  those 
occurring  in  an  artery,  except  that  there  is  but  little  internal 
coagulum. 


o  n 

Fig.  91. — Diagram  of  Early  Stage  of 
Organization  of  Thrombus,  to  show 
THE  Infiltration  of  the  Clot  with 
Leucocytes  and  Connective -Tissue 
Cells  derived  from  the  Endothelium. 

(TiLLMANNS.) 

A,  Tunica  media;  B,  tunica  intima,  under- 
going proliferative  changes,  and  there- 
fore thickened  ;  C,  blood-clot  lying  in 
lumen  of  vessel,  becoming  infiltrated 
with  leucocytes  (small  dark  cells)  and 
larger  fibroblasts  derived  from  the  endo- 
thelium. 


288  A   MANUAL  OF  SURGERY 

Surgical  Treatment  of  Haemorrhage. 

I\Iany  different  methods  are  needed,  under  varying  circumstances, 
for  the  effective  arrest  of  haemorrhage.  It  may  be  laid  down  as  a 
prehminary  axiom,  that  digital  pressure  over  the  hlecding-poinl  will 
always  check  temporarily  the  most  furious  outburst,  whilst  means  for 
its  permanent  stoppage  are  being  arranged. 

Where  the  bleeding  is  general  and  does  not  come  from  any  one  par- 
ticular vessel,  the  following  measures  can  be  utilized: 

1.  Position. — When  the  bleeding  is  from  one  of  the  extremities, 
especially  the  lower,  elevation  by  emptying  the  veins  will  determine 
a  reflex  contraction  of  the  arteries,  and  thereby  assist  ha^mostasis. 

2.  Cold  may  be  employed  in  the  form  of  ice,  cold  water,  or  lotion, 
or  simple  exposure  to  the  air,  all  clots,  sw-abs,  pledgets,  etc.,  being 
removed  for  this  purpose;  it  must,  however,  be  remembered  that  ice 
and  unsterilized  water  may  convey  infective  germs.  Such  treat- 
ment is  of  most  value  for  general  oozing  from  vascular  structures  or 
into  ca\Tties,  such  as  the  mouth,  vagina,  or  rectum. 

3.  Hot  Water  (130°  to  160°  F.)  is  a  powerful  hBemostatic.  It  is 
supposed  to  act  by  stimulating  the  involuntary  muscular  fibres  of 
the  vessel  wall;  but  probably  the  coagulation  of  the  albumin  of  the 
blood  is  an  important  factor,  as  unless  the  water  is  hot  enough  to 
blanch  the  surface  of  the  wound,  the  bleeding  is  not  stayed,  but 
rather  encouraged. 

4.  Cauterization  is  but  little  used  as  a  haemostatic,  except  for  the 
bloodless  removal  of  vascular  tumours,  either  as  a  galvano-cautery, 
a  Pacquehn's  knife,  or,  in  the  case  of  piles,  as  the  ordinary  clamp 
and  cautery.  Occasionally,  however,  it  is  used  for  bleeding  in 
tissues  which  are  infiltrated  and  thickened  by  chronic  inflammation 
so  that  a  ligature  cannot  be  applied.  It  must  be  remembered  that 
in  order  to  seal  effectually  the  mouths  of  the  vessels,  the  cautery- 
must  be  at  a  dull  red  or  black  heat  ;  a  bright  redhot  iron  cuts 
through  a  vessel  as  cleanly  as  a  knife,  and  does  not  stop  the 
haemorrhage. 

5.  Chemical  Agents  may  be  used  to  assist  in  checking  haemor- 
rhage from  spongy  tissues,  or  from  deep  cavities  or  organs,  and 
act  in  diverse  manners,  [a)  They  may  act  locally  as  styptics  by 
causing  direct  coagulation  of  the  blood — e.g.,  liq.  ferri  perchloridi  or 
pernitratis,  tannic  or  gallic  acids,  alum,  nitrate  of  silver,  st3-ptic 
colloid,  etc.  In  employing  these,  the  surface  of  the  wound  must  be 
cleansed  and  dried  as  far  as  possible,  and  the  styptic  then  applied 
on  lint  or  gauze.  Unfortunately,  the  more  active,  such  as  liq.  ferri 
perchloridi,  are  actively  caustic,  and  may  cause  sloughing;  it  is 
seldom  that  such  a  drug  is  employed,  {b)  fhey  may  increase  the 
coagulability  of  the  blood,  and  of  these  lactate  of  calcium  is  the 
most  effective.  It  is  usually  administered  per  rectum  in  a  small 
enema  containing  15  grains,  and  this  may  be  repeated  two  or  three 
times  in  a  day.  The  use  of  this  dnig  before  operations  which  are 
expected  to  be^very  sanguinary  has  been  most  satisfactory  in  many 


HEMORRHAGE  289 

cases,  (c)  They  may  be  effective  as  vaso-constriciors,  and  of  these 
tlie  chief  is  adrenalin,  the  active  extract  of  the  suprarenal  organ. 
It  is  probably  more  valuable  in  preventing  than  in  checking  haemor- 
rhage, and  is  largely  used  in  intranasal  work;  it  is  prepared  in  the 
dry  form,  smce  it  loses  its  power  when  kept  in  solution  more  than  an 
hour  or  two.  The  addition  of  cocaine  to  its  solution  increases  its 
activity,  {d)  A  large  class  of  drugs  of  the  astringent  class  are 
employed  empirically  under  varying  circumstances  to  assist  in  hsemo- 
stasis — e.g.,  turpentine,  hamamelis,  ergot,  acetate  of  lead,  etc. — but 
it  cannot  be  said  that  their  action,  though  appreciated,  is  fully 
understood,  {e)  Finally,  it  is  most  important  in  cases  of  internal 
hemorrhage,  as  from  the  lungs  or  gastro-intestinal  canal,  to  keep 
mind  and  body  quiet,  and  there  is  no  agent  under  these  circum- 
stances more  valuable  than  opium  and  its  salts. 

6.  Direct  Pressure,  as  already  mentioned,  when  available,  is 
always  effective — at  any  rate,  for  a  time.  General  oozing  from  cut 
surfaces,  which  can  be  brought  into  apposition  as  in  an  amputation 
wound,  may  be  checked  by  applying  a  firm  bandage  over  them.  In 
cavities  or  hollows,  either  natural  or  made  by  operation,  bleeding 
may  be  stopped  by  packing  with  strips  or  graduated  layers  of 
sterilized  gauze  or  lint.  Such  dressings  should  be  retained  firmly 
in  position  for  twenty-four  hours,  after  which,  if  no  further  hcemor- 
rhage  has  occurred,  the  bandages  may  be  slackened;  but  it  is 
usually  advisable  to  retain  the  deep  plugs  for  another  day  or  two. 

When  the  bleeding  is  more  serious,  and  originates  from  some  definite 
vessel  or  vessels,  more  precise  measures  have  to  be  adopted.  Digital 
pressure  over  or  on  the  cardiac  side  of  the  bleeding  spot  suffices  to 
arrest  it  for  a  time,  whilst  preparations  are  being  made  to  secure  the 
wounded  vessel.  If  possible,  a  ligature  should  be  applied  with  anti- 
septic precautions,  but  other  means  have  been  used: 

1.  Acupressure  was  introduced  by  the  late  Sir  James  Simpson  in 
order  to  obviate  the  use  of  ligatures,  but  is  now  only  used  in  excep- 
tional circumstances.  A  needle  was  passed  either  under  the  vessel 
from  the  skin,  or  over  the  vessel  from  the  surface  of  the  wound, 
and  with  it  was  sometimes  combined  the  pressure  of  a  loop  of  silk 
or  wire  passed  figure-of-8  fashion  around  the  ends  of  the  needle. 

2.  Forcipressure  is  a  plan  for  stopping  haemorrhage  by  crushing 
the  divided  end  of  the  vessel  between  the  strong  and  deeply  serrated 
blades  of  a  pair  of  forceps  with  scissor-handles  provided  with  a 
catch;  those  known  by  the  name  of  Spencer  Wells  or  Greig- Smith 
are  the  most  convenient.  In  deahng  with  small  vessels,  it  is  quite 
suffi,cient  to  leave  the  forceps  apphed  for  a  few  minutes,  perhaps 
twisting  them  before  removal ;  but  with  the  larger  it  is  advisable  to 
apply  a  Hgature,  although  it  is  claimed  for  the  Greig-Smith  pattern 
that  the  artery  is  so  thoroughly  crushed  that  this  is  unnecessary. 
In  deep  wounds,  where  it  is  difficult,  or  almost  impossible,  to  tie  the 
vessel,  the  forceps  may  be  incorporated  in  the  dressings,  and  not 
removed  for  twenty-four  hours  or  longer,  according  to  the  size  of 
the  vessel. 

19 


290  A   MANUAL  OF  SUliGERY 

3.  Torsion  was  formerly  used  as  a  means  of  sealing  the  ends  of 
divided  vessels,  before  aseptic  ligatures  were  introduced.  It  is  still 
occasionally  employed  for  small  vessels  after  forcipressurc,  and  is 
specially  useful  in  skin-grafting.  'Ihc  effect  is  to  cause  rupture  of 
the  inner  and  middle  coats  just  above  the  spot  grasped,  and  these 
curl  upwards  into  the  lumen  of  the  vessel,  whilst  the  outer  coat  is 
twisted  up  beyond.  A  coagulum  forms  upon  the  injured  structures, 
and  the  subsequent  processes  to  secure  permanent  occlusion  are 
similar  to  those  described  above. 

4.  Ligature  is  at  the  present  day  the  method  most  frequently 
used  for  arresting  bleeding  from  a  definite  source. 

The  material  should  be  of  sufficient  strength  to  secure  the  vessel, 
of  sufficient  resistance  to  maintain  its  hold  in  spite  of  being  soaked 
in  the  body  fluids,  and  yet  of  such  quality  as  to  be  absorbed,  or  so 
pure  and  unirritating  as  to  become  encapsuled  in  the  tissues. 
Catgut  suitably  prepared  is  frequently  employed.  It  is  obtained 
from  sheep's  intestines  by  allowing  them  to  putrefy  in  water,  and 
then  scraping  away  the  mucous  and  muscular  coats,  leaving  only 
the  elastic  basement  membrane  of  the  submucosa;  this  is  dried  and 
twisted  into  the  long  strands  of  commercial  catgut.  When  soaked 
in  blood-serum,  this  substance  swells  up  into  a  soft,  pulpy  mass  in 
half  an  hour,  so  that  it  is  necessary  to  harden  and  render  it  more 
resistant  before  use,  as  well  as  to  sterilize  it  thoroughly.  It  is  most 
effectively  prepared  by  immersion  in  a  mixture  of  chromic  and 
sulphurous  acids  in  accordance  with  Lord  Lister's  original  instruc- 
tions.* The  length  of  time  that  catgut  remains  unabsorbed  in  the 
tissues  varies  with  the  length  of  its  stay  in  the  chromic  acid  solution, 
and  material  calculated  to  last  ten,  twenty,  thirty,  or  forty  days 
can  be  obtained  from  instrument  makers.  It  is  always  essential 
to  sterilize  catgut  thoroughly  before  use,  and  the  best  methods 
have  been  discussed  at  p.  277. 

Sterihzed  silk  and  linen  thread  are  also  employed,  whilst  anima 
tissues,  such  as  kangaroo  tendon  and  strips  of  ox  aorta,  have  their 
advocates.  Ballance  and  Edmunds  advise  the  use  of  gold-beaters' 
skin,  prepared  from  the  peritoneum  of  an  ox,  as  a  material  for  tying 
vessels  in  their  continuity,  and  excellent  results  have  followed  its 
employment.  Pagenstecher's  celluloid  ligature  may  also  be  con- 
sidered a  safe  and  harmless  material,  and  can  be  sterilized  by  boihng. 

'Ihe  immediate  effect  of  a  ligature  on  the  arterial  xvall,  if  the  vessel 
has  been  tied  in  the  usual  way,  is  to  divide  the  inner  and  middle 
coats,  which  are  separated  from  the  outer,  and  curl  up  slightly, 
whilst  the  outer  coat  is  constricted  and  thrown  into  folds  within 
the  grasp  of  the  hgature  (Fig.  92).  If  an  artery  is  tied  in  its  con- 
tinuity, the  same  effect  is  produced  on  each  side  of  the  ligature. 
The  changes  already  described,  by  means  of  which  the  artery  is 
obhterated  and  transformed  into  a  fibro-cicatricial  cord,  manifest 
themselves  in  due  order.  If  the  ligature,  however,  is  infected  and 
irritating,  it  has  to  cut  its  way  out  through  the  vessel  wall  by 
*   Brit.  Med  Journ.,  January  18,  1908. 


HEMORRHAGE 


2gi 


an  ulcerative  process  akin  to  the  separation  of  a  slough,  thus  ex- 
posing the  patient  to  the  risk  of  secondary  haemorrhage. 

Division  of  the  inner  and  middle  coats  is  not  an  essential  element 
in  gaining  satisfactory  occlusion  of  a  vessel,  for  it  can  also  be  effec- 
tively accomplished  by  bringing  the  vascular 
tunics  into  close  approximation  with  a 
broad  animal  ligature  applied  by  what  is 
known  as  a  '  stay  knot '  (p.  32S)  without 
harming  the  tunica  intima. 


Arterial  Haemorrhage. 

Three  forms  of  arterial  haemorrhage  are 
described — viz.,  primary,  reactionary,  and 
secondary. 

I.  Primary  Arterial  Haemorrhage  is  met 
with  under  two  conditions — (i)  From  an 
open  wound;  or  (2)  where  an  artery  is 
ruptured  or  punctured  subcutaneously, 
so  that  extravasation  occurs  into  the 
tissues. 

A.  From  an  Open  Wound. — The  blood  is 
here  poured  forth  upon  the  surface,  and 
escapes  freely,  so  that  the  full  constitutional 
effects  are  experienced. 

The  principles  that  guide  us  in  its  Treat- 
ment may  be  enunciated  as  follows : 

1.  The  vessel  must  he  secured  at  the  bleeding-point,  an  operation  to 
expose  it  being  undertaken  if  necessary.  However  infiltrated  the 
part,  the  rule  of  cutting  down  to  expose  the  wounded  vessel  is  to  be 
adhered  to,  and  this  for  two  reasons:  {a)  It  is  often  impossible  to 
know  the  exact  source  of  the  haemorrhage  unless  it  is  laid  bare. 
Thus,  the  bleeding  from  a  punctured  wound  of  the  front  of  the  leg, 
which  was  apparently  derived  from  the  anterior  tibial  artery,  was 
proved  on  incision  and  careful  dissection  to  come  from  the  peroneal, 
the  wound  extending  backwards  between  the  bones.  In  the  axilla 
and  groin  such  uncertainty  often  exists,  {b)  Proximal  hgature  of 
a  vessel  at  some  distance  above  the  bleeding  spot  is  often  insufhcient 
to  arrest  the  haemorrhage,  since  the  collateral  circulation  is  quickly 
estabhshed.  In  one  or  two  regions,  however,  such  as  when  the 
vessel  wounded  is  the  deep  palmar  or  plantar  arch,  or  one  of  the 
secondary  branches  of  the  external  carotid  in  the  pterygoid  region, 
the  dissection  to  expose  the  bleeding-point  may  be  so  difficult  and 
dangerous,  or  so  Hkely  to  be  followed  by  damaging  adhesions,  that 
the  above-mentioned  rule  is  departed  from  and  proximal  hgature 
is  permissible. 

2.  Both  ends  of  the  wounded  vessel  must  be  secured  if  it  is  completely 
divided,  whilst  if  it  is  only  punctured,  a  hgature  must  be  placed  on 
each  side  of  the  puncture,  and  the  complete  di\dsion  of  the  vessel 


Fig.  92. — Effect  of  Ty- 
ing A  Ligature  firmly 

AROUND  AN  ArTERY. 

The  ligature  was  tied  at 
two  levels,  and  the  ar- 
tery then  laid  open 
longitudinally. 


292  A   MANUAL  OF  SURGERY 

effected.     The  readiness  with  which  a  collateral  circulation  is  estab- 
lished justifies  such  treatment  in  the  case  of  all  arteries  of  large  size. 

3.  It  is  only  needful  to  undertake  the  measures  detailed  above  in 
cases  where  primary  hcemorrhage  is  actually  proceeding.  If  it  has 
been  once  arrested,  it  is  unnecessary  to  search  for  the  bleeding  spot ; 
the  wound  should  be  dressed  with  the  utmost  care  not  to  dislodge 
clots  or  disturb  the  parts.  If,  however,  the  patient  is  very  faint  and 
collapsed,  and  the  surgeon  has  reason  to  anticipate  that  a  large 
trunk  has  been  injured,  it  may  be  needful  to  seek  for  and  tie  it  at 
once;  otherwise  recurrent  haemorrhage  is  likely  to  ensue  when  the 
heart's  action  becomes  more  vigorous. 

In  the  actual  treatment  of  any  particular  case,  temporary  arrest 
of  the  bleeding  may  usually  be  effected  hy  digital  compression  either 
of  the  bleeding-point  or  of  the  main  trunk  at  a  favourable  spot 
nearer  to  the  heart,  ajainst  some  resisting  structure,  such  as  a  sub- 
jacent bone.  The  common  carotid  is  controlled  by  grasping  the  neck 
from  behind,  and  compressing  the  artery  by  the  fingers  placed 
along  the  anterior  border  of  the  sterno-mastoid  against  the  trans- 
verse process  of  the  sixth  cervical  vertebra  (Chassaignac's  tubercle). 
Such  pressure  will  also  control  the  vertebral  and  inferior  thyroid 
vessels.  The  subclavian  is  to  be  compressed  in  the  third  part  of  its 
course  against  the  first  rib  by  the  finger  or  thumb  placed  immedi- 
ately behind  the  clavicle,  in  the  angle  between  it  and  the  sterno- 
mastoid,  the  pressure  being  made  downwards  and  inwards.  A  good 
deal  of  force  is  sometimes  required  in  order  to  maintain  the  pressure, 
and  this  may  be  gained  by  superimposing  the  fingers  or  thumb  of 
the  other  hand.  When  the  pressure  is  to  be  kept  up  for  some  time, 
the  padded  handle  of  a  door-key  may  be  employed  in  the  same  way, 
or  an  incision  may  be  made  and  the  vessel  exposed,  and  controlled 
by  direct  digital  pressure.  The  facial  artery  is  compressed  against 
the  lower  jaw  just  in  front  of  the  masseter  muscle;  the  temporal 
artery  against  the  zygoma  just  in  front  of  the  ear;  the  occipital  at 
a  spot  about  i\  inches  from  the  occipital  protuberance  against  the 
superior  curved  line.  To  control  the  brachial  artery,  the  arm 
should  be  grasped  from  behind,  and  the  fingers  pressed  inwards 
along  the  inner  margin  of  the  biceps  against  the  humerus.  The 
abdominal  aorta  is  controlled  in  slim  individuals  with  ease  by  pres- 
sure through  the  abdominal  wall  against  the  body  of  the  third 
lumbar  vertebra  a  little  above  and  to  the  left  of  the  umbilicus — 
i.e.,  just  above  its  bifurcation;  in  stout  persons  this  is  impossible. 
The  common  femoral  artery  is  best  compressed  immediately  below 
Poupart's  ligament.  The  surgeon  should  stand  on  the  same  side 
of  the  patient  as  the  artery  to  be  controlled,  and  use  the  finger-tips 
to  press  the  vessel  directly  backwards  against  the  pubic  ramus. 
The  fingers  of  one  hand  placed  over  the  other  may  sometimes  be 
necessary  to  maintain  sufficient  command.  Care  must  be  taken 
not  to  let  the  vessel  roll  aside,  and  so  escape  compression. 

As  digital  compression  cannot,  however,  be  comfortably  main- 
tained for  long,  mechanical  compression  of  a  limb,  as  by  a  tourniquet 


H.HMORRHAGE  293 

or  elastic  bandage,  must  be  requisitioned.  A  useful  contrivance  in 
cases  of  emergency  is  fashioned  out  of  a  large  handkerchief,  which 
is  knotted  loosely  round  the  Hmb,  and  tightened  by  the  rotation  of 
a  piece  of  wood  inserted  beneath  it ;  a  pad  is  also  placed  over  the 
main  artery,  which  is  thereby  compressed. 

The  wound  is  then,  if  need  be,  enlarged  by  incisions,  which,  whilst 
laying  the  parts  freely  open,  should  inflict  the  least  possible  damage 
on  surrounding  structures.  All  coagula  are  removed,  the  parts  are 
purified,  and  a  search  made  for  the  wounded  vessel.  It  may  be 
needful  to  relax  the  tourniquet,  and  allow  a  jet  of  blood  to  escape, 
in  order  to  ascertain  its  position.  Both  ends  should  be  sought  for 
and  tied,  a  proceeding  often  easier  said  than  done.  This  especially 
appHes  to  the  distal  end,  which  retracts,  and  possibly  does  not  bleed 
at  the  time  of  operation,  but  may  do  so  when  the  collateral  circula- 
tion becomes  established. 

B.  For  Subcutaneous  Rupture  of  an  Artery,  see  p.  299. 

n.  Intermediate  or  Reactionary  Arterial  Haemorrhage  is  the  term 
applied  to  bleeding  which  recurs  within  twenty-four  hours  of  an 
accident  or  operation.  It  may  result  from  two  chief  causes: 
{a)  Defective  apphcation  of  a  Hgature,  which  comes  undone  from 
being  badly  tied  (a  '  granny  '  knot),  or  sHps  off  from  including 
within  its  grasp  other  structures  as  well  as  the  arterial  wall;  or 
{b)  the  coagula  lying  in  the  mouths  of  divided  vessels  are  not  suffi- 
ciently firm  to  withstand  the  increasing  blood-pressure  which 
supervenes  after  the  shock  has  passed  away,  or  which  may  be  due 
to  excitement  or  the  injudicious  administration  of  stimulants.  It 
is  usually  due  to  the  second  of  these  causes,  and  is  then  not  very 
serious,  inasmuch  as  it  can  only  arise  from  the  smaller  vessels,  all 
the  larger  ones  having  probably  been  recognised  and  tied  during 
the  operation. 

Treatment. — Elevation  and  the  pressure  of  a  firm  bandage  are 
often  quite  sufficient  to  arrest  this  form  of  bleeding ;  but  if  unsuc- 
cessful, the  wound  must  be  opened  up,  washed  out  with  hot  salt 
solution,  and  any  bleeding  vessels  tied.  The  actual  cautery  may  even 
be  employed  to  check  oozing  from  cicatricial  surfaces,  and  if  it  is 
not  allowed  to  touch  the  skin,  and  the  wound  kept  aseptic,  no  delay 
in  heaUng  need  be  occasioned.  Should  the  bleeding  persist,  the 
wound  should  be  firmly  packed. 

III.  Secondary  Haemorrhage. — Under  this  title  are  included  all 
forms  of  hsemorrhage  from  wounds  which  occur  after  the  lapse  of 
twenty-four  hours.  It  is  usually  due  to  infection,  and  was  formerly 
very  common,  often  leading  to  a  fatal  termination ;  since  the  intro- 
duction of  antiseptic  surgery  it  is  but  seldom  seen,  except  where 
asepsis  cannot  be  fully  maintained,  as  in  the  mouth,  pharynx,  etc. 

The  Essential  Cause  is  almost  always  infection  of  the  wound.  In 
a  vessel  which  has  been  divided  and  ligatured,  as  on  the  face  of  an 
amputation  stump,  the  projecting  end  of  the  vessel  beyond  the 
ligature  is  practically  dead  tissue,  and  therefore  readily  attacked  by 
bacteria,  w^hich  transform  it  into  a  slough  which,  together  with  the 


294  A   MANUAL  OF  SURGERY 

infected  ligature,  has  to  be  cast  off,  and,  when  this  happens,  bleed- 
ing may  occur.  In  addition  to  this,  however,  the  infection  of  the 
wound  involves  a  suppurative  inflammation  around  the  vessel  (peri- 
arteritis), which  results  in  a  softening  of  the  vascular  tunics  by  the 
bacterial  toxins,  and  this  may  progress  in  time  to  such  an  extent 
as  to  render  them  incapable  of  resisting  the  blood-pressure,  so  that, 
sooner  or  later,,  they  give  way.  This  latter  condition  is  especially 
seen  in  vessels  tied  in  their  continuity,  and  also  occurs  in  the 
secondary  haemorrhage  which  is  sometimes  seen  in  connection  with 
abscesses  in  the  neighbourhood  of  large  vessels. 

Anything  which  interferes  with  the  \atality  of  the  vessel  wall 
may  serve  as  a  Contributory  Cause,  such  as  the  separation  from  its 
sheath  for  too  great  an  extent,  thereby  cutting  off  its  blood-supply; 
or  a  diseased  condition  of  the  arterial  wall,  as  from  atheroma,  or 
an  unhealthy  condition  of  the  patient's  blood,  or  undue  elevation 
of  blood-pressure,  as  in  Bright's  disease. 

After  ligature  of  large  vessels,  such  as  the  innominate,  first  part 
of  the  subcla\aan,  or  common  iliac,  secondary  haemorrhage  may 
occur  apart  from  infection,  if  the  inner  and  middle  coats  have  been 
divided  by  the  ligature.  The  crumpled-up  outer  coat  exposed  just 
above  the  ligature  by  the  retraction  of  the  inner  and  middle  coats 
is  insufficient  to  withstand  the  blood-pressure  in  such  large  vessels, 
and  undergoes  an  aneurismal  dilatation,  which  is  certainly  followed 
by  haemorrhage  at  an  early  date. 

The  Phenomena  are  almost  always  preceded  by  those  of  infection 
of  the  wound,  to  which  a  slight  occasional  loss  of  blood  is  added. 
This  continues  with  more  or  less  frequency  and  severitv,  until  the 
patient  is  either  worn  out  by  the  constant  repetition  of  small  losses, 
or  destroyed  by  one  or  two  severe  gushes  from  the  larger  vessels. 
The  earlier  the  bleeding  occurs,  the  less  serious  it  is,  as  it  probably 
comes  from  the  smaller  vessels,  and  can  be  easily  dealt  with.  When, 
however,  it  does  not  superv^ene  till  late,  as  on  the  tenth  or  twelfth 
day,  it  usually  arises  from  the  larger  trunks,  and  is  increasingly 
severe.  WTien  originating  from  a  vessel  tied  in  its  continuity,  it 
generally  comes  from  the  distal  end,  since  repair  is  here  less  effec- 
tive than  on  the  proximal  side  of  the  hgature,  and  resistance  to 
bacterial  infection  less  vigorous.  The  explanation  of  this  is  that 
the  vasa  vasorum  reach  the  artery  from  the  sheath,  and  run  with 
the  blood-current.  The  separation  of  the  sheath  and  the  applica- 
tion of  the  ligature  necessarily  cut  off  the  blood-supply  of  the 
vessel  wall  just  distal  to  the  ligature. 

Treatment. — The  case  must  be  watched  night  and  day  imtil  the 
wound  is  healthy,  as  although  the  bleeding  may  have  ceased  for  a 
while,  it  may  break  out  again  at  any  time.  If  the  wound  is  in  a 
hmb,  a  tourniquet  should  be  lightly  adjusted  above  it  as  a  precau- 
tionary measure,  so  that  at  a  moment's  notice  it  may  be  tightened. 

When  arising  from  an  artery  entirely  divided  across,  as  in  an  ampu- 
tation stump,  elevation  of  the  part  after  redressing  and  firm  ban- 
daging may  be  all  that  is  needed  in  early  cases.     A  recurrence  will 


H/EMORRHAGE  295 

necessitate  the  opening  up  of  the  wound,  and  the  apphcation  of 
ligatures  to  the  bleeding  vessels,  if  practicable.  The  actual  cautery 
may  be  employed  where  the  tissues  are  too  rotten  to  hold  a  ligature. 
Sloughs  may  be  cut  or  scraped  away,  and  the  wound  packed  with 
gauze  and  firmly  bandaged.  If  this  fails,  the  artery  must  be  tied 
just  above,  or  re-amputation  performed.  When  the  bleeding  comes 
from  the  main  vessel  near  the  trunk,  as  after  amputation  at  the 
shoulder  or  hip,  proximal  hgature  can  alone  be  depended  on,  should 
local  treatment  be  unsuccessful. 

When  coming  from  an  artery  tied  in  its  continuity,  the  wound  is 
opened  up,  and  the  artery  secured  again  above  and  below,  whilst 
every  effort  is  made  to  combat  the  infection.  Faihng  this,  proximal 
hgature  may  be  practicable,  but  for  the  large  vessels  of  the  trunk 
pressure  may  be  the  only  resource.  Should  re-Hgature  at  a  higher 
spot  fail  or  be  considered  inadvisable,  as  is  often  the  case  in  the 
leg,  amputation  must  be  undertaken  without  delay. 

Venous  Hsemorrhage. 

Bleeding  from  the  smaller  veins  rarely  requires  much  attention, 
in  that  the  walls,  when  once  divided,  rapidly  collapse,  and  this 
effectually  checks  further  loss  of  blood;  but  if  the  larger  veins  are 
involved,^  or  if  the  walls  are  thickened  and  rigid,  as  in  varix,  a  very 
considerable  amount  may  be  lost,  the  blood  welhng  up  in  a  dark, 
purpHsh  stream  from  the  wound,  and  rendering  its  arrest  the  more 
difftcult  from  the  fact  that,  except  in  veins  of  the  largest  size, 
there  is  no  definite  jet  or  gush  to  guide  one  to  the  wounded  spot. 
Treatment. — Divided  veins  are  usually  tied  in  the  same  way  as 
arteries,  but  it  is  often  possible  to  secure  a  puncture  or  tear  in  a 
large  vein  by  a  lateral  Hgature  without  occluding  its  whole  circum- 
ference. In  amputations  it  is  usual  to  tie  both  the  main  artery 
and  vein.  Where  it  is  difficult  to  reach  a  vein  in  order  to  tie  it, 
the  wound  may  be  packed. 

Secondary  Hsemorrhage  from  veins  is  not  common,  but  arises 
occasionally  from  infection  around  a  large  vein,  which  has  been 
punctured  and  a  lateral  hgature  appHed,  or  a  branch  of  which  has 
been  tied  at  its  point  of  union  with  the  main  trunk.  Under  aseptic 
conditions  repair  of  the  wounded  venous  wall  is  effected  without 
cessation  of  the  circulation  in  the  main  trunk.  If  the  wound  becomes 
infected,  the  hgature  is  invaded  by  germs,  as  also  the  portion  of 
vein  wall  within  its  grasp.  In  the  smaller  veins  the  inflammation 
induced  will  result  in  a  protective  thrombosis ;  but  in  a  large  vessel, 
such  as  the  internal  jugular,  where  the  blood-stream  is  rapid, 
thrombosis  may  be  hindered  in  its  occurrence,  and  haemorrhage 
may  result  from  the  wall  giving  way.  The  bleeding  from  cases  of 
this  description  will  usually  be  severe,  but  can  be  easily  controlled  by 
pressure  or  hgature  of  the  whole  trunk  above  or  below  the  wound. 
The  Entrance  of  Air  into  Veins  is,  fortunately,  a  rare  occurrence, 
as  it  is  always  fraught  with  grave  danger  to  the  patient,  inasmuch 


296  A   MANUAL  OF  SURGERY 

as  it  interferes  seriously  with  the  circulation,  and  mav  even  cause 
death.  The  air  sucked  into  the  veins  is  carried  up  to  the  right  side 
of  the  heart,  and  there  becomes  entangled  in  the  columnie  earner, 
and  is  churned  up  into  a  frothy  spumous  mixture,  which  the  heart 
can  only  eject  with  difficulty. 

The  Cause  is  usually  a  wound  of  some  vein  in  what  is  known  as 
the  '  dangerous  region  '  of  the  neck  (lower  portion)  or  axilla,  or  even 
of  such  unlikely  structures  as  the  pelvic  veins  or  cranial  sinuses. 
During  inspiration  the  movements  of  the  thorax  exercise  an  aspira- 
tory  or  suction  effect  upon  the  blood  in  the  larger  veins,  and  hence 
an}^  condition  which  prevents  the  collapsing  of  the  walls  of  the 
veins,  or  brings  about  what  is  termed  their  canalization,  predisposes 
to  this  accident.  Thus  they  may  be  held  open  at  spots  where  they 
pierce  the  deep  fascia  or  the  platysma;  if  the  coats  are  thick  and 
rigid  from  inflammation,  or  surrounded  by  indurated  tissue,  or 
buttonholed  as  by  excision  of  a  portion  of  the  walls  or  division  of  a 
branch  close  to  the  main  trunk,  or  if  undue  traction  is  exercised 
upon  the  pedicle  of  a  tumour  containing  a  wounded  vein,  then  the 
orifice  may  remain  patent,  and  air  can  be  sucked  in.  If,  however, 
the  veins  are  ver\'  distended,  as  is  often  the  case  in  the  operation 
of  tracheotomy,  then  a  wound,  even  in  the  dangerous  area,  usually 
results  in  loss  of  blood  rather  than  entrance  of  air. 

The  chief  sign  is  a  hissing,  gurgling,  or  sucking  sound,  which  is 
quite  characteristic.  A  few  bubbles  of  air  may  also  be  seen  clinging 
about  the  aperture  in  the  vessel.  If  only  a  smaU  amount  has  entered, 
or. if  the  entry  is  made  slowly,  no  bad  results  may  follow;  but  the 
usual  effect  is  to  produce  severe  faintness,  and  if  the  patient  is 
conscious,  a  feeling  of  dyspnoea  and  distress.  The  pulse  becomes 
rapid  and  almost  imperceptible,  the  pupils  widely  dilated,  and 
death  may  follow,  preceded  perhaps  by  convulsions,  although  the 
fatal  issue  may  be  postponed  for  a  few  hours.  If  the  patient  sur- 
vives, no  after-effects  remain. 

Treatment. — ^This  accident  can  usually  be  avoided  by  dealing 
cautiously  with  all  veins  in  operations  about  the  neck,  securing 
them,  if  possible,  by  ligature  or  forceps  before  their  division. 
Should  it  occur,  any  fresh  entrance  must  be  at  once  checked  by 
placing  a  finger  over  the  bleeding-point  or  pouring  lotion  into  the 
wound.  The  wound  in  the  vein  should  be  at  once  closed.  To 
combat  the  general  symptoms,  it  is  essential  to  maintain  a  good 
supply  of  blood  to  the  brain.  The  head  is  lowered,  and,  if  need  be, 
the  limbs  raised  and  bandaged,  or  the  abdominal  aorta  compressed. 
Stimulants  and  artificial  respiration  are  used  in  order  to  maintain 
the  heart's  action  and  to  overcome  the  pulmonary  obstruction. 
Warmth  and  friction  are  also  applied  to  the  extremities. 

Methods  of  Dealing  with  Haemorrhage  from  Special  Sources. 

Secondary  Branches  of  the  Carotid. — It  may  be  difficult  to  secure  the  divided 
ends. of  these  vessels  either  in  the  neck  or  head,  e.g.,  in  a  cut  throat  or  a  punc- 
tured wound  of  the  pterygoid  region.     Under  such  circumstances,  ligature  of 


HAEMORRHAGE 


297 


the  external  carotid  between  the  superior  thyroid  and  lingual  has  been  recom- 
menilcd  as  more  satisfactory  than  tying  the  common  carotid,  since  the  cerebral 
circulation  is  not  thereby  affected. 

Vertebral  Artery, — The  source  of  such  bleeding  may  be  difficult  to  ascertain, 
as  It  is  scarcely  possible  to  compress  this  vessel  without  also  including  the 
carotid;  and  hence  mistakes  in  diagnosis  have  often  arisen.  It  may  be 
feasible,  however,  to  control  the  carotid  alone  by  pinching  it  up  by  the  fingers 
placed  on  either  side  of  the  sterno-mastoid,  without  interfering  with  the  verte- 
bral. Treatment  must  follow  the  usual  course  of  cutting  down  and  tying  at 
the  bleeding-point,  if  possible.  To  do  this,  the  incision  must  be  enlarged, 
or  a  new  one  made  along  the  posterior  border  of  the  sterno-mastoid  in  order 
to  define  the  transverse  processes  of  the  vertebrae.  In  the  upper  part  of  its 
course  the  vessel  may  be  secured  by  clipping  away  a  transverse  process  if 
necessary,  due  care  being  taken  of  the  nerve  roots ;  otherwise  plugging  of  the 
vertebral  canal  or  the  use  of  st}T)tics 
must  be  depended  on.  It  is  most 
essential  that  the  carotid  should  not 
be  tied  by  mistake  in  these  cases,  as 
thereby  more  blood  is  directed  to  the 
vertebral  trunk,  and  the  bleeding  is 
correspondingly  increased. 

The  Internal  Mammary  Artery  rarely 
calls  for  treatment,  since  an  accidental 
wound  of  this  vessel  is  usually  com- 
plicated with  some  graver  mischief  to 
heart,  liver  or  lungs.  If  recognised, 
tie  at  the  bleeding  spot,  possibly 
removing  a  costal  cartilage  to  gain 
access.  The  vessel  lies  about  h  inch 
outside  the  border  of  the  sternum. 

Intercostal  Haemorrhage  usually  re- 
sults from  penetrating  wounds  also 
involving  the  rib,  and  is  not  easily 
stopped  on  account  of  the  position  of 
the  vessels  in  the  groove.  Treatment. — 
Incise  the  periosteum  longitudinally 
along  the  lower  border  of  the  rib,  and 
detach  it  and  the  vessels  from  the 
groove;  or  remove  a  portion  of  the 
bone,  and  thus  expose  the  bleeding- 
point  ;  or  in  some  cases  a  suture  passed 
round  the  rib  a  little  above  the  injury 
has  sufficed;  or  again,  pressure  may  be 
employed  by  pushing  a  piece  of  aseptic 

gauze,"  hkea  pocket,  tlxrough  the  wound  in  the  pleural  cavity,  and  then 
stuffing  it  tightly  with  wool  or  strips  of  gauze,  so  that  onTpulling^upon  it 
the  vessel  may  be  effectually  compressed. 

Wounds  of  "the  Palmar  Arches  were  formerly  much  more  dreaded  than  they 
are  at  present,  when  effective  asepsis  and  the  use  of  the  elastic  tourniquet 
allow  us  to  explore  the  depths  of  a  wound  without  much  danger  or  difficulty. 
The  position  of  the  wound  \\i\\  usually  indicate  whether  the  bleeding  comes 
from  the  superficial  or  deep  arch,  but  in  case  of  doubt  it  is  well  to  remember 
that  pressure  on  the  ulnar  trunk  mainlv  affects  the  superficial  arch,  whilst 
pressure  on  the  radial  \yi\\  chiefly  influence  the  deep.  A  wound  of  the  super- 
ficial arch  presents  little  troublein  treatment,  as  it  can  be  readily  secured  by 
catch  forceps  and  ligature ;  but  the  deep  arch  is  not  so  easily  dealt  with.  It 
lies  just  over  the  bases  of  the  metacarpal  bones  (Fig.  93,  d),  and  to  expose  it 
the  wound  must  be  freely  enlarged  by  a  longitudinal  incision,  and  the  tendons 
turned  on  one  side  or  separated.  It  may  be  possible  to  secure  the  vessel  by 
forcipressure  forceps,  and  these  may  be  left  on  for  twenty-four  hours  if  a 
ligature  cannot  be  applied.     Of  course,  the  strictest  asepsis  is  needful  m  such 


Fig.  93. — Hand,  to  show  Position 
OF  Palmar  Arches. 

A,  Radial   artery ;    B,  ulnar    artery ; 
C,  superficial  arch  :  D,  deep  arch. 


298  A   MANUAL  OF  SURGERY 

cases,  and  passive  movement  ol  the  fingers  must  be  early  undertaken,  in 
order  to  prevent  troublesome  adhesions,  bailing  such  means,  or  in  infected 
cases,  the  wound  is  packed  with  sterilized  gauze,  and  over  this  the  fingers  are 
firmly  bandaged.  The  patient  is  kept  in  bed  for  a  few  days,  and  the  arm 
elevated.  Pressure  on  the  main  vessels  above  is  scarcely  necessary  if  the 
compress  is  accurately  applied.  The  bandages  may  be  relaxed  at  the  end  of 
twenty-four  hours,  but  the  deep  dressing  should,  if  possible,  not  be  touched 
for  three  or  four  days.  If,  in  spite  of  this,  bleeding  recurs,  the  main  vessel  or 
vessels  of  the  limb  must  be  tied.  Ligature  of  the  ulnar  and  radial  arteries  at 
the  wrist  is  generally  insufficient  to  control  it,  as  there  is  often  a  communicating 
branch  of  some  size  passing  from  the  anterior  interosseous  to  the  deep  arch, 
and  hence  it  may  be  needful  to  secure  the  brachial  artery,  ascertaining  first, 
however,  by  pressure  that  such  would  be  efficacious;  for  occasionally  there  is  a 
high  division  of  the  brachial,  or  a  vas  aberrans  may  exist,  which  would  compel 
the  surgeon  to  tie  the  third  jjart  of  the  axillary. 

Bleeding  from  the  Plantar  Arch  must  be  conducted  on  similar  lines. 

The  Gluteal,  Sciatic,  or  Pudic  arteries  may  be  wounded  by  stabs  in  the 
buttock.  Treatment. — Enlarge  the  wound  in  the  direction  of  the  fibres  of 
the  gluteus  maximus,  i.e.,  downwards  and  outwards,  and  secure  the  bleeding 
vessel.  The  gluteal  trunk  emerges  from  the  pelvis  at  the  junction  of  the 
middle  and  inner  thirds  of  a  line  from  the  posterior  superior  iliac  spine  to  the 
great  trochanter;  the  pudic  crosses  the  ischial  spine  at  the  junction  of  the 
middle  and  lower  thirds  of  a  line  from  the  posterior  superior  iliac  spine  to  the 
tuber  i.schii.  The  sciatic  emerges  from  the  pelvis  just  above  and  a  little 
external  to  the  latter  spot.  The  pudic  may  also  be  divided  in  the  perineum 
by  a  penetrating  wound.  Failing  ligature  of  any  of  these  arteries  at  the  seat 
of  bleeding,  the  internal  iliac  may  need  to  be  secured. 

Haemophilia. 

By  haemophilia,  or  the  hsemorrhagic  diathesis,  is  meant  a  disease,  either 
congenital  and  hereditary,  or  casual  and  accidental,  characterized  by  a  ten- 
dency to  persistent  and  uncontrollable  bleeding  from  slight  wounds,  whether 
open  or  subcutaneous.  This  condition  is  often  associated  with  extravasation 
of  blood  into  the  joints,  and  certain  consecutive  phenomena  (Chapter  XXIII.). 
The  family  history  of  the  hereditary  cases  is  interesting,  the  disease  being 
usually  transmitted  through  the  females  of  one  or  more  generations  to  the 
males,  whilst  the  former  may  escape  entirely.  The  cause  of  this  affection 
does  not  lie  in  the  vessels,  but  in  the  blood,  and  is  probably  due  to  an  insuffi- 
ciency or  imperfection  of  the  fibrin  ferment,  or  to  the  presence  of  some  anti- 
coagulable  substance.  Unless  haemorrhage  is  actually  occurring,  nothing 
abnormal  is  noticed,  but  any  injury  is  sure  to  be  followed  by  excessive  bleed- 
ing; spontaneous  subcutaneous  ecchymoses  frequently  occur,  as  also  bleeding 
from  the  mucous  membranes.  Hence  no  operations  must  be  undertaken  on 
such  patients  unless  absolutely  urgent,  even  such  a  small  matter  as  the 
extraction  of  a  tooth  having  proved  fatal. 

The  Treatment  of  ha;mophilia  should  be  directed  more  to  correcting  the 
defect  in  the  blood  than  to  pursuing  the  usual  practice  in  dealing  with  haemor- 
rhage. The  application  or  administration  of  haemostatics,  and  of  substances 
which  tend  to  promote  coagulation  and  the  formation  of  fibrin,  should  be 
resorted  to.  Calcium  lactate,  lo  to  20  grs.  in  ^  pint  of  water  given  by  the 
rectum,  or  5  to  10  grs.  by  the  mouth,  repeated  two  or  three  times  a  day,  is 
decidedly  useful,  whilst  fibrin  ferment,  suprarenal  extract,  and  cocaine  should 
be  employed  locally.  Position  and  pressure  are  attended  to,  and  in  severe 
cases  the  actual  cautery  may  prove  useful,  or  the  prolonged  application  of 
cold.  The  subcutaneous  or  oral  administration  of  sterilized  horse  or  rabbit 
serum  in  doses  of  from  10  to  30  c.c.  has  been  recently  recommended.  Anti- 
diphtheritic  serum  may  be  employed  instead. 


CHAPTER  XIII. 

INJURIES  AND  DISEASES  OF  ARTERIES— ANEURISM- 
LIGATURE  OF  ARTERIES. 

Injuries  of  Arteries. 

Contusion  of  an  artery  is  the  result  of  \'iolence  applied  directly  to 
the  vessel  wall.  If  atheroma  or  calcification  exists,  thrombosis 
often  follows  sHght  injuries,  and  dr\'  or  senile  gangrene  may  ensue ; 
but  in  healthy  arteries  a  good  deal  of  \aolence  is  needed  to  produce 
such  an  effect,  as  their  natural  elasticity  enables  them  to  \ield  or 
shp  aside,  and  thus  the  consequences  are  usually  insignificant. 

Rupture  or  Laceration  may  also  fohow  blows  or  strains,  or  may 
result  from  fractures  or  dislocations,  or  from  attempts  to  reduce 
old-standing  dislocations,  or  to  break  down  intra-articular  adhesions. 
If  the  rupture  is  partial,  the  inner  and  middle  coats  are  usually 
torn,  and  by  projecting  into  the  lumen  of  the  vessel  constitute  a 
valve  which" prevents  the  passage  of  blood,  and  leads  to  subsequent 
thrombosis  and  occlusion.  In  cases  where  the  lesion  is  Hmited  to 
one  side  of  the  vessel,  the  clot  may  become  organized  over  that 
spot,  narrowdng  but  not  interfering"  with  the  lumen,  and  lea\ang 
an  area  of  weakness  from  which  an  aneurism  may  subsequently 
develop.  A  dissecting  aneurism  (p.  311)  may  also  result  under 
special  circumstances  from  such  an  accident.  WTien  comphcated 
with  an  infected  wound,  an  ulcerative  form  of  peri-arteritis  may 
ensue,  gi\ing  rise  later  on  to  secondary  haemorrhage. 

Complete  Rupture  of  an  artery  often  leads  to  but  httle  haemorrhage 
in  a  severe  lacerated  wound,  "such  as  is  produced  when  a  hmb  is 
torn  off:  the  inner  and  middle  coats  give  way  at  a  higher  level  than 
the  adventitia,  and  curl  up  within  it,  whilst  the  outer  coat  and 
sheath  contract  over  them,  and  thus  prevent  bleeding.  If,  how- 
ever, the  artery  is  ruptured  in  a  subcutaneous  injury,  such  as  a 
fracture  or  dis'location,  extensive  interstitial  extravasation  often 
ensues.  A  similar  condition  may  ensue  from  a  punctured  wound 
of  a  vessel,  where  the  track  leading  to  it  is  vahnilar  or  becomes 
closed  by  clot  or  some  external  application. 

Symptoms. — ^Ihe  patient  usually  feels  a  snap,  as  though  some- 
thing had  given  way,  accompanied  by  a  sudden  pain,  localized  to 

299 


300  A   MANUAL  OF  SURGERY 

the  injured  part,  and  often  shooting  down  the  limb  in  tlic  line  of 
the  vessel,  i hese  are  sueceeded  by  the  following  phenomena: 
(a)  Locally,  the  formation  of  a  diffuse,  rapidly  inereasing  swelling, 
the  skin  over  which  is  at  first  normal,  but  soon  becomes  distended 
and  bluish,  and  finally  bright  red  and  oedematous,  when  the  tumour 
is  threatening  to  give  way.  There  is  no  increased  local  heat  except 
in  the  later  stages.  Distinct  pulsation  is  usually  present  at  first, 
and  some  amount  of  thrill  and  bruit,  synchronous  with  the  heart's 
action,  although  these  subsequently  become  less  obvious,  {b)  Dis- 
tally,  diminished  sensibility  in  the  limb  quickly  follows,  together 
with  loss  of  pulsation  in  the  vessels  and  a  fall  of  temperature.  It 
lies  more  or  less  useless  and  flaccid,  and  in  colour  is  either  white 
and  blanched,  or  may  be  congested  and  oedematous  if  the  extrava- 
sated  blood  presses  upon  the  venous  trunks,  [c)  Generally,  the 
signs  of  htiemorrhage  and  shock  manifest  themselves  in  varying 
degree,  according  to  the  amount  of  blood  lost  and  the  character  of 
the  violence. 

Results. — (i)  The  swelling  may  increase  steadily  in  size  until  the 
skin  becomes  so  distended  as  to  rupture  or  slough,  and  then,  if  help 
is  not  at  hand,  the  patient  dies  of  haemorrhage.  Occasionally  the 
bleeding  continues  into  an  internal  cavity,  or  into  the  tissues  of  a 
limb,  to  such  an  extent  as  to  cause  death  without  any  external  loss 
of  blood.  (2)  Suppuration,  accompanied  by  the  general  signs  of  fever, 
may  result  from  auto-infection,  or  from  the  entrance  of  bacteria 
through  the  small  valve-like  wound.  The  whole  swelling  becomes 
red,  hot,  oedematous,  and  excessively  tender,  looking  like  a  large 
abscess.  Rupture  and  external  haemorrhage  will  probably  conclude 
the  case  if  surgical  assistance  cannot  be  obtained.  (3)  The  pressure 
of  the  extravasated  blood  upon  the  veins  or  on  the  arteries  needed 
for  the  collateral  circulation  may  determine  gawgr^fi^  of  the  extremity, 
which  is  almost  always  of  the  moist  type.  {4)  The  process  may 
become  more  or  less  limited  after  a  time  by  coagulation  occurring  in 
the  divided  mouth  of  the  vessel,  which  is  thus  occluded.  Collateral 
circulation  may  be  established,  and  thereby  the  health  and  vitality 
of  the  limb  are  maintained,  whilst  the  blood-clot  is  absorbed  or 
organized. 

The  Treatment  is  necessarily  the  same  as  for  a  divided  artery 
communicating  with  an  open  wound — viz.,  to  cut  down  on  and  tie 
both  ends.  The  circulation  is  first  temporarily  arrested  by  an 
elastic  or  other  tourniquet,  a  free  incision  made,  and  all  coagula 
removed.  The  bleeding-points  are  then  sought  for  and  tied,  the 
tourniquet  being  relaxed  to  allow  them  to  become  evident.  If  the 
distal  end  cannot  be  found,  the  wound  is  not  closed,  but  should  be 
packed  with  gauze,  and  allowed  to  granulate,  a  tourniquet  being 
kept  loosely  about  the  limb  ready  to  be  tightened  at  any  moment, 
if  necessary.  When  suppuration  is  threatening,  the  same  plan 
must  be  adopted — viz.,  free  incision  and  tying  the  ends  of  the  vessel 
if  they  can  be  found;  but  in  cases  where  from  the  oedematous  and 
unhealthy  state  of  the  surrounding  parts  this  is  impracticable,  it 


INJURIES  AND  DISEASES  OF  ARTERIES  301 

will  be  necessary  either  to  tie  the  main  trunk  on  the  cardiac  side  of 
the  rupture,  or  to  trust  to  pressure.  If  gangrene  is  imminent,  or  if 
secondary  hc-emorrhage  occurs,  amputation  is  usually  the  only 
resource. 

Penetrating  Wounds  of  arteries,  if  completely  dividing  the  vessel, 
are  always  followed  b\-  haemorrhage,  although  the  blood  may  be 
unable  to  escape  externally.  If  a  large  artery  is  cleanly  cut  across, 
the  bleeding  is  copious,  whilst  from  a  small  vessel  it  soon  ceases, 
owing  to  the  contraction  and  retraction  of  the  coats.  When  an 
artery  is  '  buttonholed  ' — i.e.,  when  a  small  segment  of  the  w^all  is 
cut  through — the  hcemorrhage  is  often  continuous  and  prolonged, 
since  retraction  cannot  take  place.  The  treatment  of  this  condi- 
tion consists  in  completing  the  division  of  the  injured  trunk,  if  it 
is  a  small  one,  thus  allowing  of  contraction  and  retraction,  or,  if 
the  vessel  is  of  large  size,  in  tying  it  above  and  below  the  opening, 
and  dividing  it  between  the  ligatures. 

If  the  wound  is  in  the  long  axis  of  the  vessel,  it  gapes  but  Kttle, 
and  the  loss  of  blood  is  often  slight,  whilst  if  transverse  or  obhque, 
both  contraction  and  retraction  tend  to  increase  the  size  of  the 
opening,  rendering  it  more  nearly  circular,  and  therefore  the  haemor- 
rhage in  such  cases  is  considerable. 

If  an  artery  is  divided  close  to  its  origin  from  a  large  main  trunk, 
the  blood  escapes  with  a  jet,  the  strength  of  which  is  proportionate 
to  the  blood-pressure  in  the  main  trunk,  and  not  to  the  size  of  the 
vessel  divided.  In  such  a  case  the  main  trunk  must  be  tied  above 
and  below  the  wound,  and  divided  between  the  hgatures,  and  the 
distal  end  of  the  di\dded  branch  also  secured. 

A  good  many  attempts  have  been  made  of  late  to  effect  the  union 
of  wounds  in  the  walls  of  arteries  without  causing  their  obhteration, 
and  wath  some  success.  Small  longitudinal  wounds  may  certainly 
be  sutured,  the  stitches  being  of  the  finest  silk  and  apphed  so  that 
the  edges  of  the  tunica  intima  are  brought  accurately  into  apposi- 
tion; Heidenhain  reports  a  case  where  a  wound  1-5  centimetres  long 
in  the  axillary  artery  was  successfully  sutured  in  this  way.  End- 
to-end  union  of  a  divided  artery  has  also  been  effected,*  the  method 
usually  adopted  being  that  suggested  by  Carrel  in  1902.  1  he  vessel 
is  controlled  above  and  below  by  suitable  haemostatic  clamps,  such 
as  Crile's;  blood-clot  is  washed  .out  of  the  cut  ends  by  sterile  salt 
solution,  and  the  adventitia  is  trimmed  off.  The  suture  material 
employed  must  be  the  very  finest  silk  sterihzed  in  vasehne.  The 
anastomosis  is  effected  by  the  use  of  a  circular  continuous  suture, 
or  better  by  a  continuous  mattress  suture  through  the  intima,  and 
a  reinforcing  continuous  running  stitch  outside.  The  difficulty  Hes 
not  so  much  in  effecting  union  as  in  doing  so  without  deteraiining 
thrombosis  either  at  the  site  of  anastomosis  or  at  the  point  of 
appHcation  of  the  clamps.  The  greatest  gentleness  is  obviously 
necessar\^  in  all  these  manipulations. 

In  punctured  wounds  of  arteries  the  size  of  the  penetrating  body 

*  J.  B.  Murphy,  Medical  Record,  January  16,   E897. 


302 


A   MANUAL  OF  SURGERY 


is  all-important.  A  vessel  may  be  traversed  by  a  needle  without 
haemorrhaj^e  or  any  subsequent  ill  effect,  but  a  larger  puncture 
results  in  extravasation.  If  it  ceases  after  a  time,  the  blood-clot  is 
absorbed,  and  the  wound  in  the  vessel  closed  by  a  cicatrix,  which 
may  subsequently  yield  to  the  blood-pressure,  and  give  rise  to  a 
circumscribed  aneurism.  This  occurrence  is  not  unfrequent  in  the 
neighbourhood  of  the  wrist  from  glass  wounds,  involving  the  radial 
or  ulnar  trunks,  and  hence  is  not  uncommon  among  window-cleaners 
or  mineral- water  bottlers. 


Arterio- Venous  Wounds  follow  penetrating  injuries  which  involve 
an  artery  and  vein  lying  in  close  contact — e.g.,  at  the  bend  of  the 
elbow  between  the  median  basihc  vein  and  the  brachial  artery,  in 
the  neck  between  the  internal  jugular  and  carotid,  in  the  groin 
between    the    femoral    vessels,    and    occasionally    in    the    orbit. 

They  are  also  met  with  in  military 
surgery,  owing  to  the  shape  of  the 
modern  bullet  and  the  limited  amount 
of  danger  caused  by  it  in  the  soft 
tissues.     Two  conditions  may  result. 

An  Aneurismal  Varix  is  produced 
l)y  a  direct  communication  between 
an  artery  and  a  vein,  no  dilated 
passage  intervening  between  the 
vessels  (Fig.  94,  A).  The  venous 
walls,  unfitted  to  withstand  arterial 
pressure,  are  thereby  dilated  and 
rendered  varicose.  A  pulsating  venous 
tumour  results,  the  dilatation  extend- 
ing for  a  variable  distance  above 
and  below  the  opening,  and  at  each 
beat  of  the  heart  a  loud  whizzing 
sound  can  be  heard,  likened  by  some 
authors  to  that  caused  by  an  im- 
prisoned bluebottle  buzzing  in  a  thin  paper  bag.  On  palpation  the 
thrill  of  the  blood  as  it  enters  the  vein  can  often  be  detected. 

Treatment. — Nothing  is  usually  required  beyond  the  application 
of  an  elastic  bandage  or  support  to  prevent  further  enlargement. 
Should  pain  or  inconvenience  arise  in  spite  of  this,  it  may  be  pos- 
sible to  repair  the  wound  in  the  arterial  wall  by  suture,  or,  failing 
that,  the  artery  must  be  secured  above  and  below  the  abnormal 
communication  with  the  vein.  Occasionally  the  latter  is  so  dis- 
tended that  it  has  to  be  removed  before  the  artery  can  be  reached. 
A  Varicose  Aneurism  differs  from  the  above  in  that  an  aneurismal 
sac  exists  between  the  artery  and  the  dilated  vein  (Fig.  94,  B).  It 
is  produced  when  the  vessels  are  placed  at  a  short  distance  from 
each  other,  or  when  extravasation  of  blood  has  separated  them. 
The  aneurism  is  of  the  false  type,  its  walls  being  composed  of 
newly-formed   cicatricial   tissue;   it   is   almost   certain   to   become 


Fig.  94. — Diagrams  of  A, 
Aneurismal  Varix  and 
B,  Varicose  Aneurism. 


A,    Artery  ;    V,   vein 
aneurism. 


AN, 


INJURIES  AND  DISEASES  OF  ARTERIES 


303 


diffuse.  The  physical  signs  arc  similar  to  those  of  aneurismal  varix, 
except  that  the  aneurism  can  sometimes  be  detected  by  palpation, 
whilst  a  soft  bruit  may  be  heard  over  it. 

Surgical  Treatment  is  always  required  in  these  cases.  Simple 
ligature  of  the  artery  above  and  below  the  abnormal  communica- 
tion will  usually  sufhce,  allowing  the  blood  in  the  sac  to  coagulate ; 
the  veins  will  subsequently  diminish  in  size,  when  the  arterial 
blood-pressure  is  removed.  Not  unfrequently  the  vein  overlaps 
the  artery,  and  has  to  be  tied  and  removed  before  the  sac  of  the 
aneurism  is  reached;  it  is  then  better  to  excise  the  sac  and  tie  the 
artery  above  and  below. 


Inflammation  and  Degeneration  of  Arteries. 

1.  Traumatic  Arteritis  is  the  result  of  injuries;  such  as  total  or 
partial  division  of  the  vessel,  laceration,  bruising,  etc.  The  phe- 
nomena are  merely  those  of  repair, 
resulting  in  closure  of  the  wound  or 
occlusion  of  the  vessel ;  they  have  been 
already  described. 

2.  Infective  Arteritis  results  from 
bacterial  invasion  of  the  arterial  wall, 
and  that  usually  from  without  (peri- 
arteritis) and  in  connection  with  infec- 
ted wounds  and  hgatures,  or  spreading 
ulceration  It  is  characterized  by 
hyperfemia  and  softening  of  the  vas- 
cular tunics,  the  fibres  of  which  lose 
their  cohesion  with  each  other,  owing 
to  the  peptonizing  action  of  the  toxins. 
In  the  smaller  arteries  thrombosis 
usually  occurs  and  seals  the  vessel; 
but  in  the  larger  there  is  considerable 
danger  of  bleeding.  Secondary  haemor- 
rhage from  arteries  tied  in  their  con- 
tinuity is  generally  due  to  this  cause, 
as  also  bleeding  from  phthisical  cav-  Fig.  95. 
ities,  the  vessels  having  previously  lost 

the  support  of  surrounding  tissues,  and  being  more  or  less  dilated 
or  aneurismal. 

3.  Embolic  Arteritis. — ^\Vhen  a  vessel  is  blocked  by  a  simple 
embolus,  obliteration  is  the  usual  consequence.  If  the  embolus  is 
infective,  as  in  pysemia  or  infective  endocarditis,  an  abscess  may 
develop;  but  if  the  irritant  is  less  intense,  the  process  may  stop 
short  of  suppuration,  and  yet  an  aneurismal  dilatation  of  the 
softened  wall  takes  place.  The  latter  process  is  the  most  common 
cause  of  spontaneous  aneurism  in  children  and  young  adults. 

4.  Acute  Endarteritis  is  usually  seen  in  the  aorta  associated  with 
acute  endocarditis,   or  sometimes  in  the  smaller  vessels  near  in- 


-Atheroma  of  Aorta. 


304 


A   MANUAL  OF  SURGERY 


flamed  wounds.  It  is  evidenced  by  the  presence  on  the  inner  aspect 
of  the  vessel  of  more  or  less  raised  patches,  somewhat  pinkish  and 
gelatinous  in  appearance,  soft  and  elastic  in  consistency. 

5.  Arterio-sclerosis  is  the  term  now  applied  to  a  degenerative  and 
inflammatory  affection  of  the  arteries,  formerly  known  as  chronic 
endarteritis.  It  usually  commences  about  middle  life,  and  is  in 
many  cases  merely  a  physiological  sign  of  the  incidence  of  senility 
due  to  the  w^r  and  tear  of  life.  In  younger  patients  and  in  its 
more  severe  fornis  it  generally  depends  on  some  form  of  chronic 
intoxication — e.g.,  syphilis,  gout,  alcohohsm,  or  lead-poisoning.     It 


Fig.  96. — Secmon  of  Atheromatous  Cerebral   Artery,      x  50. 

(ZlEGLER.) 

a,  Intima  considerably  thickened  ;  h,  bounding  elastic  lamella  of  intinia; 
c,  media;  d,  adventitia;  e,  necrosed  denucleatcd  tissue  with  masses  of 
fatty  detritus;  /  and  /^  detritus  with  cholesterine  tablets;  g,  intima 
infiltrated  with  leucocytes;  h,  infiltration  of  adventitia  with  leucocytes. 

is  also  induced  by  excessive  and  particularly  intermittent  muscular 
strain;  by  cachexia,  the  result  of  malignant  disease,  tuberculo.sis, 
or  inanition ;  it  may  follow  as  a  sequela  of  acute  infections,  such  as 
enteric  fever  or  acute  rheumatism;  or  may  arise  from  any  condi- 
tion which  leads  to  persistent  increase  in  the  arterial  tension — e.g., 
chronic  Bright's  disease. 

The  primary  changes  probably  consist  in  a  degenerative  loss  of 
elasticity  in  the  middle  and  outer  coats,  which  is  followed  by  a 
secondary  hyperplasia  of  the  tunica  intima.  The  later  changes 
vary  somewhat,  according  to  whether  the  affection  is  localized 
(nodular  variety)  or  diffuse. 


INJURIES  AND  DISEASES  OF  ARTERIES 


305 


Nodular  artcrio-sclcrosis  is  most  common  in  the  aorta  and  large 
vessels,  and  often  starts  in  the  convexity  of  the  aortic  arch  at  the 
spot  where  the  impact  of  the  blood-stream  is  felt  as  it  is  ejected 
from  the  ventricles  (Fig.  95),  or  in  places  where  the  vessel  passes 
over  or  around  some  bony  projection,  or  at  the  bifurcation  of  a 
main  artery.     In  the  early  stages  scattered  raised  patches  are  seen 
on  the  inner  lining  of  the  vessel,  translucent  and  grayish  in  aspect, 
and  of  variable   size  ;   the  overlying  endothelium  is  smooth   and 
intact.     In  the  later  stages  fibrosis  may  occur  in  the  patch,  which 
becomes  dull  white  in  colour,  and  at  length  calcification  may  ensue, 
giving  rise  to  an  atheroma- 
tous plate.     In  other  cases 
the  process  may  be  followed 
by  fatty  degeneration,  the 
patches  becoming  yellowish 
in    colour  and  irregular  in 
outline;    the}-  are  small  at 
first,  but  increase  in  size,  and 
coalesce  one  with  another. 
The  contents  are  now  fluid 
or    cheesy   in    consistency, 
constituting    the    so-called 
'  atheromatous  abscess '  (Gr. 
dOijpyj,   'gruel'    or    'pap'), 
although  no  true  pus  exists, 
the  pultaceous  material  con- 
sisting of  fatt}'  granules  and 
debris,  with  oil  globules  and 
plates  of  cholesterine  (Fig. 
96,  f^) .    It  may  be  absorbed 
entirely,  lea\-ing  a  weakened 
spot  in  the  wall  of  the  vessel, 
from  which  ananeurismmay 
arise ;  or  it  may  be  infiltrated 
with  lime  salts,  and  consti- 
tute an  atheromatous  plate ; 
or    the  tunica  intima  may 
give  wav  over  it,  allowing' the  contents  to  be  swept  into  the  general 
circulation,  where  it  probably  does  no  harm,  and  the  raw  surface 
left  behind  is  known  as  an  'atheromatous  ulcer.'     The  outer  coat 
has  by  this  time  become  thickened,  and  hence  no  immediate  ill 
result 'follows  the  breach  in  the  inner  coats,  although  subsequently 
dilatation  may  take  place,  even  though  cicatrization  of  the  ulcer 
has  occurred.'    Again,  the   blood  may  find  its   way  through   the 
opening  into  the  substance  of  the  wall  and  strip  up  the  inner  from 
the  outer  layers,  constituting  a  '  dissecting  aneurism ' ;  or  a  localized 
thrombus  mav  form,  causing  occlusion  of  the  vessel. 

Diffuse  Arieno-sclerosis  occurs  in  elderly  indi\-iduals,  commonly  in 
the  smaller  vessels,  and  may  be  associated  with  the  nodular  variety 


Fig.  97. — Syphilitic  Arteritis 


u 
?,^'> 


X   150. 


(ZlEGLER.) 

a,  Intima  greatly  thickened  by  newly-formed 
libro-cellular  tissue ;  b,  fenestrated  elastic 
lamina  of  Henle;  c,  muscle  fibres  of  media, 
infiltrated  towards  the  left;  d,  adventitia 
thickened  by  cell  infiltration  and  h^-per- 
plasia. 


3o6  A   MANUAL  OF  SURGERY 

in  the  aorta.  The  changes  arc  similar  to  those  described  above,  but 
usually  terminate  in  fibrosis  and  contraction  of  the  lumen  of  the 
vessel;  the  changes  in  the  intima  are  followed  by  thickening  of  all 
the  coats,  but  degenerative  phenomena  are  unusual.  In  the  smaller 
arteries  of  the  brain  this  change  may  interfere  seriously  with  the 
functions  of  the  part ;  whilst  in  the  vessels  of  the  limbs  it  may  result 
in  what  is  known  as  Endarteyitis  obliterans,  and  lead  to  gangrene. 
In  some  instances  even  the  main  trunks  may  be  involved  in  this 
affection. 

6.  Chronic  Syphilitic  Endarteritis  is  chiefly  met  with  in  the  late 
secondary  or  tertiary  stages,  and  is  characterized  by  an  overgrowth 
of  the  tunica  intima  (Fig.  97,  a),  which  is  subsequently  associated 
with  infiltration  of  the  media  (c),  and  much  more  so  of  the  adven- 


Fig.  98. — Syphilitic  Endarteritis  from  Near  a  Gumma,      x   120. 

titia  {d).  The  change  occurs  in  small  arteries,  especially  those  of 
the  brain  or  kidnej^s,  or  in  the  neighbourhood  of  gummata  (Fig.  98), 
and  but  rarely  in  the  larger  vessels,  although  a  considerable  per- 
centage of  individuals  affected  with  internal  aneurism  have  suffered 
from  syphilis.  It  differs  from  simple  atheroma — (i)  in  attacking 
small  arteries;  (2)  in  affecting  the  whole  circumference  of  the  vessel, 
and  not  merely  patches;  (3)  the  newly-formed  tissue  becomes 
vascular,  and  does  not  undergo  fatty  degeneration;  and  (4)  it 
leads  to  narrowing  or  occlusion  of  the  vessel  rather  than  to 
weakening  and  dilatation.  When  involving  the  cerebral  arteries, 
various  forms  of  monoplegia,  or  even  hemiplegia,  may  result. 

7.    Chronic  Tuberculous  Endarteritis  of  a  similar  type  is  met  with 
in  all  places  where  tubercle  is  actively  developing;  in  fact,  tubercles 


INJURIES  AND  DISEASES  OF  ARTERIES 


307 


are  often  fomicd  around  arterioles,  and  lead  to  their  obliteration. 
The  tuberculous  endarteritis  may,  however,  spread  widely  beyond 
the  focus  of  the  mischief,  and  in  almost  any  portion  of  pulpy 
granulation  tissue  this  change  can  be  seen. 

8.  Primary  Calcareous  Degeneration  (Fig.  99)  is  chiefly  met  with 
in  the  smaller  arteries  of  the  extremities.  It  occurs  in  elderly  people 
at  the  same  time  of  life  as  the  calcification  of  cartilages,  etc.,  and 
commences  by  the  deposit  of  lime  salts  in  the  muscular  fibres  of  the 
tunica  media,  constituting  a  series  of  calcareous  rings  which  trans- 
form the  elastic  expansile  vessels  into  rigid  tubes  hke  gas-pipes, 


3/5 


Fig.  99. — Primary  Calcareous  Degeneration  of  Arteries.     (From 
College  of  Surgeons'  Museum.) 


through  which  alone  can  pass  a  fixed  and  unchangeable  minimal 
supply  of  blood.  It  is  often  associated  with  generahzed  arterio- 
sclerosis. 

The  affected  limb  passes  into  a  condition  of  chronic  anaemia  and 
impaired  nutrition,  resulting  in  coldness  of  the  feet  or  hands,  cramps 
and  spasms  of  muscles,  sensations  of  pins  and  needles,  etc.  The 
endothelium  is  not  removed  except  in  the  later  stages,  and  then 
thrombosis  maj^  be  produced,  or  a  similar  result  may  arise  from  the 
lodgment  of  an  embolus.  Senile  gangrene  (p.  114)  is  a  common 
termination. 


3o8  A   MANUAL  OF  SURGERY 

9.  Amyloid  Degeneration  of  the  viscera  commences  in  the  arterial 
walls,  but  is  described  elsewhere  (j).  8}). 

The  Effects  of  Arterial  Inflammation  and  Degeneration  are  botli 
local  and  peripheral.  Locally,  Thrombosis  may  ])c  produced  when- 
ever the  lining  endothelium  is  removed  and  a  raw  surface  exposed, 
upon  which  fibfin  can  collect.  Under  this  fibrinous  coating  repair 
is  often  effected  without  further  complication:  but  if  the  blood- 
stream is  retarded,  or  the  lumen  of  the  tube  narrowed,  complete 
thrombosis  may  follow,  the  clot  extending  some  distance  up  or  down 
the  vessel,  or  even  from  a  branch  into  the  main  trunk,  which  may  be 
blocked  by  this  means.  Aneurism  is  also  a  result  of  any  weakening 
of  the  arterial  tunics.  Obliteration  of  the  artery  is  caused,  either  by 
thrombosis,  or  by  excessive  proliferation  of  the  tunica  intima  (as  in 
syphilitic  or  tuberculous  disease),  or  by  gradually  increasing  pressure 
from  without.  Lastly,  Spontaneous  Rupture  is  occasionally  pro- 
duced. 

Peripherally,  defective  blood-supply  and  consequent  lowered 
vitality  are  the  most  marked  results  of  arterial  disease,  leading  to 
various  forms  of  ulceration  and  gangrene.  Thus,  senile  gangrene  is 
due  to  calcareous  changes  in  the  arteries,  fatty  degeneration  of  the 
heart  follows  atheroma  of  the  coronary  arteries,  whilst  softening 
of  the  brain  may  ensue  from  various  affections  of  the  cerebral 
vessels.  Similar  results  may  also  arise  from  emboli  detached  from 
areas  of  local  disease. 

Aneurism. 

An  Aneurism  is  a  sac  filled  with  fluid  or  coagulated  blood  com- 
municating w^ith  the  interior  of  an  artery,  the  walls  of  which  have 
become  dilated. 

Causes. — i.  Changes  in  the  Vessel  Walls,  by  which  their  resistance 
to  the  intravascular  pressure  is  diminished.  Many  varieties  of 
disease,  e.g.,  atheroma,  predispose  to  aneurismal  dilatation,  especially 
if  occurring  in  syphilitic  ^r  gouty  men  about  middle  life,  in  whom, 
although  the  arterial  tunics  may  be  weakened,  the  power  of  the  heart 
and  the  resulting  blood-pressure  are  by  no  means  diminished.  The 
diffuse  form  of  arterio-sclerosis  (often  associated  with  calcification)  of 
the  peripheral  arteries  is  antagonistic  to  aneurismal  dilatation.  An}^ 
injury,  a  contusion,  a  penetrating  wound,  or  a  strain,  may  so  inter- 
fere with  the  integrity  of  the  vascular  coats  as  to  result  in  aneurism, 
and,  indeed,  a  cicatrix  in  an  arterial  wall  must  always  be  looked  on 
as  a  weak  spot  predisposing  to  dilatation.  The  lodgment  of  an 
infected  embolus  in  the  smaller  arteries  is  stated  to  be  one  of  the  most 
common  causes  of  spontaneous  aneurism  in  young  people. 

2.  Increase  in  the  Blood-Pressure  is  another  factor,  especially 
when  due  to  heavy  strain  or  exertion,  which  leads  to  irregular  excite- 
ment and  increased  action  of  the  heart.  Steady  laborious  employ- 
ment, such  as  is  seen  amongst  artisans  and  mechanics,  or  regular 
exercise,  does  not  appear  to  predispose  to  this  condition;  but 
irregular  intermittent  efforts,  in  which  for  the  time  being  every 


ANEURISM 


309 


power  is  strained  to  its  utmost,  are  very  liable  to  determine  its 
occurrence.  A  day's  exertion  in  the  hunting  or  shooting  field  by 
an  elderly  man,  accustomed  to  sedentary  occupations,  is  often  the 
cause  of  some  vascular  lesion,  such  as  aneurism,  apoplexy,  etc. 
Hence  aneurisms  are  more  frequently  seen  amongst  men  than  in 
women,  in  the  proportion  of  seven  to  one ;  whilst  they  are  much  more 
common  among  the  dwellers  in  Northern  chmates  than  in  the  more 
lethargic  and  ease-loving  inhabitants  of  the  South.  The  energy  and 
activity  of  the  Anglo-Saxon 
race  especially  predispose  them 
to  this  disease. 

Structure  of  an  Aneurism. — 
The  sac  consists  more  or  less 
evidently  of  a  distension  of  all 
or  part  of  the  original  walls  of 
the  vessel  whilst  it  is  small; 
but  as  the  aneurism  increases, 
the  original  structure  is  re- 
placed by  a  mass  of  newly- 
formed  fibrous  tissue,  due  to  a 
condensation  and  matting  to- 
gether of  the  surrounding  struc- 
tures, with  or  without  an  in- 
ternal lining  of  laminated  fibrin 
deposited  on  parts  where  the 
endothelium  has  disappeared. 
The  contents  of  the  sac  depend 
on  the  character,  age  and  size 
of  the  aneurism.  Whilst  still 
small  and  with  a  complete 
endothelial  lining,  it  contains 
fluid  blood ;  but  as  the  tumour 
grows,  and  especially  if  of  the 
sacculated  type,  fibrin  is  de- 
posited in  layers  which  gradu- 
ally encroach  on  the  cavity, 
and  may  in  time  completely 
fill  it,   so  that  in  rare  cases  a 

spontaneous  cure  results.  The  oldest  laminse  are  dry  and  yellowish- 
white  in  colour ;  those  more  recently  deposited  are  softer  and  more 
reddish,  whilst  the  last  formed  is  merely  hke  ordinary  blood  coagulum. 
No  single  lamina  covers  the  whole  area,  but  layer  is  arranged  over 
layer  (Fig.  100)  in  such  a  manner  that  the  oldest  and  necessarily 
the  smallest  laminse  are  nearest  to  the  sac  wall. 

Three  chief  forms  of  aneurism  have  been  described :  the  fusiform, 
sacculated,  and  dissecting. 

I.  The  Fusiform  Aneurism  (Fig.  loi.  A)  is  one  in  which  the  whole 
lumen  of  the  vessel  is  more  or  less  equally  expanded,  so  that  the 
swelhng  is  tubular  in  character.     It  is  generally  due  to  a  widelv- 


FiG.  100.  —  Sacculated  Aneurism. 
(Museum  of  Royal  College  of 
Surgeons.) 

The  small  mouth  of  the  saccule  is 
clearly  seen,  and  the  cavity  is  nearly 
filled  with  laminated  clot. 


3IO 


A   MANUAL  OF  SURGERY 


extended  disease  of  the  arterial  walls,  and  lience  is  more  common 
in  the  larger  internal  vessels,  such  as  the  aorta,  than  in  those  of  the 
extremities.  The  tunica  intima  is  usually  represented  throughout 
the  whole  extent  of  the  sac,  but  is  thickened  and  atheromatous  in 
patches,  the  margins  and  surfaces  of  calcareous  jjlates  being  indi- 
cated by  flocculi  of  fibrin,  which  are  attached  to  them,  although  no 
regular  laminated  deposit  may  be  present.  Ihe  tunica  media  is 
stretched,  atrophied,  and  in  the  later  stages  practically  non-existent, 
whilst  the  adventitia  is  much  thickened  by  inflammatory  new  for- 
mation and  by  incorporation  with  the  surrounding  tissues.  '1  he 
progress  of  fusiform  aneurisms  is  generally  slow,  so  that  in  some 
situations,  e.g.,  the  thorax,  they  may  attain  enormous  dimensions, 
and  cause  grave  pressure  symptoms.     A  natural  cure  is  almost 


Fig.   ioi. — Diagrams  of  Fusiform,  Sacculated,  and  Dissecting 
Aneurisms. 

In  the  fusiform  (A)  the  walls  are  expanded,  but  more  or  less  normal  in  texture ; 

in  the  sacculated   (B)   the  normal  structure  of  the  arterial  wall  ceases 

abruptly  at  the  commencement  of  the  saccule;  in  the  dissecting  (C)  the 

arterial  wall  is  split  into  two  lamellae. 
The  interrupted  fine  line  is  supposed  to  represent  the  intima;  the  continuous 

dark  line,  the  media;  and  the  continuous  fine  line,  the  adventitia. 

impossible,  and  hence,  if  unchecked  by  treatment,  rupture  of  the 
sac  is  likely  to  occur,  especiall}'  if,  as  often  happens,  one  portion  of 
the  wall  yields  more  rapidly  than  another,  thereby  inducing  a  local- 
ized sacculation. 

2.  A  Sacculated  Aneurism  (Figs.  loo  and  loi,  B)  is  due  to  the 
yielding  of  some  weak  patch  in  the  vessel  wall  which  does  not  involve 
the  whole  circumference,  or,  as  just  mentioned,  it  may  spring  from  a 
fusiform  aneurism.  It  communicates  with  the  interior  of  the  artery 
by  an  opening  of  variable  size.  All  traumatic  aneurisms,  whether 
due  to  the  yielding  of  a  cicatrix,  or  to  the  partial  division  of  the  coats 
of  the  vessel,  are  of  this  type,  which  is  hence  found  most  commonly 
in  the  extremities.     The  inner  and  middle  coats  can  usuallv  be  traced 


ANEURISM  3" 


as  far  as  the  mouth  of  the  saccule,  but  there  they  are  suddenly  lost, 
the  wall  being  constituted  by  a  mass  of  fibro-cicatricial  tissue,  upon 
which  laminated  fibrin  readily  forms,  thus  increasing  its  thickness 
and  power  of  resistance.  Their  progress  is,  however,  much  more 
rapid  than  that  of  the  fusiform,  generally  ending  in  rui)ture  or 
diffusion,  although  occasionally  a  natural  cure  results. 

3.  A  Dissecting  Aneurism  (Fig.  loi,  C)  is  one  in  which  the  blood 
forms  a  cavity  within  the  wall  of  the  vessel  by  stnppmg  up  the  inner 
from  the  outer  half,  the  hne  of  cleavage  being  withm  the  middle 
coat,  half  going  with  the  adventitia,  half  with  the  intima.  It  is 
usually  the  result  of  extensively  diffused  atheroma.  The  blood  thus 
driven  into  a  cul-de-sac  may  remain  hmited  to  this  cavity  for  some 
time,  or  it  may  find  its  way  outwards  and  become  diffused,  or  burst 
back  through  another  atheromatous  spot  in  the  interior  of  the 
vessel.  The  condition  occurs  chiefly  in  the  thoracic  or  abdominal 
aorta,  but  cannot  be  recognised  ante-mortem. 

Symptoms  and  Signs  of  a  Circumscribed  Aneurism.— These  may  be 
divided  into  two  groups:  the  intrinsic  and  extrinsic. 

Intrinsic  Signs.— A  tumour,  pulsating  synchronously  with  the 
heart's  beat,  is  present  in  the  course  of  a  vessel.  The  pulsations  are 
distensile  or  expansile  in  character,  i.e.,  the  whole  tumour  increases 
in  size  at  each  systole,  and  that  evenly  in  all  directions,  so  that  if 
the  tumour  is  hghtly  grasped  in  any  position  the  fingers  are  separ- 
ated. A  definite  thrill  can  often  be  felt  as  the  blood  enters  the  sac 
at  each  heart-beat.  If  the  supplying  vessel  is  compressed  on  the 
proximal  side,  the  pulsation  ceases,  and  the  tumour  diminishes  m 
size  and  becomes  softer;  this  is  more  marked  in  fusiform  than  in 
sacculated  aneurisms.  The  appUcation  of  pressure  to  the  sac  itself, 
whilst  the  afferent  trunk  is  compressed  above,  may  still  further 
diminish  its  size.  On  removing  the  pressure,  the  sweUmg  regains 
its  old  dimensions  in  a  certain  definite  number  of  beats,  usually  not 
more  than  two  or  three.  Pressure  on  the  distal  side  of  the  sac  makes 
it  more  tense  and  the  pulsation  more  marked,  unless  such  compres- 
sion is  very  prolonged.  On  auscultating  the  tumour,  a  bruit  of 
variable  character  may  be  heard;  usually  it  is  loud,  harsh,  and 
systohc,  but  sometimes  quiet  and  musical.  It  is  occasionally 
double  in  some  forms  of  sacculated  aneurism,  and  m  the  aorta 
when  regurgitation  through  the  aortic  valves  is  also  present.  The 
bruit  is  loudest  and  most  rasping  in  the  fusiform  vanety,  and  may 
be  absent  in  the  sacculated  form,  when  the  mouth  is  small  and  the 
cavity  nearly  full  of  clot.  ■        •  ■  -u 

The  Extrinsic  Signs  of  aneurism  are  those  occurring  m  neigti- 
bouring  or  distal  structures  from  its  constantly  mcreasmg  size  and 
pressure,  and  the  interference  produced  by  it  with  the  circulation. 
The  pulse  on  the  distal  side  is  diminished  and  delayed,  its  diminution 
being  caused  partiy  by  the  obstruction  experienced,  but  also  m  some 
cases  by  the  pressure  of  the  sac  upon  the  trunk  above  or  below  the 
tumour.  The  delay  is  due  to  the  interference  with  the  transmission 
of  the  heart's  impulse  by  the  intervention  of  the  aneurismal  sac. 


312  A   MANUAL  OF  SURGERY 

The  smaller  vessels  engaged  in  establishing  collateral  circulation 
may  be  compressed  by  the  sac,  and  thus  the  vitality  of  the  limb 
impaired.  Pressure  on  the  accompanying  vein  or  veins  results  in 
diminution  of  their  calibre,  and  possibly  a  localized  thrombosis, 
together  with  distal  congestion  and  oedema.  Compression  of  nerves 
occasions  neuralgia,  spasm,  or  paralysis.  Muscles  are  displaced, 
expanded,  and  attenuated ;  bones  may  be  eroded,  as  evidenced  by  a 
deep,  constant,  boring  pain,  and  even  spontaneous  fracture  may 
ensue;  whilst  joints  are  encroached  upon  and  disorganized.  Tubes, 
such  as  the  trachea  or  oesophagus,  are  often  constricted  and  even 
laid  open  by  ulceration.  It  is  interesting  to  note  that  resisting 
tissues,  Hke  bone,  are  much  more  liable  to  be  eroded  than  elastic, 
yielding  structures,  such  as  cartilage;  where  the  vertebral  column 
is  encroached  upon  by  an  aneurism,  the  bones  are  always  destroyed 
more  than  the  intervertebral  discs. 

A  certain  amount  of  compensatory  hypertrophy  of  the  heart  is 
often  present.  Fibrinous  masses  are  occasionally  set  free  as  emboli, 
and  lead  either  to  a  spontaneous  cure,  or  to  gangrene  of  the  parts 
supplied  by  the  vessel,  or  to  death  if  the  brain  is  involved.  Gangrene 
may  also  result  from  the  diminished  blood-supply  to  peripheral 
parts;  it  is  usually  of  the  dry  type,  involving  merely  one  or  two 
fingers  or  toes,  unless  the  veins  are  compressed,  when  it  may  be  of 
the  moist  variety. 

The  Differential  Diagnosis  of  a  circumscribed  aneurism  is  usually 
not  difficult,  but  the  following  conditions  may  simulate  it  somewhat 
closely:  i.  A  tumour  or  chronic  abscess  situated  near  an  artery,  and 
deriving  transmitted  pulsation  from  it,  is  recognised  by  the  impulse 
being  merely  heaving  in  character,  and  not  expansile ;  by  the  pulsa- 
tion ceasing  entirely  if  the  tumour  is  lifted  from  the  vessel,  or  allowed 
to  fall  away  from  it  by  assuming  a  suitable  position ;  b}^  the  size  of 
the  tumour  not  diminishing  if  the  pulsation  is  stopped  by  pressure 
on  the  vessel  above;  and  by  the  fact  that  after  stoppage  of  the 
pulsation  the  first  beat  is  equal  to  the  subsequent  ones,  whereas  in 
an  aneurism  it  almost  always  requires  more  than  one  beat  to  re- 
establish the  strength  and  force  of  the  impulse.  Moreover,  the  pulse 
below  is  not  affected  in  the  same  way  or  to  the  same  extent  as  when 
an  aneurism  is  present.  2.  An  artery  is  sometimes  pushed  fonvards 
by  an  underlying  growth,  and  its  pulsation  in  a  more  than  usually 
superficial  position  may  suggest  an  aneurism.  The  distinguishing 
features  are  the  Hmitation  of  the  pulsation  to  the  line  of  the  vessel, 
and  the  absence  of  pulsation  in  the  underlying  growth.  3.  A  pul- 
sating sarcoma  or  ncevus  is  known  by  being  rarely  limited  exactly 
to  the  line  of  the  artery,  pulsation  being  present  in  situations  where 
an  aneurismal  dilatation  could  not  be  felt,  and  being  less  forcible 
and  regular  in  its  character.  The  consistency  of  the  swelling  is 
more  variable,  and  pressure  over  the  afferent  trunk  does  not  diminish 
its  size  to  any  marked  extent.  Moreover,  a  sarcoma  is  usually  more 
adherent  to  the  deeper  structures,  and  its  hmits  are  not  so  accu- 
rately defined.    4.  The  pain  caused  by  an  aneurism  may  lead  it  to 


ANEURISM  313 

be  mistaken  for  rheumatism  or  neuralgia  {e.g.,  for  sciatica  in  popliteal 
aneurism),  and  in  every  case  of  obstinate  pain  of  this  kind  the 
arteries  should  always  be  carefully  examined. 

Natural  Terminations  and  Results. — i.  Spontaneous  Cure,  though 
very  unusual,  may  occur  in  sacculated  aneurisms,  [a)  It  may  be 
due  to  the  gradual  deposit  within  the  sac  of  fibrin,  which,  in  the  first 
place,  limits  the  expansion  and  extension  of  the  aneurism,  but  may 
finally  increase  to  such  an  extent  as  to  occupy  the  whole  cavity  and 
close  up  its  mouth.  This  condition  can  only  obtain  in  saccules  with 
small  mouths,  and  in  vessels  of  the  second  magnitude,  hardly  ever  in 
the  aorta  or  larger  trunks,  the  impetus  of  the  blood-stream  being  too 
great  to  permit  of  the  necessary  deposit  of  fibrin,  ip)  It  may  arise  as 
the  result  of  the  sudden  coagulation  of  all  the  blood  in  the  sac  from 
the  stoppage  of  the  circulation,  owing  to  the  lodgment  of  an  embolus 
either  at  the  mouth  of  the  aneurism  or  in  the  trunk  immediately 
below,  (c)  The  aneurism  may  become  so  large  as  to  compress  the 
main  vessel,  either  going  to  or  coming  from  it,  thus  bringing  about 
its  own  cure,  [d]  Again,  if  the  sac  becomes  inflamed,  consolidation 
may  occur  with  or  without  suppuration,  although  the  latter  process, 
as  will  be  seen  anon,  is  attended  with  serious  danger  to  life  and  limb. 

The  sac  becomes  more  and  more  firm,  the  pulsation  less  forcible 
and  distinct,  the  bruit  diminishes,  and  finally  consolidation  is 
effected,  a  firm  fibroid  tumour  alone  remaining,  which  gradually 
shrinks,  whilst  the  collateral  circulation  is  opened  up  so  as  to 
supply  the  limb  below.  It  is  sometimes  by  no  means  easy  to  recog- 
nise the  fibroid  mass  which  results  from  a  consolidated  aneurism, 
and  in  making  a  diagnosis  the  history  has  mainly  to  be  depended 
on.  The  existence  of  a  tumour  in  the  line  of  an  artery,  the  probable 
occlusion  of  the  main  trunk,  and  the  fact  that  the  circulation  is 
carried  on  by  means  of  collateral  branches,  are  the  chief  points 
which  can  be  ascertained  by  a  physical  examination. 

2.  Diffusion  and  Rupture  result  from  yielding  of  the  walls  of  an 
aneurism,  as  an  outcome  of  some  mechanical  injury  or  from  simple 
over-distension. 

When  an  internal  aneurism  gives  way,  the  patient  usually  ex- 
periences a  sensation  of  pain  in  the  part,  and  becomes  pale,  cold, 
and  faint,  possibly  dying  within  a  few  minutes  or,  at  most,  hours; 
or  there  may  be  a  sudden  gush  of  blood  from  the  mouth  if  the 
trachea  or  oesophagus  has  been  opened.  Sometimes  internal 
aneurisms  leak  slowly,  and  the  final  stage  lasts  some  days. 

When  an  external  aneurism  yields,  it  may  do  so  slowly  or  quickly. 
If  the  blood  becomes  effused  slowly  (a  leaking  aneurism) ,  the  tumour 
gradually  increases  in  size,  and  its  outline  is  less  clearly  limited; 
the  pulsation  diminishes  in  force  and  distinctness,  and  the  signs  of 
pressure  upon  the  veins  or  nerves  become  more  urgent,  until  gan- 
grene sometimes  supervenes.  If  the  sac  yields  suddenly  (a  ruptured 
aneurism),  the  patient  experiences  severe  pain  in  the  part  which 
becomes  tense,  swollen,  and  brawny;  all  pulsation  ceases,  both  in 
the  aneurism  and  below  it,  and  gangrene  of  the  limb  follows,  or 


314  A   MANUAL  OF  SURGERY 

even  deatli  from  syncope,  if  the  skin  gives  way.     Su})])uruti(jn  may 
also  occur  in  tliese  cases. 

3.  Suppuration  is  an  exceedingly  serious,  but  by  no  means  a  usual, 
complication.  It  may  arise  in  the  following  ways:  (u)  After  liga- 
ture of  the  main  vessel,  especially  when  the  wound  becomes  infected, 
and  there  is  a  good  deal  of  loose  cellular  tissue  around  the  sac,  as  in 
the  axilla;  {b)  after  diffusion,  partial  or  complete,  of  an  aneurism, 
where  there  is  great  tension  upon  surrounding  parts.  Auto- 
infection  or  the  presence  of  an  infective  embolus  may  finally  de- 
termine the  suppurative  process.  The  tumour  shows  signs  of  in- 
flammation, becoming  hot,  red,  painful,  and  swollen,  and  the  skin 
over  it  may  pit  on  pressure ;  whilst  fever  and  general  constitutional 
disturbance  are  also  present.  Sooner  or  later,  if  left  to  itself,  the 
tumour  points  at  one  spot  and  bursts,  giving  exit  to  a  mixture  of 
blood-clot,  pus,  and  a  greater  or  less  amount  of  bright  red  blood. 
The  patient  either  dies  at  once  from  syncope,  or  a  little  later  from 
secondary  haemorrhage  and  toxaemia,  unless  efficient  treatment  is 
adopted.  Occasionally,  but  very  rarely,  the  afferent  trunk  be- 
comes plugged  by  a  thrombus,  and  spontaneous  cure  may  thereby 
be  induced. 

Treatment  of  Aneurisms. 

I.  General  Treatment  is  employed  as  an  accessory  to  surgical 
measures,  or  must  be  depended  on  entirely  in  cases  where  local 
means  are  impracticable,  as  in  internal  aneurisms. 

In  plethoric  individuals,  where  the  disease  often  runs  a  rapid 
course,  absolute  rest,  both  mental  and  physical,  must  be  enjoined, 
with  the  removal  of  all  sources  of  irritation  and  worry.  The 
bowels  should  be  kept  gently  open,  and  constipation  and  straining 
avoided.  The  heart's  impulse  may  be  diminished  by  the  use  of 
aconite,  or  even  by  venesection  when  it  is  very  forcible.  Iodide  of 
potassium  is  usually  prescribed,  on  account  of  the  frequent  associa- 
tion of  aneurism  with  syphilis;  and  calcium  lactate  (grs.  5,  t.d.s.) 
may  be  useful  in  increasing  the  coagulability  of  the  blood.  The  diet 
must  be  suitably  diminished,  and  only  highly  nutritious  material 
allowed,  and  that  mainly  of  the  nitrogenous  type,  with  as  little  fluid 
as  possible  (not  more  than  about  a  pint  a  day). 

In  weakly  individuals,  whilst  strictly  enjoining  a  recumbent  pos- 
ture, the  surgeon  should  prescribe  iron  and  a  somewhat  more  liberal 
diet,  in  order  to  improve  the  quality  of  the  blood. 

II.  Surgical  Treatment. — A.  Ihe  ideal  plan  consists  in  dealing 
with  the  arterial  wall  ho  as  to  obliterate  the  aneurism,  but  without 
occluding  the  original  lumen  of  the  vessel,  according  to  the  sugges- 
tion of  ]\Iatas*  of  New  Orleans.  This  is  obviously  only  possible  in 
selected  cases  of  sacculated  aneurism,  but  a  number  of  satisfactory 
results  have  been  reported.  The  circulation  is  controlled  tempor- 
arily, and  the  aneurism  laid  freely  open,  so  that  its  interior  can  be 

*  Annals  of  Surgery,  February,  1903.  Also  Report  of  International  Con- 
gress of  Medicine,  London,  1913,  Section  VII.,  part  ii. 


ANEURISM  315 

emptied  completely  and  carefully  examined.  The  orifices  of  the 
smaller  collateral  branches  are  secured  by  purse-string  sutures,  and 
the  margins  of  the  main  opening  are  approximated  by  a  row  of 
Lembert's  sutures,  if  need  be,  over  a  piece  of  rubber  catheter, 
which  is  subsequently  removed ;  the  continuity  of  the  original  vessel 
being  thus  restored,  the  aneurismal  walls  are  brought  together  by 
superimposed  rows  of  Lembert's  sutures.  It  is  probable  that  in  many 
instances  the  artery  becomes  obliterated  in  spite  of  the  surgeon's  care. 
In  unsuitable  cases,  e.g.,  fusiform  aneurisms,  the  surgeon  may 
operate  with  the  intention  of  obUterating  the  cavity  of  the  sac. 
1  he  openings  of  the  main  vessel,  above  and  below,  are  first  secured 
from  ^^•ithin,  as  also  any  smaller  branches,  and  then  the  cavity  is 
obhterated  by  rows  of  stitches  as  before.  In  neither  of  these  plans 
must  the  sac  be  detached  from  its  surroundings. 

B.  Complete  Extirpation  of  the  aneurismal  sac,  as  if  it  were  a 
tumour,  may  be  looked  on  as  the  best  method  of  treatment  in  the 
majority  of  cases.  The  limb  is  exsanguinated  by  elevation,  and  in 
suitable  cases  the  aneurism  is  removed  without  opening  it,  and  the 
vessel  secured  by  Kgature  above  and  below,  as  also  any  branches 
which  may  arise'  from  it.  Sometimes,  however,  it  is  necessary  to 
open  it  and  turn  out  its  contents  before  attempting  its  extirpation, 
which  is  often  a  matter  of  considerable  difficulty  owing  to  the  ad- 
hesions present.  Not  unfrequently  the  vein  will  be  encroached 
on  in  this  dissection,  and  it  may  have  to  be  removed ;  bad  results 
are  not  hkely  to  follow,  since  the  pressure  of  the  sac  has  already 
probably  estabhshed  an  efficient  collateral  venous  circulation.  The 
results  of  this  operation  are  most  satisfactory,  since  the  length  of 
treatment  is  curtailed,  and  all  chances  of  local  recurrence  are 
removed.  Gangrene  also  is  uncommon,  since  only  one  set  of  col- 
lateral circulation  is  caUed  upon,  \dz.,  that  required  to  bridge  the 
gap  made  bv  removing  the  aneurism,  whereas  in  the  Hunterian 
operation  a  double  set  is  needed,  viz.,  at  the  site  of  the  ligature, 
and  round  the  consolidated  aneurism. 

C.  The  deposit  within  the  sac  of  fibrin,  which  shall  subsequently 
organize  and  thus  lead  to  the  obhteration  of  both  sac  and  sup- 
phdng  vessel,  was  the  ideal  aimed  at  by  the  earher  surgeons,  and  has 
still  to  be  relied  on  in  many  cases.  It  is  obvious  that  a  slow  and 
gradual  deposit  of  laminated  fibrin  is  hkely  to  be  more  satisfactory 
than  the  sudden  distension  of  the  sac  with  soft  red  clot. 

The  various  plans  adopted  with  this  end  in  view  are  as  follows : 
I.  Compression  of  the  main  vessels,  usually  on  the  proximal  side 
of  the  aneurism,  was  much  vaunted  by  the  Dubhn  school  of  surgeons 
in  the  last  century,  and  gave  not  a  few  good  results.  It  may  be 
applied  either  continuously  or  at  intervals.  If  intermiUent,  the  main 
vessel  leading  to  the  aneurism  is  controlled  by  means  of  fingers 
(digital  compression),  or  by  mechanical  contrivances  (such  as  a 
tourniquet  or  a  conical  bag  filled  with  shot),  for  as  long  a  period  as 
the  patient  can  bear,  which  usually  does  not  exceed  thirty  minutes, 
especially  if  there  is  any  nerve  in  the  immediate  neighbourhood. 


3i6  A   MANUAL  OF  SURGERY 

There  seems  to  be  no  necessity  to  arrest  completely  the  flow  of 
blood  through  the  sac,  so  long  as  the  blood-pressure  is  sufficiently 
diminished  to  permit  of  coagulation  within  it.  Continuous  pressure 
under  an  anaesthetic  aims  at  the  entire  stoppage  of  the  circulation 
through  the  sac,  so  as  to  allow  not  only  of  its  contraction,  but  also 
in  some  instances  of  the  rapid  coagulation  of  its  contents.  Such 
pressure  may  be  effected  by  the  fingers  of  relays  of  dressers,  taking 
shifts  of  ten  to  fifteen  minutes  at  a  time.  It  is  well  to  arrange  for 
some  weight,  such  as  a  conical  shot-bag,  to  rest  upon  the  thumb  or 
finger  employed,  so  as  to  reheve  muscular  strain. 

Although  in  suitable  cases  compression  may  be  given  a  trial  before 
ligature,  yet  it  is  unwise  to  persevere  with  it  for  too  long,  especially 
in  plethoric  individuals  with  high  arterial  tension,  if  signs  of  im- 
provement are  not  quickly  observed,  lest  the  collateral  circulation 
be  increased  to  an  undesirable  extent,  and  the  success  of  the  sub- 
sequent operation  jeopardized.  On  the  other  hand,  in  feeble, 
weakly  patients,  where  gangrene  of  the  limb  might  be  anticipated, 
the  opening  up  of  the  collateral  circulation  b}'  compression,  even  if 
the  aneurism  is  not  thereby  cured,  is  by  no  means  a  disadvantage. 

Necessarih',  the  skin  to  which  pressure  is  apphed  must  be  pro- 
tected from  local  irritation  by  shaving  and  removal  of  hairs,  and  the 
use  of  a  dry  aseptic  dusting-powder,  whilst  the  surface  of  any  pad 
employed  must  be  perfectly  smooth. 

2.  Ligature  of  the  main  vessels  leading  to  or  coming  from  the 
aneurisnial  sac  must  next  be  considered.  The  oldest  procedure,  the 
Operation  of  Antyllus,  consisted  in  lavnng  open  the  sac,  turning  out 
the  clots,  securing  the  vessel  above  and  below,  and  allowing  the 
wound  to  heal  by  granulation  (Fig.  102,  A).  Performed,  as  it  was 
originally,  without  antiseptics,  it  was  naturally  attended  with  great 
mortality  from  secondary  haemorrhage. 

In  Anel's  Method  (Fig.  102,  B)  the  artery  w"as  tied  just  above  the 
sac  on  the  cardiac  side,  with  no  branch  intervening ;  this  also  proved 
dangerous,  since  secondary  haemorrhage  frequently  resulted,  either 
from  suppuration  within  the  sac,  or  from  injury  to  the  sac  during  the 
operation,  or  from  yielding  of  the  arterial  wall  at  the  site  of  ligature 
from  septic  peri-arteritis.  At  the  present  time  it  is  not  unfrequently 
undertaken  successfully. 

Hunter's  Operation  (Fig.  102,  C),  which  consists  of  ligature  of  the 
main  vessel  on  the  cardiac  side  at  some  distance  from  the  aneurism, 
was  first  performed  by  him  in  1785.  The  object  is  not  to  cut  off 
absolutely  the  blood-supply  to  the  sac,  but  to  allow  the  blood  to 
enter  it  with  a  greatly  diminished  impulse,  and  in  small  amount  at 
first,  thus  permitting  of  the  contraction  of  the  sac  wall  and  of  the 
gradual  deposit  within  it  of  fibrinous  clot,  which  in  time  becomes 
organized  into  a  mass  of  firm  fibroid  tissue.  It  is  desirable,  though 
not  essential,  that  no  branch  of  large  size  should  intervene  between 
the  point  of  ligature  and  the  sac.  The  operation  is  contra-indicated 
(i)  in  cases  where  serious  cardiac  disease  co-exists,  or  when  an 
internal  aneurism  is  also  present,  rendering  undesirable  any  sudden 


ANEURISM 


317 


increase  of  the  blood-pressure,  as  by  occlusion  of  a  main  vessel; 
(2)  where  pressure  over  the  vessel  does  not  control  the  circulation 
through  the  sac;  (3)  where  the  peripheral  vessels  are  extensively 
calcified;  (4)  where  gangrene  of  the  hmb  is  threatening  or  present; 
or  (5)  where  bones  or  joints  have  been  seriously  involved. 

Distal  Ligature  is  only  practised  for  aneurisms  situated  in  positions 
where  it  is  impracticable  to  deal  with  the  artery  on  the  cardiac  side 
of  the  sac,  such  as  the  innominate,  lower  part  of  the  carotid,  or  first 
part  of  the  subclavian.  Brasdor's  Operation  consists  in  tying  the 
main  trunk  beyond  the  sac,  so  as  totally  to  cut  off  the  circulation 
through  it  (Fig.  102,  D).  In  Wardrop's  Operation  a  ligature  is 
placed  on  one  or  more  of  the  distal  branches  (Fig.  102,  E).  In  the 
former  the  sac  gradually  contracts,  and  thus  allows  of  the  deposit 
of  fibrin;  in  the  latter  proceeding,  where  the  circulation  is  only 


Fig.  102. — Methods  of  applying  Ligatures  for  Aneurisms. 

A,  Method  of  Antyllus;  B,  Anel's  operation;  C,  the  Hunterian  operation; 
D,  Brasdor's  operation;  E,  Wardrop's  method. 

partly  controlled,  the  diminution  of  the  size  of  the  aneurism  goes 
on  much  more  slowly,  and  the  chances  of  the  deposition  of  clot  in 
the  sac  are  correspondingly  lessened. 

It  is  not  unusual,  after  the  application  of  a  ligature  to  a  main 
artery  for  aneurism,  to  observe  a  return  of  pulsation  in  the  sac  after 
a  day  or  two.  In  the  majority  of  cases  this  only  continues  for  a 
short  time,  and  is  by  no  means  an  unfavourable  sign,  indicating  the 
re-estabhshment  of  the  collateral  circulation;  but  if  it  commences 
a  week  or  ten  days  after  the  operatiori,  it  is  more  likely  to  persist. 
It  is  most  frequently  seen  in  cases  where  the  main  vessel  has  been 
tied  at  some  distance  from  the  sac,  as  in  the  superficial  femoral  for 
popliteal  aneurism,  and  where  one  or  more  large  and  important 
collateral  branches  carry  blood  into  the  artery  below  the  hgature 
or  directly  into  the  sac.  The  early  recurrence  of  pulsation  needs 
no  treatment  in  most  instances ;  but  when  it  comes  on  at  a  later  stage, 
it  demands  serious  attention.     Rest,  elevation  of  the  hmb,  and 


3i8  A   MANUAL  OF  SURGERY 

judicious  pressure  over  the  trunk  above  the  site  of  ligature,  should 
tirst  be  tried.  These  failing,  the  following  courses  are  open:  {a)  The 
artery  may  be  again  tied,  either  nearer  the  sac  when  feasible,  or 
further  away  from  it;  {b)  where  the  aneurism  can  be  reached,  it 
may  be  cut  down  on  and  dissected  out,  the  best  course  to  adopt  if 
it  be  practicable;  or  (c)  amputation  just  above  the  aneurism  may 
be  called  for  as  a  last  resource. 

3.  The  Introduction  of  Foreign  Bodies  into  the  Sac  [Moore's 
Method)  has  not  been  followed  by  much  success,  although  a  few 
cases  of  abdominal  aneurism  seemed  to  have  derived  temporary 
benefit  from  it.  Steel  wire  has  been  usually  employed;  it  is  firmly 
wound  round  a  cotton  reel  to  give  it  a  spiral  coil,  and  inserted  into 
the  sac  through  a  very  fine  cannula.  Varying  lengths  from  10  feet 
to  26  yards  have  been  introduced. 

4.  The  combination  of  this  last  method  with  electrolysis  (as 
originally  suggested  and  practised  by  an  Italian,  Corradi,  in  1879) 
has  been  attended  by  some  very  happy  results,  especially  in  the 
hands  of  Stewart  of  Philadelphia.*  He  introduces  a  variable 
length  of  gold  or  silver  wire  (No.  30  gauge),  preferably  the  former, 
through  a  small  cannula,  and  then  performs  electrolysis  through  the 
wire  which  is  attached  to  the  positive  electrode,  whilst  the  negative 
electrode  is  placed  on  the  back.  Ihe  current  is  gradually  increased 
up  to  60  or  80  milliamperes,  and  the  whole  proceeding  lasts  about 
thirty  minutes.  Finally,  the  wire  is  cut  short  and  the  end  pushed 
into  the  sac,  and  the  opening  Hgatured.  Several  brilliant  results 
have  followed  this  plan  of  treatment,  including  the  cure  of  an 
innominate  aneurism,  the  patient  living  for  three  and  a  half  j-ears, 
and  of  an  aneurism  of  the  abdominal  aorta;  dealt  with  by  trans- 
peritoneal^operation. 

An  ingenious  contrivance  has  been  designed  by  Messrs.  D'Arcy 
Power  and  Colt  for  this  purpose.  It  consists  of  a  fine  wire  wisp  or 
cage,  which  can  be  introduced  closed  as  a  cartridge  through  a  special 
cannula,  and  pushed  by  a  ramrod  into  the  sac,  where  it  expands  of 
itself  umbrella-fashion,  thereby  exposing  a  large  surface  of  ware 
on  which  coagulation  can  occur;  it  is  also  arranged  for  electrolysis. 
Satisfactory  results  have  attended  its  employment. 

D.  Quite  distinct  in  principle  from  the  preceding  plans  is  that 
associated  with  the  name  of  Sir  William  Macewen,  who  looks  on 
blood-clot  as  undesirable  material  to  work  with  for  the  cure  of  an 
aneurism,  and  directs  his  attention  to  thickening  the  walls  of  the  sac 
to  such  an  extent  as  to  determine  its  occlusion,  or  to  prevent  its 
subsequent  dilatation.  To  this  end  he  employs  Acupuncture,  intro- 
ducing several  fine  needles  into  the  sac  and  leaving  them  to  be  played 
upon  for  a  time  by  the  blood-stream,  so  as  to  scratch  and  irritate  the 
further  wall  of  the  sac,  and  thus  cause  an  inflammatory  hyperplasia, 
which  shall  subsequently  organize  into  dense  fibro-cicatricial  tissue. 
The  process  must  be  repeated  as  often  as  is  considered  necessary. 
In  his  own  hands  excellent  results  have  been  obtained;  but  whilst 

*  British  Medical  Journal,  August  14,  1897;  Philadelphia  Medical  Journal, 
June  25,  1898. 


ANEURISM 


319 


admitting  its  value  for  internal  aneurisms,  we  cannot  but  think 
that  for  those  involving  peripheral  vessels  other  methods  would  be 
more  rapid  and  equally  effective. 

E.  Amputation  may  be  required  in  the  treatment  of  aneurisms 
under  a  variety  of  circumstances:  [a)  When  extensive  gangrene  of 
the  Hmb  has  occurred  or  is  imminent ;  {h)  for  diffusion  or  suppuration 
of  an  aneurism  when  everything  else  has  failed;  (c)  for  secondary 
haemorrhage  as  a  last  resource;  [d)  in  some  cases  of  recurrent 
aneurism:  [e)  when  joints  have  been  opened  or  bones  eroded  to  such 
an  extent  as  to  impair  the  utihty  of  the  hmb;  and,  finally,  (/)  in 
a  few  cases  of  subclavian  aneurism  amputation  at  the  shoulder- 
joint  has  been  practised  in  order  to  diminish  the  amount  of  blood 
flowing  through  the  sac. 

The  Treatment  of  a  Diffuse  Aneurism  varies  somewhat  according 
to  whether  the  diffusion  is  slow  or  rapid.  In  a  leaking  aneurism 
the  main  vessel  leading  to  the  swelhng  must  be  tied,  if  this  has  not 
already  been  undertaken,  and  the  influence  of  this  measure,  com- 
bined with  rest,  elevation,  and  careful  general  treatment,  observed. 
Should  the  process  not  be  stayed,  the  case  is  treated  as  a  diffuse 
or  ruptured  aneurism  by  laying  open  the  sac,  after  exsanguinating 
the  hmb  by  elevation  and  the  use  of  an  elastic  band,  and  securing, 
if  possible,  the  main  vessel  above  and  below,  as  also  any  branches 
which  may  open  into  the  sac,  if  they  can  be  found.  If  there  is  any 
e\ddence  of  incipient  gangrene,  or  if  secondary  haemorrhage  super- 
venes, amputation  must  be  undertaken.  In  such  cases  everything 
will  depend  on  the  efficient  maintenance  of  asepsis. 

The  Treatment  of  an  Inflamed  Aneurism  is  always  a  matter  of 
anxiety  from  the  risk  of  recurrent  and  fatal  haemorrhage.  If  the 
main  trunk  has  not  been  previously  tied,  this  should  at  once  be 
undertaken  so  as  to  reduce  the  blood-pressure  in  the  sac,  and  the 
effect  carefully  watched;  an  ice-bag  should  also  be  apphed  to  the 
part,  and  the  limb  elevated.  If  no  good  result  follows,  or  if  the  artery 
has  already  been  tied,  nothing  remains  but  to  lay  the  sac  freely  open 
and  endeavour  to  secure,  by  ligature,  the  main  trunk  above  and 
below,  as  well  as  any  smaller  branches.  Unfortunately,  the  walls 
are  often  soft  and  rotten,  so  that  hgatures  cut  out ;  should  bleeding 
supervene,  the  ca-vity  may  be  packed  with  gauze  in  the  hope  of 
checking  it,  and  determining  repair  by  granulation,  but  more 
often  amputation  will  be  required. 

Special  Aneurisms. 

Aneurism  of  the  Thoracic  Aorta  is  most  commonly  of  the  fusiform 
tj'pe  in  the  early  stages,  but  a  hmited  sacculation  often  supervenes 
as  the  disease  advances.  The  symptoms  vary  with  the  part  affected, 
(i)  In  the  ascending  part  of  the  arch  the  swelhng  rarely  reaches  a 
great  size,  especially  if  it  is  intrapericardial,  the  sac  usually  rup- 
turing before  marked  pressure  signs  are  evident. 

(2)  WTien  arising  from  the  transverse  part  of  the  arch,  the  symptoms 
vary  with  the  direction  taken  by  the  enlargement.     If  it  projects 


320  A   MANUAL  OF  SURGERY 

Upwards,  a  pulsating  tumour  may  appear  at  the  episternal  notch, 
and  cerebral  effects  may  then  ensue  from  interference  with  the 
circulation  through  the  carotids,  or  from  pressure  on  the  venous 
trunks.  If  it  extends  anteriorly,  it  may  form  a  large  pulsating 
tumour  to  the  right  of  the  sternum  with  comparatively  slight 
pressure  effects,  except  the  pain  arising  from  its  erosion  of  the 
thoracic  wall.  If  the  enlargement  takes  place  either  posteriorly  or 
downwards  within  the  concavity  of  the  arch,  symptoms  of  dyspnoea 
and  dysphagia  are  early  produced  from  the  close  contiguity  of  the 
trachea,  oesophagus,  and  pulmonary  vessels.  Pressure  upon  the 
left  recurrent  laryngeal  nerve,  as  it  passes  round  the  aorta,  results 
in  spasm  of  the  laryngeal  muscles,  especially  of  the  crico-ary- 
tenoideus  posticus,  producing  suffocative  attacks  of  dyspnoea  and 
a  loud  metallic  or  brassy  cough,  which  is  very  characteristic.  At 
a  later  date  the  nerve  is  paralyzed,  and  then  the  voice  becomes 
affected,  and  the  vocal  cord  fixed  and  immobile,  but  without 
serious  dyspnoea.  Laryngeal  or  tracheal  stridor  may  be  noticed  in 
these  cases,  and  a  dragging  down  of  the  trachea  synchronous  with 
the  heart's  action  (the  so-called  'tracheal  tug').  Radiographic 
examination  is  a  valuable  means  of  diagnosis,  since  the  aneurism 
gives  a  dark  shadow  on  the  screen  or  plate. 

(3)  Aneurisms  of  the  descending  arch  and  thoracic  aorta  often  attain 
considerable  dimensions,  and  may  project  posteriorly  to  the  left  of 
the  vertebral  column,  causing  a  pulsating  swelling.  The  only  pro- 
minent symptoms  are  pain,  clue  to  erosion  of  ribs  or  vertebrae,  and 
interference  with  deglutition,  which  may  be  so  great  as  to  suggest 
the  presence  of  an  cesophageal  constriction ;  in  fact,  before  a  bougie 
is  passed  in  any  case  of  dysphagia  it  is  alwa^-s  advisable  to  make 
certain  by  radiography  that  an  aneurism  is  not  present.  Ausculta- 
tion in  the  left  vertebral  groove  may  also  reveal  the  existence  of 
a  systolic  bruit  where  such  a  condition  exists. 

Treatment.  —  Little  can  be  done  beyond  ordinary  medical 
measures,  such  as  rest,  diet,  and  the  administration  of  iodide  of 
potassium.  When  the  aneurism  has  projected  in  front,  the  intro- 
duction of  coils  of  iron  wire  or  horsehair  has  been  attempted,  and 
in  one  or  two  cases  with  partial  or  temporary  success ;  whilst  Stewart's 
method  of  electrolysis  and  Macewen's  plan  of  acupuncture  have  been 
used  with  some  benefit  for  supposed  cases  of  sacculated  aneurism. 
Dyspnoea  may  be  at  times  severe,  but  tracheotomy  should  never  be 
undertaken,  death  seldom  resulting  from  this  cause. 

Ligature  of  the  right  carotid  and  right  subclavian,  or  of  the  left 
carotid  alone,  has  been  adopted  in  cases  of  aneurism  of  the  ascending 
aorta  or  of  the  arch.  A  certain  amount  of  improvement  followed 
some  of  the  operations,  but  it  is  quite  possible  that  this  was  as  much 
due  to  the  enforced  rest  in  bed  as  to  the  operation.  Of  course,  if 
the  lower  end  of  the  carotid  is  involved  in  the  aneurismal  swelling, 
distal  ligature  may  do  some  good,  as  in  a  case  of  our  own,*  where  the 
left  carotid  and  subclavian  were  tied,  with  a  short  interval  between 
♦  British  Medical  Journal,  December  3,  1898. 


ANEURISM 


321 


the  operations.  The  patient's  condition  improved  greatly  for  a 
time,  and  she  was  able  to  return  to  work,  but  the  aneurism  finally 
burst  into  the  left  pleura  about  three  years  after  the  first  operation. 

Innominate  Aneurism  is  usually  of  the  tubular  variety,  and  fre- 
quently associated  with  a  similar  enlargement  of  the  aorta.  It 
presents  a  pulsating  tumour  behind  the  right  sterno-clavicular 
articulation — i.e.,  between  the  heads  of  origin  of  the  sterno-mastoid 
— projecting  either  into  the  episternal  notch  or  outwards  into  the 
subclavian  triangle,  and  perhaps  pushing  the  cla\icle  forwards. 
The  pulse  in  both  the  right  temporal  and  radial  arteries  is 
diminished;  oedema  of  a  brawny  character  of  the  right  side  of  the 
head  and  neck,  and  of  the  right  arm,  is  caused  by  pressure  on  the 
right  innominate  vein,  whilst  less  commonl}'  similar  changes  on  the 
left  side  ma\'  follow  compression  of  the  left  vein  or  of  the  superior 
vena  cava  ;  pain  shooting  into 
the  neck  and  arm  is  often  pro- 
duced by  impHcation  of  the 
brachial  nerves;  hyperemia  and 
sweating  of  the  right  side  of  the 
face  with  dilatation  of  the  right 
pupil  may  result  from  irritation 
of  the  sympathetic  trunk.  Dys- 
pncea  is  induced  by  direct 
pressure  on  the  trachea,  which 
may  be  displaced  or  flattened, 
or  by  compression  of  the  right 
recurrent  laryngeal  nerve.  Dys- 
phagia occurs  from  pressure  on 
the  oesophagus.  The  course  of 
the  case  is  slowly  progressive, 
and  death  most  commonly  results 
from  asphyxia  or  from  rupture 
of  the  sac. 

Treatment. — ^Rest  and  the  ad- 
ministration of  large  doses  of  iodide 

of  potassium  may  cause  improvement,  but  distal  ligature  is  the 
most  hopeful  proceeding.  It  is  obviously  impossible  to  cut  off  all 
the  blood  passing  through  the  sac  to  the  three  main  divisions — \az., 
the  carotid,  subclavian,  and  vertebral — with  safety  to  the  patient 
(Fig.  103).  Ligature  of  any  one  of  these  by  itself  offers  but  little 
prospect  of  improvement,  whilst  t\-ing  both  carotid  and  subcla\nan, 
with  an  interval  of  more  than  a  week  between  the  two  operations, 
has  practically  the  same  effect  as  a  single  ligature,  for  b}'  that  time 
the  collateral  circulation  will  have  been  estabhshed.  Simultaneous 
ligature  is  doubtless  the  best  plan  of  treatment  to  adopt ;  it  places 
the  sac  in  the  best  possible  condition  for  the  deposit  of  fibrin,  whilst 
the  additional  step  of  tynng  the  third  part  of  the  subcla^aan  does  not 
add  materiallv  to  the  risk  of  the  operation,  which  is  mainly  due 
to  the  effect  "on  the  cerebral  circulation.     Should  these  operative 


Fig.  103. — Application  of  Liga- 
tures FOR  Innominate  Aneur- 
ism.    (After  Erichsen.) 

lA,    Innomiiiate   aneurism;     S,    sub- 
gclavian  artery;  C,  carotid;  V,  verte- 
bral arterv. 


322  A  MANUAL  OF  SURGERY 

measures  seem  undesirable,  recourse  must  be  hud  to  Stewart's  or 
Maccwen's  method. 

Aneurism  of  the  Common  Carotid  is  usually  situated  at  the  upper 
part  of  the  truuk  near  thr  liifurcation,  and  more  often  on  the  right 
than  on  the  left  side.  The  root  of  the  right  carotid  is  also  not 
unfrequently  dilated,  but  the  intrathoracic  portion  of  the  left 
carotid  is  rarely  affected,  except  in  conjunction  with  the  aorta. 
No  other  external  vessel  is  so  frequently  the  seat  of  aneurism  in 
women.  The  ordinary  intrinsic  signs  of  an  aneurism  are  present, 
and  the  pressure  symptoms  are  mainly  referable  to  interference 
with  the  cerebral  circulation,  to  irritation  of  the  cervical  sympa- 
thetic trunk,  or  to  pressure  upon  the  larynx,  pharynx,  or  trachea. 
The  progress  of  these  cases  is  usually  slow. 

Diagnosis. — (i)  From  similar  disease  at  the  root  of  the  neck  the  dis- 
tinction is  often  made  with  difficult}',  since  either  an  aortic,  inntmii- 
nate,  or  subclavian  aneurism  ma\'  push  upwards  so  as  to  simulate  it 
somewhat  closel3^     Percussion  and  auscultation  of  the  upper  part 
of  the  chest,  together  with  a  careful  investigation  into  the  history 
of  the  case,  and  a  digital  examination  of  the  limits  of  the  pulsating 
mass,   may  suffice  to  determine  the  point.     The  pressure  effects 
must  also  be  carefully  considered.     '  Pressure  on  the  left  recurrent 
laryngeal  nerve  would  distinguish  an  aortic  aneurism  from  one  on 
the  right  vessels ;  pressure  on  the  right  nerve  in  like  manner  excludes 
an  aortic  aneurism.     Pressure  on  the  left  innominate  vein  indicates 
aortic  aneurism  rather  than  innominate;  compression  of  the  internal 
jugular  or  subclavian  vein  only  points  to  carotid  or  subclavian 
aneurism.     A  "  tracheal  tug  "  indicates  an. aneurism  of  the  aorta  ' 
(Pearce  Gould).     The  differences  in  the  peripheral  pulses  in  the 
radial  and  temporal  arteries  may  also  give  useful  information.     If 
the  left  radial  pulse  is  alone  aneurismal,  the  root  of  the  left  sub- 
clavian is  diseased,  whilst  if  the  left  temporal  is  also  affected,  it 
suggests  an  aneurism  of  the  transverse  part  of  the  arch  beyond  the 
innominate.     When  both  radial  and  temporal  vessels  on  the  right 
side  show  signs  of  interference  with  the  pulse,  innominate  aneurism 
is  probably  present,  whilst  an  affection  of  only  one  of  these  branches 
indicates  that  the  corresponding  carotid  or  subclavian  is  dilated. 
One  source  of  fallacy  must  not  be  forgotten,  viz.,  that  any  one  of 
these  trunks  may  be  occluded  or  compressed  by  a  neighbouring 
aneurism  without  being  dilated,  and  hence  the  quality  of  the  pulse 
must  be  taken  into  consideration  rather  than  its  actual  volume, 
and  to  this  end  the  sphj^gmograph  is  a  useful  adjunct  in  diagnosis. 
(2)  From  abscess,  tumours,  or  enlarged  glands  with  a  transmitted 
impulse,  a  carotid  aneurism  is  recognised  by  an  application  of  the 
general  principles  detailed  above  (p.  312).     (3)  Pulsating  or  cystic 
goitre  may  be  distinguished  from  a  carotid  aneurism  by  noting  that 
the  goitre  is  not  as  a  rule  limited  to  one  side  of  the  neck,  the  isthmus 
being  also  involved;  that  the  most  fixed  part  of  the  tumour  is  in  the 
median  line,  and  not  under  the  sterno-mastoid  muscle ;  and  that  the 
swelling  moves  up  and  down  during  deglutition,  an  aneurism  re- 


ANEURISM  323 

^maining  fixed.  (4)  An  aneurism  close  to  the  bifurcation  may  be 
simulated  by  an  abnormal  arrangemenl  of  the  terminal  branches,  the 
external  carotid  crossing  the  internal  from  behind  forwards,  and 
being  pushed  outwards  sufficiently  to  cause  a  pulsating  swelling 
beneath  the  skin.  This  condition  is  usually  symmetrical,  and  can 
be  recognised  by  careful  palpation. 

Treatment. — Ligature  of  the  carotid  above  or  below  the  omo-hyoid 
is  the  treatment  usually  adopted,  and  generally  with  great  success. 
If  the  aneurism  is  near  the  root  of  the  neck,  the  distal  operation 
(Brasdor's)  must  be  undertaken. 

Aneurism  of  the  External  Carotid  is  seldom  met  with,  except  as 
an  extension  of  one  involving  the  bifurcation.  The  usual  pheno- 
mena are  presented  near  the  angle  of  the  jaw,  and  well  above  the 
thyroid  cartilage.  Pressure  results  are  early  experienced,  e.g., 
paralysis  of  one  side  of  the  tongue  through  implication  of  the  hypo- 
glossal nerve,  aphonia,  or  dysphagia.  In  suitable  cases,  the  sac 
may  be  dissected  out  after  securing  the  branches  arising  from  it; 
failing  this,  the  common  trunk  must  be  tied. 

Aneurism  of  the  Internal  Carotid  (extracranial  portion)  presents 
symptoms  which  closely  resemble  those  caused  by  an  aneurism  of 
the  bifurcation  or  of  the  external  carotid,  except  that  the  sweUing 
projects  more  into  the  pharynx,  from  which  it  is  separated  merely 
by  the  pharyngeal  wall.  It  appears  as  a  tense  pulsating  tumour, 
placed  immediately  under  the  mucous  membrane,  and  looking 
dangerously  like  an  abscess  of  the  tonsil.  The  Treatment  consists 
in  tying  the  common  carotid. 

Intracranial  Aneurism  occurs  more  commonly  upon  the  internal 
carotid  and  its  branches  than  upon  those  arising  from  the  vertebrals, 
although  the  basilar  artery  is  more  often  affected  than  any  other 
single  vessel.  The  aneurisms  are  generally  fusiform  in  character, 
and  their  origin  is  often  obscure,  being  attributed  to  a  blow  or  fall; 
in  children  they  are  stated  to  result  from  the  lodgment  of  infected 
emboli.  They  sometimes  cause  no  symptoms  until  the  patient  is 
suddenly  seized  with  a  rapidl}^  fatal  apoplexy  from  rupture  of  the 
sac.  Symptoms,  if  present,  are  due  rather  to  compression  of  the 
brain  than  to  erosion  of  the  more  resistant  bony  structures.  Pain 
which  is  more  or  less  fixed  and  continuous  may  be  complained  of, 
or  there  may  be  a  feeling  of  pulsation,  or  of  opening  and  shutting 
the  top  of  the  skull.  Sight,  hearing,  and  other  functions  of  the  brain, 
may  also  be  impaired,  but  physical  changes  in  the  eyes,  such  as 
optic  neuritisor  atrophy,  are  not  induced,  unless  there  is  direct 
pressure  on  some  part  of  the  optic  tract.  Occasionally  a  loud 
whizzing  bruit  may  be  heard  on  auscultating  the  skull.  The  only 
Treatment  possible,  if  a  diagnosis  can  be  established,  is  ligature  of 
the  internal  carotid  artery,  and  even  this  will  be  of  little  use  if  the 
basilar  is  affected. 

Orbital  Aneurism. — Protrusion  of  the  eyeball,  together  with 
pulsation,  which  can  be  felt  or  even  seen  (pulsating  exophthalmos), 
is  always  an  indication  that  some  vascular  lesion  is  present  within 


324  A   MANUAL  OF  SURGERY 

the  orbit,  {a)  It  is  occasionally  congmZ/rt/,  aiul  then  probably  due 
to  the  presence  of  a  deep  cavernous  angioma,  {b)  It  is  most  fre- 
quently traumatic  in  origin,  resulting  from  a  penetrating  wound, 
or  a  blow  on  the  head,  which  may  have  caused  a  fracture  of  the 
base  of  the  skull ;  in  these  the  lesion  present  is  generally  an  aneuris- 
mal  varix  between  the  internal  carotid  and  the  cavernous  sinus. 
(r)  It  may  be  non-traumatic ,  and  result  from  an  aneurism  of  the 
ophthalmic  artery,  or  from  thrombosis  of  the  cavernous  sinus. 
'1  he  patient  complains  of  intra-orbital  pain  and  tension;  the  con- 
junctival and  retinal  vessels  are  distended,  and  a  marked  bruit  may 
be  present  on  auscultation.  The  movements  of  the  eyeball  are 
limited,  vision  is  impaired,  and  the  cornea  may  become  opaque  from 
exposure;  finally,  the  whole  globe  may  be  disorganized.  A  marked 
mitigation  of  all  s3'mptoms  usually  follows  compression  of  the 
carotid. 

Diagnosis. — Sarcoma  of  the  orbital  wall  may  exhibit  many  of  the 
characters  of  intra-orbital  aneurism.  Careful  palpation  will,  how- 
ever, generally  demonstrate  the  existence  of  a  definite  tumour;  the 
pulsation,  moreover,  is  less  marked,  and  the  bruit  less  distinct. 
The  distortion  of  the  eyeball  and  ocular  axis  is  often  considerable 
in  malignant  tumours,  but  vision  is  not  so  early  affected. 

Treatment. — Ligature  of  the  internal  carotid  is  the  only  means 
which  holds  out  any  prospect  of  benefit,  except  in  the  congenital 
cases,  where  electrolysis  has  been  very  successful. 

Subclavian  Aneurism  is  most  frequently  seen  in  men,  and  par- 
ticularly in  those  who  carry  weights  on  their  shoulders;  the  right 
vessel  is  more  often  affected  than  the  left.  Any  part  of  the  artery 
may  be  involved,  but  the  greatest  dilatation  naturally  occurs  in  the 
third  portion.  A  pulsating  tumour  develops  in  the  subclavian 
triangle,  which  may  project  above  the  clavicle,  but  often  extends 
backwards,  outwards,  and  downwards,  causing  pressure  effects 
upon  the  veins  and  nerves  of  the  arm,  and  also  hiccough  by  irrita- 
tion of  the  phrenic.  Occasionally  it  encroaches  on  the  dome  of  the 
pleura  and  apex  of  the  lung,  and  has  been  known  to  burst  into  the 
pleural  cavity.  It  does  not  increase  in  size  very  rapidly,  being 
surrounded  by  dense  unyielding  structures,  and  never  compresses 
the  trachea  or  oesophagus.  No  special  difficulty  presents  itself  in 
diagnosis  as  a  rule,  although  in  the  early  stages  it  may  be  somewhat 
simulated  by  a  normal  artery  pushed  forwards  by  an  exostosis  of 
the  first  rib,  or  by  a  supernumerary  cervical  rib. 

The  Treatment  of  subclavian  aneurism  is  surrounded  with  difficul- 
ties, and  the  results  hitherto  obtained  have  been  most  unsatisfactory. 
Extirpation  has  been  undertaken  with  success  after  turning  up  the 
middle  third  of  the  clavicle,  as  also  Matas'  operation,  but  the  aneur- 
ism is  seldom  sufficiently  limited  to  allow  of  these  proceedings 
Stewart's  method  of  electrolysis,  and  needling  the  sac  according  to 
Macewen's  method,  have  been  adopted  with  occasional  success,  but 
cannot  be  relied  on.  Ligature  of  the  innominate  trun1<  suggests  itself 
as  the  operation  to  be  adopted  for  cure  by  the  Hunterian  method.' 


ANEURISM  325 

and  recent  records  wonld  certainly  encourage  one  to  repeat  it  in  any 
suitable  case,  combined  with  simultaneous  ligature  of  the  carotid, 
so  as  to  avoid  backflow  of  blood.  Ligature  of  the  first  part  of  the 
subclavian  is  occasionally  possible,  and  a  few  successful  cases  have 
now  been  reported,  although  the  first  nineteen  cases  in  which  it  was 
attempted  died. 

As  a  last  resource,  the  plan  suggested  by  the  late  Sir  WiHiam 
Fergusson  may  be  followed,  viz.,  amputation  at  the  shoulder -joint  and 
distal  ligature  as  near  the  sac  as  possible.  Distal  hgature  alone  is 
usually  unsuccessful,  since  the  great  bulk  of  the  blood  needed  for 
the  nutrition  of  the  arm  still  passes  through  the  sac,  and  there  is 
no  means  of  checking  this  except  by  the  removal  of  the  hmb. 

Axillary  Aneurism  is  usually  the  result  of  falls  on  the  outstretched 
arm,  or  injuries  to  the  shoulder,  such  as  fractures  or  dislocations,  or 
of  attempts  to  reduce  them.  A  pulsating  tumour  develops,  and  its 
pressure  causes  pain,  local  and  neuralgic,  or  oedema  of  the  arm. 
When  the  upper  part  of  the  vessel  is  affected,  the  pulsation  is  felt 
immediately  below  the  clavicle,  and  may  project  up  into  the  neck, 
displacing  the  clavicle  forwards;  if  placed  lower  down,  the  aneurism 
occupies  the  axilla.  The  progress  of  the  case  is  often  rapid,  and  the 
thoracic  cavitv  may  even  be  encroached  on.  Treatment. — Com- 
pression (digital)  or  ligature  of  the  third  part  of  the  subclavian  artery 
is  required,  but  if  the  aneurismal  sac  extends  under  the  clavicle, 
it  may  be  necessary  to  secure  the  second  part  of  the  artery,  due  care 
being  taken  of  the  phrenic  nerve. 

Aneurisms  of  the  brachial  artery,  or  of  any  of  the  vessels  of  the 
forearm,  require  no  special  notice.  They  are  almost  invariably 
traumatic  in  origin,  and  should  be  treated  by  extirpation. 

Abdominal  Aneurism. — The  abdominal  aorta  may  become  the  seat 
of  aneurism,  either  at  the  upper  part  near  the  coehac  axis,  or  at  the 
bifurcation.  A  pulsating  tumour  is  observed  near  the  middle  line, 
and  either  close  to  the  umbihcus  or  in  the  epigastric  notch;  the 
pulsation  is  expansile  in  type,  and  remains  the  same  in  character 
whatever  the  position  of  the  patient.  Pain,  locaHzed  in  the  back 
from  erosion  of  the  vertebrae,  or  neuralgic  from  pressure  on  the  solar 
plexus  or  lumbar  nerves,  is  the  chief  symptom,  whilst  oedema  of  the 
lower  extremities  may  arise  from  compression  of  the  vena  cava. 
There  may  be  some  concurrent  derangement  of  the  intestinal  func- 
tions. Occasionally  aneurisms  form  independently  on  the  spleiiic, 
hepatic,  or  mesenteric  vessels.  Diagnosis. — Many  conditions  give 
rise  to  epigastric  pulsation.  Cardiac  pulsation  may  be  felt  in  the 
epigastrium  when  the  heart  is  dilated,  but  should  be  easily  recog- 
nised; as  also  an  impulse  transmitted  from  the  aorta  through  a 
collection  of  faeces  or  a  cancerous  growth.  The  examination  of  such 
a  case,  if  need  be  under  an  anaesthetic,  should  be  conducted  not  only 
in  the  dorsal  decubitus,  but  also  in  the  genu-pectoral  position,  so 
as  to  remove  the  weight  of  the  viscera  from  the  aorta,  when  the 
pulsation  will  cease  or  be  much  diminished.  Radiography  is  of 
great  service  in  the  diagnosis  of  these  cases. 


326  A   MANUAL  OF  SURGERY 

Treatment. — Failing  medical  treatment  by  rest  and  diet,  compres- 
sion was  formerly  relied  on,  being  applied  either  on  the  distal  or 
proximal  aspect  of  the  sac.  The  method  is,  however,  clumsy  and 
liable  to  bruise  the  abdominal  viscera.  More  recently  treatment 
by  needling  the  sac  has  been  employed,  and  certainly  in  Macewen's 
hands  at  least  one  case  has  been  brilliantly  successful.  There  is 
also  one  instance  on  record  where  the  introduction  of  wire  into  the 
sac,  combined  with  electrolysis,  cured  an  aneurism  as  large  as  an 
orange;  the  abdomen  was  opened,  and  electrol3'sis  was  maintained 
for  thirty-seven  minutes. 

Iliac  or  Inguinal  Aneurism  arises  from  either  the  common  or  ex- 
ternal iliac,  or  from  the  common  femoral;  it  is  frequently  sacculated 
in  tj'pe  and  lobulated  in  shape  owing  to  the  pressure  of  fascial  or 
other  structures.  The  symptoms  are  very  tvpical,  and  diffusion  is 
certain  to  ensue  sooner  or  later.  The  Diagnosis  cannot  be  well 
mistaken  in  the  early  stages,  but  later  on,  and  specially  when  situ- 
ated high  in  the  iliac  fossa,  it  may  be  difficult  to  distinguish  from  a 
pulsating  sarcoma.  Treatment. — Extirpation  is,  of  course,  the  best 
plan  to  adopt  if  it  be  possible,  but  more  frequently  one  must  depend 
on  proximal  ligature.  For  an  inguinal  aneurism,  the  external  ihac 
may  be  tied  with  every  prospect  of  success.  If  the  aneurism  is 
situated  higher,  ligature  of  the  common  ihac  may  be  undertaken 
(transperitoneal  operation),  or  even  of  the  aorta.  The  latter  opera- 
tion has  been  performed  in  ten  instances,  and  in  all  a  fatal  result 
followed,  although  two  patients  lived  thirty-nine  and  forty-eight 
days  respectively.  Failing  any  of  these  methods,  compression  of 
the  aorta  or  common  iliac  may  be  emploved. 

Aneurisms  of  the  Gluteal  and  Sciatic  Arteries  are  usually  traumatic 
in  origin,  and  present  as  pulsating  swellings  in  the  buttock,  the 
gluteal  situated  at  the  upper  part  of  the  sciatic  notch,  whilst  the 
sciatic  lies  more  deeply,  and  may  be  partly  intrapelvic.  Pain  in 
the  limb  from  pressure  on  the  sciatic  nerve  is  a  prominent  symptom, 
especially  in  the  sciatic  variety.  The  Diagnosis  is  by  no  means 
easy,  especially  from  a  pulsating  sarcoma.  Treatment. — \\'hen 
the  diagnosis  is  established,  transperitoneal  ligature  of  the  internal 
iliac  artery  should  always  be  adopted.  If  the  sac  is  laid  open  from 
the  buttock  as  a  result  of  a  mistaken  diagnosis,  the  old-fashioned 
plan  of  treatment  must  be  followed,  viz.,  to  turn  out  the  clots  and 
secure  the  bleeding-points. 

Femoral  Aneurism  is  the  title  given  to  one  forming  in  the  course 
of  the  superficial  femoral  artery.  It  is  not  uncommonly  tubular,  and 
occurs  almost  invariably  in  males.  Treatment  consists  either  in 
extirpation,  or  ligature  of  the  common  or  superficial  femoral  trunk. 

Popliteal  Aneurism  occurs  almost  invariably  in  men,  constituting 
a  pulsating  tumour  in  the  ham,  rendering  the  knee  painful  and  stiff, 
and  so  much  do  the  symptoms  resemble  those  of  chronic  rheuma- 
tism that  in  every  such  case  the  popliteal  space  should  be  examined. 
The  limb  is  usually  kept  semiflexed,  and  the  aneurism  often  increases 
rapidly  in  size.     If  the  main  swelUng  is  situated  in  front  of  the 


LIGATURE  OF  VESSELS  327 

vessel,  there  is  some  likelihood  of  the  knee-joint  becoming  implicated 
and  neighbouring  bones  carious;  when  it  extends  posteriorly, 
diffusion  is  not  uncommonly  followed  by  gangrene,  on  account  of 
the  pressure  exercised,  not  only  upon  the  vein,  but  also  upon  the 
articular  branches  of  the  popliteal  artery,  which  are  most  important 
factors  in  maintaining  the  collateral  circulation.  The  Diagnosis 
has  to  be  made  from  chronic  enlargement  and  abscess  of  the  pop- 
liteal glands,  but  in  these  there  is  less  disturbance  of  the  circulation 
in  the  foot;  from  bursal  tumours,  by  their  want  of  mobility  and 
pulsation;  or  from  solid  tumours,  e.g.,  pulsating  sarcoma  of  the 
femur  or  tibia,  by  attention  to  the  general  principles  already 
enunciated.  In  a  few  instances  spontaneous  cure  has  resulted  from 
the  pressure  of  the  sac  upon  the  artery  above. 

Treatment. —Compression  has  been  eminently  successful  in  many 
of  these  cases.  Ligature  of  the  femoral  artery  at  the  apex  of 
Scarpa's  triangle  is,  however,  the  plan  most  commonly  adopted, 
and  wath  the  greatest  success.  In  cases  where  either  of  these 
methods  has  failed,  or  where  the  aneurism  has  become  diffuse  or 
recurred,  extirpation  of  the  sac  is  the  best  course  to  adopt. 

Ligature  of  Vessels. 

This  operation  is  performed  to  arrest  the  flow  of  blood  to  the 
peripher}',  in  order  either  to  check  haemorrhage,  or  to  promote  the 
cure  of  an  aneurism,  or  to  diminish  the  rate  of  growth  of  some 
tumour,  or  to  influence  beneficially  some  peripheral  organ  by  re- 
ducing its  blood-supply,  or  as  a  preliminary  to  removing  some 
vascular  structure,  such  as  the  tongue. 

Operation. — The  artery  is  examined  as  far  as  is  possible,  so  that  a 
healthy  portion  may  be  selected  for  applying  the  ligature.  The 
various  structures  {raUying-po-ints)  met  with  on  the  way  to  the 
artery  are  recognised,  and  drawn  aside,  if  need  be,  so  as  to  lay  bare 
the  sheath  of  the  vessel,  which  is  opened  over  the  artery  by  a 
longitudinal  incision  about  |  inch  in  length.  The  aneurism  needle 
is  inserted  unarmed,  and  gently  manipulated  up  and  down,  so  as  to 
free  the  vessel  all  round,  a  matter  of  no  great  difficulty  if  the  sheath 
has  been  correctly  opened  and  the  arterial  wall  exposed.  The 
ligature  may  then  be  passed  through  the  eye  of  the  needle,  and 
carried  round  the  vessel,  tied  in  a  direction  exactly  at  right  angles 
to  the  longitudinal  axis;  in  doing  so  the  artery  must  not  be 
dragged  out  of  its  sheath,  but  the  ligature  should  be  tightened  by 
the  tips  of  the  forefingers  meeting  upon  it.  The  opening  in  the 
sheath  should  be  closed  over  the  ligature  by  a  fine  buried  stitch, 
and  the  various  structures  displaced  in  reaching  the  vessel  are 
similarly  secured  in  good  position. 

Method  of  Application  of  the  Ligature. — In  the  smaller  vessels 
and  those  of  medium  size  all  that  is  needed  for  security  is  a  reef  knot 
tied  firmly;  but  in  the  largest  trunks — e.g.,  the  innominate,  first 
part  of  the  subclavian,  and  common  iliac — it  is  advisable  to  employ 


328 


A   MANUAL  OF  SURGERY 


what  is  termed  the  stay  knot  (Fig.  104).  Two  strands  of  Hgature 
are  passed  round  the  vessel  side  by  side  and  half-knotted;  the  two 
ends  on  each  side  are  then  taken  up  together  and  tied  across  in  one 
knot.  The  degree  of  tension  used  in  these  cases  is  such  as  to 
approximate  completely  the  vessel  walls,  but  without  rupturing  the 
inner  or  middle  coats,  thereby  minimizing  the  risks  of  secondary 
haemorrhage.  Broad  strands  of  animal  ligature — e.g.,  gold-beater's 
skin  or  ox  aorta — should  be  employed  in  these  cases. 

Some  surgeons  recommend  that  two  ligatures  should  be  applied 
to  the  artery,  and  the  vessel  divided  between  them.  This  plan  is 
suggested  to' avoid  longitudinal  traction  on  the  site  of  ligature,  which 
necessarily  results  from  the  fact  that  all  arteries  in  the  body  are  main- 
tained more  or  less  upon  the  stretch,  as  evidenced  by  their  retraction 
when  divided  ;  it  is  supposed  that  secondary  haemorrhage  is  pre- 
disposed to  by  this  condi- 
tion With  modern  aseptic 
methods  this  precaution 
is  of  little  significance. 

The  rule  usually  followed 
is  to  pass  the  needle  from 
inipoytant  structures,  such 
as  the  vein,  but  really  this 
is  a  matter  of  little  import- 
ance when  the  above  direc- 
tions have  been  carefully 
carried  out,  and  especially 
in  superficial  vessels. 
Should  the  vein  he  acci- 
dentallv  punctured,  the  needle  must  be  at  once  withdrawn  and  the 
puncture  in  the  vein  secured  by  ligature,  whilst  the  artery  is  tied  a 
little  higher  or  lower.  In  dealing,  however,  with  the  smaller  vessels, 
where  the  vense  comites  are  in  close  contact  with  the  arteries,  no 
harm  will  attend  their  inclusion  in  the  ligature. 

After-Treatment.— The  patient  must  be  kept  at  rest  for  at  least 
three  weeks  in  order  to  secure  permanent  obliteration  of  the  artery 
and  the  effective  development  of  a  collateral  circulation,  especially 
in  dealing  with  the  larger  vessels  and  in  elderly  people.  When  the 
main  artery  to  one  of  the  extremities  has  been  tied,  the  limb  should 
be  wrapped  in  aseptic  wool  and  slightly  raised,  and  if  there  is  any 
likelihood  of  gangrene,  it  should  be  thoroughly  purified. 

There  are  two  great  dangers  liable  to  follow  the  ligation  of  an 
artery  in  its  continuity: 

1.  Secondary  Hsemorrhage  {vide  p.  293). 

2.  Gangrene  may  arise  from  a  variety  of  causes:  {a)  From  simple 
loss  of  vitality,  owing  to  a  defective  collateral  circulation,  as  when 
the  peripheral  vessels  are  calcareous  and  rigid.  The  tissues  which 
receive  the  smallest  amount  of  blood  die  first,  e.g.,  the  fingers  or  toes, 
or  the  subcortical  white  substance  of  the  brain.  Severe  loss  of  blood 
after  the  operation,  as  from  secondary  haemorrhage,  may  also  deter- 


FiG.   104. — Stay  Knot. 


LIGATURE  OF   VESSELS  329 

mine  tissue  necrosis.  Under  such  circumstances  it  almost  always 
takes  on  the  dry  form,  [h)  Interference  with  the  venous  return,  as 
by  injury  to  the  vein  during  operation,  or  the  pressure  of  a  tight 
bandage,  or  thrombosis  induced  subsequently  by  infective  periphle- 
bitis, Ts  very  likely  to  cause  gangrene,  and  then  it  is  of  the  moist 
t\'pe.  (r)  Unsuitable  after-treatment,  such  as  too  great  elevation 
of  the  limb,  the  injudicious  application  of  an  ice-bag  or  hot-water 
bottle  during  the  period  of  chminished  vitality  immediately  following 
the  operation,  or  even  an  attack  of  erysipelas,  may  also  bring  about 
the  death  of  some  of  the  tissues.  The^Treatment  of  aseptic  gangrene 
following  ligature  is  expectant  in  character,  the  parts  being  allowed 
to  separate"naturally.  But  if  there  is  much  pain,  or  any  tendency 
to  spread,  or  if  infection  is  present,  giving  rise  to  fever  and  general 
disturbance,  it  is  wiser  to  remove  the  limb  well  above  the  line  of 
demai'cation. 

The  Innominate  Artery  has  now  been  tied  with  success  on  at  least  six  occa- 
sions out  of  a  total  of  about  thirty  operations.  An  incision  is  made  along  the 
lower  third  of  the  anterior  border  of  the  sterno-mastoid,  and  is  prolonged  down- 
wards to  sweep  over  the  upper  edge  of  the  episternal  notch.  The  platysma 
and  the  superficial  and  deep  fasciae  are  divided,  and  the  anterior  jugular  vein 
secured  if  necessary  between  two  ligatures;  the  sterno-mastoid  is  drawn  out- 
wards, and  its  inner  tendinous  fibres  are  divided,  whilst  the  sterno-hyoid  and 
-thyroid  muscles  are  severed  close  to  the  sternum  and  drawn  inwards.  The 
carotid  sheath  is  now  laid  bare  and  opened  at  its  lower  part,  so  as  to  expose 
the  carotid  artery  and  enable  it  to  be  tied,  and  by  followdng  this  downwards 
the  innominate  trunk  is  reached.  In  some  cases  it  may  expedite  matters  to 
remove  portions  of  the  sternum  and  inner  end  of  the  clavicle.  The  right 
internal  jugular  and  innominate  veins  lie  to  the  outer  side  of  the  artery,  but 
if  much  engorged  may  project  over  it,  and  must  then  be  drawn  aside  by 
retractors,  whilst  the  inferior  thjToid  plexus  may  course  directly  do\\-nwards 
to  reach  the  left  innominate  vein,  which  crosses  the  vessel.  To  the  outer  or 
right  side  and  behind  the  veins  are  placed  the  vagus  nerve  and  pleural  sac, 
and  these  must  be  carefully  separated  from  the  artery,  whilst  the  needle  is 
passed  from  without  inwards,  and  from  below  upwards.  A  double-curved 
aneurism  needle  will  probably  be  required  to  effect  this.  A  broad  animal 
ligature  should  be  used  for  this  vessel,  and  the  inner  and  middle  coats  must 
not  be  di\'ided. 

Collateral  Circulation. — Intracranial  :  Vertebrals  and  carotids  in  the  circle  of 
Willis. 

Face  and  Neck  :   Branches  of  the  two  external  carotids  across  middle  line. 

Trunk  :  First  aortic  intercostal  with  superior  intercostal  of  subclavian ;  upper 
aortic  intercostals  with  thoracic  branches  of  axillary  and  intercostals  of  internal 
mammary;  deep  epigastric  and  phrenic  with  terminal  divisions  of  internal 
mammary. 

The  Carotid  Artery  may  be  tied  either  above  or  below  the  level  at  which  it  is 
crossed  bv  the  anterior  belly  of  the  omo-hyoid.  The  line  of  the  vessel  is  indi- 
cated by  that  drawn  from  the  sterno-clavicular  articulation  to  a  point  midway 
between  the  angle  of  the  jaw  and  the  tip  of  the  mastoid  process,  the  bifurca- 
tion being  on  a  level  ^vith  the  upper  border  of  the  thyroid  cartilage. 

Ligature  above  the  Omo-hvoid. — The  vessel  is  here  more  superficial,  and  the 
ligature  is  applied  on  a  level  with  the  cricoid  cartilage.  The  patient  lies 
upon  the  back,  with  the  chin  raised  and  the  head  turned  towards  the  opposite 
side.  A  3-inch  incision  is  made  in  the  line  of  the  vessel,  the  centre  on  a  level 
with  the  cricoid  (Fig.  105,  D).  The  skin,  platysma,  and  fasciae  are  divided, 
and  the  anterior  edge  of  the  sterno-mastoid  defined.  The  deep  fascia  is 
incised  along  its  inner  border,  so  that  it  may  be  drawn  aside  by  a  retractor; 
the  sterno-mastoid  branch  of  the  superior  thyroid  artery  may  be  divided  at 


330 


A   MANUAL  OF  SURGERY 


this  stage.  On  the  inner  side  of  the  wound  the  omo-hyoid  muscle  must  now 
be  looked  for,  tremling  forwartls  and  upwards  from  under  to\er  of  the  sterno- 
mastoid.  In  the  angle  formed  liy  these  two  structures  the  pulsation  of  the 
vessel  should  be  felt  and  the  sheath  readily  recognised,  with  the  descendens 
cervicis  nerve  upon  it.  It  is  opened  on  the  inner  side,  and  the  artery  well 
cleared.  The  needle  is  passed  from  without  inwards,  and  if  the  sheath  has 
been  efficiently  opened,  the  vagus  nerve  will  nm  no  risk  of  being  included. 

Ligature  below  the  Omo-hyoid. — A  similar  incision  is  made,  but  lower  in  the 
neck,  reaching  from  the  cricoid  cartilage  nearly  to  the  sterno-clavicular  joint. 
The  sterno-mastoid  is  drawn  outwards,  and  perhaps  the  anterior  fibres  may 

need  to  be  divided ;  the  sterno- 
hyoid and  -thyroid  muscles  are 
retracted  inwards  or  divided,  and 
the  omo-hyoid  can  usually  be 
drawn  upwards.  The  sheath  is 
thus  exposed,  and  opened  on  the 
inner  side,  the  needle  being  passed 
as  in  the  previous  operation.  It 
must  be  remembered  that  both 
internal  jugular  veins  are  directed 
towards  the  right  side  in  the  lower 
part  of  their  course,  and  hence  the 
left  vein  is  likely  to  lie  somewhat 
in  front  of  the  artery.  The  inferior 
th\Toid  veins  may  also  be  seen, 
and  need  to  be  drawn  aside  or 
ligatured. 

The  effects  of  ligature  of  the 
carotid  upon  the  brain  are  of  great 
interest  and  importance.  Statistics 
prove  that  about  25  per  cent,  of 
the  patients  develop  cerebral  symp- 
toms, either  immediately  in  the 
form  of  syncope  from  cerebral 
anaemia,  or  in  the  course  of  a  few 
days  from  cerebral  softening, 
causing  hemiplegia.  A  fatal  issue 
is  likely  to  result  in  about  half  the 
cases  thus  affected. 

Collateral  Circulation.  —  Intra- 
cranial :  Circle  of  Willis. 

Extracranial  :  Communications 
across  the  middle  line  of  branches 
of  the  external  carotids  and 
vertebrals;  inferior  th>Toid  with 
the  superior  thyroid;  profunda 
cervicis  with  princeps  cervicis  of 
occipital  ;  superficial  cervical  ivith 
branches  of  occipital  and  vertebral. 
Ligature  of  the  Internal  Carotid. — An  incision  is  made  along  the  anterior 
border  of  the  sterno-mastoid,  its  centre  being  opposite  the  great  cornu  of  the 
hyoid  bone;  the  muscle  is  pulled  backwards,  and  the  ]wsterior  belly  of  the 
digastric  is  seen  and  drawn  up.  The  external  carotid  is  displaced  forwards, 
and  then  the  internal  carotid  in  its  sheath  appears.  The  latter  is  opened,  and 
the  aneurism  needle  passed  from  the  jugular  vein. 

The  Collateral  Circulation  to  the  brain  is  maintained  by  the  circle  of  Willis. 
Ligature  of  the  External  Carotid  is  occasionally  required,  the  site  of  election 
being  between  the  superior  thyroid  and  lingual  branches.  An  incision  is  made 
along  the  anterior  border  of  the  sterno-mastoid,  3  inches  in  length,  its  centre 
corresponding  to  the  great  cornu  of  the  hyoid  bone.  The  edge  of  the  muscle 
is  defined  and  drawn  outwards,  and  the  posterior  belly  of  the  digastric  sought 


Fig.  105. — Incisions  for  Various  Oper- 
ations ON  Head  and  Neck. 

A,  Flap  incision  used  in  trephining  for 
meningeal  haemorrhage;  B,  flap  incision 
for  operation  on  roots  of  the  fifth  nerve ; 

C,  incision  for  ligature  of  lingual  artery; 

D,  for    ligature    of    common    carotid; 

E,  for  ligature  of  vertebral  artery;  F, 
for  ligature  of  the  third  part  of  the  sub- 
clavian; G  and  G^,  incisions  used  for 
tying  first  part  of  axillary;  H,  for  liga- 
ture of  internal  mammary  arterj^. 


LIGATURE  OF   VESSELS 


331 


for  above  the  hypoglossal  nerve  lying  just  below  it.  ihe  sheath  is  now 
opened  below  the  tip  of  the  great  eornu,  and  the  need  e  passed  from  without 
TnwaJds  The  operation  may"  be  rendered  dilftcult  by  the  presence  of  enlarged 
SSs  or  veins,  espeeially  the  lingual,  facial,  and  superior  thyroid,  which  1  e 
fnkonrof  the  vessel.  The  superior  laryngeal  nerve  is  placed  immediately 
behind  it,  and  must  be  avoided.  ^„„;oi 

CoUateml  Ciyculation.-Vrde  ligature  of  the  common  carotid  (extra-cranial 

^'"^Ligatoe  Of  the  Lingual  Artery  is  chiefly  employed  as  a  preliminary  to 
removal  of  the  tongue  for  mafignant  disease.  The  vessel  can  be  secured  either 
close  to  its  origin  Irom  the  external  carotid,  or  in  the  submaxillary  triangle 
under  cover  of  the  hyoglossus  muscle.  ,  •     1^     1  4.1,    4-v,^ 

In  Z  SubmaxUlary   Triangle.-The  patient  lies  on  his   back    with  the 
shoulders  raised,  and  the  head  Extended  backwards  and  turned  to  the  opposite 


Fig.  106.— Ligature  of  Lingual  Artery.  (Tillmanns.) 
The  submaxillary  gland  (Gs)  has  been  drawn  over  the  side  of  t^e  Jaw  with  a 
hook;  I,  external  carotid;  2.  internal  jugular  artery;  ^^''^^^''^.^ll^'y'. 
4,  ranine  branch  of  facial  artery;  5,  hypoglossal  nerve  M  dig,  digastric 
M  styl.  stylo-hyoid ;  M  myho,  mylo-hoid ;  M  hyogl,  hyoglossus.  The  place 
where  the  artery  is  tied  is  indicated  by  a  window  m  the  hyoglossus, 
through  which  it  can  be  seen. 

side  A  crescentic  incision  with  its  convexity  downwards  is  made  com- 
mencing about  I  inch  below  the  symphysis  menti,  ^^^  extending  back  to  the 
sterno-mastoid.  the  centre  opposite  the  great  cornu  of  the  ^^y^^J  Ji°^^/5;|- J°^: 
C)  The  integument  and  platysma  are  divided,  the  lower  bolder  of  the  suD 
maxillary  gland  is  defined,  and  along  it  the  deep  fascia  is  incised  The  gfana 
Snow  dLwn  upwards  and  held  over  the  margin  of^he  jaw  with  a  retractor 
(Fi-  106  Gs).  On  opening  up  the  wound  thoroughly  the  two  bellies  of  tlae 
digastric  muscle  (M  dig)  ar"e  seen  converging  to  the  hyoid  bone  the  anterior 
be^fy  passing  superficifl  to  the  fibres  of  the  mylo-hyoid  --^l^  (^jS 
which  course  nearly  transversely  to  the  mandible,  and  of  which  the  posterior 
fibres  may  be  divided  with  advantage.  The  digastric  tendon  is  drawn  c^own 
with  a  blunt  hook,  and  in  the  space  thus  cleared  the  ^^yog^^^^X  "d 
(M  hvogl)  becomes  evident  with  its  fibres  passmg  vertically  "P^^"^^'  ^^Jj 
resting  upon  it  the  hypoglossal  nerve  (5)  c our smg  forwards  to  get  under  cover 
of  the  mylo-hyoid,  and  either  above  or  below  it  the  ranine  ^^m .  The  fibi  es  oi 
the  hyoglossus  are  now  divided  transversely  midway  between  the  nerve  and 


332  A   MANUAL  OF  SURGERY 

the  hyoid  bonu,  and  in  the  oj)ening  made  by  their  retraction  is  seen  the  artery 
(3),  lying  on  the  mitldle  constrictor.  Should  it  not  be  found  in  this  situation, 
the  incision  in  the  hyoglossus  should  be  extended  backwards,  and  the  vessel 
will  then  usually  come  in  sight. 

In  the  Neck  Close  to  its  Origin  — ^An  incision  is  made  along  the  anterior  border 
of  the  sterno-mastoid  similar  to  that  needed  for  ligature  of  the  external  carotid. 
The  muscle  is  drawn  backwards,  and  the  great  cornu  of  the  hyoid  bone  defined. 
The  small  space  is  now  cleared  between  that  bony  process  anil  the  posterior 
belly  of  the  digastric,  in  which  the  artery  can  be  felt  resting  upon  the  middle 
constrictor,  and  secured  just  as  it  rises  from  the  external  carotid. 

The  Facial  Artery  may  be  exposed  and  tied  through  a  horizontal  incision, 
I  inch  m  length,  made  directly  over  the  vessel  as  it  crosses  the  lower  border  of 
the  jaw  immediately  in  front  of  the  masseter. 

The  Temporal  Artery  is  reached  in  front  of  the  auditory  meatus  through  a 
vertical  incision,  and  must  be  carefully  isolated  from  the  auriculo-temporal 
nerve. 

The  Occipital  Artery  is  tied  through  an  incision  extending  from  the  apex  of 
the  mastoid  process  backwards  for  about  2  inches  towards  the  occipital  pro- 
tuberance. The  posterior  fibres  of  the  sterno-mastoid,  the  splenius,  and 
trachcio-mastoid,  are  divided  so  as  to  expose  the  artery  as  it  emerges  from  the 
groo\x^  on  the  under  surface  of  the  mastoid  process,  where  it  is  easily  secured. 

The  Subclavian  Artery  has  been  tied  in  each  part  of  its  course,  but  most 
frequently  in  the  third.  Ligatures  of  the  first  and  second  parts  are  such 
unusual  proceedings  that  we  must  refer  students  to  larger  textbooks  for 
descriptions. 

For  Ligature  of  the  third  part  the  patient  is  placed  on  the  back,  close  to  the 
edge  of  the  table;  the  arm  is  well  depressed,  and  the  head  turned  to  the 
opposite  side.  The  skin  is  drawn  down  by  the  left  hand,  and  an  incision 
3  or  4  inches  long  made  over  the  clavicle  (Fig.  105,  F).  On  releasing  the  skin 
it  retracts  upwards,  so  that  the  wound  comes  to  be  situated  about  5  inch  above 
the  clavicle,  and  thus  the  external  jugular  vein  is  more  efficiently  protected. 
The  incision  should  be  placed  with  its  centre  about  i  inch  to  the  inner  side 
of  the  middle  of  the  clavicle,  and  should  expose  the  space  between  the  sterno- 
mastoid  and  trapezius  muscles,  the  fibres  of  which  are  divided  to  a  suitable 
extent  if  they  encroach  abnormally  upon  the  bone.  The  external  jugular  and 
other  veins  often  give  the  surgeon  much  trouble;  they  are  either  drawn  aside 
or,  if  necessary,  divided  between  ligatures.  The  deep  fascia  is  incised  in  the 
line  of  the  wound,  care  being  taken  to  avoid  the  transverse  cervical  and  supra- 
scapular arteries,  the  former  of  which  is  above  the  line  of  operation,  whilst  the 
latter  is  hidden  behind  the  clavicle.  The  posterior  belly  of  the  omo-hyoid,  if 
seen  at  all,  is  drawn  upwards.  Various  layers  of  fascia  must  be  carefully  cut  or 
torn  through  until  the  nerves  of  the  brachial  plexus  appear;  the  finger  can 
then  readily  define  the  scalene  tubercle  on  the  first  rib.  The  subclavian  vein 
is  situated  in  front  of  the  finger,  but  on  a  lower  level,  whilst  the  artery  itself 
can  be  detected  pulsating  under  the  pulp  of  the  finger  between  it  and  the  rib. 
The  cords  of  the  brachial  plexus  are  placed  above  and  external  to  it,  the  lower 
cord  passing  down  behind.  The  needle  is  insinuated  from  above  downwards, 
and  must  be  kept  very  close  to  the  artery  to  prevent  all  possibility  of  in- 
cluding the  lowest  cord  of  the  plexus.  The  operation  in  a  thin  patient  may 
be  easy,  but  in  a  stout  subject,  with  a  short  thick  neck  and  high  clavicle,  the 
greatest  difficulty  may  be  experienced  in  finding  the  vessel.  The  chief  dangers 
arise  from  wounding  the  pleural  cavity,  or  the  superficial  veins,  or  from 
ligaturing  one  of  the  cords  of  the  brachial  plexus. 

Collateral  Circulation. — Thoracic  set  :  Branches  of  the  aortic  intercostals  and 
internal  mammary  with  thoracic  branches  of  axillary. 

Scapular  set  :  Suprascapular  and  posterior  scapular  with  subscapular  and 
its  dorsalis  branch  in  the  venter  or  on  the  dorsum  of  scapula. 

Acromial  set  :  Suprasca]:)ular  'cvith  acromio-thoracic. 

The  Internal  Mammary  Artery  (Fig.  105,  H)  may  be  exposed  and  tied  by 
dividing  the  intercostal  aponeurosis  and  muscles  for  an  inch  or  more  from  the 
outer  edge  of  the  sternum,  from  which  it  is  distant  about  i  inch. 


LIGATURE  OF   VESSELS  333 

Ligature  of  the  Vertebral  Artery  has  been  undertaken  for  wounds,  for 
secondary  haemorrhage  after  ligature  of  the  innominate,  and  m  the  treatment 
of  epilepsy  but  without  much  permanent  bencht  m  the  last  case.  An  incision 
is  made  along  the  lower  halt  of  the  posterior  border  of  the  sterno-mastoid 
(Fi"-  los  E)  the  platysma  and  deep  fascia  are  divided,  and  the  muscle  drawn 
forwards'  The  scalenus  anticus  is  clearly  defined,  together  with  the  phrenic 
nerve  The  interval  between  it  and  the  longus  colli  muscle  can  now  be  demon- 
strated, with  the  ascending  cervical  artery  lying  upon  it.  The  anterior  trans- 
verse process  of  the  sixth  cervical  vertebra  must  be  made  out.  Just  below 
this  the  vertebral  vessels  are  found  entering  the  canal  m  the  transverse  pro- 
cess and  the  vein  which  is  placed  anteriorly,  is  drawn  outwards  to  allow  the 
needle  to  be  passed  from  without  inwards.  A  few  sympathetic  twigs  are 
often  included  in  the  ligature,  and  may  cause  contraction  of  the  pupil. 

Ligature  of  the  Thyroid  Vessels  is  sometimes  used  as  a  means  of  arrestmg 
the  growth  of  a  goitre.  .  .  4.     -^^ 

The  superior  thyroid  artery  is  tied  through  an  incision  along  the  anterior 
margin  of  the  sterno-mastoid,  which  has  its  centre  opposite  the  upper  border 
of  the  thyroid  cartilage;  the  external  carotid  is  defined,  and  the  superior 
thyroid  secured  at  its  origin.  ...  ,  ,,      -^^^^ 

The  inferioy  thyroid  artery  is  reached  through  an  mcision  along  the  inner 
border  of  the  sterno-mastoid,  extending  upwards  from  the  clavicle  for  3  inches 
This  muscle  and  the  subjacent  carotid  sheath  are  drawn  outwards,  the  sterno- 
hyoid and  -thyroid  usually  needing  to  be  divided.  The  transverse  process 
of  the  sixth  cervical  vertebra  is  sought  for,  and  the  vessel  found  passing 
inwards  immediately  below.  It  is  taken  up  just  behind  the  carotid,  and  as 
far  from  the  recurrent  laryngeal  nerve  as  possible.  ^    ..  1 

The  Axillary  Artery  is  tied  for  punctured  wounds  of  the  axilla,  as  a  distal 
operation  for  subclavian  aneurism,  occasionally  for  wovmds  of  the  palmar 
arch  and  possibly  for  secondary  haemorrhage  from  the  brachial.  iwo 
classical    operations    are    described   and   practised   in   classes   on   operative 

^""^rYioature  of  the  first  part  of  the  vessel  is  usually  undertaken  through  a  curved 
incision  with  its  concavity  upwards,  extending  from  tlie  coracoid  process  to 
just  below  the  sterno-clavicular  joint  (Fig.  105,  G^).  The  clavicular  origin 
of  the  pectoralis  major  is  divided,  and  the  costo-coracoid  membrane  exposed 
and  divided.  Branches  of  the  acromio-thoracic  axis  are  displaced,  and  the 
main  trunk  is  exposed  by  a  blunt  dissector  and  forceps.  The  vein  lies  withm 
and  below,  and  the  cords  of  the  brachial  plexus  above  and  to  the  outer  side. 
The  divided  muscular  fibres  should  be  subsequently  sutured  together 

An  incision  which  gives  an  unusually  good  approach  and  involves  less 
division  of  muscular  fibres  is  one  which  follows  the  lower  border  of  the  clavicle 
from  its  centre  outwards  to  the  coracoid  process,  and  then  turns  down  to  he  over 
the  interspace  between  the  pectorahs  major  and  deltoid  muscles  (tig  105  U). 
This  intersection  is  opened  up  and  the  outermost  fibres  of  the  pectoralis  which 
arise  from  the  clavicle  are  divided.  The  costo-coracoid  membrane  is  thus 
exposed,  and  the  cephalic  vein  will  act  as  a  guide  to  the  vessels 

2.  Ligature  of  the  third  part  of  the  artery  is  performed  from  the  axilla,  the 
arm  is  fully  abducted,  and  the  surgeon  stands  between  it  and  the  body  An 
incision  is  made  in  the  course  of  the  vessel  (Fig.  107,  A) .  The  inner  border  of 
the  coraco-brachialis  muscle  is  clearly  defined,  and  drawn  slightly  outwards, 
and  the  median  nerve,  together  with  the  musculo-cutaneous  trunk,  at  once 
comes  into  view.  On  drawing  these  inwards,  the  artery  itself  is  seen,  with  the 
vein  to  the  inner  side.     The  needle  is  passed  from  the  vein 

Collateral  Circulation .—li  above  the  acromio-thoracic,  the  same  as  tor  tne 
third  part  of  the  subclavian  (g-.w.).  .  ,•    ,     ^  o-(-oi=  „„v/. 

If  above  the  subscapular  and  circumflex:  Long  thoracic  and  mtercostals  wit 
thoracic  branches  of  subscapular;  suprascapular  and  posterior  scapular  w</ 
scapular  branches  of   subscapular;  suprascapular  and  acromio-thoracic  with 
posterior  circumflex  in  the  deltoid.  ,•   ,     i  +1,,.  a,iT-,A,-ir.r 

If  below  the  circumflex,  same  as  for  ligature  of  brachial  above  the  supeuor 
profunda— i.e.,  posterior  circumflex  with  superior  profunda  m  tlie  deltoid. 


334 


A   MANUAL  OF  SURGERY 


,-s^ 


The  Brachial  Artery  may  need  to  be  ligatured  for  haemorrhage  from  the 
palmar  arches,  or  from  a  wound  in  the  forearm  or  about  the  elbow,  for 
aneurisms,  or  for  arterio-venous  wounds  at  the  bend  of  the  elbow.  It  may  be 
tied  in  one  of  two  places: 

1.  At  the  Middle  0/  the  Arm. — The  arm  is  held  away  from  the  side  at  a  right 
angle,  with  the  hand  supine,  but  with  no  support  beneath  it,  for  fear  of  pushing 
forwards  the  triceps  and  displacing  the  vessel.     The  surgeon  stands  between 

the  arm  and  the  trunk.  An  incision 
2  inches  long  is  made  in  the  line  of  the 
vessel  along  the  inner  border  of  the  biceps 
muscle  (Fig.  107,  B),  and  the  thin  fascial 
investment  of  the  limb  divided.  The  inner 
edge  of  the  muscle  is  clearly  exposed,  and 
by  drawing  it  slightly  forwards  the  median 
nerve  is  brought  into  view,  and  perhaps  the 
basilic  vein.  The  nerve,  which  is  at  this 
spot  crossing  the  artery  from  without  in- 
wards, is  drawn  inwards,  and  the  sheath 
of  the  vessel  found  beneath  it.  The  artery 
is  separated  from  its  venae  comites,  and 
the  ligature  passed  and  tied. 

The  operation  is  by  no  means  always 
easy,  as  there  are  many  traps  into  which 
the  beginner  may  fall.  Thus  the  median 
nerve  may  cross  behind  the  vessel  instead 
of  in  front  of  it;  the  basilic  vein  may  lie 
over  its  situation,  and  be  mistaken  for  it; 
or  there  may  be  a  high  division,  the  two 
trunks  usually  lying  close  together.  The 
most  common  mistake  consists  in  not 
defining  the  biceps  muscle,  and  in  seeking 
for  the  artery  behind  its  proper  situation. 

2.  At  the  Bend  0/  the  Elbow.— ■h.n  oblique 
incision  is  made,  about  2  inches  long, 
parallel  to  the  inner  border  of  the  biceps 
tendon,  its  lower  end  corresponding  to  the 
crease  of  the  elbow  (Fig.  107,  C).  The 
incision  should  be  placed  at  an  angle  of 
forty-five  degrees  to  the  axis  of  the  limb, 
and  to  the  outside  of,  and  nearly  parallel 
to,  the  median  basilic  vein,  which,  if  seen, 
must  be  drawn  inwards.  The  bicipital 
fascia  is  now  incised,  and  the  artery 
with  its  venae  comites  exposed  in  the 
loose  fat,  the  median  nerve  being  well 
away  on  the  inner  side. 

Collateral    Circulation. —  If     above    the 

origin  of  the  superior  profunda,  posterior 

circumflex     in     deltoid      with     ascending 

branches  of  superior  profunda. 

If  below  the  origin  of  the  inferior  profunda,  the  anastomoses  around  the 

elbow-joint. 

The  Ulnar  Artery  rarely  needs  ligature  except  for  palmar  haemorrhage  or 
direct  wounds.  In  the  former  case  the  artery  can  easily  be  secured  just 
above  the  wrist,  in  the  latter  case,  by  enlarging  the  original  wound.  Various 
stereotyped  operations  are  described,  but  are  more  often  seen  in  the  examina- 
tion-room or  dead-house  than  in  the  operating  theatre.  It  should  be  borne 
in  mind  that  the  artery  curves  inwards  from  the  centre  of  the  bend  of  the 
elbow  to  the  radial  side  of  the  pisiform  bone.  The  lower  two-thirds  of  its 
course  is  indicated  by  a  line  drawn  from  the  internal  condyle  of  the  humerus  to 
the  same  spot  below. 


Fig.  107. — Incisions  for  tying 
THE  Arteries  of  the  Arm. 

A,  Third  part  of  the  axillary;  B, 
brachial;  C,  brachial  at  the 
bend  of  the  elbow;  D,  middle 
third  of  radial ;  G,  middle  third 
of  ulnar;  E  and  F,  lower  thirds 
of  radial  and  ulnar. 


LIGATURE  OF    VESSELS  335 

1.  At  the  II>/s^.— An  incision  about  i  inch  in  length  is  made  directly  up- 
wards from  the  liexure  of  the  wrist  in  the  line  of  the  vessel  (Fig.  107,  F).  The 
deep  fascia  is  opened,  the  tendon  of  the  flexor  carpi  ulnaris  drawn  to  the  inner 
side,  and  the  vessels  are  then  seen,  accompanied  by  the  nerve  which  lies  to  the 
ulnar  side  of  the  artery. 

2.  /«.  the  Middle  of  the  Forearm. — An  incision  is  made  along  a  line  drawn 
from  the  anterior  edge  of  the  tip  of  the  inner  condyle  to  the  radial  side  of  the 
pisiform  bone  (Fig.  107,  G).  The  white  line  indicating  the  intermuscular 
septum  between  the  flexor  carpi  ulnaris  and  flexor  sublimis  digitorum  is  then 
sought  for  and  opened  up;  it  is  often  very  slightly  marked,  and  may  be 
difficult  to  distinguish.  If  the  correct  interspace  has  been  opened,  the  surgeon 
is  directed  towards  the  ulna,  and  readily  finds  the  vessels  under  cover  of  the 
flexor  carpi  ulnaris,  with  the  nerve  lying  a  little  way  to  the  inner  or  ulnar  side. 

3.  The  upper  limit  of  the  idnar  artery  can  be  reached  through  an  oblique 
incision  along  the  upper  border  of  the  pronator  teres,  thus  opening  up  the  ante- 
cubital  fossa,  and  exposing  the  bifurcation  of  the  brachial. 

Radial  Artery. — The  line  of  the  vessel  extends  from  the  middle  of  the  bend 
of  the  elbow  to  the  interspace  at  the  wrist  between  the  flexor  carpi  radialis  and 
the  supinator  longus.  It  then  turns  outwards,  and  may  be  felt  beating  in  the 
space  described  by  French  anatomists  as  '  la  tabatiere  '  (or  snuff-box) ,  between 
the  tendons  of  the  extensor  primi  and  extensor  secundi  internodii  muscles. 

1.  At  the  Back  of  the  Wrist  the  vessel  may  be  secured  by  opening  up  the 
above-mentioned  intertendinous  hollow,  where  the  artery  is  found  coursing 
onwards  to  the  base  of  the  first  interosseous  space.  The  incision  is  placed 
obliquely  between  the  tendons,  extending  from  the  back  of  the  styloid  process 
of  the  radius  to  the  base  of  the  first  metacarpal  bone. 

2.  Above  the  Wrist  an  incision  is  made  in  the  line  of  the  vessel  (Fig.  107,  E), 
which  is  found  after  division  of  the  fascia  between  the  supinator  longus,  and 
flexor  carpi  radialis. 

3.  In  the  Middle  or  Upper  Third  of  the  Forearm  an  incision  is  made  in  the 
line  of  the  vessel  (Fig.  107,  D),  and  the  inner  border  of  the  supinator  longus 
sought  for  and  retracted.  The  vessels  are  found  under  cover  of  this  structure, 
with  the  radial  nerve  to  the  outer  side,  though  separated  by  an  interval  above. 

Ligature  of  the  Abdominal  Aorta*  has  been  undertaken  in  fourteen  instances 
for  severe  primary  or  secondary  haemorrhage,  or  for  diffuse  inguinal  or  iliac 
aneurism,  when  no  other  method  of  treatment  was  practicable.  All  these 
cases  have  proved  fatal,  in  most  instances  from  infection  and  secondary 
haemorrhage.  The  operation  consists  in  opening  the  abdomen  through  an 
incision  slightly  to  the  left  of  the  middle  line,  having  the  umbilicus  on  a  level 
with  its  centre.  The  intestines  are  retracted,  and  the  posterior  laj^er  of  the 
serous  membrane  covering  the  aorta  carefully  divided ;  there  is  then  no  diffi- 
culty in  passing  a  ligature  around  the  vessel.  Possibly  it  would  be  well  to 
prevent  excessive  backflow  of  blood  by  securing  one  or  both  of  the  common 
iliac  trunks  in  addition;  such  would  in  no  way  interfere  with  the  collateral 
circulation. 

The  Common  Iliac  Artery  extends  for  a  distance  of  2  inches  from  the  bifurca- 
tion of  the  aorta  opposite  the  left  side  of  the  body  of  the  fourth  lumbar  vertebra 
to  the  front  of  the  sacro-iliac  synchondrosis.  It  may  be  reached  through  an 
incision  made  in  the  median  line  with  its  centre  a  little  below  the  umbilicus. 
The  vessel  is  sought  for  and  exposed  by  an  incision  through  the  posterior 
layer  of  the  parietal  peritoneum,  and  a  ligature  passed  and  tied .  The  ureter 
which  crosses  the  artery  just  above  its  bifurcation  must  be  carefully  avoided. 

Collateral  Circulation. — Blood  reaches  the  external  iliac  and  its  branches  by 
means  of  the  anastomosis  of  the  lumbar  arteries  with  the  circumflex  iliac,  and 
of  the  superior  epigastric,  lumbars,  and  intercostals  with  the  superficial  and 
deep  epigastric.  The  internal  iliac  and  its  branches  are  supplied  by  the  union 
of  (a)  the  lumbar  branches  with  the  ilio-liimbar;  [b)  the  middle  sacral  with 

*  See  Tillaux  and  Riche,  Revue  de  Chirurgie,  January,  February,  and  March, 
1901. 


336 


A   MANUAL  OF  SURGERY 


Fig.    io8 


Incisions       for 


the  lateral  sacral ;  (c)  the  retropubic  anastomosis  of  the  two  obturator  arteries; 
and  [d)  the  communications  of  the  pudic,  haemorrhoidal,  and  vesical  trunks 
with  those  of  the  opposite  side. 

Ligature  of  the  Internal  Iliac  Artery  is  occasionally  performed  for  haemor- 
rhage from,  or  aIK•u^i^^m  of,  one  of  its  branches,  the  gluteal  being  that  most 
commonly  affected.  The  trunk  is  a  short  one,  at  most  i^  inches  in  length, 
and  is  best  reached  by  opening  the  abdomen  in  the  middle  line  below  the 
umbilicus  (Fig.   io8,  C),  pushing  aside  the  intestines,  and  searching  for  the 

bifurcation  of  the  common  iliac.  The  pos- 
terior layer  of  the  peritoneum  is  then  care- 
fully incised,  the  ureter  avoided,  and  an 
armed  aneurism  needle  passed  without 
wounding  the  vein. 

The  Collateral  Circulatimi  is  the  same  as 
that  given  for  the  internal  iliac  division  of 
the  common  iliac. 

The  External  Iliac  Artery  is  easily  acces- 
sible in  any  part  of  its  course,  which  measures 
from  3i  to  4  inches  in  length;  it  has  but 
few  branches,  and  those  situated  low  down. 
Its  position  is  indicated  by  the  lower  two- 
thirds  of  a  line  drawn  from  the  bifurcation 
of  the  aorta  to  midway  between  the  anterior 
superior  spine  and  the  symphysis  pubis — i.e., 
to  a  point  a  little  internal  to  the  middle  of 
Poupart's  ligament. 

Many  suggestions  as  to  the  best  means 
of  reaching  the  artery  have  been  made,  and 
both  trans-  and  extra-peritoneal  methods 
have  been  adopted.  It  is  so  readily  secured, 
however,  by  the  latter  that  it  seems  unneces- 
sary to  open  the  peritoneum.  There  are  two 
chief  forms  of  extraperitoneal  operation. 

Astley  Cooper's  Operation. — An  incision  is 
made  parallel  to  the  outer  half  of  Poupart's 
ligament,  commencing  a  little  to  the  inner 
side  of  its  centre,  and  |  inch  above  it,  and 
extending  upwards  and  outwards  to  about 
I  inch  internal  to  the  anterior  superior  spine 
(Fig.  108,  G).  The  external  oblique  apo- 
neurosis is  divided  along  this  line,  and  the 
exposed  lower  margins  of  the  internal  oblique 
and  transversalis  muscles  arching  over  the 
inguinal  canal  are  drawn  upwards  by  retrac- 
tors. The  transversalis  fascia  and  loose 
subperitoneal  fat  are  now  opened  with 
forceps  and  director,  and  the  vessel  is  felt 
pulsating  immediately  under  the  finger. 
The  epigastric  and  circumflex  iliac  arteries 
must  not  be  damaged  during  this  manipu- 
lation, since  they  are  important  factors  in  the 
collateral  circulation.  The  needle  is  passed  from  within  outwards,  the  ligature 
tied,  and  the  divided  muscular  and  aponeurotic  structures  united  by  buried 
sutures. 

Abernethy's  Modified  Operation  is  more  commonly  utilized.  The  incision, 
about  4  inches  in  length,  extends  from  a  point  i.^  inches  within  and  above  the 
anterior  superior  iliac  spine  to  just  external  to,  and  4  inch  above,  the  middle 
of  Poupart's  ligament  (Fig.  108,  F).  Through  this  the  aponeurosis  of  the 
external  oblique  is  divided  along  the  course  of  its  fibres,  as  al.so  the  internal 
oblique  and  transversalis.  The  transversalis  fascia  is  now  carefully  incised ; 
it  varies  considerably  in  thickness,  being  sometimes  well  developed,  but  is 


Operations  on  Lower  Part 
OF  Abdomen  and  Upper 
Part  of  Thighs. 

A,  Mott's  incision  for  retro- 
peritoneal ligature  of  com- 
mon iliac  artery;  B,  Mar- 
cellin  Duval's  incision  for  the 
same;  C,  incision  for  trans- 
peritoneal ligature  of  inter- 
nal iliac  artery;  D,  incision 
for  excision  of  hip  by  the 
anterior  method ;  F,  Aber- 
nethy's modified  operation 
for  ligature  of  external  iliac; 
G,  Astley  Cooper's  incision 
for  same;  H,  ligature  of 
femoral  artery  at  apex  of 
Scarpa's  triangle;  K,  liga- 
ture of  femoral  artery  in 
Hunter's  canal. 


LIGATURE  OF   VESSELS  337 

occasionally  so  attenuated  as  to  be  scarcely  recognisable.  The  fingers  are 
now  introduced  into  the  wound,  and  the  peritoneum  and  its  contents  stripped 
from  the  iliac  fossa,  and  drawn  inwards  and  forwards,  where  they  are  kept 
out  of  the  way  by  a  broad  spatula,  in  the  space  thus  opened  up  one  can 
see  the  iliacus  muscle  covered  by  its  fascia,  and  to  its  inner  side  the  rounded 
outline  of  the  psoas.  The  vessel  lies  to  the  inner  border  of  this,  and  can 
usually  be  readily  found,  enveloped  in  a  fascial  sheath,  with  the  genito-crural 
nerve  coursing  over  it,  and  perhaps  some  lymphatic  glands  upon  it.  The 
artery  is  separated  from  the  vein  which  lies  to  the  inner  side,  and  the  needle 
passed  from  within  outwards.  If  the  transversalis  fascia  has  not  been 
properly  opened,  it  is  quite  possible  to  strip  it  up  together  with  the  peri- 
toneum, and  carry  the  vessels  forwards  with  it,  when  they  m.ay  be  found  under 
cover  of  the  spatula. 

Of  these  two  operations,  the  latter  is  probably  the  better.  By  Cooper's 
method  the  artery  is  tied  very  close  to  important  collateral  branches,  whilst 
but  a  small  portion  of  the  trunk  is  exposed,  so  that  if  this  is  diseased  and  un- 
suitable for  the  application  of  a  ligature,  no  further  choice  is  possible.  In 
Abemethy's,  on  the  other  hand,  the  vessel  is  tied  well  away  from  collateral 
branches,  and  if  the  exposed  portion  of  the  trunk  is  diseased,  the  common 
iliac  can  be  reached  and  secured  without  much  difficult}'  by  extending  the 
incision  upwards.  The  wound  also  involves  muscular  tissue,  and  therefore 
better  repair  is  secured  with  less  likelihood  of  a  subsequent  hernia. 

Collateral  Circulation. — -Anterior  set  :  Superior  epigastric  of  internal  mam- 
mary, lumbar,  and  lower  intercostals  with  superficial  and  deep  epigastric  in 
sheath  of  rectus. 

Posterior  set  :  Gluteal  and  sciatic  with  internal  and  external  circumflex  and 
first  perforating  of  profunda  at  back  of  great  trochanter  (crucial  anastomosis) . 

External  set:  Ilio-lumbar  and  gluteal  with  deep  and  superficial  circumflex 
iliac  and  ascending  branch  of  external  circumflex. 

Internal  set  :  Obturator  with  internal  circumflex;  and  terminal  divisions  of 
internal  pudic  with  superficial  and  deep  external  pudic. 

The  Common  Femoral  Artery  is  but  rarely  ligatured,  except  as  a  preliminary 
measure  in  amputation  at  the  hip-joint,  since  the  number  of  branches  arising 
from  it  is  likely  to  interfere  with  its  sound  occlusion,  and  the  collateral  circula- 
tion is  better  after  ligature  of  the  external  iliac.  It  ma}'  be  reached  b}'  a 
vertical  incision  over  the  line  of  the  vessel,  extending  both  a  little  above  and 
below  Poupart's  ligament.  The  superficial  lymphatics  and  veins  must  be 
carefully  avoided,  the  fascia  lata  divided,  the  sheath  exposed  and  opened,  and 
the  ligature  passed  from  the  inner  side. 

Collateral  Circulation. — Internal  set  :  Obturator  with  internal  circumflex, 
and  internal  pudic  with  external  pudic. 

External  set  :  Circumflex  iliac  with  ascending  branch  of  external  circumflex. 

Posterior  set  :  Gluteal  and  sciatic  with  internal  and  external  circumflex,  and 
first  perforating ;  comes  nervi  ischiadic!  with  perforating  of  the  profunda  and 
muscular  of  popliteal. 

The  Superficial  Femoral  Artery  is  indicated  by  a  line  drawn  from  midway 
betAveen  the  anterior  superior  spine  and  the  symphysis  pubis  to  the  tuberosity 
of  the  internal  condyle,  the  limb  being  flexed,  abducted,  and  everted.  It  may 
be  secured  at '  the  site  of  election  ' — i.e.,  at  the  apex  of  Scarpa's  triangle — or  in 
Hunter's  canal. 

Ligature  at  the  Apex  of  Scarpa's  Triangle. — -A  4-inch  incision  is  made  in  the 
line  of  the  artery,  the  centre  being  about  4  inches  (or  a  hand's  breadth)  below 
Poupart's  ligament  (Fig.  108,  H).  The  integument  and  fasciae  are  divided, 
the  inner  border  of  the  sartorious  exposed,  and  the  sheath  found  immediatel}' 
behind  it,  the  muscle  being  dra^vn  slightly  outwards;  the  middle  cutaneous 
nerve  is  perhaps  brought  into  view.  The  vein  is  placed  behind  the  artery  at 
this  level. 

Collateral  Circulation. — External  circumflex  with  lower  muscular  of  femoral, 
anastomotica  magna,  and  superior  articular  of  pophteal. 

Profunda  f emoris  by  its  perforating  and  terminal  branches  with  the  muscular 
and  articular  branches  of  femoral  and  popliteal. 


338 


A   MANUAL  OF  SURGERY 


Ligature  in  Hunter's  Canal. — An  incision  4  inches  in  length  is  made  along 
the  line  of  the  artery  in  the  middle  of  the  thigh  (I'ig.  luS,  K).  The  sartorius  is 
exposed  by  division  of  the  fascia  lata,  its  liljres  running  downwartls  and 
inwards;  its  outer  border  should  be  defined,  and  the  muscle  retracted  inwards. 
The  aponeurotic  covering  of  Hunter's  canal  is  now  in  view,  stretching  between 
the  adductor  longus  ancl  vastus  internus;  it  is  incised,  and  the  sheath  of  the 
vessel  found  below  it,  with  the  nerve  to  the  vastus  internus  lying  to  its  outer 
side,  the  long  saphenous  nerve  crossing  it  from  without  inwards,  and  the  vein 
passing  behind  it,  to  become  external  lower  down.  A  common  mistake  made 
by  students  in  tying  this  artery  on  the  deatl  subject  is  to  burrow  down  along 


Fig.  109. — Incisions  for  Ligature  of 
THE  Upper  Part  of  the  Popliteal 
(A),  AND  of  the  Posterior  Tibial 
Arteries  (B,  C,  and  D). 

E,  Site  for  Introduction  of  knife  in 
Tenotomy  of  TibiaHs  Posticus;  F, 
Ditto  for  Tendo  Achillis. 


Fig.  iio. — Incisions  for  Liga- 
ture of  Anterior  Tibial  (A 
AND  B)  AND  Peroneal  (C) 
Arteries.  D,  Site  for  Intro- 
duction OF  Knife  in  Teno- 
tomy of  Peronei. 


the  vastus  internus  on  the  outer  side  of  the  vessels;  this  is  to  be  avoided  by 
always  keeping  close  to  the  under  surface  of  the  sartorius  until  the  glistening 
transverse  fibres  of  Hunter's  aponeurosis  are  clearly  visible. 

Collateral  Circulation  is  maintained  through  the  profunda  and  its  branches. 

The  Popliteal  Artery  may  be  tied  either  just  after  it  has  passed  through  the 
adductor  opening,  or  in  the  depths  of  the  popliteal  .space,  but  preferably  in  the 
former  situation.     Neither  operation  is  often  required . 

To  tie  the  upper  part,  the  liml)  is  fully  abducted  and  everted  so  as  to  enable 
the  adductor  tubercle  and  tendon  of  the  adductor  magnus  to  be  clearly  defined. 
An  incision,  4  inches  in  length,  is  then  made  from  the  tubercle  upwards 
(Fig.  109,  A),  and  the  tendon  exposed.  The  internal  saphenous  vein  and  nerve 
may  be  seen,  but  are  drawn  backwards  by  means  of  a  broad  retractor,  together 
with  the  sartorius,  gracilis,  and  semi-membrano.sus.  If  possible,  the  branch 
of  the  anastomotica  magna  which  courses  along  the  tendon  should  be  spared 
The  fascial  space  behind  is  now  opened  up,  and  the  artery  found  surrounded  by 


LIGATURE  OF    VESSELS 


339 


a  good  deal  of  loose  connective  tissue.  The  vein  is  usually  seen  on  the  outer 
side,  and  is  here  \erv  thick  and  dense,  so  that  in  the  dead  subject  it  can  be 
readily  mistaken  for  the  artery. 

The"  loiaer  part  is  tied  through  an  incision  in  the  middle  line  of  the  popliteal 
space,  dividing  the  deep  fascia  ami  drawing  out  of  the  way  the  heads  of  the 
gastrocnemius  muscle  and  the  internal  popliteal  nerve.  The  vein  is  superficial 
to  the  artery,  and  is  found  by  following  the  short  saphenous  trunk. 

Collateral  Circulation  is  maintained  by  the  anastomoses  around  the  knee- 
joint. 

The  Posterior  Tibial  Artery  but  seldom  requires  to  be  ligatured  except  for 
haemorrhage,  or  on  the  face  of  amputation  stumps;  hence  the  operations 
described  below  are  rarely  seen  away  from  the  dead-house.  The  line  of  the 
vessel  is  indicated  by  one  drawn  from  the  centre  of 
the  popliteal  space  to  a  point  a  finger's  breadth  behind 
the  internal  malleolus. 

1.  In  the  Middle  of  the  Calf. — -The  leg  is  placed  on  its 
outer  side  and  flexed,  and  an  incision  4  inches  long  is 
made  a  finger's  breadth  behind  the  inner  border  of  the 
tibia  (Fig.  109,  B),  dividing  the  skin  and  subcutaneous 
tissues,  the  long  saphenous  vein  and  nerve  being  drawn 
aside  if  necessary.  The  tibial  origin  of  the  soleus  is 
thus  exposed,  and  incised  directly  towards  the  tibia, 
until  the  fibrous  aponeurosis  on  its  deeper  surface  is 
met  with.  This  having  been  cut  through,  the  muscle 
is  drawn  backwards  with  the  retractor,  and  the  vessels, 
ensheathed  in  a  deep  layer  of  fascia,  are  seen  lying  on 
the  tibialis  posticus,  and  with  the  posterior  tibial  nerve 
to  the  outer  side. 

2.  In  the  Lower  Third  of  the  Leg. — An  incision  is  made 
midwav  betw^een  the  tendo  Achillis  and  inner  border  of 
the  tibia  (Fig.  109,  C).  The  skin  and  fasciae,  including 
the  upper  part  of  the  internal  annular  ligament,  are 
divided,  and  the  vessels  seen  lying  on  the  flexor 
longus  digitorum,  with  the  nerve  behind  and  to  the 
outer  side. 

3.  Behind  the  Malleolus. — An  incision  is  made  about 
a  finger's  breadth  from  the  malleolus,  curving  round 
its  lower  border  (Fig.  109,  D).  The  deep  fascia  (or,  as 
it  is  here  termed,  the  internal  annular  ligament)  is 
divided  over  the  vessels  between  the  tendons  of  the 

flexor  longus  digitorum  and  flexor  proprius  hallucis,  and  the  artery  is  then 
readilv  cleared  and  ligatured.  The  sheaths  of  the  tendons  should  not  be  opened. 
The  Anterior  Tibial  Artery  is  found  along  a  line  stretching  from  a  point  mid- 
way between  the  outer  tuberositv  of  the  tibia  and  the  head  of  the  fibula  above 
to  the  central  point  between  the' two  malleoli  belo\v.  It  may  be  tied  in  three 
situations. 

1.  In  the  Upper  Third  of  the  Leg. — An  incision  is  made  exactly  in  the  line  of 
the  arterv  (Fig.  no.  A),  and  the  deep  fascia  incised.  The  intermuscular  space 
between  the  tibialis  anticus  and  the  extensor  communis  digitorum  is  opened. 
The  vessel  lies  between  these  muscles  upon  the  interosseous  membrane,  the 
anterior  tibial  nerve  being  to  the  outer  side. 

2.  In  the  Middle  of  the  Leg  (Fig.  no,  B). — The  same  intermuscular  space  is 
opened,  being  indicated  here  by  a  definite  white  line,  due  to  a  slight  subfascial 
deposit  of  fat.  The  vessels  lie  between  the  tibialis  anticus  and  the  deeply- 
placed  extensor  proprius  hallucis,  the  nerve  usually  lying  on  the  artery  and 
needing  to  be  drawn  aside. 

3.  In  the  Lower  Third  of  the  Leg. — An  incision  is  made  in  the  line  of  the 
artery,  reaching  upwards  for  2  inches  from  a  point  just  above  the  ankle 
(Fig.  Ill,  A).  The  deep  fascia  and  upper  part  of  the  annular  ligament  are 
divided,  and  the  vessel  is  found  between  the  tendons  of  the  tibiahs  anticus 
and  of  the  extensor  proprius  hallucis,  the  nerve  lying  to  the  outer  side. 


Fig.  III. — Incisions 
FOR  Ligature  of 
Lower  Part  of 
Anterior  Tibial 
(a)  and  dorsalis 
Pedis  (B)  Arter- 
ies.    C,  Site  for 

PERFORMING    TEN- 
OTOMY OF  Tibialis 

Anticus. 


340  A   MANUAL  OF  SURGERY 

The  Dorsalis  Pedis  Artery  extends  from  the  centre  of  the  line  between  the 
two  malleoli  to  the  interval  between  the  bases  of  the  first  two  metatarsal  bones. 
An  incision  is  made  in  this  direction  (Fig.  iii,  B),  the  deep  fascia  opened,  and 
the  artery  found  lying  between  the  extensor  proprius  hallucis,  which  has  now 
crossed  and  is  internal  to  the  vessel,  and  the  innermost  slij)  of  the  extensor 
brevis  digitorum.  It  is  not  always  easy  to  find,  and  for  practical  purposes 
the  best  plan  would  be  to  divide  the  vessel  by  an  incision  extending  to  the 
bones,  and  then  pick  up  and  tie  the  bleeding  ends. 

The  Peroneal  Artery  can  be  reached  through  an  incision  along  the  posterior 
border  of  the  centre  of  the  fibula,  the  leg  being  laid  on  its  inner  side  (Fig.  no,  C). 
The  outer  edge  of  the  soleus  is  defined  and  drawn  inwards,  the  lower 
fibres  of  attachment  to  the  fibula  being  divided  if  necessary.  The  flexor 
longus  hallucis  is  thereby  exposed,  and  incised  in  such  a  manner  as  to  allow 
the  surgeon  to  reach  the  postero-internal  border  of  the  fibula;  the  artery  is 
then  readily  found  lying  in  an  osseo-aponeurotic  canal. 


CHAPTER  XIV. 
AFFECTIONS  OF  THE  ^VEINS— ANGIOMATA. 

Venous  Thrombosis. 

By  Thrombosis  is  meant  intravascular  coagulation  in  any  part  of  the 
circulatory  system.  Normally,  the  blood  remains  in  a  fluid  condi- 
tion, owing  to  some  inter-action  between  it  and  the  vessel  walls. 
Any  factor  producing  a  disturbance  of  this  normal  equihbrium  may 
determine  thrombosis,  and  any  part  of  the  vascular  tract  may  be 
affected  by  it,  whether  the  heart,  arteries,  veins,  or  capillaries;  but 
it  is  in  the  veins  that  it  occurs  most  frequently. 

Causes.— (i)  Changes  in  the  vessel  i&alls,  as  a  result  of  which  the 
integrity  of  the  endothelium  is  disturbed— ^.g.,  injury  (either  division, 
rupture,  puncture,  compression,  or  contusion),  inflammation  or 
degeneration  (as  in  varicose  veins') . 

(2)  Changes  in  the  constitution  of  the  blood  whereby  its  coagulability 
is  increased.  In  clinical  work  this  is  brought  about  most  frequently 
by  infective  conditions,  which  lead  to  an  excess  of  toxins  in  the  blood. 
HcEmorrhage  up  to  half  of  the  whole  amount  in  the  body  also 
increases  ifs  coagulabihty,  but  excess  of  leucocytes,  as  in  leukaemia, 
has  the  opposite  effect.  . 

(3)  Diminished  rate  of  the  blood-stream  predisposes  to  thrombosis  it 
some  other  condition  is  present  to  determine  it.  lister  showed  years 
ago  that  blood  can  remain  fluid  for  a  long  time  if  confined  m  a  tube 
formed  of  a  suitable  length  of  healthy  vein  wall;  but  when  either  ot 
the  preceding  factors  is  present,  a  retardation  of  the  blood-stream 
materially  assists  in  causing  coagulation.  Thus,  when  a  vein  is 
pressed  upon  by  a  tumour,  the  obstruction  to  the  blood-flow  pro- 
duces a  clot  at  the  spot  where  the  nutrition  of  the  wall  is  interfered 
'N^dth.  After  fevers,  such  as  typhoid,  where  the  character  of  the 
blood  is  somewhat  altered  and  the  action  of  the  heart  weakened  by 
changes  in  the  muscular  fibres,  the  defective  vis  a  tergo  causes  a 
retardation  of  the  flow  in  the  veins,  as  a  result  of  which  the  intra- 
venous pressure  is  diminished,  and  coagulation  is  probably  deter- 
mined by  some  sHght  injury  or  pressure  which  is  not  noticed  by  the 
patient.  .  -,, 

The  Character  of  the  clot  varies  with  its  rate  of  formation,     ^t 

341 


342  A   MANUAL  OF  SURGERY 

developed  slowly,  tlic  so-called  white  tlirombus  is  met  with,  con- 
sisting merely  of  layers  of  fibrin,  similar  to  that  formed  in  an 
aneurism.  If  the  process  is  more  rapid,  a  certain  number  of  red 
corpuscles  are  entangled  in  the  meshes  of  the  clot;  sudden  coagula- 
tion produces  the  ordinary  red  thrombus,  which  at  first  is  not  ad- 
herent to  the  wall,  but  becomes  so  later  on,  especially  at  its  base. 
Bacteriological  examination  will  often  reveal  the  presence  of 
organisms  in  the  thrombus. 

ihe  Effects  of  thrombosis  may  be  considered  under  the  following 
headings:   local,  distal,  and  proximal. 

Locally  :  {a)  The  clot  may  be  organized  into  connective  tissue, 
a  fibrous  cord  replacing  the  vessel  in  the  same  way  as  was  described 
for  arterial  thrombosis  (p.  287).  Three  weeks  is  about  the  shortest 
period  to  allow  for  the  safe  fixation  of  the  clot  within  the  vessel. 
ib)  The  lumen  of  the  vein  may  be  re-established  by  the  fixation  of 
the  thrombus  to  one  side  of  the  vein  wall,  or  by  canalization  of  the 
clot  or  of  the  fibrous  cicatrix  replacing  it,  owing  to  the  dilatation 
of  the  vessels  contained  within,  (c)  The  clot  may  shrink  or  become 
loosened  in  an  ampulla  or  a  varicose  vein,  forming  a  fibrinous  mass, 
which  is  subsequently  infiltrated  with  calcareous  particles,  consti- 
tuting a  vein-stone  or  PhJeholith.  {d)  Suppuration  ma}^  occur  in 
and  around  the  clot  as  a  result  of  its  bacterial  contents.  The  result 
will  be  the  formation  of  an  abscess  locally,  which  may  be  limited, 
or  may  spread  widely  along  the  course  of  the  vein  (periphlebitis), 
and  in  all  probability  the  development  of  pyaemia.  This  may  be 
hindered  for  a  time  by  the  formation  of  a  cap  of  healthy  red  clot, 
which  covers  over  and  protects  the  infected  portion. 

Distally,  congestion  of  the  terminal  veins  results,  and  if  a  main 
trunk  is  affected,  (edema  of  the  limb  follows,  and  possibly  ulceration 
or  gangrene.  If,  however,  the  condition  affects  the  femoral  vein  of 
a  person  in  the  recumbent  position,  there  may  be  little  or  no  nedema 
as  long  as  the  limb  is  elevated.  In  favourable  cases  collateral  circu- 
lation is  soon  established  by  the  opening  up  and  dilation  of  other 
venous  channels,  which  after  a  time  may  become  varicose,  and,  if 
situated  superficially,  are  often  very  obvious.  Thus,  if  the  external 
iliac  vein  is  occluded  above  Poupart's  ligament,  a  greatly  increased 
amount  of  blood  will  be  carried  by  the  internal  saphena  vein,  and 
some  of  it  will  find  its  way  via  the  superficial  epigastric  and  pudic 
veins  across  the  middle  line  to  the  internal  saphena  of  the  opposite 
side.  These  branches  become  dilated  and  varicose,  and  the  inverted 
A  of  the  two  superficial  epigastric  veins  is  very  characteristic.  If 
the  inferior  vena  cava  is  obstructed,  the  mammary  and  epigastric 
veins  become  dilated  and  tortuous,  the  latter  standing  out 
prominently  on  the  anterior  abdominal  wall  (Fig.  112). 

Proximally,  the  process  may  gradually  extend  upwards,  and 
finally  involve  larger  and  more  important  trunks  than  that  in  which 
it  originated.  Moreover,  a  portion  of  a  thrombus  may  be  detached 
as  an  Embolus  (Fig.  113,  B).  If  the  clot  is  imdergoing  molecular 
disintegration,  and  only  minute  portions  are  set  free,  they  are  filtered 


AFFECTIONS  OF  THE   VEINS  343 

of(  by  the  lungs  or  kidneys,  and  no  symptoms  need  be  caused.  If, 
however,  a  large  portion  is  detached,  urgent  dyspnrea  and  even 
death  occur  from  obstruction  to  the  pulmonary  vessels  and  subse- 
quent arrest  of  the  circulation.  If  the  clot  becomes  infected,  and 
fragments  conveying  organisms  are  carried  into  the  circulation, 
pyemia  is  the  result,  preceded,  however,  in  the  portal  area  by  pyle- 
phlebitis— i.e.,  suppurative  phlebitis  of  the  portal  trunks  in  the  liver. 
Venous  thrombosis  is  of  most  interest  to  the  surgeon  when  it 
involves  the  main  femoral  or  iliac  vein,  and  is  then  most  frequently 
seen  on  the  left  side  of  the  body,  possibly  spreading  to  the  vena  cava, 
and  developing  at  a  later'  date  in  the  other  limb.  It  is  not  an  un- 
common complication  of  parturition,  and  is  then  due  to.  extension 


Fig  112— Varicose  Condition  of  the  Veins  of  the  Abdominal  Wall 
Secondary  to  Permanent  Obstruction  of  the  Inferior  Vena  Cava. 

The  original  of  this  photograph  is  a  doctor  in  active  practice,  and  the  throm- 
bosis of  the  vena  cava  occurred  twenty-seven  years  previously,  after  an 
accident.  On  one  or  two  occasions  severe  haemorrhage  has  occurred 
from  the  dilated  veins. 

of  the  clotting  from  the  pelvic  veins  {phlegmasia  albadolens).  From 
a  similar  cause  it  may  follow  operations  on  the  pelvic  viscera— ^.g., 
hysterectomy.  It  is  not  a  rare  complication  of  suppurative  appen- 
dicitis, and  may  spread  from  veins  divided  in  the  parietal  incision, 
or  on  the  right  side  from  direct  involvement  of  the  iliac  vein  in  the 
inflammatory  trouble ;  it  may  develop  in  the  course  of  typhoid  fever; 
or,  finally,  any  condition  or  operation  which  depresses  the  patient's 
vitahty  and  keeps  him  bedridden  with  the  legs  quiet  may  lead  to 
this  trouble.     Thus,  one  of  the  worst  cases  we  have  seen  occurred 


344' 


A   MANUAL  OF  SURGERY 


after  a  severe  operation  for  glands  in  the  neck,  which  healed  by  first 
intention. 

The  Clinical  Signs  and  Treatment  arc  as  for  Phlebitis  (p.  346). 


Embolism. 

An  Embolus  is  the  term  applied  to  any  foreign  body  which  travels  for  a 
greater  or  less  distance  in  the  bloodvessels  until  it  becomes  lodged  within 
them  and  causes  obstruction.  There  are  four  main  varieties  of  embolus: 
(a)  Simple  Emboli^ — e.g.,  blood-clot,  granulations  or  fibrinous  vegetations 
from  the  cardiac  valves  after  acute  endo- 
carditis, atheromatous  plates,  air-bubbles,  fat 
globules,  etc.  {b)  Infective  Emboli  consist  of 
either  zoogloea  masses  of  bacteria  or  disinte- 
grated portions  of  blood-clot  carrying  micro- 
organisms, and  are  the  cause  of  the  abscesses  in 
pyaemia,  (c)  Malignant  Emboli  are  formed  by 
portions  of  some  malignant  growth,  from  which 
the  various  secondary  deposits  originate;  these 
are  met  with  more  frequently  in  the  sarcomata 
than  in  the  carcinomata.  (d)  Parasitic  Emboli 
also  occur,  such  as  the  ova  and  scolices  of  the 
TcBuia  echinococcus  and  the  Filaria  sanguinis 
hominis. 

Emboli  may  be  detached  from  the  heart,  veins, 
or  arteries,  although  necessarily  they  are  never 
arrested  in  a  systemic  vein,  but  only  in  the 
arteries  or  portal  vein.  They  are  of  all  sizes, 
and  the  character  of  the  resulting  symptoms  de- 
pends much  on  this.  A  large  embolus  started 
in  a  peripheral  vein  lodges  in  one  of  the  branches 
of  the  pulmonary  artery,  and  may  cause  instant 
death;  a  smaller  one  is  arrested  in  one  of  the 
smaller  arteries  of  the  lung  and  may  do  but  little 
harm,  whilst  minute  ones  may  possibly  pass 
through  the  pulmonary  capillaries  to  the  left 
side  of  the  heart,  and  subsequently  become  im- 
pacted in  the  systemic  vessels. 

Effects  of  an  Embolus.    The  Local  effects  of 

the  lodgment  of  a  simple  embolus  consist,  firstly, 

in  the  deposit  of  fibrin  upon  it,  rendering  the 

obstruction  complete,  if  this  is  not  already  the 

case;  organization   of   the  thrombus    usually  follows,   although   occasionally 

it  may  disintegrate  and  disappear.      The  local  effects  of  infective,  malignant, 

and  parasitic  emboli  are  dealt  with  elsewhere. 

The  Distal  effects  of  embolic  obstruction  depend  entirely  on  the  relation  of 
the  vessel  blocked  to  the  surrounding  circulation. 

(i)  Should  the  embolus  be  lodged  in  an  artery  which  gives  off  anastomotic 
branches  below  the  point  of  obstruction,  or  if  the  capillary  anastomosis  is 
abundant,  a  transient  aneemia  is  all  that  occurs  in  most  cases.  If  the  artery 
is  small,  or  goes  to  unimportant  structures,  no  symptoms  need  arise  from  this; 
but  if  the  vessel  is  large,  or  supplies  delicate  and  important  tissues,  serious 
results  may  follow  even  a  temporary  arrest  of  the  circulation;  thus,  embolus 
of  the  central  artery  of  the  retina  always  causes  permanent  blindness,  although 
the  retina  still  lives. 

(2)  Should  the  embolus  block  what  is  called  a  '  terminal  artery  '  {i.e.,  one 
with  no  anastomosis  between  the  embolus  and  the  terminal  capillaries),  or  a 
vessel  with  insufficient  collateral  circulation,  the  obstruction  will  lead  to  death 
of.  at  any  rate,  a  portion  of  the  anaemic  region — e.g.,  gangrene  in  a  limb,  or 


Fig.  113. — Thrombus  and 
Embolus.  (Keen  and 
White.) 

,    Thrombus   in   situ ;   B, 
[^  embolus    detached    from 
the  same. 


AFFECTIONS  OF  THE   VEINS  345 

wliite  or  yellow  softening  in  the  brain.  In  an  organ  such  as  the  kidney  or 
spleen,  the  result  of  embolic  obstruction  to  one  of  the  terminal  arteries  is  the 
development  of  an  infarct ;  i.e.,  a  wedge-shaped  area  of  tissue  with  the 
blocked  artery  at  its  apex  becomes  devitalized,  and  in  consequence  looks  white 
and  feels  firmer  than  the  surrounding  parts.  The  tissues  cannot  be  properly 
stained  for  microscopic  purposes.  Sometimes  the  anaemic  area  becomes 
engorged  with  blood  to  such  an  extent  as  to  lead  to  extravasation,  and  a  firrn, 
solid  patch  of  a  dark  red  colour  results,  known  as  a  hsemorrhagic  infarct. 
Whatever  its  appearance,  the  infarct  is  subsequently  invaded  by  granulation 
tissue  developed  from  the  surrounding  healthy  parts,  and  this  finally  results 
in  the  formation  of  a  depressed  cicatrix  containing,  perhaps,  a  few  h^matoidm 
crystals.  The  conditions  necessary  for  the  production  of  an  infarct  are  met 
with  in  the  lungs,  spleen,  kidney,  and  brain;  in  the  liver  the  anastomosis  is 
generally  too  free  to  allow  of  its  formation,  although  it  has  been  known  to 

occur.  ,      T>     •      .i-u 

Effects  of  the  Lodgment  of  Emboli  in  Various  Organs.— In  the  Bram,  the 

middle  cerebral  artery  is  most  commonly  blocked,  resulting  m  immediate 
hemiplegia,  which  may  be  almost  entirely  recovered  from,  but  commonly  leaves 
some  impairment  of  function.  In  children  the  symptoms  are  less  marked 
but  aneurism  of  the  aiiected  vessel  occasionally  follows.  In  the  Central 
Artery  of  the  Retina,  sudden,  total,  and  irremediable  blindness  is  produced ; 
the  branches  of  the  vessel  are  seen  to  be  almost  empty,  the  retina  becomes 
oedematous,  the  macula  alone  retaining  its  normal  colour,  appearing  as  a 
cherry-red  spot,  contrasting  markedly  with  the  pallid  oedematous  tissues 
around.  In  the  Lung,  fatal  results  supervene  from  obstruction  to  the  mam 
pulmonary  artery;  attempts  have  been  made  to  save  life  by  opening  the 
chest,  incising  the  pulmonary  artery,  and  scraping  or  pulling  out  the  clot, 
and  subsequently  suturing  the  vessel.  It  is  obvious  that  such  a  proceeding 
is  not  often  likely  to  be  feasible.  If  one  of  the  smaller  branches  is  blocked,  a 
certain  amount  of  pain  and  dyspnoea  is  produced,  followed  by  the  formation 
of  an  infarct,  as  indicated  by  blood-stained  sputum,  dulness,  bronchial 
breathing,  and  bronchophony.  In  the  Liver,  an  embolus  of  the  hepatic  artery 
causes  sudden  hypochondriac  pain,  and  perhaps  a  temporary  glycosuria.  The 
portal  vein  and  its  branches  are  not  unfrequently  obstructed  by  emboli, 
which,  being  usually  of  an  infected  nature,  give  rise  to  pya^mic  symptoms 
(pylephlebitis).  In  the  Spleen,  a  sudden  pain  in  the  left  hypochondrium  is 
experienced,  the  organ  becomes  enlarged,  and  a  considerable  rise  of  tempera- 
ture may  follow.  In  the  Kidney,  sudden  pain  in  the  loin  and  a  temporary 
hiematuria  constitute  the  main  symptoms.  In  the  Intestine,  localized  ulcera- 
tion or  extensive  gangrene  is  likely  to  follow,  according  to  the  size  of  the 
vessel  obstructed.  In  the  Limbs,  the  emboli  usually  lodge  at  the  bifurcations 
of  main  vessels,  often  saddling  across  the  fork,  and  blocking  both  branches. 
Sudden  pain  is  felt  at  the  spot,  shooting  downwards,  and  either  recovery  or 
gangrene  ensues  (p.  113).  Here,  also,  it  has  been  attempted  to  remove  or 
tunnel  the  clot  by  open  operation,  but  the  results  have  not  been  satisfactory; 
massage  to  break  it  up  and  drive  it  on  may  also  be  tried. 

Phlebitis. 

Phlebitis,  or  inflammation  of  the  vein  wall,  arises  from  a  variety 
of  causes,  and  is  not  uncommon  in  surgical  practice.  The  following 
forms  are  described: 

I.  Simple  Phlebitis,  in  which  a  more  or  less  localized  inflammation 
of  the  wall  of  a  vein  is  attended  by  thrombosis,  which  extends  for 
a  variable  distance  up  and  down  the  vessel,  {a)  It  may  arise  from 
injury,  either  subcutaneous  or  open,  or  from  the  continued  pressure 
and  irritation  of  a  tumour  or  aneurism ;  [h)  it  may  be  gouty  or  rheu- 
matic in  nature,  attacking  the  larger  veins  of  the  lower  extremity, 


346  A   MANUAL  OF  SURGERY 

or  vessels  which  liave  been  long  subject  fo  varix.  (c)  It  may  follow 
primar}'  thrombosis,  either  in  the  main  trunk  or  in  a  varicose  periph- 
eral vein;  or  [d]  it  may  be  induced  by  inflammation  of  the  tissues 
around  the  vein  {periphlebitis),  usually  of  bacterial  origin.  In  the 
last  case  the  bacteria  gradually  spread  through  the  vein  wall,  and 
finall\-  invade  the  clot. 

2.  Infective  Phlebitis  is  a  much  more  serious  condition,  inasmuch 
as  the  thrombus  resulting  tlierefrom  is  always  invaded  by  micro- 
organisms, and  the  disease  is  often  of  the  spreading  type.  It  arises 
(a)  in  traumatic  cases  where  asepsis  has  not  been  maintained,  the 
organisms  invading  the  clot  which  lies  in  the  open  mouth  of  the  vein; 
or  {b)  as  a  result  of  infective  periphlebitis  in  wounds,  or  in  infective 
inflammation  of  bones,  such  as  when  a  suppurative  mastoiditis  leads 
to  disease  of  the  lateral  sinus;  and  (c)  by  auto-infection  of  the  clot 
present  in  simple  phlebitis,  as,  e.g.,  in  varicose  veins. 

Morbid  Anatomy.— The  walls  of  the  vein  are  congested  and  thick- 
ened, and  the  endothelial  lining  is  hypertrophied;  the  thrombus  con- 
tained in  the  vessel  varies  in  its  characters.  If  aseptic,  it  early  be- 
comes adherent  to  the  vein  wall  and  organized,  or  is  absorbed.  If 
infected,  it  becomes  soft  and  pultaceous,  resembling  dirty-looking 
pus;  a  locahzed  abscess  may  form  within  the  vein,  and  the  suppura- 
tion may  extend  for  some  distance  along  and  around  the  vein.  In 
the  niore  favourable  cases  the  spread  of  the  infection  is  limited  by 
the  terminal  portions  of  the  clot  remaining  firm  and  unaffected. 

The  Symptoms  of  inflammation  of  a  superficial  vein  are  sufficiently 
obvious.  The  vessel  becomes  swollen,  hard,  and  painful,  with 
localized  enlargements  or  knobs  corresponding  to  the  valves  or  to  the 
pouches  in  varicose  veins.  The  skin  over  them  is  dusky  and  con- 
gested, and  there  ma}'  be  some  <  edema  of  the  region  from  which  the 
blood  flowing  in  the  vein  is  gathered;  this,  however,  rarel}'  amounts 
»to  m.uch,  since  the  collateral  circulation  is  alwa^^s  abundant.  The 
temperature  is  usually  raised,  and  the  patient  feels  ill.  If  suppura- 
tion occurs,  the  signs  of  a  localized  abscess  are  noted,  and  perhaps 
pyaemic  manifestations  supervene. 

When  the  deeper  veins  are  involved,  it  may  be  impossible  to  detect 
them  on  palpation,  although  a  blocked  common  femoral  can  usually 
be  felt;  but  acute  deeply-seated  pain  over  the  vein  and  well-marked 
fever  are  characteristic  evidences  of  what  has  occurred.  Qidema  of 
a  more  or  less  solid  character  develops,  although  if  the  limb  is  main- 
tained in  the  horizontal  position  throughout  the  attack  this  need 
not  occur.  Obliteration  of  the  vessel,  and  any  of  the  local, 
distal,  or  general  processes  detailed  as  characteristic  of  thrombosis 
(p.  342)  may  result. 

The  onset  of  an  infective  periphlebitis  is  marked  by  fever  and 
perhaps  rigors,  whilst  the  local  signs  are  due  to  rapid  extension  of  a 
suppurative  inflammation  along  the  vein  and  its  branches,  so  that 
a  large  tract  of  tissue  is  very  quickly  invaded,  and  diffuse  suppura- 
tion follows.  The  onset  of  pyamia  is  indicated  by  a  repetition  of 
rigors,  and  the  development  of  secondary  abscesses. 


AFFECTIONS  OF  THE   VEINS  347 

Treatment. — In  the  simple  variety  tlie  limb  is  kept  absolutely  at 
rest  to  limit  the  inflammation  and  prevent  the  detachment  of 
emboli,  and  also  elevated  to  assist  venous  return.  Locally,  bella- 
donna fomentations  may  be  applied,  or  the  parts  may  be  painted 
witli  glycerine  and  extract  of  belladonna,  swathed  in  a  thick  layer 
of  cotton-wool,  and  lightly  bandaged.  The  patient  should  be  kept 
on  an  unstimulating  though  nutritious  diet,  and  the  general  health 
attended  to.  When  every  sign  of  inflammation  has  subsided,  and 
sufficient  time  has  been  allowed  for  the  absorption  or  organization 
of  the  clot  (three  weeks  as  an  absolute  minimum — six  weeks  for 
choice),  massage  may  be  commenced,  to  assist  in  the  removal  of 
oidema  and  local  thickening,  and  an  elastic  bandage  is  usually 
serviceable  in  restoring  the  circulation.  Operation  is  sometimes 
undertaken  in  cases  of  phlebitis  associated  with  varix,  but  not  when 
the  deeper  veins  are  involved.  If  abscesses  form,  they  must  be 
opened  antisepticalh*. 

Infective  phlebitis  is  treated  in  a  similar  fashion  until  suppuration 
occurs,  and  then  the  pus  must  be  evacuated,  and  it  is  sometimes 
remarkable  to  note  how  quickly  the  process  quiets  down  w^hen  once 
drainage  is  effected.  A  spreading  periphlebitis  will  often  involve  an 
extensive  area,  but  the  process  must  be  followed  up  ruthlessly  by 
the  knife  and  the  parts  laid  open.  The  wounds  thus  made  should 
be  lighth*  packed  and  allowed  to  granulate;  at  the  same  time  the 
limb  is  raised  and  kept  absolutely  quiet.  Should  pyemic  phe- 
nomena develop,  it  may  be  necessary  to  place  a  ligature  between  the 
disintegrating  clot  and  the  heart,  and  to  scrape  or  wash  away  the 
infective  material ;  thus,  in  thrombosis  of  the  lateral  sinus,  following 
suppuration  in  the  middle  ear,  the  internal  jugular  vein  should  be 
ligatured,  the  lateral  sinus  opened,  and  the  clot  removed.  Of  course, 
such  treatment  is  only  feasible  in  cases  where  a  single  trunk  is 
affected.  When  the  process  involves  the  veins  of  a  limb,  and  cannot 
be  stopped  by  either  of  these  plans  of  treatment,  the  question  of 
amputation  may  have  to  be  raised. 

Varicose  Veins,  or  Varix. 

A  vein  is  said  to  be  in  a  condition  of  varix  when  it  has  become 
permanently  lengthened,  dilated,  and  more  or  less  tortuous.  The 
superficial  veins  of  the  leg,  especially  the  internal  and  external 
saphena,  are  those  most  commonly  affected ;  the  spermatic  veins  are 
often  in  a  similar  condition,  constituting  what  is  known  as  a  varico- 
cele, w^hilst  piles  are  primarily  due  to  varicosity  of  the  haemorrhoidal 
plexus.  We  shall  here  only  deal  with  the  first  of  these  three  mani- 
festations. 

Causes. — \''arix  is  due,  in  the  first  place,  to  some  inherited  weak- 
ness of  the  venous  wall,  or  irregularity  in  the  arrangement  of  the 
valves,  though  possibly  this  produces  no  effect  until  some  exciting 
cause  comes  into  action  and  throws  a  strain  on  the  circulation.  The 
facts  that  varix  sometimes  appears  quite  earl}^  in  life  and  without 


348  A   MANUAL  OF  SURGERY 

adequate  cause,  and  often  involves  the  same  vein  in  different 
members  of  a  family,  coniirm  this  statement. 

Any  condition  which  leads  to  frequently  repeated  or  more  or  less 
permanent  distension  of  a  vein  may  result  in  varix — e.g.,  prolonged 
standing,  as  in  those  serving  behind  counters;  the  pressure  of  tight 
garters,  especially  if  worn  below  the  knee;  prolonged  or  forcible 
exertion  of  the  limb;  the  pressure  of  a  pregnant  or  displaced  uterus, 
or  of  a  pelvic  tumour.  Severe  exertion^ — such  as  occurs  in  football- 
playing,  hard  training,  weight-lifting,  etc.- — throws  a  heavy  strain  on 
the  vein  walls,  and  sometimes  leads  to  the  giving  way  of  the  valves, 
usually  from  above  downwards  in  the  legs.  This  valvular  incom- 
petence results  in  increasing  pressure  on  the  venous  walls,  which 
gradually  pass  into  a  condition  of  varix. 

Obstruction  to  and  occlusion  of  the  deeper  veins  is  another  well- 
recognised  cause  of  varix,  and  we  have  already  drawn  attention  to 
the  effects  produced  by  blocking  of  the  common  femoral  vein  and 
inferior  vena  cava.  A  less  known  instance  is  the  varix  of  the  in- 
ternal saphena  or  some  of  its  branches  below  the  knee  which  follows 
thrombosis  of  the  venae  comites  of  the  posterior  tibial,  due  to  strains 
of  the  leg  and  similar  injuries.  If  the  thrombus  is  absorbed,  the 
dilatation  disappears;  but  if  the  block  is  permanent,  the  superficial 
veins  become  varicose,  usually  extending  to  just  below  the  knee. 
Any  abnormal  communication  between  an  artery  and  a  vein  also 
causes  varix,  from  the  inability  of  the  latter  to  withstand  arterial 
blood-pressure  {vide  Aneurismal  Varix,  p.  302).  The  tendency  to 
varix  increases  with  age  till  the  middle  period  of  life  is  reached,  and 
is  favoured  by  the  relaxation  of  the  system  resulting  from  sedentary 
habits.  When  once  a  vein  has  become  varicose  and  its  walls  thin  and 
expanded,  the  valves  become  incompetent,  and  the  weight  of  the 
superincumbent  blood  still  further  increases  the  mischief. 

Morbid  Anatomy .^ — To  the  naked  eye  a  varicose  vein  in  an  early 
stage  appears  thickened,  distended,  and  tortuous;  the  walls  are  so 
thick  that  the  vein  when  cut  across  does  not  collapse,  but  presents  a 
gaping  mouth,  like  an  artery;  the  valves  atrophy,  and  are  function- 
ally useless.  After  a  time  the  walls  become  further  stretched  and 
irregularly  expanded,  forming  here  and  there  cyst-like  dilatations, 
which  are  very  obvious  under  the  attenuated  skin,  to  which  they  are 
often  adherent.  Microscopically,  the  change  consists  in  a  trans- 
formation of  the  normal  structures  of  the  vein  wall  into  fibro-cica- 
tricial  tissue.  The  tunica  media  is  mainly  affected,  most  of  the 
muscular  fibres  disappearing,  whilst  the  tunica  intima  is  but  little 
changed,  and  the  adventitia  thickened.  In  the  pouches  the  mifldle 
coat  is  atrophied,  and,  indeed,  is  often  completely  absent. 

Clinical  History. — The  enla^'ged  veins  are  seen  ramifying  under  the 
skin  with  a  more  or  less  tortuous  and  serpentine  course  (Fig.  114). 
and  they  often  feel  thickened.  One  or  more  veins  may  be  affected, 
and  the  tortuosity  may  be  at  parts  so  marked  as  to  constitute  large 
clusters  of  dilated  vessels,  which  look  bluish  under  the  thin  and 
stretched  integument.     In  other  cases  a  single  vein  is  enlarged,  and 


AFFECTIONS  OF  THE   VEINS 


349 


Stands  out  prominently  under  the  skin ;  or  perhaps  one  or  more  cyst- 
Hke  pouches  develop  in  connection  with  these  (Fig.  115).  The  upper 
end  of  the  internal  saphena  is  sometimes  dilated  so  as  to  form  a  large 
pouch,  in  which  a  marked  thrill  is  felt  when  the  patient  coughs, 
thereby  simulating  a  femoral  hernia.  In  other  cases,  although  this 
portion  of  the  vein  is  not  dilated,  yet  its  valves  are  incompetent,  and 
the  thrill  produced  by  coughing  can  be  felt  even  below  the  knee  if 
that  portion  of  the  vein  is  dilated. 

The  Effects  of  varicose  veins  are  very  varied.     The  limb  often  feels 
heavy  and  tired;  forcible  exertion  may  cause  a  sensation  of  tension. 


H^^l 

■ 

^^^^^$^1 

iS5^' 

Fig.     114. — Varix     of     Internal 
Saphena  Veins. 

The  left  foot  is  a  good  illustration 
of  pes  planus  (fiat-foot). 


Fig.  115. — -Varix  of  Left  In- 
ternal Saphena,  showing 
AN  Ampulla  above. 


and  after  standing  or  exercise  there  is  usually  some  cedema  of  the 
ankle.  The  capillaries  in  the  papillae  often  become  dilated,  appear- 
ing as  minute  reddish  puncta,  which  subsequently  run  together  and 
form  brownish  patches  of  pigmentation.  Eczema  is  induced  by  the 
irritation  of  rough  and  coarse  trousers  or  dirt,  often  terminating  in 
actual  ulceration.  Any  lesion,  such  as  a  scratch  or  abrasion,  instead 
of  healing  readily  under  a  scab,  tends  to  spread  and  form  an  ulcer. 
Injury  to  the  vein  may  lead  to  thrombosis  and  subsequent  cure,  but 
coagulation  sometimes  occurs  spontaneously  in  cysts  or  acute  kinks, 
especially  in  gouty  subjects.     The  clot  may  subsequently  shrink  and 


35°  A   MANUAL  OF  SURGERY 

form  a  small  librinous  or  calcareous  mass,  known  as  a  '  phlcbolitli,' 
but  sometimes  the  thrombosis  spreads  into  deeper  or  larger  veins, 
and  then  fragments  of  clot  may  be  detached  as  emboli.  Occasionally 
the  dilated  pouch  of  a  varicose  vein  gives  way,  and  an  alarming  rush 
of  blood  results;  the  same  may  follow  the  extension  of  ulceration 
through  the  vein  wall.  The  blood  under  these  circumstances  is 
derived,  not  only  from  the  lower,  but  also  from  the  upper  end;  and 
if  the  valves  have  become  incompetent,  a  column  of  blood  extending 
from  the  right  auricle  is  thus  tapped  near  its  lower  end,  and,  unless 
prompt  precautions  are  taken,  the  patient's  life  may  be  lost. 

The  Treatment  of  varicose  veins  may  be  described  as  palliative  and 
radical. 

Palliative  Treatment  consists  in  removing  any  source  of  obstruc- 
tion in  the  shape  of  tight  garters,  in  limiting  the  amount  of  standing, 
in  moderate  massage,  together  with  the  apphcation  of  either  an 
elastic  stocking  or  an  indiarubber  bandage.  The  bowels  should  be 
regulated,  and  the  general  health  attended  to.  Eczema  may  be 
treated  by  the  application  of  soothing  and  drying  ointments,  e.g., 
ung.  zinci  benzoatis;  or  if  the  skin  is  chronically  infiltrated  and 
thickened,  by  the  use  of  weak  tarry  applications,  e,g.,  ol.  Rusci  (i  part 
to  4  of  vaseline),  or  of  ichthyol  (5  or  10  per  cent,  in  vaseline).  Vari- 
cose ulcers  are  suitably  treated  (p.  103),  but  repair  is  often  delayed 
till  the  veins  have  been  dealt  with  by  operation. 

Radical  Treatment  consists  in  the  excision  of  the  distended  veins. 
Before  operating  it  is  important  to  investigate  the  history  and  ascer- 
tain if  the  condition  is  due  to  thrombosis  of  the  deep  trunks,  as  inter- 
ference might  then  do  more  harm  than  good.  Operation  is  specially 
indicated  when  thin,  dilated  pouches  exist;  when  elastic  stockings 
cannot  be  comfortably  worn,  as  in  the  tropics;  when  ulcers  are 
present  which  refuse  to  heal ;  when  the  condition  is  very  extensive 
and  painful,  and  especially  if  large  bunches  of  dilated  veins  are  seen; 
or  when  there  is  a  distinct  impulse  or  thrill  on  coughing,  due  to 
valvular  incompetence. 

Various  methods  of  operating  have  been  adopted:  [a]  Small 
portions  may  be  rem.oved  at  several  different  situations.  1  he  skin  is 
pinched  up  over  the  vein,  and  incised  by  transfixion;  the  vessel  is 
usually  bared  by  this  means,  but  may  need  a  little  clearing.  An 
aneurism  needle  is  passed  beneath  it,  and  the  vein  isolated  suffici- 
ently to  allow  of  its  being  grasped  by  two  pairs  of  forceps,  and 
divided  between.  Each  end  is  now  freed,  and  drawn  out  of  the 
wound  as  far  as  possible ;  it  is  then  ligatured  and  removed.  Probably 
2^  inches  of  vein  may  be  taken  away  through  a  i-inch  incision  1  he 
wound  is  sutured  without  drainage  and  dressed,  [b)  Long  incisions 
are  made,  perhaps  6  inches  or  more,  through  which  larger  clusters  of 
veins  may  be  dealt  with.  The  wound  should  not  lie  over  the  most 
dilated  parts  of  the  vessel,  as  there  the  skin  is  often  thin  and  un- 
healtliy,  but  should  be  curved  so  as  to  include  as  much  sound  skin  as 
possible,  whilst  crossing  the  vessels  once  or  twice.  All  collateral 
branches,  especially  the  deep  ones,  must  be  secured,  and  this,  in  fact , 


AFFECTIONS  OF  THE   VEINS  351 

constitutes  the  groat  advantage  of  the  operation,  viz.,  that  so  many 
anastonn)sing  channels  are  obhterated.  In  very  bad  cases  most 
extensive  operations  are  sometimes  required,  the  incisions  involving 
nearly  the  whole  length  of  the  limb,  [c)  A  simpler  procedure  has 
been  advocated  by  Trendelenburg,  viz.,  the  removal  of  a  portion  of 
the  internal  saphena  close  to  the  saphenous  opening,  so  as  to  break 
the  weight  of  the  superjacent  column  of  blood.  In  many  cases,  but 
especially  where  there  is  an  impulse  on  coughing,  and  the  vein  fills 
from  above,  this  is  essential,  though  it  is  also  desirable  that  the 
enlarged  veins  lower  down  should  be  excised. 

After  an  operation  for  varix  the  patient  should  remain  in  the  re- 
cumbent posture  for  three  weeks,  to  allow  clots  to  become  firm  and 
to  permit  the  circulation  to  accommodate  itself  to  the  new  arrange- 
ments. On  first  rising  from  bed,  it  is  well  to  support  the  limb  for  a 
time  by  a  '  Crepe  Velpeau  '  bandage. 

Inflamed  Varicose  Veins  are  not  unfrequent,  and  may  result  in  a 
natural  cure  of  the  condition.  The  symptoms  are  those  of  a  super- 
ficial phlebitis,  and  the  treatment  indicated  for  that  condition  should 
be  followed.  In  cases  where  there  is  much  pain  it  may  be  justifiable 
to  excise  the  thrombosed  vessels,  taking  the  precaution  first  to 
secure  by  ligature  the  vein  above  the  clot,  so  as  to  prevent  any  risk 
of  embolic  detachment.  Operation  of  a  similar  type  is  also  required 
when  thrombosis  is  gradually  spreading  upwards,  and  threatening  to 
affect  the  deep  trunks — ij.,<^.,  in  the  neighbourhood  of  the  saphenous 
opening;  or  when  portions  of  clot  are  being  detached  as  emboli, 
giving  rise  to  pulmonary  symptoms. 

Haemorrhage  from  a  Ruptured  Vein  needs  prompt  and  decisive 
treatment.  The  bleeding  spot  should  be  commanded  by  digital 
compression,  and  the  patient  laid  on  the  back  with  the  limb  elevated, 
until  either  a  pad  of  antiseptic  dressing  can  be  applied  to  the  wound, 
or  a  handkerchief  or  bandage  secured  over  it. 

Venesection. 

Venesection  or  phlebotomy  is  a  means  of  treatment  which  has 
largely  fallen  into  disuse  of  late  years,  but  is  still  occasionally  em- 
ployed with  benefit.  When  a  patient  is  becoming  cyanosed,  and 
asphyxia  is  threatening  either  [a)  as  a  result  of  pulmonary  engorge- 
ment from  mitral  incompetency,  owing  to  the  heart  being  unable  to 
drive  the  blood  into  the  systemic  circulation ;  or  {b)  as  a  consequence 
of  some  accident  involving  the  chest  wall  and  lungs,  whereby  the 
blood-aerating  surface  is  so  diminished  that  it  cannot  deal  with  the 
blood  reaching  it  through  the  right  side  of  the  heart,  which  hence 
becomes  enormously  distended,  and  threatens  to  stop  in  a  condition 
of  diastole:  or  (c)  where  inflammation  of  the  brain  is  pending,  and 
the  pulse  is  hard  and  full;  or  [d)  in  a  few  inflammatory  states  in 
strong,  full-blooded  indi^dduals  where  the  pulse-tension  is  high — in 
any  of  these  conditions  venesection  may  be  used  with  advantage. 

The  median  basihc  vein  at  the  bend  of  the  elbow  is  that  usually 


352  A   MANUAL  OF  SURGERY 

opened,  since  it  is  larger  than  the  median  cephahc,  though  placed 
more  directly  over  the  brachial  artery,  from  which  it  is  only  separated 
by  the  bicipital  fascia. 

Requisites. — A  strip  of  bandage  about  4  feet  long;  a  scalpel  or 
lancet;  a  graduated  bleeding-bowl;  and  finally  something,  such  as  a 
stick  or  bandage,  to  be  grasped  by  the  hand,  so  as  to  cause  contrac- 
tion of  the  muscles,  thus  pressing  the  blood  from  the  deep  into  the 
superficial  veins  along  the  communicating  branch  which  enters  the 
median  jiist  below  its  bifurcation. 

Operation. — The  patient  should  be  seated  in  a  chair  or  in  bed; 
standing  would  produce  syncope  too  rapidly,  whilst  the  recumbent 
posture  would  allow  too  great  an  abstraction  of  blood  before  Nature's 
danger-signal  {i.e.,  syncope)  is  evident.  The  skin  in  front  of  the 
elbow  having  been  purified,  as  also  the  hands  of  the  surgeon  and  the 


Fig.  116. — Venesection. 

lancet,  the  bandage  is  tied  round  the  arm  with  sufficient  tightness  to 
arrest  the  venous  circulation  whilst  the  arterial  supply  is  unimpeded. 
Grasping  the  stick  firmly  causes  the  veins  to  become  prominent. 
The  median  basihc  is  now  steadied  by  the  left  thumb,  and  an  in- 
cision made  into  it  (Fig.  116,  A).  Blood  will  flow  from  it  in  a  full 
stream,  and  is  collected  in  the  bowl.  When  sufficient  has  been 
withdrawn,  the  stick  is  removed  from  the  patient's  hand,  a  sterilized 
swab  is  pressed  over  the  bleeding  spot,  the  bandage  above  is  relaxed, 
and  a  pad  of  antiseptic  dressing  placed  over  the  wound  and  firaily 
bandaged  in  position;  the  arm  is  kept  at  rest  for  a  few  days  to  allow 
the  small  incision  to  heal.  Occasionally  neuralgic  pain  is  caused  by 
the  impUcation  of  some  of  the  fibres  of  the  internal  cutaneous  nerve 
in  the  cicatrix ;  whilst,  if  the  lancet  is  plunged  too  deeply,  an  arterio- 
venous wound  may  be  produced. 

Angiomata. 

Tumours  of  bloodvessels  present  varying  appearances  according 
to  the  situation  and  the  character  of  the  vessels  of  which  they  are 
composed.  They  are  frequently  of  congenital  origin  or  developed 
soon  after  birth.  They  involve  most  commonly  the  skin  or  mucous 
membrane  together  with  the  underlying  tissues,  and  are  then  known 
as  nsevi ;  but  they  are  occasionally  acquired  and  develop  in  deeper 


ANGIOMATA  353 

organs,  such  as  the  liver.  According  to  their  structure  they  are 
divided  into  three  main  groups,  the  simple  or  capillary  naevus,  the 
cavernous  naevus,  and  the  plcxiform  angioma. 

I.  The  simple  or  Capillary  Naevus  (mother's  mark)  is  exceedingly 
common,  and  consists  of  a  mass  of  dilated  capillaries  held  together 
by  a  small  amount  of  connective  tissue.  It  is  usually  located  in  the 
skin,  but  may  also  involve  the  subcutaneous  tissues;  the  tubular 
form  of  the  constituent  vessels  always  remains.  It  occurs  in  the 
form  of  a  slightly  raised  flattened  mass,  bright  red  or  purple  in 
colour,  according  to  the  relative  amount  of  arterial  or  venous  blood 
present,  and  with  occasionally  a  somewhat  irregular  or  nodulated 
surface,  in  which  larger  vessels  may  be  seen  ramifying.  Several 
such  growths  may  be  present  in  the  same  individual,  and  they  are 
usually  quite  small,  rarely  exceeding  an  inch  or  two  in  diameter; 
they  are  present  at  birth  or  appear  soon  after.  The  head  and  face 
are  the  parts  most  commonly  affected.  Angiomata  of  the  mucous 
membranes  are  often  a  source  of  considerable  danger  and  trouble 
from  haemorrhage,  especially  in  the  bladder  and  nose. 

A  more  superficial  variety  known  as  the  port- wine  stain  often 
extends  widely  over  the  face  and  neck,  and  is  somewhat  dusky  in 
colour;  this  condition  consists  merely  of  a  network  of  fine  vessels, 
and  does  not  project  above  the  surface. 

Occasionally  a  nevoid  development  may  be  observed  having  a 
hnear  distribution  down  the  long  axis  of  a  hmb,  or  running  trans- 
versely half  round  the  trunk,  and  Hmited  almost  exactly  by  the 
middle  fine;  this  condition  is  known  as  ncevus  unius  lateris.  It 
may  consist  purely  of  a  vascular  manifestation,  or  the  skin  may 
be  hypertrophied  and  covered  with  small  soft  papillary  ex- 
crescences. 

The  term  Spider  Nsevus  (A^.  araneus)  is  appUed  to  a  small  angioma, 
which  develops  usually  in  young  people,  and  generally  on  the  face, 
from  which  radiate  a  considerable  series  of  fine  red  fines.  ^^Tlen 
irritated  they  bleed  easily,  but  are  readily  cured  by  the  appfication 
of  carbonic  acid  snow  or  a  pointed  cautery. 

It  is  not  uncommon  in  middle-aged  people  to  find  a  number  of 
small  red  spots  on  the  trunk,  which  sometimes  persist  for  a  while  and 
then  disappear.  These  telangiectases  (or  De  Morgan  sfots)  consist 
of  dilated  capillaries,  and  are  possibly  degenerative  in  origin.  At  one 
time  they  were  looked  on  as  associated  with  cancer,  and  they  cer- 
tainly often  occur  in  women  with  mammary  cancer;  but  further 
experience  has  proved  that  no  such  sinister  significance  is  to  be 
attached  to  them. 

Left  to  themselves,  simple  naevi  may  remain  unchanged  or  dis- 
appear ;  more  often  they  increase  in  size  more  or  less  rapidly,  and  may 
invade  surrounding  tissues,  requiring  active  treatment  in  order  to 
check  their  progress.  Sometimes  they  persist  unaltered  till  middle- 
hfe,  and  then  may  increase  rapidly,  giving  rise  to  a  considerable 
vascular  tumour,  purple  in  colour,  and  occasionally  becoming 
prominent  and  pendulous.     Such  a  tumour  is  soft  and  easily  com- 

23 


354 


A   MANUAL  OF  SURGERY 


pressible,  being  in  reality  a  cavernous  angioma;  it  may  ulcerate,  and 
profuse  haemorrhage  may  result. 

Treatment  is  usually  simple  in  the  extreme.  Small  superficial 
Ucevi  can  be  completely  cured  by  some  form  of  cauterization,  the 
best  results  being  obtained  by  the  use  of  carbonic  acid  snow.  Appli- 
ances for  the  suppl\-  and  employment  of  this  agent  are  (jbtainable  at 
instrument  makers.  In  exposed  situations  electrolysis  (p.  53) 
may  be  the  best  plan  to  adopt,  but  excision  will  often  give  a  good 
result. 

2.  A  Cavernous  Naevus  (Fig.  117)  most  commonly  involves  the 
subcutaneous  or  submucous  tissues,  but  is  sometimes  associated 
with  a  superficial  naevus.  It  consists  of  dilated  spaces  where  the 
tubular  form  of  the  constituent  vessels  is  lost,  the  arteries  often 


w^l^ 


•hx. 


mi' 


Fig.  117. — Section  of  Cavernous  Angioma.     (Museum  of  Royal  College 

OF  Surgeons.) 

In  one  or  two  of  the  cavernous  spaces  thrombi  more  or  les.s'adhcrent 
can  be  seen. 

opening  directly  into  thin-walled  cavities  lined  with  endotheUum 
without  the  intervention  of  capillaries.  The  tumour  thus  produced 
is  a  more  or  less  prominent  swelling,  soft  to  the  touch,  and  easily 
compressible,  but  re-filling  when  the  pressure  is  removed.  There  is 
usually  no  pulsation  or  bruit,  although  both  may  be  present ;  and  the 
mass  may  be  definitely  circumscribed,  or  more  or  less  diffuse.  If 
subcutaneous,  the  skin  over  it  is  somewhat  bluish  in  colour;  when 
the  skin  is  involved,  the  mass  presents  a  dusky  red  appearance. 
Occasionally  these  growths  undergo  spontaneous  cure  from  inflam- 
mation and  thrombosis,  and  cj^sts  are  sometimes  found  in  the  centre 
of  a  na^void  mass,  indicating  that  a  partial  attempt  at  this  process 
has  occurred.  A  similar  condition  arises  in  the  viscera,  especially 
the  liver,  and  it  is  not  difficult  in  certain  suitable  cases  to  demon- 
strate that  it  has  been  formed  by  a  dilation  of  the  capillaries  between 
the  lobules,  the  liver  substance  meanwhile  disappearing  by  a  process 
of  simple  atrophy. 


ANGIOMATA  355 

The  Treatment  is  by  no  means  as  simple  as  in  the  former  variety. 
The  following  plans  may  be  mentioned: 

(i)  Excision  of  the  growth  should  always  be  adopted  where 
practicable.  The  bleeding  is  never  great,  even  if  the  naivoid  tissue 
is  encroached  upon  by  the  knife,  and  only  a  few  vessels  will  need 
to  be  tied.  Circular  growths  should  be  removed  by  crescentric 
incisions,  and  a  little  undercutting  will  usually  enable  the  edges 
to  be  approximated  easily.  In  exposed  situations  Halstead's  sub- 
cuticular suture  should  be  utilized. 

(2)  Where  excision  is  impossible,  electrolysis  should  be  emplo3^ed. 
It  consists  in  the  passage  of  an  electric  current  through  the  mass, 
producing  chemical  and  physical  changes  in  the  contained  blood. 
For  details,  see  p.  53. 

3.  Plexiform  Angioma. — This  term  is  now  usually  apphed  to 
an  angioma  in  which  the  arterial  element  predominates,  although 
veins  and  capillaries  are  also  present.  The  growth  is  usually  seen 
in  young  people,  and  affects  most  frequently  the  scalp,  especially 
the  temporal  or  occipital  regions.  A  tumour  is  produced  which  is 
soft  and  compressible,  pulsating  forcibly,  and  with  a  marked  bruit 
(cirsoid  aneurism,  p.  724).  It  usually  consists  of  large  obvious  dilated 
pouches,  the  skin  over  which  is  thinned,  and  may  give  rise  to 
serious  hfemorrhage,  or  grave  infective  troubles.  Sometimes  the 
growth  consists  of  smaller  arteries,  and  partakes  more  of  the 
character  of  an  arterial  neevus,  but  the  tubular  condition  of  the 
vessels  is  often  lost.  This  variety  (aneurism  by  anastomosis)  is 
sometimes  found  in  the  interior  of  bones  (p.  596),  in  some  forms  of 
pulsating  exophthalmos,  and  in  the  scalp. 

A  Nsevo-Lipoma  is  the  name  given  to  a  somewhat  rare  tumour, 
in  w^hich  a  fatty  element  is  blended  with  Ucevoid  tissue.  It  is 
usually  of  congenital  origin,  or  at  any  rate  appears  early  in  life. 
It  gives  rise  to  a  sw^elling,  lobulated  and  doughy,  like  a  fatty  tumour, 
although  it  is  usually  a  little  denser  in  texture  than  the  ordinary 
lipoma.  It  may  be  possible  to  reduce  its  size  by  compression,  but 
no  thrill  or  pulsation  can  be  detected;  a  few  dilated  veins  or  capil- 
laries are  often  seen  on  the  surface.     The  only  treatment  is  excision. 


CHAPTER  XV. 

DISEASES  OF  |THE  LYMPHATICS. 

Rupture  or  Division  of  the  Thoracic  Duct  may  occur  as  a  result  of 
a  penetrating  or  bullet  wound  of  the  neck,  or  during  operations  in  the 
supra-clavicular  fossa.  The  main  trunk  has  also  been  torn  in  a 
fracture  of  the  spine,  and  the  lymph  has  escaped  into  the  pleural 
cavity.  Wounds  near  the  outflow  into  the  junction  of  the  jugular 
and  subclavian  veins  usually  involve  one  or  more  of  the  several 
branches  into  which  the  main  trunk  divides  before  opening  into  the 
venous  system;  lymph  or  chyle  escapes,  but  if  the  divided  vessel  is 
tied,  no  further  trouble  arises  as  a  rule.  Failing  ligature,  the  wound 
should  be  packed  with  gauze,  and  the  flow  generally  ceases  after  a 
while.  Should  this  not  occur,  an  attempt  must  be  made  to  anasto- 
mose the  divided  end  of  the  duct  with  one  of  the  deep  veins,  for  a 
persistent  and  excessive  loss  of  lymph  means  the  exhaustion  of  the 
patient. 

In  a  few  cases  the  opening  of  the  thoracic  duct  has  been  obstructed 
or  compressed,  leading  to  such  backward  tension  that  the  recepta- 
culum  chyli  has  ruptured  and  the  peritoneal  and  pleural  cavities 
have  been  filled  with  a  serous  or  chylous  exudation.  Virchow 
described  one  case  where  the  opening  was  congenitally  absent  (in 
a  calf) ,  and  the  lymphatics  throughout  the  body  were  enormously 
distended,  especially  those  of  the  small  intestine. 

Acute  Lymphangitis,  or  Inflammation  of  the  Lymphatic  Vessels, 
ensues  almost  invariably  from  the  absorption  and  passage  along  the 
lymphatics  leading  from  an  infected  wound  of  bacteria  (usually 
streptococci)  and  toxins,  which  give  rise  to  inflammation  of  the 
lymphatic  vessels  involved  and  of  the  tissues  around  them,  and  this 
may  even  run  on  to  suppuration.  Ihe  walls  of  the  lymphatics 
become  hyperaemic  and  infiltrated,  and  the  tissues  around  are 
inflamed.  Ihe  lymph  is  said  to  coagulate  in  the  vessels,  forming  a 
pinkish  clot.  The  process  is  usually  limited  by  the  nearest  lym- 
phatic glands,  which  arrest  and  filter  off  the  toxic  products,  with 
or  without  the  occurrence  of  suppuration;  but,  in  spite  of  this,  a 
general  infection  of  the  system  occasionally  results. 

Clinical  Signs. — The  causative  wound  may  be  obviously  infected, 
or  is  possibly  very  slight  and  covered  by  a  dry  scab.     The  charac- 

356 


DISEASES  OF  THE  LYMPHATICS  357 

teiistic  appearance  is  that  of  fine  red  lines  or  streaks  following  the 
course  of  the  lymphatics,  perhaps  up  to  the  nearest  glands;  the 
parts  thus  inflamed  are  tender  and  oedematous.  If  the  mischief  is 
limited  to  the  main  trunks  [tubular  lymphangitis),  they  may  be  felt 
hard  and  cord-like,  and  the  red  lines  remain  isolated  from  each 
other;  but  if  all  the  smaller  lymphatic  channels  of  a  part  are  affected 
[yctifoym  lymphangitis),  the  redness  merges  into  a  generalized  blush, 
and  the  condition  is  identical  with  cellulitis.  Localized  foci  of 
suppuration  in  the  course  of  the  lymphatics  often  follow,  the  redness 
increasing  and  the  parts  becoming  dusky  and  brawny,  until  finally 
the  centres  soften  and  fluctuate.  These  phenomena  are  associated 
with  fever  and  malaise,  the  temperature  rising  to  102°  or  103°, 
possibly  attended  by  rigors,  vomiting,  and  diarrhoea. 

Under  suitable  treatment  resolution  rapidly  follows,  but  suppura- 
tion may  occur  either  in  the  glands  or  in  some  loose  mass  of  cellular 
tissue  traversed  by  the  lymphatic  trunks,  or  as  a  chain  of  abscesses 
in  the  course  of  the  vessels.  Occasionally  the  lymphatic  vessels 
become  permanently  occluded,  and  a  form  of  solid  or  lymphatic 
oedema  results.  Recurrent  attacks  of  this  type  are  not  uncommon 
in  connection  with  chronic  eczema  or  ulcers  of  the  leg,  and  may 
lead  to  elephantiasis.  In  the  worst  cases  the  patient  dies  from 
general  septicaemia,  or  from  exhaustion  following  diffuse  suppuration. 

Treatment  is  at  first  directed  to  the  causative  focus,  which  must  be 
opened  up  and  purified,  so  as  to  cut  off  the  supply  of  bacteria  and 
toxins  to  the  lymphatics.  The  limb  itself  is  kept  at  rest  in  a  slightly 
elevated  position,  and  fomented,  or  soaked  in  a  hot  bath;  Bier's 
treatment  of  induced  hyperaemia  is  often  useful.  Abscesses  are 
opened  as  soon  as  they  develop.  Any  subsequent  oedema  is 
remedied  by  massage  and  firm  bandaging,  provided  no  venous  com- 
plications are  present. 

Constitutional  treatment  consists  in  the  administration  of  a 
purge,  followed  by  a  light  and  nutritious  diet,  quinine  and  tonics, 
care  being  taken  that  constipation  is  not  thereby  produced. 

Chronic  Lymphangitis  either  results  as  a  sequela  of  an  acute  attack, 
or  is  met  with  as  a  separate  condition.  It  is  most  frequently  seen  in 
connection  with  venereal  disease,  the  dorsal  lymphatics  of  the  penis 
becoming  enlarged,  hard,  and  cord-like,  especially  in  cases  of 
primary  syphilis.  This  is  usually  accompanied  by  a  solid  oedema- 
tous condition  of  the  prepuce  and  enlargement  of  the  inguinal 
glands.  Under  appropriate  antisyphilitic  treatment,  the  swelling 
quickly  subsides. 

A  tuberculous  type  of  chronic  lymphangitis  also  exists  in  which  a 
primary  focus,  say,  on  a  finger,  is  associated  with  secondary  deposits 
along  the  lymphatics  up  the  arm.  Each  nodule  is  at  first  of  firm 
consistency,  but  gradually  softens  and  breaks  down.  Naturally, 
such  a  case  is  liable  to  be  followed  by  general  dissemination.  The 
treatment  consists  in  the  excision,  if  possible,  of  each  focus. 

The  cheeks  and  nose  are  occasionally  the  seat  of  a  chronic 
relapsing  lymphangitis,  due  to  the  absorption  of  septic  material 


358  A   MANUAL  OF  SURGERY 

from  sores  within  the  nostril.  It  is  characterized  by  patches  of 
hypentmia  and  some  amount  oi  tissue  infiltration,  and  for  its  cure 
the  causative  lesions  must  be  treated.  The  thick  li})s  of  a  tuberculous 
child  are  of  a  similar  nature,  and  due  to  the  constant  irritation  of 
cracks  along  the  lip  margin. 

Lymphatics,  like  bloodvessels,  are  liable  to  distension  and  dilata- 
tion, which  may  l)e  either  congenital  or  acquired,  and  are  known  as 
Lymphangioma  (»r  Lymphangiectasis.  It  is  impossible  to  draw  an 
absolute  line  of  distinction  between  the  two  conditions,  but  the 
latter  term  is  applied  mainl}'  to  cases  where  normal  lymphatics  are 
dilated  and  their  continuity  with  the  normal  lymphatic  circulation 
persists,  whilst  a  lymphangioma  is  the  result  of  a  new  formation. 
Not  unfrequently  the  two  conditions  develop  side  by  side. 

Lymphangiomata*  are  growths  composed  of  newly-formed  lym- 
phatics, together  with  a  variable  amount  of  connective  tissue,  which 
is  sometimes  of  a  fatty  nature.  They  may  be  congenital  or  acquired, 
but  even  in  the  latter  case  there  is  probably  an  underlying  con- 
genital element,  which  was  only  awaiting  some  irritation  or  localized 
injury  to  determine  its  development.  Two  varieties  may  be  de- 
scribed, the  capillary  and  cavernous. 

(a)  The  Capillary  Lymphangioma  is  usually  congenital  in  origin, 
but  often  increases  considerably  as  the  child  grows,  and  may  attain 
large  proportions.  When  developing  in  the  skin,  it  may  be  termed 
a  lymphatic  naevus,  and  in  origin  and  development  it  well  merits  the 
title.  The  patch  is  usually  of  a  dull  yellowish-brown  colour,  but  this 
varies  with  the  amount  of  blood  present ;  it  may  be  smooth-topped 
like  a  wheal,  or  wart-like  in  appearance,  but  on  examination  with  a 
lens  each  projecting  point  contains  a  vesicle.  This  type  of  growth 
is  sometimes  ver}^  extensive,  and  may  be  associated  with  tumours  of 
the  underlying  connective  tissues.  Thus,  a  large  fatty  mass  was 
removed  from  the  anterior  thoracic  wall  of  a  child,  the  greater 
portion  of  the  projecting  surface  of  which  was  covered  with  a 
capillary  lymphangioma.  The  only  treatment  for  this  condition  is 
excision  or  cauterization. 

In  the  subcutaneous  tissues  the  capillary  variety  is  often  associated 
with  large  cj-sts  of  the  cavernous  type.  It  constitutes  a  soft  swelling 
which  when  cut  into  has  a  spongy  texture  and  exudes  a  large  amount 
of  lymph,  with  some  blood.  This  form  is  rarely  well  defined,  and 
may  burrow  widely,  invading  and  infiltrating  the  tissues,  and,  in- 
deed, in  some  cases  may  almost  be  looked  on  as  of  a  malignant 
nature.     Free  excision  is  the  only  cure. 

[b)  Cavernous  Lymphangioma. — The  lymphatics  here  lose  their 
tubular  condition  and  give  rise  to  cyst-like  swellings  which  vary 
much  in  size. 

In  the  skin  they  are  rarely  larger  than  a  split  pea,  and  may  co-exist 
with  the  capillary  variety.     Any  part  of  the  body  may  be  affected, 

*  See  Carless,  '  Some  Cases  of  Lymphangioma,'  Brit.  Journ.  oj  Children's 
Diseases,  February,  1904,  p.  56. 


DISEASES  OF  THE  LYMPHATICS  359 

and  the  lesion  manifests  itself  as  a  scries  of  small  vesicles,  which 
persist  and  are  unaccompanied  by  any  inflammatory  redness,  thus 
serving  to  distinguish  it  from  herpes.  They  contain  lymph,  and,  if 
opened,  a  considerable  flow  of  this  fluid  (lymphorrhoea)  may  result, 
lasting  for  some  time.  They  have  been  observed  most  frequently 
on  the  inner  side  of  the  thigh  and  on  the  prepuce.  Treatment  con- 
sists in  excision,  or  in  laying  them  open  and  cauterizing  the  base. 

In  the  deeper  structures  large  multilocular  cystic  sweUings  may 
be  produced;  these  are  most  frequently  seen  in  the  neck,  and  the 
condition  is  often  termed  a  Cystic  Hygroma  (Fig.  1 18) .  The  descrip- 
tion given  in  Chapter  XXXI L  would  apply  equally  well  to  a  tumour 
of  this  nature  in  any  other  part  of  the  body.     Removal  by  dissec- 


FiG.   1 1 8. — Cystic  Hydroma  of  Neck.     (From  a  Photograph.) 

The  patient  was  a  child  of  a  few  weeks.  The  cyst  was  opened  and  the  mass 
partially  removed.  Recurrence  ensued,  and  a  further  operation  of  a  very 
extensive  character  was  required.  As  the  lymphangiomatous  tissue  had 
invaded  the  sterno-mastoid  and  the  parotid  gland,  it  was  impracticable  to 
remove  it  totally.  The  child  finally  succumbed  to  infective  lymphangitis 
and  exhaustion. 

tion  is  often  very  difficult,  especially  in  old-standing  neglected  cases; 
the  limitations  of  the  mass  are  sometimes  very  indefinite,  and  it 
may  be  necessary  to  leave  the  wound  open  and  pack  it,  so  as  to 
ensure  healing  by  granulation. 

Lymphangiectases  are  more  frequently  acquired  than  congenital, 
but  the  latter  condition  occurs,  and  is  then  probably  due  to  some 
abnormal  development  of  the  lymphatics  or  to  ante-natal  inflam- 
matory mischief. 

Macroglossia  and  macrocheilia  are  congenital  enlargements  of  the 
tongue  and  lip,  due  to  lymphatic  obstruction  and  to  an  associated 
overgrowth  of  the  connective  tissues  of  the  parts. 

The  condition  known  as  Chylous  Hydrocele,  in  which  there  is  an 
effusion  of  milky  fluid  (presumably  chyle)  into  the  tunica  vaginalis, 
is  probably  due  to  some  such  obstructive  cause.  In  a  case  under 
our  care  the  lymphatics  of  the  spermatic  cord  were  dilated  by  a 
similar  fluid  in  a  beaded  manner. 

Elephantiasis  is  a  hypertrophic  condition  of  the  subcutaneous 
tissues  and  skin  resulting  from  chronic  lymphatic  obstruction.     Two 


36o 


A   MANUAL  OF  SURGERY 


chief  varieties  are  described:  (i.)  E.  arahum,  due  to  a  development 
in  the  lymphatics  of  living  parasites,  viz.,  the  Filaria  sanguinis 
hominis  ;  (ii.)  the  non-filarial  type,  which  may  arise  from  many 
causes,  such  as  the  deposit  of  tuberculous  or  cancerous  material  in 
lymphatic  glands;  the  obliteration  of  l^'mphatic  channels  in  opera- 
tions for  removing  such  glands;  recurrent  attacks  of  lymphangitis  in 
cases  of  chronic  eczema  or  ulcer,  leading  to  a  graduallv  increasing 
obliteration  of  lymphatics.  The  condition  generally  affects  the 
legs,  but  the  scrotum  is  not  uncommonly  involved,  and  occasionally 


Fig.   1 19. — Non-filarial  Elephantiasis  of  Both  Legs. 

From  a  woman  who  had  never  been  out  of  England.     The  cause  was  not 
apparent,  but  had  been  in  action  many  years. 


the  mammffi,  arms,  or  face.  The  accompanying  illustrations 
(Figs.  119  and  120)  indicate  that  the  non-filarial  type  may  be  just 
as  severe  as  the  other  (Fig.  121),  although  this  is  unusual. 

Three  chief  phenomena  manifest  themselves  as  the  outcome  of 
such  obstruction — viz.,  [a)  Solid  or  lymphatic  oedema,  a  condition  in 
which  the  subcutaneous  tissues  become  firm,  infiltrated,  and  brawny, 
but  the  fluid  cannot  be  expressed  from  them,  as  in  an  ordinary 
oedema,  and  hence  the  part  does  not  pit  on  pressure,  {h)  Hyperplasia 
follows,  affecting  not  only  the  subcutaneous  tissues,  which  are  greatly 
thickened,  but  also  the  skin,  which  becomes  coarse  and  wart-like  in 
appearance,  (c)  The  warty  stage  is  usually  preceded  by  a  develop- 
ment of  vesicles  (dilated  lymphatics)  in  the  papilUe,  and  from  these 


DISEASES  OF  THE  LYMPH  AT  ICS  361 

when  ruptmcd  a  considerable  ilow  of  lymph  {lymphoyrJum)  may 
follow.  If  infection  supervenes,  chronic  ulceration  and  recurrent 
lymphangitis  may  ensue. 

Elephantiasis  Arabum  [syn. :  Barbadoes  Leg)  requires  but  little 
notice  here,  as  it  is  seldom  seen  in  this  country,  being  mainly  limited 
to  the  tropics,  especially  the  West  Indies  and  South  America.  The 
legs,  scrotum,  and  vulva  are  the  parts  most  frequently  attacked,  but 
the  face  or  breast  may  also  be  affected.  It  manifests  itself  as  a 
hyperplasia  of  variable  size  of  the  subcutaneous  tissues,  whilst  the 


Fig.  120. — NoN-FiLABiAL  Elephantiasis  of  Scrotum,  Penis,  and  Thighs. 
(From  a  Photograph.) 

The  patient  was  a  young  man,  and  the  cause  of  the  trouble  suppuration  of  the 
inguinal  glands  after  scarlatina;  the  cicatrices  of  the  incisions  requn-ed  m 
order  to  deal  with  the  glands  are  plainly  to  be  seen.  The  scrotum  was 
much  enlarged  and  very  solid;  the  skin  over  it  was  covered  with  papil- 
lomatous growths,  due  to  lymphatic  dilatation.  The  skin  of  the  penis  was 
much  thickened,  and  the  subcutaneous  tissues  infiltrated.  Over  the 
thighs  were  scattered  numbers  of  vesicles,  which,  when  pricked,  exuded 
lymph,  and  some  of  these  were  becoming  transformed  into  solid  fibrous 
growths.     The  legs  and  feet  were  also  in  a  condition  of  solid  oedema. 

skin  becomes  thickened  and  wart-like,  and  from  it  a  copious  dis- 
charge of  lymph  may  escape.  The  parts  sometimes  attain  enormous 
dimensions,  the  scrotum  even  reaching  to  the  ground  when  the 
patient  is  sitting  (Fig.  121).  The  disease  persists  for  many  years, 
and  is  not  directly  fatal. 

The  condition  is  due  to  the  obstruction  caused  by  the  develop- 
ment of  the  Filaria  sanguinis  hominis  in  the  lymphatics.  These 
are  spread  by  the  agency  of  mosquitoes,  in  whose  bodies  the  inter- 
mediate stage  is  passed.     The  dead  mosquito,  with  its  parasitic 


362 


A   MANUAL  OF  SURGERY 


contents,  falls  upon  the  water,  and  in  this  medium  the  ova  find 
an  entrance  into  the  human  stomach,  where  the  young  worm  is 
set  free,  bores  through  the  gastric  mucous  membrane,  and  linally 
becomes  lodged  in  the  lymphatics,  especially  those  of  the  extremities. 
Not  more  than  two  or  three  pairs  of  mature  filarise  are  generally 
present  in  the  same  individual.  The  body  of  the  female  worm 
(which  attains  a  length  of  3  inches)  is  mainly  occupied  by  the 
reproductive  organs,  and  a  countless  number  of  embryonic  lilarise 
are  produced.  Some  remain  coiled  up  in  the  lymphatic  spaces,  and 
give  rise  to  the  phenomena  of  lymphatic  obstruction.  Others 
become  uncoiled,  and  are  then  about  ^^^  inch  in  length;  they  find 


Fig.   121. — Filarial  Elephantiasis  of  Scrotum  and  Penis 
IN  A  Japanese. 


their  way  into  the  blood-stream,  sometimes  at  night  [F.  nocturna), 
sometimes  in  the  day  [F.  diurna),  and  can  be  readily  seen  under 
the  microscope  (p.  65).  They  are  taken  into  the  bod}'  of  a  mos- 
quito with  the  blood  which  it  abstracts,  and  thus  a  fresh  generation 
is  developed. 

The  Treatment  is  extremely  unsatisfactory.  In  the  filarial 
variety,  if  one  can  localize  the  situation  of  the  parent  filarije,  as  has 
been  possible  in  a  few  cases,  they  should  be  excised;  but  even  then 
the  lymphatic  obstruction  may  persist.  This  may  be  dealt  with  in 
either  variety  by  elevation  of  the  limb  and  elastic  pressure ;  but  when 
the  condition  is  due  to  lymphatic  obstruction  in  the  groin,  it  may  be 


DISEASES  OF  THE  LYMPHATICS  363 

possible  to  find  the  dilated  lymph  trunks  and  implant  them  into  a 
tributary  of  the  internal  saphena  vein  {lytnphangcioplasty),  so  as  to 
relieve  the  limb  of  its  engorgement  with  lymph.  It  has  also  been 
suggested  to  construct  artificial  lymphatics  by  introducing  a  care- 
fullv  steriHzed  silk  thread  through  the  subcutaneous  tissues  of  the 
thickened  area,  leaving  it  buried  therein,  and  carrying  it  up  into 
normal  tissues  (Sampson  Handley).  This  has  acted  fairly  well 
in  draining  awa}'  the  fluid  from  the  brawny-  arms,  sometimes 
seen  in  the  last  stages  of  a  cancerous  breast  [q.v.),  but  it  is  of 
httle  avail  in  the  lower  extremity  owing  to  the  counter-influence  of 
gravity.  Finally,  when  a  Hmb  is  involved,  amputation  may  be  de- 
sirable. \Mien  the  scrotum  is  affected,  the  morbid  tissue  can  be 
freely  dissected  away,  sufficient  sl-dn  being  left  to  cover  in  the  wound 
if  possible;  the  penis  and  testes  must  first  be  isolated,  and  then  the 
scrotum  amputated,  a  tourniquet  being  used  to  restrain  the  bleeding. 

Affections  of  Lymphatic  Glands. 

Acute  Lymphadenitis,  or  Inflammation  of  Lymphatic  Glands. — The 
Cause  of  this  condition  is  almost  always  the  absorption  of  some 
irritative  material  (toxic  or  infective)  from  the  periphery.  There  is 
always  an  increased  flow  of  hTnph  from  an  inflamed  part,  resulting 
in  an  enlargement  of  the  glands  to  which  the  lymph  is  carried,  which 
quickly  subsides  when  the  inflammatory  process  is  at  an  end.  In 
infective  conditions  the  enlargement  is  more  obvious  and  painful, 
and  suppuration  frequently  results;  in  fact,  the  l^TTiphatic  glands 
must  be  looked  on  as  the  filters  by  means  of  w^hich  many  sources  of 
disease  are  ehminated.  It  is  curious  that  certain  peripheral  in- 
fective conditions  are  not  at  all  hable  to  produce  h-mphadenitis — 
e.g.,  spreading  gangrene  and  many  forms  of  cellulitis;  possibly  the 
acuteness  of  the  process  causes  hnnphatic  thrombosis,  and  thus 
hinders  absorption.  A  certain  amount  of  peri-adenitis  is  always 
present,  even  in  the  early  stages;  it  may  be  of  Httle  importance,  or 
be  so  severe  and  extensive  as  to  constitute  a  diffuse  suppurative 
cellulitis. 

Clinical  History. — The  glandular  trouble  may  be  associated  with 
a  typical  Ivmphangitis,  or  be  independent  of  it,  and  the  causative 
lesion  may  have  almost  disappeared  before  the  glands  become 
affected.  The  glands  become  enlarged  and  tender,  and  if  super- 
ficial, the  skin  over  them  is  red  and  oedematous,  and  the  surrounding 
tissues  are  infiltrated  and  brawny.  When  pus  forms,  softening 
occurs  in  the  centre  of  the  mass,  and  fluctuation  may  become 
e^-ident ;  where  there  is  much  loose  areolar  tissue  around  the  glands, 
as  in  the  axilla,  the  pus  may  burrow  widely.  Fever,  malaise,  and  all 
the  general  phenomena  associated  with  an  acute  inflammation,  are 
usuallv  well  marked. 

Treatment. — The  offending  wound  or  causative  lesion  must  be 
dealt  with  by  such  measures  as  maj^  be  needed  to  hasten  its  restora- 
tion to  a  healthy  state.     Fomentations  or  poultices  are  appfied  over 


364  A   MANUAL  OF  SURGERY 

the  gland,  and  the  patient,  after  the  administration  of  a  purge,  may 
be  given  quinine  and  iron,  if  necessary.  As  soon  as  pus  has  formed, 
it  shonld  be  let  out  by  an  incision,  and  the  wound  dressed  anti- 
septically. 

I  lu'  Axillary  Glands  are  usually  affected  as  a  result  of  poisoned  wounds  of 
the  hand  or  fingers,  although  other  glands  exist  lower  down  in  the  arm,  viz., 
the  supracondyloid,  just  above  the  internal  condyle.  Boils  in  the  axilla  and 
excoriations  or  infected  wounds  of  the  breast  may  also  cause  an  axillary  abscess. 
In  this  region  a  suppurative  peri-adenitis  is  often  superadded,  extending 
widely  under  and  between  the  pectoral  muscles,  reaching  even  up  to  the 
clavicle  {vide  axillary  cellulitis,  p.  87).  Care  must  be  taken  in  opening  such 
an  abscess  to  avoid  the  main  vessels  by  cutting  from  above  downwards,  mid- 
way between  the  anterior  and  posterior  axillary  folds,  whilst  Hilton's  method 
should  be  adopted  in  all  cases  where  the  pus  is  situated  deeply. 

In  the  Groin  there  are  three  groups  of  glands:  (i)  The  oblique  set,  running 
parallel  to  Poupart's  ligament,  and  becoming  inflamed  in  affections  of  the 
penis,  scrotum,  perineum,  anus,  buttock,  and  lower  part  of  the  abdomen; 
(2)  a  superficial  vertical  set,  running  with  the  long  saphena  vein,  and  receiving 
lymph  from  all  the  superficial  parts  of  the  limb,  except  perhaps  those  from 
which  the  blood  is  returned  by  the  external  saphena  vein,  the  popliteal  glands 
receiving  the  lymph  from  this  region;  and  (3)  the  deep  vertical  set,  receiving 
he  deep  lymphatics  of  the  linib.  Abscess  in  the  groin  is  opened  by  a  vertical 
incision,  so  as  to  allow  the  wound  to  gape  when  the  patient  sits,  and  prevent 
pocketing  of  matter. 

Suppuration  in  the  glands  of  the  Neck  is  exceedingly  common,  arising  most 
often  from  affections  of  the  scalp  (eczema  or  pediculosis),  ear  (otorrhoca  or 
eczema),  throat,  or  lips.  As  to  the  exact  distribution  of  the  lymphatics,  we 
must  refer  students  to  anatomical  textbooks  When  opening  a  cervical 
abscess,  care  must  be  taken  to  avoid  important  structures,  such  as  the  external 
jugular  vein,  and  to  make  incisions  across  the  fibres  of  the  platysma  in  order  to 
gain  space  for  efficient  drainage. 

Chronic  Lymphadenitis. — Three  chief  varieties  of  chronic  inflam- 
mation of  h'mphatic  glands  are  met  with — viz.,  the  simple,  S3'philitic, 
and  tuberculous. 

1.  Chronic  Simple  Lymphadenitis  is  a  condition  resulting  from  some 
peripheral  irritation,  wliich  is  insufficient  to  cause  an  acute  attack. 
Occasionally  it  is  due  to  blows  or  to  strains,  as  in  over-walking, 
being  then  the  outcome  of  obstruction  to  the  lymphatic  flow  from 
compression  or  rupture  of  the  efferent  vessels.  The  glands  become 
enlarged,  tender,  and  painful,  but  as  a  rule  they  are  not  adherent 
to  one  another  or  to  adjacent  structures,  and  show  but  little  tendency 
to  suppurate.  This  condition  often  precedes,  and,  indeed,  may  be 
looked  on  as  a  predisposing  cause  of,  tuberculous  lymphadenitis. 
The  Treatment  consists  in  keeping  the  part  at  rest,  and  removing,  if 
possible,  all  sources  of  local  irritation.  The  general  health  should 
also  be  attended  to,  especially  in  children  predisposed  to  the  develop- 
ment of  tuberculous  disease. 

2.  Chronic  Syphilitic  Lymphadenitis. — The  lymphatic  glands  are 
involved  in  several  ways  in  the  course  of  syphilitic  disease:  {a)  Th  i 
primary  lesion  is  associated  with  the  development  of  an  indolent 
bubo  in  the  nearest  lymphatic  glands  (p.  157).  {b)  In  the  second 
stage,  when  general  infection  has  occurred,  the  glands  in  many  parts 
of  the  body  are  infected  in  the  same  indolent  fashion  (p.  160).     (c)  In 


DISEASES  OF  THE  LYMPHATICS  365 

the  tertiar^^  period  the  lymphatic  glands  maj^  undergo  a  true  gumma- 
tous change,  or  become  enlarged  and  tender  owing  to  the  absorption 
of  infective  material  from  a  broken-down  gumma. 

3.  Chronic  Tuberculous  Lymphadenitis  occurs  most  commonly  in 
children  or  young  adults,  and  especially  in  those  whose  surroundings 
are  unhealthy,  and  whose  general  condition  is  deteriorated  by  in- 
sufficient or  bad  food  and  want  of  fresh  air.  Some  local  focus  of 
irritation  is  usually  present  in  the  form  of  pediculosis  capitis,  decayed 
teeth,  chronic  otorrhoea,  adenoids,  or  eczema  of  the  face.  As  a  result 
of  this,  neighbouring  glands  become  chronically  inflamed,  and,  as 
the  late  Sir  T.  Burdon  Sanderson  expressed  it,  '  the  soil  is  thereby 
prepared  for  the  seed.'  The  bacilli  are  conveyed  to  the  gland  by  the 
blood  or  lymph,  gaining  access  through  some  breach  of  surface,  or 
even  through  a  healthy  mucous  membrane ;  or  perhaps  they  may  be 
derived  from  some  deep  focus  of  quiescent  tubercle,  say,  in  the 
bronchial  or  mediastinal  glands.  Any  lymphoid  tissue  in  the  body 
may  become  the  seat  of  tuberculous  disease;  but  the  glands  of  the 
neck,  which  derive  their  lymph  from  the  mouth,  throat,  nose,  ears, 
and  scalp,  are  more  commonly  involved  than  any  others.  Ihe 
axillary  and  inguinal  glands  are  not  unfrequently  affected,  whilst 
tuberculous  disease  of  those  in  the  mesentery  gives  rise  to  the  affec- 
tion known  as  '  tabes  mesenterica.'  For  the  general  facts  as  to  the 
pathology  of  tuberculosis,  see  p.  176. 

The  earliest  manifestation  of  the  disease  consists  in  a  fleshy  en- 
largement of  the  glands,  which  cannot  at  first  be  distinguished  from 
a  simple  chronic  hyperplasia.  The  gland  may  be  enlarged  to  many 
times  its  natural  size,  and  on  section  looks  pinkish  in  colour,  and  is  of 
firm  consistence.  Microscopically,  all  that  is  noticed  is  a  great  in- 
crease in  the  lymphoid  corpuscles,  together  with  some  overgrowth 
and  thickening  of  the  fibrous  capsule  and  trabecule.  When  tuber- 
culous infection  has  occurred,  the  characteristic  nodules  can  be  seen 
under  the  microscope,  but  there  is  at  first  no  change  in  the  naked 
eye  appearances.  Caseation  follows  sooner  or  later,  appearing  as 
foci  scattered  through  the  gland,  which  gradually  coalesce  to  con- 
stitute larger  masses,  which  may  in  time  involve  the  whole.  Should 
the  case  recover  without  suppuration,  the  gland  gradually  shrinks, 
and  becomes  small,  hard,  and  often  closely  adherent  to  surrounding 
tissues,  whilst  the  caseous  material  is  absorbed,  or  undergoes  calci- 
fication.  This  latter  change  is  often  seen  in  the  mediastinal  and 
mesenteric  glands,  but  is  not  very  common  in  the  neck. 

More  frequently  suppuration  ensues,  sometimes  from  a  simple 
liquefaction  of  the  caseating  material,  sometimes  from  a  superadded 
infection  with  p3'ogenic  organisms.  Foci  of  pus  develop  at  various 
spots  in  the  parenchjoiia,  and  w^hen  once  formed,  these  gradually 
amalgamate  and  cause  the  destruction  of  the  rest  of  the  gland. 
Several  of  these  abscesses  ma}'  unite  one  with  another,  and  thus  a 
large  multiloculated  cavity  containing  pus  mixed  with  caseous  debris 
is  formed.  A  certain  amount  of  peri-adenitis  is  almost  always 
present,  though  not  to  any  great  extent  in  the  early  stages;  when. 


366  A   MANUAL  OF  SURGERY 

however,  suppuration  has  occurred,  the  enlarged  glands  become 
adherent  to  one  another  and  to  surrounding  structures.  In  the 
more  chronic  cases  the  fibro-cicatricial  tissue  thus  formed  may  be 
so  extensive  as  to  fix  the  mass  firmly  to  the  deeper  parts,  such  as  the 
main  vessels  and  nerves,  rendering  removal  dangerous  and  almost 
impracticable.  Important  vessels  are  occasionally  eroded  b}^  an 
extension  of  the  suppurative  process,  and  this  may  lead  to  fatal 
haemorrhage.  Sooner  or  later  the  abscess,  if  left  to  itself,  bursts  at 
one  or  several  spots,  giving  exit  to  the  pus  and  caseous  debris,  and 
leaving  ulcerated  openings,  which  are  surrounded  by  skin  that  is 
undermined,  thin,  and  purplish,  and  through  which  granulations 
protrude.  A  variable  amount  of  pus  escapes  from  these  until  all  the 
caseous  material  has  disappeared,  so  that  the  condition  may  persist 
for  many  years  before  healing  occurs,  and  even  then  the  cicatrix  is 
often  puckered  and  more  or  less  keloidal,  and  may  retain  its  vascu- 
larity for  a  much  longer  period  than  would  a  healthy  scar.  Lym- 
phatic cedema  in  the  region  drained  by  the  affected  glands  is  some- 
times observed  as  a  late  consequence  of  this  affection. 

Treatment  in  the  early  stages  consists  mainly  in  improving  the 
general  health  by  means  of  suitable  diet  and  tonics,  such  as  cod-liver 
oil  and  syrup  of  the  iodide  of  iron,  together  with  residence  in  a 
healthy,  bracing  place,  especially  at  the  seaside  or  on  high  moorland. 
All  sources  of  local  irritation,  septic  roots  of  teeth,  enlarged  tonsils, 
adenoids,  etc.,  must  be  removed  so  as,  if  possible,  to  prevent  infec- 
tion with  pyogenic  organisms;  and  counter-irritants,  such  as  iodine 
paint,  are  best  avoided.  Rest  of  the  affected  part  should  be  enforced 
as  much  as  possible;  in  some  cases  the  application  of  splints  to 
restrict  movement  is  advisable.  Small  doses  of  tuberculin  are  often 
useful  (p.  184). 

Operative  Treatment. — Too  much  time  should  not  be  wasted  in 
palliative  measures,  inasmuch  as  the  longer  the  glands  are  left,  the 
firmer  will  be  the  adhesions  which  they  are  likely  to  contract  to 
surrounding  tissues,  and  the  more  difficult  the  dissection  for  their 
removal.  Operation  is  indicated  when  the  glands  persist  in  spite  of 
suitable  care,  and  still  more  if  they  enlarge  or  show  evidences  of 
suppuration. 

In  the  neck  every  effort  must  be  made  to  avoid  operation,  but  it  is 
well  to  remind  patients  or  their  friends  that  the  scar  of  an  aseptic 
operation  is  less  obvious  than  that  which  follows  the  opening  of  an 
abscess  and  the  scraping  out  of  a  gland.  When  abscesses  form,  it 
must  be  remembered  that  there  is  frequently  a  deep  sub-fascial  origin, 
communicating  with  the  superficial  subcutaneous  collection  of  pus  by 
a  narrow  aperture;  unless  this  deep  focus  is  dealt  with  efficiently,  the 
wound  will  not  heal.  It  may  sometimes  be  practicable  to  scrape  away 
all  the  deep  tuberculous  material  at  the  time  that  the  abscess  is  opened; 
but,  failing  that,  the  wound  is  allowed  to  heal  as  far  as  possible,  and 
then  at  a  later  date  the  whole  mass  of  glands  involved  in  the  process  is 
removed.  When  extirpation  of  glands  is  required,  the  incision  varies 
with  the  situation  of  the  mass,  but  every  precaution  is  taken  to 


DISEASES  OF  THE  LYMPHATICS 


367 


minimize  the  deformity  and  searring.  In  the  upper  part  of  tlie  neck, 
when  the  glands  he  in  front  of  the  sterno-mastoid,  an  almost  trans- 
verse incision  may  be  employed,  or  one  following  the  creases  of  the 
skin  and  very  similar  to  that  for  ligature  of  the  lingual  artery 
(Fig.  122,  B).  In  the  lower  half  of  the  neck  an  incision  along  the 
anterior  or  posterior  border  of  the  sterno-mastoid  (E)  will  often 
su;fiice,    or    if    the   glands  ^..ss?^-^- 

extend  backwards  a  trans- 
verse one  just  above  the 
clavicle  (A^). 

Wlien  enlarged  glands  are 
present  both  in  front  of  and 
behind  the  sterno-mastoid,  as 
well  as  beneath  it,  their  re- 
moval is  perhaps  most  satis- 
factorily accomplished  b}^  a 
method  suggested  by  Halstead. 
The  incision  commences  close 
to  the  tip  of  the  mastoid 
process,  and,  passing  forwards 
just  behind  the  jaw,  sweeps 
across  the  neck  to  the  middle 
of  the  clavicle  (Fig.  122,  A); 
a  second  incision  runs  trans- 
versely' just  above  the  clavicle 
(A^).  The  flaps  thus  marked 
out  are  dissected  up  so  as  to 
la}^  bare  the  sterno-mastoid 
and  the  enlarged  glands.  The 
deep  dissection  commences 
from  below  and  behind.  The 
supraclavicular  triangle  is  first 
cleared,  the  omo-hyoid  muscle 
being  di\dded,  but  sutures  are 
left  on  the  ends  for  identifica- 
tion. The  anterior  end  is 
drawn  up,  and  serves  to  raise 

the  sterno-mastoid,  which  is  then  divided  obliquely  (D)  below  the  spinal 
accessory  nerve  (C).  The  divided  ends  are  turned  up  and  do^\^l  so  as  to 
expose  freelv  the  glands  lying  on  the  carotid  sheath,  which  are  dealt  with 
from  below  upwards.  Special  care  must  be  taken  of  the  nerves  and  of  the 
internal  jugular,  but  it  is  better  to  tie  and  remove  this  structure  than  to 
leave  it  in  the  wound  with  a  number  of  lateral  ligatures  applied,  which 
might  possiblv  be  forced  ofi  bv  the  suddenly  increased  intravenous  tension 
induced  by  the  post-anaesthetic  vomiting.  When  all  the  glands  have 
been  removed,  the  di\-ided  muscles  are  carefully  replaced  and  sutured 
together,  and  divided  fascis,  etc.,  approximated  by  buried  sutures.  In 
this,  as  in  all  neck  operations,  the  skin  is  brought  together  by  Halstead's 
intradermic  suture,  and  it  is  wonderful  how  little  scarring  and  deformity 
follow  this  extensive  procedure. 

The  pre-awicular  gland  Ijang  on  the  capsule  of  the  parotid  is 
sometimes  affected,  and  may  cause  facial  paralysis,  either  as  a  result 
of  the  sclerosing  peri-adenitis,  or  from  injudicious  surgery.  Any 
incisions  made  ^vith  a  view  to  remove  the  gland  or  to  open  an  abscess 
therein  should  be  made  in  the  direction  of  the  fibres  of  the  facial 
nerve — i.e.,  horizontally. 


/A' 

Fig.  122. — Incisions  for  Removal  of 
Tuberculous  Glands  from  the  Neck. 

A  and  A^-,  For  removal  of  glands  from  both 
triangles  (Halstead's  method) ;  B,  for  remov- 
ing glands  from  submaxillary  and  upper 
carotid  regions;  E,  for  removing  glands  in 
lower  part  of  posterior  triangle;  C,  spinal 
accessory  nerve;  D,  site  for  di\'ision  of 
sterno-mastoid . 


368  A^MANUAL  OF  SURGERY 

In  the  groin,  tuberculous  glands  arc  often  mistaken  for  some  con- 
dition due  to  venereal  disease.  The  history  of  onset  and  the  extreme 
chronicity  should  suffice  to  establish  a  diagnosis.  Ihe  iliac  glands 
will  often  be  found  similarly  affected,  and  operations  in  this  region 
are  sometimes  very  extensive  in  consequence.  Well-marked  peri- 
adenitis is  usually  present  in  the  iliac  fossa,  and  the  glands  may  be 
very  adherent.  Atrophy  of  the  testicle  sometimes  follows,  either 
from  division  of  the  spermatic  vessels,  or  from  their  imphcation  in 
the  cicatrix. 

Tumours  of  Lymphatic  Glands. 

Lymphadenoma,  or  Hodgkin's  disease,  is  characterized  by  a  pro- 
gressive enlargement  of  the  lymphatic  glands  and  of  the  l3aTiphoid 
tissue  of  the  spleen,  liver,  and  other  organs.  The  affected  glands 
and  the  masses  in  the  viscera  are  quite  characteristic  in  structure, 
and  have  a  very  different  appearance  from  that  seen  in  simple 
hyperplasia  or  in  infective  processes.  The  gland  is  homogeneous  on 
section,  the  distinction  between  cortex  and  medulla  being  lost.  The 
amount  of  stroma  varies  considerably,  and  the  glands  are  hard  or 
soft  according  to  its  relative  abundance  or  not.  One  type  does  not 
appear  to  pass  into  the  other,  and  the  soft  form  is,  in  most  cases, 
more  malignant  and  more  rapid  in  growth  than  the  hard.  There  is 
a  relative  decrease  of  lymphocytes  in  the  glands,  and  an  increase  in 
the  endothelial  elements,  some  of  which  are  multi-nucleated.  Nothing 
is  known  as  to  its  cause,  but  it  is  probably  an  infective  disease. 

Hodgkin's  disease  is  most  common  in  young  adults,  but  no  age  is 
exempt ;  it  is  decidedly  more  common  in  males  than  in  females.  In 
some  cases  the  cause  of  the  original  enlargement  of  glands  is  some 
inflammatory  lesion,  such  as  otitis  media  or  dental  caries,  but  often 
no  such  origin  can  be  traced.  The  glands  first  affected  are  usually 
the  cervical,  and  the  disease  may  remain  limited  to  a  larger  or 
smaller  group  of  these  for  a  considerable  time  before  other  manifes- 
tations show  themselves ;  this  condition  is  sometimes  termed  benign 
or  localized  lymphadenoma .  In  other  cases  internal  glands  become 
affected  first,  and  this  most  commonly  in  the  mediastinal  group, 
the  retro-peritoneal  glands  coming  next  in  order  of  frequency. 
When  the  disease  is  more  advanced,  lymphadenoid  tissue  in  any 
part  of  the  body  may  be  affected.  The  spleen  is  usually  somewhat 
enlarged,  and  in  about  half  the  cases  presents  localized  grayish- 
white  tumours  (the  hard-bake  spleen).  Similar  growths  may  occur 
in  the  liver,  kidneys,  etc.,  or  in  the  skin. 

The  early  symptoms  are  shght,  the  only  thing  noticed  being  the 
glandular  enlargement.  In  this  stage  the  glands  are  soft  and 
elastic,  and  not  adherent  to  the  skin  or  to  one  another;  they  have 
little  or  no  tendency  to  caseate  or  suppurate.  When  the  internal 
glands  are  first  affected,  the  earhest  symptoms  may  be  those  of 
pressure.  This  is  most  marked  in  the  mediastinal  group  of  cases, 
in  which  pressure  on  the  superior  vena  cava  is  early  noted,  leading 
to  engorgement  of  the  superficial  thoracic  veins. 


DISEASES  OF  THE  LYMPHATICS  369 

In  the  later  stages  intermittent  febrile  attacks  appear,  associated 
with  swelling  and  pain  in  the  glands,  possibly  due  to  a  superadded 
mild  pyogenic  infection ;  periadenitis  results,  and  the  glands  often 
fuse  together,  forming  hard  masses  of  large  size,  whilst  the  disease 
becomes  generalized.  The  blood  shows  a  moderate  grade  of  anaemia 
of  the  secondary  type,  with  a  sHght  increase  of  leucocytes,  especially 
of  the  lymphocytes.  Gradually  the  pyrexia  becomes  more  con- 
stant, and  the  patient  passes  into  a  cachectic  condition. 

Diagnosis.  —  (i)  From  lymphatic  Icitcocythcemia  (pp.  65,  67) 
Hodgkin's  disease  is  recognized  by  the  entire  absence  of  blood 
changes  in  the  early  stages,  and  by  the  presence  merely  of  a  second- 
ary anaemia  in  the  later.  Moreover,  lymphadenoma  usually  limits 
itself  to  regions  in  which  adenoid  tissue  is  normally  present ;  leucocy- 
thfemia  may  develop  new  growths  in  any  part  of  the  body.  (2)  From 
lymphosarcoma  it  is  known  by  the  fact  that  it  is  almost  invariably 
limited  to  the  glands,  and  does  not  infiltrate  surrounding  tissues. 
Lympho-sarcoma  is  characterized  chiefly  by  its  tendency  to  infiltrate, 
and  also  by  producing  secondary  deposits  in  tissues  which  are  not 
rich  in  adenoid  tissue.  (3)  From  tuberculous  disease  of  glands  the 
diagnosis  is  often  difficult.  Tubercle  is  more  common  in  the  very 
young,  and  is  more  frequently  bilateral.  The  glands  have  a  greater 
tendency  to  fuse  together  as  a  result  of  periadenitis,  and  to  sup- 
purate. In  doubtful  cases  microscopic  examination  of  an  excised 
gland  may  be  required  to  settle  the  diagnosis. 

The  Treatment  of  Hodgkin's  disease  is,  as  a  rule,  most  unsatisfac- 
tory. In  the  earher  stages  removal  of  the  enlarged  glands  is  easily 
effected,  but  recurrence  is  the  usual  result.  In  the  later  stages, 
when  several  attacks  of  inflammation  have  occurred,  removal  may 
be  most  difficult.  Probably  the  best  treatment  consists  in  the 
administration  of  arsenic  and  the  exposure  of  the  enlarged  glands 
to  X  rays.  Arsenic  must  be  administered  in  large  doses  for  some 
considerable  time,  or  possibly  salvarsan  may  be  substituted  for  it. 
In  one  case  recently  treated  the  happiest  results  followed  the 
administration  of  one  dose  of  0*6  gramme  salvarsan  and  X  rays; 
several  previous  operations  had  been  f  oh  owed  by  relapse. 

Lymphatic  Leucocythsemia  is  of  little  surgical  interest  except  in  so 
far  as  it  simulates  Hodgkin's  disease.  The  symptoms  are  much 
more  severe  than  in  the  latter,  and  marked  blood  changes  are 
present;  the  number  of  the  leucocytes  is  enormously  increased, 
reaching  150,000  or  more  per  cubic  millimetre,  and  there  is  a  great 
preponderance  of  lymphocytes,  which  constitute  from  90  to  99  per 
cent  of  all  cells  present.  There  is  also  anaemia,  often  of  some 
severity  (pp.  65  and  67).  Arsenic  is  valuable,  and  operative  treat- 
ment useless.  Recently  X-ray  treatment  has  been  employed  to  the 
spleen  and  ends  of  the  long  bones  with  temporary  benefit. 

Lympho-Sarcoma. — This  term  has  been  used  with  very  different 
meanings,  but  is  best  restricted  to  tumours  which  have  a  structure 
approximating  to  that  of  lymphadenoid  tissue — i.e.,  which  consist 
of  small  round  cells,  resembling,  if  not  identical  with,  ordinary 

24 


370  A   MANUAL  OF  SURGERY 

lymphocytes,  set  in  a  reticulated  stroma;  there  is  no  distinction 
between  cortex  and  medulla.  They  closely  resemble  a  small  round- 
celled  sarcoma,  except  that  the  stroma  is  more  obvious;  their 
sarcomatous  nature  is  evidenced  rather  by  chnical  than  by  histo- 
logical characters — viz.,  by  the  fact  that  they  invade  and  destroy 
surrounding  tissues. 

Lympho-sarcoma  may  commence  in  any  part  of  the  body,  but  in 
the  vast  majority  of  cases  it  originates  in  pre-existing  adenoid  tissue, 
most  commonly  in  the  glands  at  the  root  of  the  neck,  the  tonsil,  or 
the  mediastinum.  It  may  also  affect  the  intestines  (commencing 
probably  in  the  Peyer's  patches)  or  the  testis.  When  commencing 
in  a  region  where  its  development  can  be  followed,  it  is  seen  to  form 
a  rapidly-growing  tumour,  which  is  at  first  firm,  elastic,  and  painless; 
later  on,  however,  as  it  increases  in  size,  it  becomes  tender,  and  may 
cause  great  pain  from  pressure  on,  or  implication  of,  nerves.  It 
early  contracts  adhesions  to  surrounding  parts,  and  gives  rise  to 
secondary  growths  in  neighbouring  glands  by  direct  transmission. 
The  superjacent  skin  is  at  first  unaltered  in  colour  and  texture,  but 
as  the  tumour  increases,  it  becomes  congested  and  shiny,  and  con- 
tains a  network  of  dilated  veins.  Finally,  ulceration  occurs,  and  is 
followed  by  the  sprouting  up  of  a  bleeding  fungating  mass,  similar 
in  character  to  that  formed  by  any  other  rapidly-growing  malignant 
tumour.  Dissemination  of  the  growth  throughout  the  viscera 
follows,  death  resulting  from  exhaustion  and  cachexia. 

The  Treatment  consists  in  the  removal  of  the  mass,  where  prac- 
ticable, without  delay.  If,  however,  extensive  adhesions  exist,  this 
becomes  absolutely  impossible,  and  radio-therapy  can  alone  be 
relied  on. 

Secondary  Growths  in  Lymphatic  Glands  are  a  special  feature  of 
all  cancerous  tumours.  In  the  sarcomata  they  are  less  common, 
but  are  always  present  in  the  case  of  melanotic  sarcoma,  lympho- 
sarcoma, and  usually  in  sarcoma  of  the  testis,  tonsil,  and  thyroid 
The  special  characteristics  of  these  are  noted  elsewhere. 


CHAPTER  XVI. 

AFFECTIONS  OF  NERVES. 

The  simplest  and  most  common  forms  of  injury  to  which  nerves  are 
hable  are  Contusions  and  Strains,  causing  a  sensation  of  tinghng, 
or  pins  and  needles,  which  usually  wears  off  in  the  course  of  a  few 
hours.  In  severe  cases  variable  degrees  of  loss  of  power  and  sensa- 
tion may  ensue,  and  in  hysterical  women  more  or  less  neuralgia. 
In  patients  suffering  from  gout,  syphihs,  or  rheumatism,  a 
chronic  peripheral  neuritis  is  readily  induced,  often  of  a  some- 
what intractable  type,  and  this  even  develops  in  healthy  indi- 
viduals. Treatment  consists  in  gentle  friction  with  stimulating 
liniments. 

Compression  of  a  nerve  is  usually  due  to  the  presence  of  a  tumour 
or  aneurism,  or  to  some  displacement  or  inflammation  of  bones;  in 
fractures  a  nerve  may  be  included  in  the  callus  formed  in  the 
process  of  repair,  the  symptoms  not  appearing  till  four  or '  five 
weeks  after  the  injury;  or  it  may  be  met  with  in  the  form  of  crutch 
palsy,  or  as  a  result  of  spUnt  pressure.  The  early  symptoms  are 
those  of  irritation,  e.g.,  cramp,  and  spasm  of  muscles  or  neuralgic 
pain;  w^hilst  later  on  paralysis  and  anaesthesia  appear,  combined 
sometimes  with  trophic  phenomena.  If  the  compressing  cause 
can  be  removed,  recovery,  at  any  rate  of  a  partial  character, 
follows  in  time  under  suitable  treatment,  such  as  massage  and 
electricity. 

Rupture  of  nerves  without  an  external  wound  only  occurs  in  con- 
nection with  severe  injuries,  such  as  dislocations  or  fractures,  and 
even  then  total  di\dsion  is  rare,  the  sheath  retaining  its  integrity, 
although  the  axis  cyhnders  may  have  given  way.  Immediate  par- 
alysis and  loss  of  sensation  usually  follow,  and  may  persist  for  a  time, 
although  repair  not  unfrequently  occurs,  since  the  sheath  remains 
intact.  The  doubt  alwa^/s  existing  as  to  the  condition  of  the  sheath 
regulates  the  Treatment"^  which  must  be  followed,  viz.,  one  of  ex- 
pectancy. Friction  and  electricity  should  be  applied  to  the  parts, 
and  only  when  these  have  failed  should  operation  be  undertaken 
Secondary  nerve  suture  under  these  circumstances  is  not  a  very 
successful  proceeding. 

371 


372  A   ^MANUAL  OF  SURGERY 

Total  Division  of  a  Nerve.* — The  Immediate  Effects  arc :  {a)  Par- 
alysis of  the  muscles  suppHed  by  the  nerve ;  (6)  complete  anaesthesia 
of  the  parts  supplied  by  it,  which,  however,  is  not  necessarily  per- 
manent, since  sensation  may  be  conveyed  by  collateral  trunks,  the 
ana;sthetic  area  passing  through  gradual  stages  of  partial  sensation 
before  recovery  is  complete,  (c)  Vasomotor  paralj^sis  is  also  pro- 
duced, the  limb  becoming  hyperajmic  and  warmer  for  a  few  days, 
and  then  subsequently  colder  and  insufficiently  supplied  with  blood, 
{d)  The  excito-secretory  nerves  are  paralyzed  so  that  glands  lose 
their  functions  for  a  time. 

The  Secondary  Effects  vary  with  the  character  of  the  nerve  injured, 
and  are  much  more  comphcated  than  the  former. 

1.  Changes  in  the  Nerve. — Locally,  the  two  ends  retract  very 
slightly,  perhaps  not  more  than  the  twelfth  of  an  inch,  and  the  space 
thus  formed  fills  with  blood,  which  is  quickly  absorbed  and  replaced 
by  granulation  tissue,  and  this  in  turn  by  a  bulb-like  mass  of  fibro- 
cicatricial  tissue  {traumatic  neuroma),  within  which  are  found  spaces 
filled  with  fine  nervous  fibrillae  coiled  up  in  loops.  After  an  ampu- 
tation, most  of  the  divided  nerves  are  found  to  have  developed  these 
typical  bulbous  ends  (Fig.  123),  whilst  in  nerves  accidentally  severed 
in  their  continuity  the  bulbous  mass  which  forms  on  the  upper  end 
is  separated  by  an  interval  from  the  atrophied  lower  end,  though 
there  is  usually  a  fibrous  connection  between  the  two.  These  bulbs 
are  often  the  seat  of  severe  neuralgia.  In  a  few  rare  instances 
immediate  union  of  a  divided  nerve  is  supposed  to  have  occurred,  as 
indicated  by  total  and  rapid  restoration  of  function. 

Peripherally,  the  so-called  Wallerian  degeneration  commences 
about  the  fourth  day  after  the  accident,  in  consequence  of  the 
separation  of  the  nerve  from  its  trophic  centres.  It  first  shows  itself 
in  the  medullary  substance,  which  undergoes  a  form  of  segmenta- 
tion, becoming  broken  up  into  irregular  masses  of  myehn,  which  are 
absorbed  by  leucocytes  or  connective-tissue  cells,  and  disappear 
entirely  in  about  a  month.  The  axis  cyUnders  also  degenerate  and 
disappear.  The  neurilemma  cells  proliferate  in  columns  and  form 
a  fibro-cellular  rod,  which  represents  the  nerve,  and  early  loses  all 
power  of  conducting  nervous  or  electric  stimuli,  although  attempts 
at  regeneration  are  made  at  both  ends. 

Proximally,  degeneration  of  the  medullary  sheath  occurs.,  similar  to 
that  which  is  seen  in  the  distal  portion,  but  only  extending  as  far  as 
the  next  node  of  Ranvier.     It  is  of  but  little  significance. 

2.  Changes  in  the  Muscles. — Complete  paralysis  of  motion  neces- 
sarily occurs  when  a  motor  nerve  has  been  divided,  and  the  muscles 
involved  slowly  waste  and  undergo  degeneration.  The  atrophy  is 
not  noticed  at  first,  and  is  not  so  rapid  as  that  arising  from  infantile 
palsy,  since  it  is  simply  due  to  separation  from  the  trophic  centres, 
and  not  to  their  destruction.     Deformit}^  may  ensue,  owing  to  the 

*  For  an  elaborate  investigation  of  this  subject,  see  Head  and  Sherren  on 
'  The  Consequences  of  Injury  to  the  Peripheral  Nerves  in  Man,'  in  Brain, 
Summer  Number,  1905,  part  ex. 


AFFECTIONS  OF  NERVES 


373 


unbalanced  action  of  opposing  groups  of  muscles.  The  electrical 
changes,  too,  are  important.  The  faradic  current  rapidh^  loses  its 
power  over  the  paralyzed  muscles,  and  its  effects  totally  chsappear 
in  two  or  three  weeks,  whilst  the  galvanic  excitabihty  remains  for 
weeks  or  months,  and  even  then  only  slowly  diminishes,  so  that  a 
condition  develops  in  which  the  galvanic  current  produces  a  much 
greater  contraction  than  the  faradic  {reaction  of  degeneration,  p.  51). 
As  long  as  this  phenomenon  remains,  there  is  a  hope  that  restoration 
of  the  continuity  of  the  nerve  may  be  followed  by  restoration  of 
function;  but  when  the  muscles  react  neither  to  galvanic  nor  to 
faradic  stimuh,  the  case  may  be  looked  upon  as  beyond  repair. 

3.  Various  modifications  of  Sensation  are  produced.  Head  and 
Sherren*  have  demonstrated  that  different  types  of  sensory  impulse 
are  carried  by  separate  groups  of  nerve-fibres,  and  that  the  peri- 
pheral distribution  of  these  varies  con- 
siderably, [a)  Deep  sensation  consists 
in  the  appreciation  of  pressure,  in- 
cluding heavy  touch  and  painful  pres- 
sure, and  in  the  recognition  of  the 
positions  and  movements  of  joints  and 
muscles.  These  stimuh  are  carried 
by  motor  nerves,  and  distributed 
to  muscles,  tendons,  ligaments,  etc. 
Section  of  all  the  sensory  nerves  to 
the  skin  of  a  part  does  not  destroy  this 
form  of  sensation,  {h)  Protopathic 
sensation  takes  cognisance  of  painful 
cutaneous  stimuli,  and  of  the  effects 
of  temperatures  below  20°  and  above 
50°  C.  The  distribution  is  somewhat 
indefinite  and  diffuse,  following  rather 
the  nerve-root  areas  than  those  of  the 
peripheral  nerves.  The  superficial  Fig.  123.— Traumatic  Neuroma 
extent  supplied  by  a  particular  nerve  of  Posterior  Tibial  Nerve 
is  only  recognised  when  all  other  after  Amputation  of  Leg. 
sensory  nerves  to  the  part  are  divided  (From  King's  College  Hos- 
/-r^-        -^  J  \       ^1  1         •  PiTAL  Museum.) 

(i'lgs.  124  and  125).     The  overlappmg 

of  these  areas  will  explain  the  persistence  of  certain  forms  of  sensa- 
tion when  the  nerve  apparently  supplying  that  area  has  been  divided. 
(c)  Epicritic  sensation  includes  the  appreciation  of  light  touch  (as 
by  a  wisp  of  wool),  the  localization  of  stimuh,  the  recognition  of 
moderate  degrees  of  temperature  (between  20°  and  40°  C),  and  the 
power  of  discriminating  between  two  stimuli  simultaneously  applied, 
as  by  the  points  of  a  compass ;  its  distribution  corresponds  with  fair 
accuracy  to  that  of  the  peripheral  nerves. 

Section  of  a  purely  sensory  nerve  causes  loss  of  the  epicritic  and 
protopathic  forms  of  sensation  only,  but  the  area  over  which  the 
epicritic  sense  is  lost  is  greater  than  that  over  which  protopathic 

*  Op.  cit.,  James  Sherren,  '  Injuries  of  Nerves  and  their  Treatment,'  1908. 


374 


A   MANUAL  OF  SURGERY 


sensation  is  absent,  owing  to  the  overlapping  of  neighbouring  nerve 
areas.  Section  of  a  mixed  nerve  causes  loss  of  all  three  types  of 
sensation  in  any  area  exclusively  supplied  by  that  nerve,  but  if 
there  is  much  anastomosis  with  neighbouring  nerves  protopathic 
sensation  is  little  affected.  Section  of  a  posterior  nerve-root  affects 
protopathic  sensation  more  extensively  than  the  epicritic.  In  in- 
complete division  or  injury  of  sensory  nerves,  epicritic  sensation  is 
abolished  more  extensively  than  protopathic. 

4.  The  blood-suppl}'  to  a  paralyzed  part  is  diminished,  and  the 
circulation  feeble;  hence  the  extremities  usually  become  cold  and 
their  vitality  lowered.  Chilblains  are  readily  produced,  and  the 
unwise  application  of  heat  ma}*  cause  blistering  or  even  sloughing; 
wounds  heal  badly,  and  ulceration  from  slight  irritants  is  very 
likely  to  occur,  e.g.,  corneal  ulceration  after  division  of  the  fifth 
nerve,  and  perforating  ulcers  of  the  foot.  Atrophy  of  the  smaller 
bones  may  follow,  and  ankylosis  of  the  terminal  joints  of  the  fingers 


Fig. 


124.  biG.   125. 

Fig.  124  indicates  the  area  of  protopathic  sensation  supplied  by  the  median 

nerve,  as  determined  by  section  of  all  other  sensory  nerves  to  the  haml. 
Fig.  125.  Ditto  for  ulnar  nerve,      (.\fter  Sherren.) 

or  toes.  In  a  growing  child  the  development  of  the  part  is  alwa3^s 
more  or  less  impaired.  If,  however,  the  nerve  is  partially  divided 
and  the  ends  irritated,  more  serious  changes  occur.  The  skin  be- 
comes thin,  atrophic,  bluish-red,  and  shiny  ('  glossy  skin  '  of  Weir 
Mitchell),  or  it  may  be  rough  and  covered  with  scaleS;  or  even 
oedematous.  The  cutaneous  appendages  are  also  involved,  the 
hairs  falling  out,  the  nails  becoming  rough,  brittle,  and  scaly,  and  the 
sebaceous  and  sweat  glands  either  discharging  an  abundant  secre- 
tion, or  remaining  absolutely  functionless. 

5.  In  a  few  cases  changes  have  developed  in  the  central  nervous 
system  which  are  of  much  interest.  In  the  early  stages  reflex  spasms 
or  paralyses  are  sometimes  met  with  as  temporary  phenomena ;  but 
at  a  later  date  more  serious  symptoms  may  result.  Thus,  in  a 
glass  wound  of  the  median  nerve,  a  healthy  man  treated  at  hospital 
developed  a  typical  epileptic  fit  whenever  the  neuralgic  bulbous 
end  was  touched.  The  bulb  was  excised,  and  the  nerve  cleanly 
sutured,  but  without  effect,  the  epilepsy  and  pain  still  remaining. 


AFFECTIONS  OF  NERVES  375 

The  median  nerve  was  divided  above  the  elbow,  and  a  portion 
removed,  but  without  benefit.  Finally,  the  patient  passed  into  a 
condition  of  chronic  dementia,  and  died,  no  obvious  lesions  being 
found  on  post-mortem  examination. 

Regeneration  of  a  divided  nerve  must  necessarily  occur  if  restora- 
tion of  function  is  to  be  obtained.     Attempts  at  regeneration  are 
always  e\ddent  in  the  distal  segment,  whether  or  not  it  has  been 
sutured  to  the  upper  end,  but  in  the  latter  case  the  phenomena  are 
later  in  appearance  and  are  never  carried  to  perfection,  owing  to  the 
intervention  of  the  end-bulb.     Considerable  discussion  has  arisen 
as  to  whether  the  new  axis  cyhnders  grow  downwards  from  the 
central  end  to  the  peripheral,  or  w^hether  they  are  developed  in  the 
distal  segment.     Ballance   and  Purves   Stewart,   who   favour  the 
latter  theory,  state  that  the  proUferated  neurilemma  cehs  always 
retain  thei/ longitudinal  direction,  and  that  about  three  or  four 
weeks  after  the  division  (a  Uttle  later,  if  no  operation)  thin  beaded 
threads  begin  to  show  themselves  along  one  side  of  such  a  spindle- 
shaped  cell,  and,  graduallv  growing  downwards,  stretch  out  towards 
their    nearest    neighbours.     The   union    of    these   small   segments 
constitutes  the  new  axis  cylinder,  which  is  gradually  covered  m  by 
a  medullary  sheath,  also  apparently  the  product  of  the  neurilemma 
cells,  and  finallv  joins  with  the  central  end  of  the  nerve.     Halli- 
burton and  Edmunds,  and  others  of  the  opposing  school,  teach  that 
regeneration  of  the  axis  cyhnders  always  proceeds  from  above  down- 
wards, the  new  fibrillge  forcing  their  way  down  along  the  sheath  of 
the  nerve,  and  look  on  the  changes  in  the  peripheral  end  as  merely 
preparatory — and  this  opinion  is  probably  correct.     In  any  case  the 
process   is   slow   and   takes   many   months   to   reach   completion. 
Chnically,  the  earhest  evidence  of  regeneration  is  a  shght  return  of 
sensation,  which  is  at  first  protopathic,  and  only  slowly  becomes  of 
an  epicritic  tvpe.     Motion  is  generally  much  later  in  its  restoration 
than  sensation,  and  may  never  be  enrirely  recovered.     Under  very 
favourable  circumstances  it  is  possible  for  an  interval  even  as  great 
as  i|  inches  to  be  bridged  over  by  this  process,  but  such  an  event  is 
very  unusual.     The  use  of  a  nerve-graft  under  these  condirions 
may  direct  the  energies  of  the  neuroblastic  cells,  but  the  graft  is 
itself  quite  passive. 

The  Treatment  of  a  divided  nerve  depends  upon  its  size  and 
function.  If  small  and  of  shght  importance,  no  special  treatment 
is  required ;  but  any  of  the  main  nerves  of  the  extremities  must  be 
dealt  wnth  at  once  by  Primary  Nerve  Suture.  This  is  best  accom- 
plished by  using  a  domestic  sewing  needle  without  cutting  edges, 
or  a  fine  Hagedorn  needle,  and  the  finest  catgut ;  one  or  more  stitches 
should  pass  through  the  nerve,  and  the  rest  merely  through  the 
sheath.  Absolute  asepsis  is  essential  in  order  to  obtain  satisfactory 
results,  it  is  most  desirable  that  the  nerve  should  be  protected 
from  the  pressure  of  adhesions  by  wrapping  it  in  gold-beater's  skin 
or  Cargile  membrane.  In  wounds  involving  the  nerves  about  the 
wrist  the  deep  fascia  should  also  be  carefully  sutured  to  prevent  the 


376  A   MANUAL  OF  SURGERY 

formation  of  adhesions  between  the  nerves  and  tendons  to  the  skin, 
whereby  subsequent  mobility  would  be  impaired. 

If  the  wound  has  been  inflicted  months  before,  and  a  bull)  has 
formed,  Secondary  Nerve  Suture  must  be  employed.  The  nerve  is 
first  exposed  by  a  free  incision  through  the  cicatrix,  the  two  ends 
identified  and  isolated,  and  the  fibrous  tissue  of  the  bulb  removed 
to  a  sufficient  extent  to  expose  healthy  nerve  fibrilla;  the  divided 
ends  are  then  brought  together  with  as  little  tension  as  possible. 
To  bridge  the  gap  traction  upon  each  end  of  the  nerve  may  be  em- 
ployed to  stretch  it,  and  the  hmb  subsequently  placed  in  such  a 
position  as  to  relax  the  parts — e.g.,  the  wrist  flexed  to  a  right  angle, 
or  the  elbow  bent  (except  when  dealing  with  the  ulnar  nerve  above 
the  elbow,  flexion  of  which  increases  the  tension  on  the  nerve). 
Resection  of  a  segment  of  bone  may  be  justifiable  in  certain  cases 
to  allow  the  divided  ends  to  be  approximated. 

Nerve-grafting,  in  order  to  bridge  over  a  defect,  has  not  up  to  the 
present  been  followed  by  much  success.  A  nerve  similar  in  size 
to  that  to  be  operated  on  is  removed  from  an  animal  just  killed,  and 
carefull}^  stitched  in  position.  Since  it  merely  acts  as  a  carrier  to 
the  neuroblastic  cells,  the  same  result  would  possibly  be  obtained 
by  passing  several  fine  strands  of  catgut  from  one  end  to  the  other. 

N erve-anastomosis  has  been  utihzed  in  a  few  cases  of  facial  par- 
alysis, and  in  a  few  other  instances  in  order  to  restore  movement.  A 
suitably-placed  motor  nerve  is  laid  bare,  and  either  the  whole  trunk 
or  a  portion  of  it  united  to  the  divided  end  of  the  affected  nerve;  in 
time  motor  phenomena  have  manifested  themselves  with  some 
degree  of  benefit. 

During  the  time  that  the  paralysis  continues,  the  limb  must  be 
massaged,  the  fingers  or  toes  worked  daily  to  keep  them  from  getting 
stiff,  and  the  muscles  treated  with  electricity,  and  preferably  by 
means  of  the  electric  bath,  one  electrode  being  placed  in  a  basin  of 
warm  saline  solution,  and  the  other  against  the  patient's  back,  and 
the  affected  limb  dipped  in  the  water  till  it  becomes  of  a  bright  red 
colour.  In  the  intervals  the  paralyzed  muscles  should  be  kept 
relaxed  by  suitable  splints  or  apparatus  so  as  to  prevent  over- 
stretching by  opposing  unbalanced  muscles,  which  would  subse- 
quently impair  their  utility.  Anaesthetic  parts  must  also  be  pro- 
tected from  pressure. 

In  many  cases  where  the  original  wound  has  been  complicated  by 
suppuration  the  impaired  mobihty  is  as  much  due  to  the  inflam- 
matory adhesions  of  joints  and  tendons  as  to  paralysis. 

Acute  Neuritis  is  not  very  common.  It  is  usually  due  to  injur}-, 
gout,  or  rheumatism,  but  is  occasionally  obser^^ed  in  connection  with 
infected  wounds.  The  nerve  may  sometimes  be  felt  to  be  swollen  or 
tender,  whilst  severe  pain  of  a  neuralgic  type  is  often  experienced. 
On  microscopic  examination  the  ordinary  signs  of  inflammation  are 
well  marked,  though  mainl}-  in  the  sheath.  The  Treatment  consists 
of  rest  to  the  hmb,  together  with  leeching  or  dr}-cuppiiig  over  the 


AFFECTIONS  OF  NERVES  377 

course  of  the  nerve,  combined  with  belladonna  fomentations  and 
suitable  general  therapeutic  measures. 

Chronic  Neuritis,  or  Perineuritis,  is  much  more  common  than  the 
former.  It  consists  pathologically  in  an  increase  of  all  the  con- 
nective tissue  of  a  nerve,  both  around  it  and  between  the  fascicuh, 
with  compression  of  the  vessels  and  nerve-fibres.  It  may  result 
from  injury,  such  as  sprains,  strains,  or  pressure,  especially  when 
the  patient  is  suffering  from  syphiHs,  rheumatism,  or  gout,  and  is 
met  with  after  influenza  and  in  various  toxic  conditions,  e.g., 
alcohohsm,  diabetes,  malaria,  etc.  It  is  very  common  in  the  fifth 
nerve,  and  in  the  branches  of  the  brachial  plexus.  The  Symptoms 
vary  a  good  deal  with  the  nerve  affected,  which  can  occasionally 
be  felt  thickened  and  tender  on  pressure.  More  or  less  severe 
neuralgia  results,  accompanied  by  loss  of  power  in  the  case  of  a 
motor  or  mixed  nerve.  Trophic  lesions  may  also  be  induced,  such  as 
perforating  ulcer,,  or  ankylosis  of  the  terminal  joints  of  fingers  or  toes. 

The  Treatment  in  the  early  stages  consists  in  the  administration 
of  anti-diathetic  remedies,  and,  indeed,  iodide  of  potassium,  with  or 
without  mercury,  is  generally  applicable.  Locally,  prolonged  rest  is 
needed,  with  counter-irritation  in  the  form  of  blisters,  and  later  on 
massage.  If  there  is  any  paresis,  the  muscles  must  be  stimulated 
daily  by  the  faradic  current  or  electric  bath ;  radiant-heat  baths  are 
also  valuable,  and  ionic  medication.  Pain  is  combated  by  aspirin 
or  other  drugs,  or  by  administering  hypodermically  morphia  or 
atropine.  Faihng  these,  acupuncture  may  be  adopted,  in  which 
needles  are  passed  into  the  substance  of  the  nerve,  and  allowed  to 
remain  for  a  few  moments ;  this  probably  acts  by  reheving  the  in- 
flammatory tension  within  the  sheath.  Various  operative  measures 
dealt  with  under  neuralgia  may  be  called  for  in  severe  and  pro- 
tracted cases. 

For  Tumours  of  nerves,  see  p.  212. 

Neuralgia  is  a  condition  which  either  the  physician  or  the  surgeon 
may  be  called  upon  to  treat ;  it  is  exceedingly  common,  and  may  be 
one  of  the  most  terrible  afflictions  to  which  the  human  frame  is 
subject.  It  is  characterized  by  paroxysmal  or  intermittent  pain  of  a 
darting  or  stabbing  type,  which  follows  the  course  of  some  particular 
nerve  or  nerves,  especially  the  trigeminal.  The  attack  usually  com- 
mences suddenly,  and  the  pain  steadily  increases  until  it  reaches  a 
chmax,  and  then  gradually  or  rapidly  subsides.  These  paroxysms 
may  last  minutes  or  hours,  and  may  recur  at  varying  intervals, 
either  a  few  in  a  day  or  many  in  an  hour ;  they  may  be  induced  by 
sudden  noises,  a  draught  of  air,  etc.  Moreover,  pressure  over  the 
affected  trunks  may  originate,  relieve,  or  increase  the  pain,  whilst 
the  skin  affected  by  them  is  often  intensely  tender,  and  even  hyper- 
aemic  and  oedematous  (the  points  douloureux  of  Valleix).  Occasion- 
ally adjacent  muscles  become  spasmodically  and  sympathetically 
contracted  during  the  attack,  whilst  excessive  secretion,  such  as 
from  the  lachrymal  or  sweat  glands,  is  also  induced.     Herpes  is 


378  A   MANUAL  OF  SURGERY 

sometimes  met  witli  in  tli(>  area  of  distribution  of  the  affected  nerve 
{e.g.,  shingles  in  connection  with  intercostal  neuralgia).  Neuralgic 
manifestations  may  occur  in  any  sensory  or  mixed  nerve,  such  as 
the  intercostals  or  sciatic,  or  in  com])le\  bodies,  such  as  the  l)reast, 
testis,  or  the  larger  joints. 

The  Causes  of  neuralgia  are  very  diverse,  and  the  surgeon  often 
has  to  look  far  afield  in  order  to  find  them.  Thus,  as  predisposing 
causes  may  be  mentioned  the  hysterical  temperament,  anaemia, 
and  depressing  circumstances  of  all  kinds,  especially  mental  anxiety 
and  worry.  '1  he  direct  causes  may  be  toxic — e.g.,  malaria,  influenza, 
lead,  or  mercury;  reflex — e.g.,  ovarian  disease,  worms,  etc.;  central, 
from  disease  of  the  spinal  cord  or  brain ;  radical,  from  pressure  on  the 
nerve-roots  as  they  emerge  from  the  spinal  canal  or  cranium;  or 
peripheral,  owing  to  lesions  of  the  trunks  induced  either  by  trauma, 
inflammation,  or  new  growths. 

In  the  absence  of  any  recognisable  or  remediable  cause.  Treatment 
consists  primarily  in  attention  to  the  general  health,  and  the  local 
application  of  counter-irritants  and  sedatives.  Iron  and  arsenic 
may  be  given  to  anaemic  patients;  anti-spasmodics,  such  as  valeri- 
anate of  zinc,  to  hysterical  women;  quinine  or  arsenic  for  malaria; 
whilst  sea-bathing  or  change  of  air  is  often  advisable.  Iodide  of 
potassium  and  mercury  are  beneficial  in  all  cases  due  to  syphilis. 
When  the  pain  is  excessive,  morphia,  even  in  large  doses,  may  be 
required.  Empirical  remedies,  such  as  aspirin,  antipyrine,  phen- 
acetin,  menthol,  and  croton-chloral  hydrate  will  sometimes  do  good. 
Neuralgia  is  a  favourable  field  for  hydro-  or  electro-therapy,  or  for 
ionic  medication  (p.  54)  with  cocaine  or  other  drugs. 

When,  however,  medicinal  agents  fail,  surgical  measures  are  indi- 
cated in  order  to  allay  the  patient's  sufferings.  The  following 
are  the  more  usual  methods  adopted: 

1.  In  purely  Sensory  Nerves,  such  as  the  trigeminal,  destruction 
of  the  nerve  tissue  by  the  injection  into  the  trunk  of  alcohol  (70  per 
cent.)  has  been  much  used  recently.  Simple  division  or  neurotomy 
has  often  been  resorted  to,  but  the  relief  gained  is  of  a  most  tem- 
porary nature,  since  sensory  nerves  readily  unite  after  division,  and 
sensation  is  rapidly  restored;  hence  the  operation  has  fallen  into 
discredit.  A  more  satisfactory  proceeding  is  neurectomy,  or  the  re- 
moval of  a  portion  of  the  nerve  trunk,  which  does  temporary  good 
even  in  cases  due  to  central  causes,  probably  by  placing  the  centre 
in  a  condition  of  rest  through  the  exclusion  of  afferent  stimuli.  As 
large  a  portion  of  the  affected  nerve  should  be  removed  as  possible, 
and  Thiersch  suggested  a  plan  of  nerve-extraction  in  which  the  trunk 
is  laid  bare  at  a  suitable  spot,  and  then  grasped  with  forceps  and 
twisted  out. 

Finally,  if  all  such  measures  have  failed,  the  roots  of  the  nerves 
may  be  divided  either  within  the  skull  or  in  the  spinal  canal,  or  the 
ganglia  connected  with  their  roots  may  be  removed. 

2.  In  a  Mixed  Nerve,  conveying  motor  as  well  as  sensory  stimuli, 
nerve-stretching  has  to  be  mainly  relied  upon.     The  trunk  is  laid  bare, 


AFFECTIONS  OF  NERVES  379 

and  traction  i-xercisod,  l)oth  centrally  and  peripherally,  by  means  of 
a  blunt  hook  if  the  nerve  is  small,  or  by  the  fin.t^er  placed  under  it  if 
large.  The  clinical  effect  is  to  abolish  the  conductivity  of  the  nerve 
for  a  time,  either  completely  or  partially;  but  since  it  is  not  divided, 
repair  and  restoration  of  function  follow.  The  elasticity  and  exten- 
sil)ility  of  the  nerves  are  considerable,  and  the  force  needed  to  cause 
their  rupture  has  been  accurately  estimated.  It  varies  much  in 
different  individuals,  and  allowance  must  be  made  for  this  in  all 
operations.  Thus,  the  sciatic  nerve  will  stand  about  as  much  trac- 
tion as  an  ordinary  man  can  make  with  his  finger  and  thumb;  it 
should  be  apphed  steadily  and  continuously,  not  in  a  series  of  jerks. 
The  effect  of  stretching  is  to  free  the  nerve  from  external  inflam- 
matory adhesions,  and  to  alter  the  relations  between  the  sheath  and 
its  contents.  The  perineurium  has  its  fibrillae,  which  are  naturally 
wavy,  straightened  out,  thereby  compressing  the  lymphatic  spaces 
between  the  fibres,  and  possibly  rupturing  the  nervi  nervorum. 
The  nerve  becomes  hyper^emic,  and  the  medullar}^  sheath  of  the 
tubules  may  be  irregularly  broken  up. 

Affections  of  Special  Nerves. 

The  Cranial  Nerves. — The  Olfactory  Nerve  may  be  involved  in 
fractures  extending  across  the  cribriform  plate  of  the  ethmoid,  or  in 
severe  cases  of  contusion  of  the  anterior  lobes  of  the  brain  without 
fracture,  resulting  in  loss  of  smell  (anosmia). 

The  Optic  Nerve  is  sometimes  ruptured  in  fractures  of  the  base  of 
the  skull  running  into  the  optic  foramen,  or  divided  by  penetrating 
or  bullet  wounds,  leading  to  sudden  irremediable  blindness;  or  it 
may  be  compressed  by  effused  blood  or  inflammatory  exudation, 
either  within  or  outside  of  its  sheath,  causing  more  or  less  complete 
loss  of  vision  ;  if  the  hemorrhage  has  not  been  very  extensive, 
vision  may  be  in  measure  restored.  Orbital  cellulitis  not  unfre- 
quently  causes  pressure  on  the  nerve,  either  immediately  as  a 
result  of  the  inflammation,  or  subsequently  by  cicatricial  contrac- 
tion. Syphilitic  disease  of  the  sheath,  or  the  formation  of  a 
gumma  in  its  neighbourhood,  or  intra-orbital  aneurisms  or  tumours, 
may  likewise  interfere  with  vision  from  pressure  on  the  trunk. 
Optic  neuritis  (p.  776),  or  more  accurately  pap  ill  oedema,  is  an 
oedematous  condition  of  the  intra-ocular  termination  of  the  nerve 
in  the  fundus  oculi,  due  to  increased  tension  of  cerebro -spinal  fluid; 
it  is  a  frequent  result  of  cerebral  tumours  or  inflammation,  and  is 
generally  followed  by  optic  nerve  atrophy  and  blindness. 

The  Third  Nerve  [motor  oculi)  being  entirely  motor,  paralytic 
symptoms  are  those  to  be  looked  for.  They  may  arise  from  central 
causes,  such  as  syphihtic  or  degenerative  changes  in  the  floor  of  the 
third  ventricle;  or  from  -peripheral  lesions,  such  as  aneurisms, 
tumours,  gummata,  trauma,  etc.,  either  in  the  orbit,  sphenoidal 
fissure,  or  base  of  the  skull.  The  Symptoms  of  complete  paralysis 
are  as  follows:  [a)  Ptosis,  or  drooping  of  the  upper  eyehd,  from  loss 


38o  A   MANUAL  OF  SURGERY 

of  power  in  the  levator  palpebme;  {h)  external  strabismus,  or  squint, 
from  paralysis  of  the  inner,  upper,  and  lower  recti,  the  eye  Ijeing 
also  directed  a  little  downwards  from  paralysis  of  the  inferior 
oblique;  (c)  mydriasis,  or  dilatation  of  the  pupil,  from  palsy  of  the 
iris;  {d)  loss  of  accommodation,  from  the  ciliary  muscle  being 
paralyzed;  and  {e)  some  slight  protrusion  of  the  eyeball  (exoph- 
thalmos), owing  to  most  of  its  muscles  being  flaccid  and  relaxed. 
Diplopia  is  the  most  marked  functional  result.  In  consequence, 
however,  of  its  close  proximity  to  the  fourth,  fifth,  and  sixth  nerves 
in  the  walls  of  the  cavernous  sinus  and  sphenoidal  fissure,  symptoms 
referable  to  these  trunks  are  often  associated  with  the  above,  as  also 
venous  congestion  of  the  eye  and  orbit  from  pressure  on  the  sinus. 
Should  the  eyeball  be  totally  immobilized  from  paralysis  of  all  its 
muscles  without  venous  congestion,  the  condition  is  known  as 
'  ophthalmoplegia  externa,'  and  is  always  due  to  central  disease 
affecting  the  floor  of  the  third  ventricle,  and  probably  of  syphilitic 
or  tabetic  origin.  The  Treatment  in  most  cases  consists  in  the 
administration  of  mercury  and  iodide  of  potassium. 

Paralysis  of  the  Fourth  Nerve  {Pathetic),  which  supplies  the  su- 
perior obhque  muscle,  results  in  defective  movement  of  the  eyeball 
downwards  and  outwards,  with  diplopia  on  attempting  to  look 
down. 

The  Fifth  or  Trigeminal  Nerve  is  occasionally  torn  in  head  in- 
juries, giving  rise  to  anaesthesia,  with  perhaps  ulceration  of  the  cor- 
nea; but  such  cases  are  exceedingly  rare.  Much  more  common  is 
the  affection  known  as  trigeminal  neuralgia,  or  tic-douloureux, 
which  occurs  in  old  people,  particularly  women.  It  is  to  be  dis- 
tinguished from  the  simpler  forms  of  neuralgia  due  to  some  local 
irritation  or  general  weakness  by  the  paroxysmal  character  and 
violence  of  the  pain ;  hence  the  term  '  epileptiform  tic  '  has  been 
applied  to  it,  and  not  inaptly  represents  its  terrible  nature.  As  a 
rule  it  commences  in  the  infra-orbital  or  inferior  dental  branches, 
radiating  thence  to  all  the  other  divisions  of  the  nerve.  The  par- 
oxysms are  not  very  frequent  at  first,  but  they  increase  both  in 
number  and  severity,  until  at  last  the  patient,  utterly  prostrate, 
either  becomes  a  morphia  habitue,  or  may  even  attempt  suicide. 
The  condition  is  often  influenced  considerably  by  the  general 
health,  and  intermissions  of  varying  length  occur.  The  attacks  are 
accompanied  by  twitching  of  the  muscles  of  the  face,  and  even  of 
the  neck;  also  by  unilateral  sweating  and  hyperemia  of  the  head, 
and  the  development  of  such  marked  '  points  douloureux,'  that 
possibly  the  patient  cannot  brush  her  hair  or  wash  her  face  on 
the  affected  side.  Lachrymation  is  a  marked  feature  during 
the  attacks,  and  the  secretion  of  saliva  or  of  nasal  mucus  may 
be  increased. 

The  Cause  is  imknown;  in  a  few  cases  tumours  of  an  cndo- 
theliomatous  character  have  been  found  involving  the  Gasserian 
ganglion,  but  in  the  great  majority  nothing  abnormal  can  be  found 
either  in  the  ganglion  or  its  branches. 


AFFECTIONS  OF  NERVES  381 

In  the  Treatment  of  epileptiform  tic  all  sources  of  reflex  irritation 
should  be  relieved  or  treated,  such  as  carious  teeth,  errors  of  refrac- 
tion, intranasal  trouble,  ovaritis,  etc.  A  word  of  warning  is  needed 
against  the  wholesale  extraction  of  healthy  teeth  for  this  affection, 
which  may,  indeed,  be  aggravated  rather  than  improved  by  such 
treatment.  The  various  analgesic  remedies  will,  of  course,  be  em- 
ployed, but  morphia  is  often  the  only  drug  that  gives  relief.  In  most 
cases  Operative  Measures  sooner  or  later  are  required.  Alcohol 
injections*  by  Schlosser's  method  is  reported  to  give  good  results, 
but  further  experience  is  required  to  demonstrate  the  permanence  of 
the  relief  from  pain.  Neurotomy  and  nerve-stretching  only  give 
temporary  relief,  and  excision  even  of  large  portions  of  the  nerve- 
trunks  is  frequently  followed  by  recurrence.  The  only  procedure 
that  holds  out  any  certain  hope  of  cure  is  removal  of  the  Gasserian 
ganglion,  or,  at  any  rate,  of  its  lower  half;  the  facts  that  the  first 
division  of  the  nerve  is  not  often  involved  in  trigeminal  tic,  that  the 
nutrition  of  the  eyeball  is  largely  dependent  on  the  maintenance  of 
its  nerve-supply,  and  that  the  upper  part  of  the  ganglion  is  inti- 
mately adherent  to  the  outer  wall  of  the  cavernous  sinus,  have  deter- 
mined the  practice  of  leaving  intact  the  ophthalmic  portion  of  the 
ganglion  in  the  majority  of  cases.  The  results  of  this  operation  have 
been  very  gratifying,  and  have  improved  with  increased  practice 
and  modern  methods.  At  the  same  time  it  must  not  be  looked  on 
as  devoid  of  operative  dangers  or  risks ;  and  hence,  if  the  neuralgia 
is  definitely  limited  to  one  division  only,  injection  with  alcohol,  or 
an  intra-  or  extra-cranial  neurectomy  is  advisable  before  attacking 
the  ganglion;  recurrence  after  such  an  operation,  or  the  primary 
involvement  of  two  divisions,  indicates  the  major  operation. 

The  Supra-orbital  Nerve  does  not  very  commonly  require  operation,  since 
neuralgia  of  this  trunk  is  usually  distinct  from  epileptiform  tic,  and  more 
amenable  to  therapeutic  measures.  The  pain  often  recurs  about  the  same 
time  each  day  (hence  the  term  brozv  ague),  and  may  be  treated  by  giving  a  pill 
containing  ferri  sulph.  i  grain,  quininae  disulph.  2  grains,  and  morphin.  hydro- 
chlor.  i\  grain,  four  hours  before  the  attack  is  expected,  and  repeating  it  every 
hour  till  six  pills  in  all  have  been  taken.  Should  the  pain  persist,  neurectomy 
may  be  undertaken.  The  nerve  emerges  from  the  orbit  through  the  supra- 
orbital notch,  lying  at  the  junction  of  the  inner  and  middle  thirds  of  the  upper 
margin  ;  it  is  reached  by  an  incision  following  the  course  of  the  eyebrow, 
through  which  the  orbicularis  is  divided  along  the  line  of  its  fibres  (Fig.  126,  a). 
By  incising  the  periosteum  and  depressing  it,  together  with  the  orbital  fat,  the 
nerve  can  be  followed  back  for  some  distance,  and  a  considerable  portion 
removed. 

The  Infra-orbital  Nerve  emerges  from  the  foramen  of  the  same  name  at  a  spot 
about  |-  inch  below  the  centre  of  the  lower  margin  of  the  orbit.  It  can  be 
reached  and  divided  by  a  horizontal  or  curved  incision  placed  over  this  site 
(Fig.  126,  c) ;  but  since  such  an  operation  is  unlikely  to  give  more  than  tem- 
porary relief,  the  root  of  the  second  division  should  be  at  once  attacked  if  opera- 
tive procedures  are  necessary.  It  is  most  desirable  to  divide  the  nerve  behind 
Meckel's  ganglion,  and  hence  the  operations  which  are  performed  from  the 
face  (either  Wagner's,  which  follows  the  floor  of  the  orbit,  or  Carnochan's, 

*  For  details  and  methods  of  injecting  the  various  branches  of  the  fifth 
nerve,  see  Purves  Stewart,  Brit.  Med.  Journ.,  September  25,  1909. 


382 


A   MANUAL  OF  SURGERY 


which  traverses  the  antrum)  arc  objectionable,  whilst  they  are  almost  certain 
to  leave  ugly  cicatrices  (I'ig.  126,  d). 

The  pterygoid,  or,  as  it  is  called,  the  Braun-Lossen  operation,  is  without  doubt 
the  best  extracranial  method  for  dealing  with  the  root  of  the  second  division. 
A  flap  of  skin  and  subcutaneous  tissue  is  dissected  forwards  from  the  side  of 
the  face  (Fig.  105,  B),  so  as  to  exi)ose  the  zygoma,  which  is  cleared,  sawn 
through  back  and  front,  and  turned  down  together  with  the  masseter.  The 
temporal  tendon  is  thereby  exposed,  and  by  drawing  this  back,  and  if  need  be 
removing  the  coronoid  process  completely  or  in  part,  it  is  possible  to  see 
into  the  pterygo-maxillary  fossa,  and  to  hook  up  the  root  of  the  second 
branch  of  the  trigeminal  as  it  emerges  from  the  foramen  rotundum  and 
divide  it.     By  severing  the  nerve  also,  as  it  emerges  from  the  infra-orbital 

foramen  through  an  incision  in  the  face, 
the  whole  trunk  is  set  free,  and  can  be 
removed  by  traction,  all  the  dental 
branches  being  torn  across.  The  displaced 
structures  are  then  put  back  in  position, 
the  zygoma  is  sutured  with  silver  wire, 
and  the  incision  in  the  skin  closed.  The 
results  gained  by  this  method  have  been 
very  satisfactory. 

It  is  probable  that  an  intracranial  sec- 
tion of  the  root  of  the  second  division, 
followed  by  filling  the  foramen  rotundum 
from  inside  by  rubber  or  a  metal  plug, 
will  give  equally  good  or  better  results 
with  less  risk  and  deformity.  The  Hartley- 
Krause  plan  of  procedure  for  removal  of 
the  Gasserian  ganglion  is  employed. 

In  the  third  division  trigeminal  tic 
usually  affects  the  lingual  and  inferior 
dental  branches,  and  should  be  dealt  with 
at  the  foramen  ovale  by  intracranial  or 
extracranial  section  of  the  trunk. 

The  Inferior  Dental  Nerve  is  sometimes, 
however,  the  seat  of  neuralgia,  due  to 
compression  in  its  bony  canal  as  a  result 
of  dental  troubles.  It  may  then  suffice 
to  trephine  the  outer  bony  wall  of  the 
inferior  maxilla,  making  the  necessary 
incision  along  its  lower  border,  and  re- 
move half  its  thickness,  so  as  to  expose 
the  nerve  in  its  canal. 

Extracranial  section  of  the  third  division 
at  the  foramen  ovale  is  best  accomplished 
by  turning  forward  a  flap  of  skin  and  sub- 
cutaneous tissue  from  the  parotid  region 
(Fig.  105,  B),  exposing  thus  the  ]:>arotid 
gland  with  the  socia  parotidis  and  the  masseter  muscle.  The  masseter  is  then 
divided  transversely  immediately  below  the  socia  parotidis,  and  the  vertical 
ramus  of  the  inferior  maxilla  cleared  of  muscle  and  periosteum,  so  as  to  allow 
the  application  of  a  |-inch  trephine  just  below  the  sigmoid  notch,  the  remain- 
ing bridge  of  bone  being  subsequently  removed  by  cutting  pliers.  The  lingual 
and  dental  nerves  are  usually  found  close  together,  emerging  from  under  the 
outer  pterygoid  muscle,  and  lying  between  the  internal  pterygoid  and  the  mandi- 
ble. By  retracting  the  external  pterygoid  outwards,  the  foramen  ovale  can 
usuallj'  be  seen,  if  electric  illumination  is  employed,  and  the  nerve-trunks  divided 
at  the  point  of  exit.  A  good  deal  of  bleeding  often  occurs  from  the  internal 
maxillary  vessels  and  their  branches.  The  wound  usually  heals  well,  and 
leaves  but  little  scar,  although  some  impairment  in  the  mobility  of  the  jaw  may 
result  from  the  cicatrization  following  disturbance  of  the  muscles  and  tissues, 


Fig.   126. 

Incision  for  division  of  supra- 
orbital nerve;  b,  line  indicat- 
ing position  of  supra-trochlear 
nerve,  passing  from  angle  of 
mouth  through  the  inner  can- 
thus;  the  short  cross-line  at  its 
upper  end  is  the  incision  re- 
cjuired  to  expose  it;  c,  position 
of  infra-orbital  nerve  and  in- 
cision; d,  Carnochan's  in- 
cision for  neurectomy  of  the 
second  division. 


AFFECTIONS  OF  NERVES  383 

Removal  0/  the  Gassenan ga-nglion  is  now  usually  undertaken  thiough  the  tem- 
poral region  by  some  modifieation  of  what  is  known  as  the  Hartley- Krause 
method.  The  pterygoid  route*  originally  I'ollowcd  in  the  pioneer  operations  by 
the  late  Mr.  William  Rose  must  be  acknowledged  to  give  insufficient  exposure 
to  ensure  satisfactory  removal  of  the  ganglion,  and  has  now  been  discarded. 

The  Hartley-Krause  operation  was  devised  independently  by  the  two  sur- 
geons whose  names  are  associated  with  it.  An  0-shaped  flap  is  marked  out 
in  the  temporal  region,  the  base  situated  just  above  the  zygoma.  Through 
this  the  subjacent  bone  is  removed,  exposing  the  dura  mater,  which  is  gently 
stripped  up  from  the  middle  fossa  of  the  skull  as  far  as  the  cavernous  sinus. 
The  middle  meningeal  artery  is  exposed  and  tied  just  above  the  foramen 
spinosum,  or  the  foramen  may  be  plugged  with  purified  sponge  or  wax. 
Haemorrhage  from  the  small  vessels,  especially  the  veins,  of  the  dura  mater 
is  sometimes  profuse,  but  usually  ceases  upon  gentle  pressure.  The  dura 
mater  and  temporo-sphenoidal  lobe  of  the  brain  are  held  up  by  suitably- 
shaped  spatulae,  and  the  second  and  third  divisions  of  the  nerve  are  seen  run- 
ning from  the  ganglion  to  their  foramina,  where  they  are  cut  across.  The 
dural  sheath  of  the  ganglion  (cavum  Meckelii)  is  opened,  the  ganglion  itself 
detached  from  the  bone,  and  as  much  of  it  as  is  thought  necessary  removed. 
The  cavernous  sinus  may  be  wounded  in  this  stage,  or  the  dura  itself  give 
way  and  cerebro-spinal  fluid  escape.  Removal  of  the  spatulae  allows  the 
brain  to  re-expand,  and  the  wound  can  then  be  closed. 

Special  care  must  be  taken  of  the  eye,  as  its  nutrition  is  likely  to  suffer. 
The  conjunctival  sac  should  be  washed  out  before  operation  with  warm 
sublimate  solution  (i  in  2,000),  and  the  lids  stitched  together.  These  stitches 
are  removed  on  the  fourth  or  fifth  day,  and  the  conjunctiva  washed  with  warm 
boracic  lotion,  but  a  pad  should  be  kept  over  the  eye  for  at  least  a  fortnight. 

The  Sixth  Nerve  may  be  torn  or  compressed,  either  in  its  intra- 
cranial course  along  the  inner  wall  of  the  cavernous  sinus,  or  as  it 
passes  through  the  sphenoidal  fissure,  or  in  the  orbit,  as  a  result  of 
penetrating  wounds  or  blows.  Its  division  causes  paralysis  of  the 
external  rectus  and  consequent  internal  strabismus. 

The  Seventh  or  Facial  Nerve  may  be  paralyzed  from  a  great  variety 
of  causes,  which  may  be  described  under  the  following  headings: 

(a)  Intracranial  Lesions. — If  simply  cortical,  as  from  pressure, 
haemorrhage,  degeneration,  etc.,  a  limited  portion  of  the  opposite 
side  of  the  face  is  usually  involved.  If  subcortical,  or  in  the  corona 
radiata  or  corpus  striatum,  as  from  haemorrhage,  or  softening  due  to 
carotid  thrombosis  or  embolus,  the  paralysis  appears  on  the  opposite 
side  together  with  hemiplegia,  but  only  the  lower  half  of  the  face 
is  affected,  the  associated  movements  of  the  eyelids  being  left.  If 
the  lesion  is  situated  in  the  pons,  the  deep  facial  centres  may  be  im- 
plicated, and  then  paralysis  with  rapid  atrophy  of  the  facial  muscles 
ensues  on  the  same  side  as  the  lesion,  together  with  loss  of  power  of 
the  opposite  arm  and  leg  (crossed  paralysis) .  If  the  root  of  the  nerve 
between  the  centres  and  the  internal  auditory  meatus  is  involved, 
the  whole  of  the  same  side  of  the  face  is  paralyzed,  accompanied,  as 
a  rule,  by  deafness. 

(b)  Cranial  Lesions. — There  are  two  not  uncommon  causes  grouped 
under  this  heading,  viz.,  (i.)  fracture  of  the  base  of  the  skull,  in- 

*  For  a  description  of  this  operation,  see  Rose,  '  On  the  Surgical  Treatment 
of  Trigeminal  Neuralgia  '  (Lettsomian  Lectures,  1892) :  Bailliere,  Tindall  and 
Cox;  and  J.  Hutchinson,  'The  Surgical  Treatment  of  Facial  Neuralgia'; 
Bale,  Sons  and  Danielsson,  Limited. 


384 


A   MANUAL  OF  SURGERY 


volving  the  petrous  bone,  the  paralysis  supervening  either  imme- 
diately after  the  injury  from  laceration,  a  rare  phenomenon,  or  some 
weeks  later  from  implication  in  organizing  blood-clot  or  callus,  the 
usual  cause;  or  (ii.)  as  a  complication  of  chronic  otorrhcea,  due  to 
compression  or  inflammation  of  the  nerve  in  the  aqueductus  Fallopii. 
In  both  these  forms  the  palsy  is  complete  on  the  side  affected,  and 
owing  to  the  communication  of  the  facial  with  the  petrosal  nerves 
in  this  part  of  its  course,  there  may  be  unilateral  drooping  of 
the  velum  palati,  the  uvula  being  deflected  towards  the  sound 
side. 

(c)  'Extracranial  lesions  from  injury,  inflammation  from  exposure 
to  cold,  or  the  pressure  of  a  tumour,  e.g.,  malignant  disease  of  the 


Figs.   127  and   128. — Right-sided  Facial  Paralysis. 

On  the  left  hand  the  face  is  in  a  position  of  rest;  on  the  right  hand  an  attempt 
has  been  made  to  close  the  eyes,  that  on  the  paralyzed  side  remaining 
open,  and  the  eyeball  rolling  upwards  and  outwards,  whilst  the  asym- 
metry of  the  face  becomes  more  manifest. 

parotid.  This  variety  has  been  called  '  Bell's  palsy,'  and  is  usually 
characterized  by  the  whole  side  of  the  face  being  affected,  but  with- 
out implication  of  the  palate  or  uvula. 

The  general  Signs  of  facial  paralysis  (Fig.  127)  are  as  follows:  The 
side  of  the  face  is  immobile  and  expressionless,  all  the  natural  folds 
and  wrinkles  being  lost ;  the  eye  cannot  be  completely  closed,  and  on 
attempting  to  do  so  (Fig.  128)  the  eyeball  is  usually  seen  to  roll 
upwards  and  outwards;  ulceration,  and  even  perforation,  of  the 
cornea  may  result  from  this  exposure.  From  the  drooping  and 
relaxation  of  the  lower  eyelid,  the  apposition  of  the  punctum  lachry- 
male  to  the  conjunctiva  is  imperfect,  and  thus  tears  escape  over  the 


AFFECTIONS  OF  NERVES  385 

face  (epiphora),  a  condition  aggravated  by  the  loss  of  tlie  suction- 
like action  of  the  lachrymal  sac,  owing  to  the  associated  paralysis  of 
the  tendo  oculi  and  tensor  tarsi.  On  attempting  to  move  the  face,  as 
in  laughing  or  showing  the  teeth,  the  muscles  on  the  non-paralyzed 
side  are  alone  contracted,  and  marked  asymmetry  results  from  the 
drawing  over  of  the  opposite  side.  The  lips  cannot  be  closed  firmly, 
and  hence  whistling  and  such-like  actions  are  prevented.  Food 
collects  between  the  cheek  and  the  teeth,  owing  to  paralysis  of  the 
buccinator,  and  the  patient  after  a  meal  has  to  clear  out  the  debris 
with  a  spoon  or  his  fingers. 

The  Treatment  of  facial  paralysis  must,  if  possible,  be  directed  to 
its  cause.  Accidental  division  of  its  extracranial  portion  must  be 
followed  by  suture,  either  immediate  or  secondary.  When  due  to 
the  pressure  of  a  tumour,  it  may  be  possible  to  free  it  by  operation. 
In  cases  caused  by  cold,  medical  treatment,  including  massage  and 
electricity,  must  be  relied  on,  and  will  usually  prove  effective. 
When  the  paralysis  persists,  and  especially  if  due  to  some  cranial 
lesion  which  cannot  be  reached,  nerve -anastomosis  may  be  under- 
taken, the  whole  or  a  portion  of  the  spinal  accessory  or  hypoglossal 
nerve  being  united  to  the  divided  peripheral  end  of  the  facial  nerve. 
The  results  hitherto  obtained  in  a  few  cases  have  been  encouraging ; 
facial  movements  slowly  return,  but  are  first  elicited  by  and  accom- 
panied with  movement  of  the  shoulder  or  tongue;  in  time,  however, 
they  become  more  independent,  but  are  rarely  quite  free.  How- 
ever, the  operation  gives  a  certain  amount  of  muscular  power, 
and  may  remove  the  facial  asymmetry  so  characteristic  of  this 
lesion. 

Facial  Tic  (or  histrionic  spasm)  consists  of  a  clonic  contraction  of 
the  facial  muscles,  due  to  some  central  lesion  in  the  pons  or  cortex, 
or  the  reflex  result  of  an  irritative  lesion  of  the  nasal  mucous  mem- 
brane or  of  the  teeth.  The  condition  causes  great  discomfort  to  the 
patient,  and  may  involve  the  whole  side  of  the  face,  or  merely  one 
part  of  it,  such  as  the  orbicularis  oculi.  Treatment  consists  in  the 
administration  of  nerve  tonics  or  antispasmodics,  in  the  removal 
of  sources  of  reflex  irritation,  and,  failing  that,  in  stretching,  or  even 
in  severe  cases  dividing,  the /acta/ w^n'g. 

Operation. — The  facial  nerve  is  exposed  immediately  below  the  ear,  its  posi- 
tion being  indicated  by  a  horizontal  line  dra\\-n  from  the  middle  of  the  anterior 
border  of  the  mastoid'  process,  and  usually  corresponding  to  the  point  where 
the  mastoid  meets  the  lobule  of  the  ear.  The  incision  extends  from  just 
behind  the  external  meatus  along  the  anterior  border  of  the  sterno-mastoid 
muscle  to  the  level  of  the  angle  of  the  jaw.  The  parotid  gland  is  separated 
from  the  muscle,  and  both  are  well  retracted,  exposing  by  this  means  the 
posterior  bellv  of  the  digastric.  The  facial  nerve  is  found  above  this,  running 
directly  forwards  from  the  centre  of  the  mastoid  process.  The  great  auricular 
nerve  is  divided  in  the  superficial  incision,  and  the  posterior  auricular  vessels 
^\-ill  require  a  ligature.  The  internal  jugular  vein  is  close  to  the  posterior 
margin  of  the  wound.  The  operation  is  a  deep  one,  and  by  no  means  easy  in 
a  patient  with  a  thick  neck.  The  effect  of  stretching  the  nerve  is  to  paralyze 
It  temporarily,  but  the  ultimate  results  have  been  by  no  means  encouraging, 
only  one  case  out  of  twenty  collected  by  Godlee  being  successful. 


3»6  A    MANUAL  OF  SVRGERV 

The  Auditory  Nerve  may  be  injuicd  in  fractures  of  the  base  of  the 
skull,  either  one  ox  both  sides  being  involved.  Incurable  deafness 
usualh'  results,  often  associated  with  facial  palsy. 

It  is  a  little  doubtful  what  effect  would  be  produced  by  injury  ol 
the  Glosso-pharyngeal  Nerve,  but  in  one  case  in  which  it  was  sup- 
posed to  be  compressed  tlie  j)atient  suffered  from  difficulty  in 
swallowing  and  speaking,  together  with  i)ersistent  ulceration  of 
the  tongue;  death  resulted  fnjm  (edema  of  the  glcjttis. 

A  severe  crushing  injury  to  the  Pneumogastric  Nerve  may  prove 
reipidly  fatal  from  lieart  failure  or  ])ulnionaiy  congestion,  but  less 
serious  lesions  result  in  palpitation,  vomiting,  and  a  sense  of  suffoca- 
tion; such  phenomena  sometimes  manifest  themselves  after  head 
injuries,  especially  fractures  involving  the  posterior  fossa,  and  indi- 
cate that  the  jugular  foramen  has  been  encroached  on.  The  nerve 
is  also  exposed  to  injury  in  operations  about  the  neck,  e.g.,  ligature 
of  the  carotid,  or  removal  of  tuberculous  or  malignant  glands. 
Irritation  causes  vomiting,  coughing,  or  perhaps  a  temporary  inhibi- 
tion of  the  heart's  action;  one-sided  division  sometimes  does  com- 
paratively little  immediate  harm,  but  if  both  nerves  are  divided, 
death  results  from  laryngeal  paralysis  or  from  such  complications 
as  oidema  or  congestion  of  the  lungs. 

The  effect  on  the  larynx  of  these  lesions  is  described  elsewhere 
(p.  906),  but  one  meiy  note  here  that  in  the  early  stages  compression- 
paralysis  of  the  recurrent  laryngeal  nerve,  as  by  an  aneurism,  affects 
the  abductor  muscle  (crico-arytenoideus  posticus),  the  result  being 
that  the  cord  involved  is  approximated  to  the  middle  line,  and  then 
the  voice  is  not  impaired,  although  dyspmea  is  present.  At  a  later 
stage  compression-paralysis  corresponds  to  the  phenomena  pro- 
duced by  complete  section  of  the  nerve,  as  in  an  operation  for 
goitre,  viz.,  the  cord  lies  in  the  cadaveric  position,  i.e.,  half-way 
between  its  position  in  phonation  and  deep  inspiration;  in  this, 
breathing  is  unimpaired,  but  the  voice  is  husky. 

1  he  Spinal  Accessory  Nerve  may  be  irritated,  either  at  its  exit  from 
the  skull  l)y  a  fracture  running  through  the  jugular  foramen,  or  in 
its  peripheral  course  by  inflamed  lymphatic  glands,  etc.  It  is  occa- 
sionally divided  in  operations  for  the  removal  of  tuberculous  or 
malignant  glands,  and  in  children  this  may  cause  serious  deformity 
from  drooping  of  the  shoulder,  especially  if  the  branches  of  the 
cervical  plexus  supplying  the  trapezius  are  also  severed.  Clonic 
spasm  of  the  sterno-mastoid  and  trapezius  is  generall}'  due  to  central 
changes,  and  it  is  for  this  form  of  spasmodic  torticollis  that  stretching 
or  division  of  the  spinal  accessory  nerve  is  employed. 

Operation. —  i  lie  ntiAf  runs  downwanls  and  backwards  at  right  angles  to 
the  centre  of  a  line  passing  from  the  angle  of  the  jaw  to  the  ajjcx  of  the  mastoid 
process;  it  enters  the  deep  asj^ect  of  the  sterno-mastoid  about  3  inches  below 
that  sj)ot.  An  incision  is  made  along  the  anterior  border  of  the  sterno-mastoid, 
reaching  from  the  ear  to  the  cornu  of  the  hyoid  bone.  The  fascia  is  divided, 
and  the  muscle  drawn  backwards  to  expose  the  posterior  belly  of  the  digastric, 
from  under  the  lower  border  of  which  the  nerve  emerges,  passing  first  in  front. 


AFFECTIONS  OF  NERVES  387 

ami  Iheii  hilow  the  transverse  process  of  the  atlas,  which  ean  be  readily  felt. 
The  operation  has  not  given  good  results,  since,  even  ii  the  twitching  of  the 
head  and  neck  ceases,  the  spasmodic  phenomena  often  recur  elsewhere. 

The  Hypoglossal  Nerve  may  be  accidentally  divided  in  an  opera- 
tion, or  compressed  by  an  aneurism  of  the  external  carotid,  t)r  by 
a  new  growth.  Unilateral  paralysis  or  weakness  of  the  tongue 
results,  the  organ,  when  protruded,  being  directed  towards  the 
paralyzed  side. 

The  Spinal  Nerves. 

The  nerves  constituting  the  Cervical  Plexus  are  exposed  to  injury 
either  from  blows,  dislocations  of  the  cervical  spine,  penetrating 
wounds,  or  during  operations.  No  very  serious  results  follow, 
except  in  the  case  of  the  Phrenic  Nerve,  division  of  which  may  cause 
instant  death  by  paralysis  of  the  diaphragm,  although  when  but  one 
nerve  is  divided  the  patient  can  survive.  Irritation  of  the  nerve 
gives  rise  to  spasmodic  cough  or  hiccough. 

The  Brachial  Plexus  may  occasionally  be  divided  by  cuts  or  stabs 
in  the  lower  part  of  the  posterior  triangle,  and  the  accident  will  be 
characterized  by  the  motor  or  sensory  phenomena  corresponding  to 
the  particular  nerves  involved;  obviously  the  upper  nerves  of  the 
plexus  are  most  exposed  to  this  form  of  injury.  Treatment  consists 
in  laying  the  parts  open  by  a  suitable  incision,  finding  the  divided 
ends,  and  performing  primary  nerve  suture. 

Tears  or  contusions  of  the  plexus,  a  more  common  accident,  may 
be  complete  or  partial,  and  result  from  injuries  in  which  the  arm  is 
dragged  suddenly  upwards,  as  when  in  falling  a  person  clutches  at 
some  projecting  body,  or  from  forcible  depression  of  the  shoulder  in 
a  fall  whilst  the  head  is  driven  towards  the  opposite  side,  the  nerve- 
roots  being  thereby  wrenched  from  their  attachments,  or  the  nerve- 
trunks  compressed  by  the  clavicle  against  the  first  rib.  Long- 
continued  hyper-extension  and  abduction  of  the  arm,  as  during  an 
operation  in  the  Trendelenburg  position,  also  cause  undue  traction 
of  the  roots  of  the  plexus,  especially  of  the  fifth  and  sixth  nerves. 
A  fracture  of  the  clavicle  by  direct  violence  may  result  in  injury  of 
the  plexus,  as  also  the  pressure  of  a  cervical  rib.  Dislocation  of  the 
head  of  the  humerus  into  the  axilla,  or  the  attempts  to  reduce  it, 
may  also  be  responsible  for  injuries,  especially  to  the  inner  cord. 
The  lesions  consist  either  of  a  complete  rupture  of  the  nerve-trunks, 
or  of  a  partial  rupture  with  hsemorrhage  into  and  around  the 
sheaths.  If  the  sheaths  remain  untorn,  repair  is  usually  established 
after  a  time;  but  where  a  complete  laceration  has  occurred,  much 
cicatricial  tissue  is  Hkely  to  form,  and  unless  operation  is  under- 
taken, repair  is  improbable. 

Symptoms.— Sometimes  the  whole  arm  is  paralyzed,  and  lies 
flaccid  and  arnxsthetic  by  the  patient's  side.  Sensation  is  alone 
present  down  the  inner  side  of  the  arm  as  far  as  the  elbow  (inter- 
costo-humeral  nerve),  and  for  a  more  limited  portion  on  the 
outer  side.     Paralysis  often  involves  the  pectoralis   and  scapular 


388  A   MANUAL  OF  SURGERY 

muscles,  but  the  rliumboids  and  serratus  magnus  retain  their  nerve- 
supply. 

More  frequent!}'  the  manifestations  correspond  to  that  seen  in 
the  brachial  birth  palsy,  due  to  the  forcible  stretching  and  tearing 
of  the  root  of  the  hfth  cervical  nerve,  and  sometimes  in  part  of  the 
sixth.  It  is  caused  by  overstretching  of  the  head  during  delivery, 
and  may  occur  equally  in  vertex  or  breech  presentations ;  but  is 
usually  unilateral,  and  affects  more  frequently  the  left  arm.  The 
result  in  this,  as  is  traumatic  cases,  is  the  appearance  of  what  is 
known  as  the  Erb-Dnchenne  paralysis,  i.e.,  loss  of  power  of  the 
deltoid,  biceps,  spinati,  brachialis  anticus,  and  supinators,  together 
with  anaesthesia  or  paresthesia  in  the  region  supplied  by  the  fifth 
root.  The  arm  is  adducted  and  rotated  in  at  the  shoulder,  and  the 
fore-arm  is  extended  and  pronated.  The  lesion  in  infants  is  not 
likely  to  be  noted  at  birth,  but  becomes  apparent  in  a  few  weeks. 

If  the  injurv  is  limited  to  the  inner  cord  of  the  plexus,  the  symptoms 
produced  are  chiefly  localized  in  the  hand  where  the  intrinsic  muscles, 
both  of  the  median  and  ulnar  groups,  are  paralyzed,  together 
with  loss  of  sensation  along  the  inner  side  of  the  arm  and  fore-arm. 

Occasionally  the  effect  is  more  limited,  as  when  a  blow  on  the  back 
of  the  neck  leads  to  paralysis  of  the  serratus  magnus  and  rhomboids, 
and  to  the  subsequent  development  of  a  '  winged  scapula.' 

Treatment  necessarily  varies  with  the  situation  and  probable 
degree  of  the  injury.  Obvious  causes  of  pressure,  such  as  the  de- 
pressed fragments  of  a  broken  clavicle  or  the  callus  derived  therefrom, 
must  be  removed.  A  diagnosis  of  complete  rupture  of  the  nerves 
can  only  be  made  in  most  cases,  however,  after  the  development  of 
the  reaction  of  degeneration,  and  hence  expectant  measures  must 
be  adopted  in  the  early  stages.  The  arm  is  kept  to  the  side,  and 
fomentations  applied  to  relieve  the  pain.  After  a  while  massage 
and  electricity  are  employed,  and  it  is  most  interesting  in  many 
cases  to  watch  the  gradual  restoration  of  power  and  sensation  to  a 
paralyzed  limb.  The  appearance  of  the  reaction  of  degeneration 
indicates  that  the  period  of  inactivity  is  over,  and  an  attempt  must 
be  made  bv  operation  to  restore  the  continuity  of  the  nerves.  They 
are  exposed  by  a  curved  incision  running  parallel  to  the  clavicle,  and 
following  up  the  posterior  border  of  the  sterno-mastoid.  The  scalenus 
anticus  is  defined,  and  the  nerve-roots  found  emerging  from  be- 
tween it  and  the  scalenus  medius;  cicatricial  tissue  is  removed;  the 
ends  of  the  nerves  are  freshened  and  sutured  together.  The  results 
of  such  operations  have  been,  on  the  whole,  encouraging. 

Neuritis  and  neuralgia  of  the  brachial  plexus  occur,  and  are 
treated  along  the  usual  lines.  Should  the  neuralgia  persist  and 
prove  uncontrollable,  or  if  clonic  spasm  of  the  muscles  of  the  arm  and 
shoulder  develop,  stretching  of  the  brachial  plexus  may  be  required. 

The  Circumflex  Nerve  is  liable  to  injury  from  its  exposed  position, 
winding  round  the  outer  side  of  the  neck  of  the  humerus  about  a 
finger's  breadth  above  the  middle  of  the  deltoid.  Blows  upon  the 
shoulder  may  in  this  way  cause  paralysis;  it  is  sometimes  torn  or 


AFFECTIONS  OF  NERVES  389 

compressed  in  fractures  of  the  surgical  neck  of  the  humerus,  or  in 
dislocation  of  tlie  sh(nilder,  or  it  may  be  impacted  in  the  callus 
arising  from  the  former  injury.  Paralysis  of  the  deltoid  and  teres 
minor  follows,  evidenced  by  inability  to  raise  the  arm  from  the  side, 
whilst  the  wasting  of  the  former  muscle  causes  undue  prominence  of 
the  acromion.  There  may  be  temporary  anaesthesia  over  the  pos- 
terior fold  of  the  axilla,  but  this  does  not  last  long.  No  operative 
treatment  has  been  adopted,  although  there  is  no  reason  why  it 
should  not  be  attempted  in  suitable  cases. 

The  Musculo-spiral  Nerve  is  not  unfrequently  damaged  in  frac- 
tures and  dislocations  of  the  upper  extremity  of  the  humerus,  but 
is  chiefly  exposed  to  injury  in  the  musculo-spiral  groove,  where  it 
hes  close  to  the  bone.  It  is  implicated  with  or  without  other  nerves 
in  crutch  palsy,  or  by  lying  asleep  with  the  arm  across  the  edge  of 
a  chair  or  table,  as  so  frequently  occurs  in  drunken  people  ('  Satur- 
day-night paralysis  ').  It  is  not  unknown  after  operations  when  the 
outstretched  arm  has  rested  on  the  edge  of  the  table,  or  when  the 
Trendelenburg  position  has  been  adopted  and  the  arms  have  been 
kept  above  the  patient's  head,  the  upper  end  of  the  humerus  pressing 
against  the  brachial  plexus.  In  this  position  the  arms  should  not  be 
raised  to  more  than  a  right  angle  with  the  trunk,  or  may  be  folded 
across  the  chest.  The  resulting  paralytic  symptoms  are  not  con- 
fined to  the  musculo-spiral  nerve. 

Total  division  of  the  nerve  causes  the  following  symptoms : 

A.  Anaesthesia.     If  the  nerve  is  divided  in  the  upper  third  of  the 

arm — i.e.,  above  the  origin  of  its  external  cutaneous 
branch — there  is  loss  of  both  epicritic  and  protopathic 
sensation  over  the  radial  half  of  the  dorsum  of  the  hand, 
of  the  epicritic  a  little  more  than  of  the  protopathic. 
Section  of  the  radial  nerve  in  the  upper  third  of  the 
fore-arm  causes  no  loss  of  sensation,  which  is  supphed  to 
the  back  of  the  hand  by  the  external  cutaneous  of  the 
brachial  plexus ;  but  section  in  the  lower  third  causes  a 
hmited  loss  of  epicritic  sense  over  the  back  of  the  thumb. 

B.  Paralysis  of  the  following  groups  of  muscles: 

(i.)   Of  the  extensor  of  the  fore-arm  (triceps);  hence  the  fore- 
arm can  only  be  extended  by  its  own  weight, 
(ii.)    Of  the  long  and  short  supinators;  hence  the  hand  is  pro- 

nated,  the  only  supinator  remaining  being  the  biceps, 
(iii.)  Of  the  radial  and  ulnar  extensors  of  the  wrist ;  hence  wrist- 
drop (Fig.  129),  a  condition  also  present  in  certain  lesions 
of  toxic  or  central  origin,  e.g.,  lead  palsy, 
(iv.)  Of  the  extensors  of  the  fingers  and  thumb,  which  either 
hang  hmp  and  motionless,  or  may  be  bent  up  into  the 
palm  from  the  unopposed  action  of  the  flexor  muscles. 
If,  however,  the  wrist  and  proximal  phalanges  are  sup- 
ported and  extended,  the  terminal  phalanges  can  be 
straightened  by  the  action  of  the  interossei  and  lum- 
bricales. 


390  A    MANUAL  OF  SURGERY 

Treatment  consists  in  massage  and  electricity  applied  to  the 
muscles,  whilst  fixation  of  the  deformity  and  secondary  changes 
in  the  length  of  the  muscles  are  prevented  by  the  application  of  a 
palmar  splint.  The  absence  of  improvement,  together  with  the 
appearance  of  the  reaction  of  degeneration,  indicates  that  the  nerve 
has  been  torn  across,  and  indicates  the  necessity  for  operative 
treatment.  The  nerve  is  laid  bare  at  the  site  of  injury,  scar  tissue 
removed,  and  the  ends  approximated  and  sutured,  if  possible. 
Should  this  be  impossible,  nerve-grafting  may  be  attempted. 

Operation. — The  musculo-.spiral  nerve  can  be  exposed  on  the  outer  side  of 
the  arm  after  it  has  traversed  the  external  intermuscular  septum,  where  it  lies 
between  the  brachialis  anticus  and  supinator  longus.  To  define  this  inter- 
section the  fore-arm  is  semi-ffexed  and  pronated,  and  an  incision  made  extend- 
ing from  the  centre  of  the  crease  of  the  elbow  upwards  and  outwards  along  a 
line  made  by  prolonging  upwards  the  radial  border  of  the  fore-arm,  which  in 


Fig.   129.- — Wrist-drop   from  Paralysis  of  the  Musculo-spiral  Nerve. 

(TiLLMANNS.) 

this  position  corresponds  with  the  supinator  longus  muscle.  The  interspace 
is  opened  up,  and  the  nerve  found  together  with  the  termination  of  the 
superior  profunda  artery.  From  this  point  the  nerve  may  be  traced  upwards, 
if  necessary,  by  dividing  the  intermuscular  septum,  and  retracting  or  dividing 
the  triceps. 

To  expose  the  upper  part  of  the  nerve  as  it  enters  the  groove,  the  arm  is 
placed  over  the  body,  and  the  posterior  border  of  the  deltoid  defined.  An 
oblique  incision  is  made  a  finger's  breadth  behind  this,  and  the  intersection 
between  the  long  and  outer  heads  of  the  triceps  found.  By  opening  up  this 
space  the  finger  can  be  passed  down  to  the  bone,  and  the  nerve,  together  with 
the  superior  profunda  artery,  readily  exposed. 

Where  the  nerve  is  impacted  in  the  callus  arising  from  a  fracture  of  the 
middle  of  the  shaft  of  the  humerus,  it  is  often  best  to  expose  it  by  a  median 
incision  down  the  back  of  the  arm,  splitting  the  triceps,  the  centre  of  the 
wound  being  opposite  the  insertion  of  the  deltoid. 

The  Median  Nerve  may  be  damaged  in  fractures  and  dislocations 
of  the  humerus,  but  is  most  frequently  injured  just  above  the  wrist 
by  glass  wounds,  due  either  to  bursting  of  bottles,  etc.,  or  to  thrust- 
ing the  hand  and  arm  through  a  window.  Paralysis  necessarily 
results  in  these  cases,  with  the  following  symptoms: 

If  divided  just  above  the  lerist  : 

A.  Anaesthesia.  Loss  of  epicritic  sensation  over  the  palmar 
aspect  of  the  radial  side  of  the  hand,  over  the  front  of  the 


AFFECrrONS  OF  NERVES  39^ 

thiimli,  index,  micldlc,  and  half  the  ring  fingers,  and  over 
varying  portions  of  the  dorsum  of  tlie  same  (Fig.  130); 
loss  of  protopathie  sensation  including  analgesia  to  pin- 
pricks over  a  much  more  limited  portion,  varying  con- 
siderably in  different  cases  with  the  area  of  distribution 
of  the  terminal  branches  of  the  external  cutaneous  and 
ulnar  nerves. 
B.   (i.)   Paralysis  of  the  outer  group  of  the  short  muscles  of  the 
thumb  {i.e.,  abductor,  opponens,  and  outer  half  of  the 
flexor   brevis   pollicis),    so   that    the   thenar   eminence 
wastes,  and  the  move- 
ment of  '  opposition  ' 
is     impaired,     the 
thumb  remaining  ex- 
tended   by    the    side 
of  the  fingers  (Duchen- 
ne's  '  ape-hand  ')" 
(ii.)  Paralysis  of  the  outer 
two    lumbrical    mus- 
cles,   causing   loss   of 
power   of    flexion    at 
the     metacarpo-     fig.    130.  —  Division     of    Median 
phalangeal    joints    of  Nerve  above  the  Wrist. 

the  index  and  middle  (After  Sherren.) 

fingers.  Xhe  shaded  parts  indicate  the  area 

The  great  impairment   of   mo-         over    which   epicritic   sensation  is 
bihty  in   the   hand    and   fingers        lost 

so    often    seen    in    these    cases  +i,  4.  • 

depends  not  so  much  on  paralysis  of  muscles  as  on  the  fact  that  m 
the  majority  of  them  the  synovial  sheaths  of  the  wnst  are  also 
laid  open  and  involved  in  septic  inflammation,  which  leads  to  the 
formation  of  diffuse  adhesions.  Hence  the  progress  is  often  un- 
satisfactory, even  when  the  nerve  has  been  skilfully  sutured. 

If  divided  at  the  bend  of  the  elbow  or  in  the  arm,  to  the  above- 
described  symptoms  are  added : 

(i.)  Loss  of  pronation  from  paralysis  of  the  two  pronators, 
(ii.)  Paralysis  of  the  flexor  carpi  radiahs,  causing  defective  wrist 
flexion  on  the  radial  side  and  impaired  radial  abduction, 
(iii  )  Paralysis  of  the  flexor  longus  polKcis,  of  the  flexor  subhmis, 
and  the  outer  half  of  the  flexor  profundus  digitorum, 
leading  to  loss  of  power  in  the  hand-grasp,  especially  on 
the  radial  side,  and  perhaps  hyper- extension  of  the  wrist, 
(iv.)   Paralysis  of  the  palmaris  longus. 
The  Ulnar  Nerve  is  exposed  to  injury  at  the  wrist,  as  also  m  the 
hollow  between  the  olecranon  and  the  inner  condyle  of  the  humerus, 
and  paralysis  may  be  caused  by  wounds,  fractures,  blows,  imph- 
cation  in  callus,  etc.     The  symptoms  are  very  characteristic. 
//  divided  at  the  elbow  :  ,•    1     c 

A.  Analgesia  or  loss  of  protopathie  sensation  of  the  httle  finger 


392 


A    MANUAL  OF  SURGERY 


and  ulnar  border  of  the  palm,  back  and  front,  seldom 
of  the  ring  linger;  anaesthesia  to  light  touch   (loss  of 
epicritic  sensation)  of  the  ulnar  side  of  the  front  of  the 
wrist  and  palm,  of  the  back  of  the  hand,  and  of  the  little 
and  half  the  ring  fingers,  back  and  front  (Fig.  131). 
P>.   (i.)   Paralysis  of  the  flexor  carpi  ulnaris,  causing  weakness  in 
flexion  and  in  ulnar  adduction  of  the  wrist, 
(ii.)   Paralysis  of  the  inner  half  of  the  flexor  profundus,  with 
weakened  hand-grasp,  especially  in  the  ring  and  little 
fingers, 
(iii.)  Paralysis  of  the  two  inner  lumbricales  and  of  all  the 
interossci ;  hence,  loss  of  adduction  and  abduction  of  the 
fingers,  with  flexion  of  the  two  last  phalanges  in  each 


Fig.   131.  Fig.   132. 

Anaesthesia  resulting  from  Division  of  Ulnar  Nerve.    (After  Sherren.) 

In  Fig.   131   the  nerve  was  divided  above  the  origin  of   the  dorsal  branch; 

in   Fig.  132  below  that  branch  close  to  the  wrist.      The  continuous  dark 

line  indicates  the  limits  of  the  loss  of  epicritic  sensation;  the  shaded  area 

shows  the  loss  of  protopathic  sensation. 

finger  and  hyper-extension  at  the  metacarpo-phalangeal 

joint    {main- en-griff e)    or    claw-hand   (Fig.    133).     The 

interosseous    spaces    also    become    very    evident    from 

atrophy  of  these  muscles. 

(iv.)  Paralysis  of  the  short  muscles  of  the  little  finger,  of  the 

inner  group  of  short  thumb  muscles   (adductor  trans- 

versus,  adductor  obliquus,  and  deep  portion  of   flexor 

brevis),  and  of  the  palmaris  brevis. 

If  divided  just  above  the  wrist,  the  anaesthesia  only  involves  the 

palmar  aspect  of  the  hand  and  back  of  the  terminal  phalanges 

(Fig.   132),   whilst  the  paralysis  merely  affects  the  short  palmar 

muscles.     Additional    impairment    of    movement    may,    however, 

arise  from  septic  inflammation  of  the  long  tendons  and  their  sheaths. 

Treatment. — If  divided,  the  nerve  must  be  dealt  with  (according 

to  the  rules  already  given)  at  the  injured  spot. 

The  Intercostal  Nerves  are  frequently  the  seat  of  severe  neuralgia, 
cither  from  a  chronic  neuritis,  probably  of  toxic  origin,  from  com- 
pression by  tumours  or  inflammatory  lesions  of  the  ribs,  or  from 
injury  or  pressure  directed  to  the  nerve-roots  as  they  emerge  from 
the  spine,  as  in  spinal  caries  (girdle-pain) .     Herpes  zoster  or  shingles 


AFFECTIONS  OF  NERVES 


393 


is  sometimes  associated  with  such  pain,  and  may  be  followed  by 
some  amount  of  an;esthesia. 

The  Twelfth  Dorsal  Nerve  is  not  unfrequently  the  seat  of  neuralgia 
of  a  somewhat  severe  type,  following  its  distribution  to  the  anterior 
abdominal  wall  and  buttock,  and  occasionally  leading  to  a  mistaken 
diagnosis  of  some  abdominal  lesion,  e.g.,  appendicitis  or  chronic 
ovaritis,  and  not  a  few  operations  have  been  unnecessarily  under- 
taken in  consequence.  In  some  cases  it  is  caused  by  the  undue  pro- 
jection of  the  tip  of  the  last  rib,  which 
becomes  injured  and  inflamed,  the  nerve 
becoming  adherent  thereto;  removal  of 
the  rib  or  its  tip  suffices  to  cure  the 
patient.  In  not  a  few  cases  of  operations 
on  the  kidney  the  nerve  becomes  en- 
tangled in  the  scar,  and  this  is  a  source 
of  most  troublesome  pain,  the  only  cure 
of  which  is  to  cut  down,  free  the  nerve, 
and  pull  out  its  central  end. 

Sciatica,  or  neuralgia  of  the  great 
sciatic  nerve,  is  a  most  painful  affection, 
and  often  exceedingly  intractable.  It 
may  arise  from  the  following  Causes: 
[a)  Inflammation  of  the  neurilemma 
(acute  or  chronic),  the  result  of  cold, 
injury,  gout,  rheumatism,  syphilis,  and 
many  toxic  agents;  ip)  pressure  upon 
the  extrapelvic  portion  of  the  nerve,  as 
by  aneurisms,  tumours,  or  old-standing 
dislocations  of  the  head  of  the  femur  on 
the  dorsum  ilii ;  (c)  similar  pressure  upon 
the  nerve  in  the  pelvis,  or  as  it  emerges 
through  the  sacro-sciatic  notch,  as  from 

sarcoma  or  osteoma  of  the  pelvic  bones,  rectal  or  uterine  cancer, 
a  pregnant  uterus,  or  uterine  fibroids ;  {d)  pressure  upon  the  nerve- 
roots  in  the  spinal  canal,  as  from  caries  or  sarcoma;  [e)  chronic 
diseases  of  the  spinal  cord,  such  as  tabes. 

The  Symptoms  are  very  characteristic,  the  pain  shooting  down 
the  back  of  the  thigh  and  being  often  referred  to  the  toes.  It  is  of  a 
paroxysmal  nature,  and  may  be  brought  on  by  pressure  over  almost 
any  part  of  the  nerve  or  by  movements  of  the  thigh,  and  hence  the 
patient's  gait  is  stiff  and  shambling.  Tenderness  in  the  fine  of  the 
nerve  is  felt  when  the  cause  is  a  peripheral  neuritis,  and  the  trunk 
may  sometimes  be  detected  on  palpation  as  a  thickened  cord.  The 
limb  is  usually  kept  slightly  bent,  but  complete  flexion  of  the  thigh 
on  the  pelvis  is  an  impossibility ;  and  if,  when  the  patient  is  standing 
against  a  wall,  the  limb  can  be  raised  to  a  right  angle  with  the  knee 
extended,  it  is  certain  that  sciatica  is  not  present.  Careful  examina- 
tion of  the  patient's  pelvis  must  be  made  before  determining  that  a 
case  is  '  merely  sciatica,'  especially  if  the  pain  has  lasted  any  time. 

The  Treatment  necessarily  varies  with  the  cause.     If  due   to 


Fig.  133. — Claw-hand  (Main- 
en-Griffe)  from  Ulnar 
Paralysis.  (After  Byrom 
Bramwell.) 


394  A    MANUAL  OF  SURGERY 

neuritis  or  perineuritis,  general  anti-svphilitic  or  anti-rheumatic 
measures  may  be  adopted,  and  blisters  or  sedative  remedies  in  the 
more  acute  cases  apjilied  to  the  back  of  the  thigh.  Hypodermic 
injections  of  mf>rphia  and  atropine  may  also  be  useful;  but  if  all 
the  usual  anti-neuralgic  remedies  have  been  exhausted  without 
benefit,  dretchin^  of  the  nerve  may  be  employed.  This  may  be 
accomplished  without  operation  by  tiexing  the  thigh  upon  the 
abdomen  and  then  extending  the  knee;  in  cases  of  sciatica  an 
anaesthetic  will  be  required  for  this,  but  it  may  be  attempted  before 
undertaking  operative  procedures. 

The  nerve  is  best  exposed  for  stretching  at  the  point  where  it  emerges  from 
under  cover  of  the  ghitcus  maximus,  midway  between  the  tuber  ischii  and  the 
great  trochanter.  The  patient  Hes  in  the  prone  position  with  the  Hmb  sHghtly 
flexed,  and  a  4  or  5  inch  incision  is  made  vertically  downwards  from  the  gluteal 
fold  in  the  middle  line  of  the  thigh.  The  lower  border  of  the  gluteus  maximus 
is  first  exposed,  and  its  fibres  are  seen  running  downwards  and  outwards.  The 
hamstring  muscles  emerging  from  under  it  are  drawn  inwards,  and  the  nerve  is 
found  ensheathed  in  loose  connective  tissue;  it  is  stretched,  by  a  finger  hooked 
under  it,  both  pcrijiherally  and  proximally. 

The  External  Popliteal  Nerve  may  be  divided  during  a  subcu- 
taneous tenotom}'  of  the  biceps,  to  which  it  lies  immediately  in- 
ternal; or  compressed,  as  it  winds  round  the  neck  of  the  fibula,  by 
strapping,  bandages,  or  splints;  or  it  may  be  injured  in  fractures  of 
the  neck  of  the  fibula.  Total  division  causes  anaesthesia  of  the 
dorsum  of  the  foot,  and  of  a  varying  portion  of  the  front  and  outer 
side  of  the  leg,  together  with  paralysis  of  the  extensor  and  peroneal 
groups  of  muscles.  In  the  earlier  stages  inability  to  dorsi-flex  the 
foot  results  in  a  condition  of  '  drop-foot,'  but  later  on  the  contrac- 
tion of  the  unbalanced  opposing  groups  results  in  the  paralytic 
form  of  talipes  equino-varus.  The  nerve  may  be  exposed  by  making 
an  incision  ij  inches  long  to  the  inner  side  of  the  biceps  tendon, 
terminating  at  the  neck  of  the  fibula.  The  knee  is  then  flexed,  and 
the  nerve  is  readily  found  embedded  in  the  loose  cellular  tissue  of 
the  popliteal  space. 

The  Internal  Popliteal  Nerve  is  much  less  exposed  to  injury  owing 
to  its  more  sheltered  position.  Division  results  in  loss  of  epicritic 
and  protopathic  sensation  over  the  sole  of  the  foot,  and  of  epicritic 
sensation  for  the  plantar  surface  of  all  the  toes  and  for  the  dorsal 
aspect  of  the  outer  four;  also  in  paralysis  of  the  calf  muscles,  flexors 
of  the  foot  and  toes,  and  of  the  short  muscles  of  the  sole.  Paralytic 
talipes  calcaneo-valgus  is  very  likely  to  ensue.  The  nerve  is  laid 
bare,  by  a  vertical  incision  in  the  middle  of  the  popliteal  space, 
which  should  avoid  the  short  saphena  vein.  After  division  of  the 
deep  fascia,  the  nerve  is  the  most  superficial  structure. 

If  the  Tibial  Nerves  are  divided,  the  resulting  effects  are  more 
limited;  thus,  paralysis  of  the  extensors  of  the  foot  and  paralytic 
talipes  equinus  result  from  division  of  the  anterior  tibial ;  and  par- 
alysis of  the  short  and  long  flexors  of  the  foot  and  of  the  interossei, 
with  resulting  talipes  calcaneo-valgus,  follow  lesions  of  the  posterior 
tibial.  The  nerves  may  be  exposed  in  the  same  way  as  the  accom- 
panying arteries  (p.  339). 


AFFECTIONS  OF  NERVFS  395 

The  Sympathetic  Nerve-trunk  in  the  neck  is  occasionally  com- 
pressed by  aneurisms  or  tumours.  If  merely  irritated,  dilatation 
of  the  pupil  on  the  same  side  and  unilateral  sweating  of  the  head  and 
face  arc  produced;  but,  if  divided,  the  pupil  is  contracted  from  un- 
balanced action  of  the  third  nerve.  It  has  also  been  completely 
excised  on  both  sides  in  the  treatment  of  Graves'  disease  and  for 
glaucoma,  and  the  operation  appears  to  be  of  some  value. 

The  Nerve-Roots. 

It  is  a  well-known  fact  that  during  the  development  of  the  embr^^o 
the  primitive  spinal  cord,  which  was  originally  co-terminous  with  the 
trunk  and  with  the  vertebral  column,  graduall}'  lags  behind  in  its 
growth,  so  that  at  birth  and  subsequently  it  does  not  extend  down 
the  canal  further  than  the  lower  border  of  the  first  lumbar  vertebra. 
This  necessarily  involves  a  displacement  of  the  attachment  of  the 
spinal  nerves  upwards,  so  that  these  points  of  origin  of  the  nerves 
do  not  correspond  to  the  inter-vertebral  foramina,  and  a  variable 
length  of  the  nerve  exists  within  the  canal  formed  at  first  by  the 
junction  of  the  anterior  or  motor  ramus  with  the  ganglionated 
posterior  or  sensory  ramus.  In  the  cervical  region  each  spinal 
segment  is  about  one  vertebra  above  its  corresponding  body;  in  the 
upper  dorsal  region  this  interval  amounts  nearly  to  two  vertebrse; 
whilst  all  the  spinal  segments  corresponding  to  the  lumbar,  sacral, 
and  coccygeal  nerves  are  crowded  between  the  tenth  dorsal  and  the 
first  lumbar  vertebrae. 

The  nerve-roots  after  this  downward  intraspinal  course  pass 
through  the  intervertebral  foramina,  where  they  are  exposed  to 
injury  and  pressure,  and  after  various  divisions  and  combinations 
constitute  the  peripheral  nerves.  It  must  be  remembered  that 
almost  all  the  peripheral  nerve-trunks  are  derived  from  a  number 
of  nerve-roots,  and  the  complex  distribution  of  these  has  been  care- 
fully worked  out.  It  follows  that  the  distribution  of  sensation  over 
the  trunk  according  to  the  nerve-roots  is  a  very  different  thing  to 
that  of  the  peripheral  nerves,  and  the  practitioner  and  student  must 
carefulty  study  the  diagrams  appended  (Figs.  134  and  135)  in  order 
to  familiarize  themselves  with  this  arrangement.  Particularly 
noticeable  is  the  amount  of  overlapping  of  sensory  areas,  a  pro- 
vision whereby  defective  sensation  due  to  localized  injuries  may 
be  minimized.  Sherrington  has  shown  that  in  apes  cutaneous 
anaesthesia  will  not  result  from  the  division  of  any  two  consecutive 
posterior  nerve-roots,  but  only^  when  three  are  divided;  this  has  been 
confirmed  in  man.  The  control  of  muscles  or  groups  of  muscles 
is  similarly  distributed  over  two  or  three  consecutive  nerve-roots, 
presumably  with  a  similar  object;  whilst  the  nerve-fibres  from 
muscles,  tendons,  ligaments,  etc.,  upon  which  the  muscular  tone 
and  control  of  the  limbs  so  much  depends,  also  enter  the  cord  by 
several  nerve-roots. 

Pressure  on  the  nerve-roots  may  be  caused  by  tumours  of  the  spine 
or  spinal  cord,  by  tuberculous  or  gummatous  lesions,  or  by  callus  or 


396 


A    MANUAL  OF  SUnGRRY 


Fig.    134.— Nerve-root  Areas:  Anterior  Aspect  of  Trunk. 
(After  Head  and  Osler.) 


Al'l'ECTlONS  OF  NERVES 


397 


Fic    135.— Nerve-root  Areas:   Posterior  Aspect.      (After  Head  and 

OSLER.) 


3y«  A    MANUAL  OF  SUliGEUY 

adhesiuns  loniung  abt)Ut  the  intervertebral  foramina.  Intense  neur- 
algia is  the  most  prominent  symjjtom,  together  with  hyperiesthesia ; 
this,  it  will  be  noted,  always  follows  the  nerve-root  areas,  and  not 
those  of  the  peripheral  nerves.  Herpes  zoster  may  be  induced  by 
the  affection,  and  in  tinu'  an;estliesia  may  follow. 

Division  olt  the  Posterior  Roots  (Forster's  operation)  lias  now 
been  undertaken  lor  a  variety  of  conditions,  and  may  be  looked 
on  as  justiliable  in  suitable  cases,  such  as — (i)  Intractable  neuralgia, 
due  either  to  irremovable  pressure  or  to  an  ascending  neuritis, 
where  medical  methods  are  of  no  avail.  (2)  To  relieve  persistent 
visceral  crises  and  the  lightning  pains  of  tabes  dorsalis.  The  crises 
are  supposed  to  be  due  to  the  irritation  in  these  organs  of  sensory 
sympathetic  fibres,  which  enter  the  cord  in  the  posterior  nerve- 
roots.  (3)  The  relief  of  certain  spastic  deformities,  more  particularly 
of  the  legs,  has  been,  perhaps,  the  most  successful  result  of  this 
operation.  This  proceeding  is  based  on  the  presumption  that 
interference  with  the  upper  motor  pyramidal  track  {i.e.,  between 
the  cortex  and  the  spinal  centres)  not  only  impairs  the  passage  of 
excito-motor  impulses,  but  also  hampers  the  conduction  of  in- 
hibitory impulses  from  cortex  to  spinal  centre.  The  result  of  this 
is  that  peripheral  stimuli  reaching  the  centres  from  below  have  an 
undue  power  of  producing  reflex  activity,  and  hence,  in  such  con- 
ditions as  the  cerebral  diplegia  of  children,  spastic  contraction  of 
muscles  is  induced,  and  the  mere  placing  of  the  foot  on  the  ground 
in  the  attempt  to  walk  produces  such  spastic  contortions  as  to 
render  progress  impossible.  The  distribution  of  afferent  stimuli 
through  at  least  three  nerve-roots  renders  it  possible  to  divide 
suitably  selected  nerve-roots  in  order  to  minimize  this  spastic 
condition  without  producing  anaesthesia  or  ataxia,  providing  that 
not  more  than  two  consecutive  posterior  nerve-roots  are  ever 
severed.  The  result  of  such  a  procedure  is  that  the  spasticity 
gradually  diminishes,  and  after  suitable  freeing  of  contracted 
muscles  (by  massage,  forcible  movements,  or  even  by  tenotomy, 
myotomy,  etc.)  and  educational  exercises,  walking  becomes  possible. 

The  Operation  itself  for  a  spastic  condition  of  the  legs  is  conducted 
usually  in  two  stages.  The  first  consists  in  removal  of  the  laminae 
of  the  whole  of  the  lumbar  vertebrae,  and  in  opening  the  upper  ])art 
of  the  sacral  canal.  A  guiding  stitch  is  introduced  into  the  muscles 
opposite  the  tip  of  the  fifth  lumbar  spine  to  act  as  a  landmark  to 
assist  in  the  identification  of  the  nerve-roots.  The  first  sacral  roots 
leave  the  dural  canal  at  this  level.  The  removal  of  the  laminae 
must  be  wide,  and  should  include  the  internal  articular  processes, 
so  as  to  allow  of  a  clear  recognition  of  the  deeper  parts.  After  a 
suitable  interval  the  wound  is  reopened,  and  the  spinal  membranes 
incised;  it  is  desirable  to  do  this  without  h;emorrhage,  thereby 
rendering  identification  of  the  nerve-roots  more  satisfactory.  In 
most  cases  of  cerebral  diplegia  or  spastic  })araplegia  it  suffices  to 
divide  the  jxjsterior  nerve-roots  of  the  second,  third,  and  fifth  lumbar 
nerves,  and  that  of  the  second  sacral. 


CHAPTER  XVII 

SURGICAL  DISEASES  OF  THE  SKIN  AND  OF  THE 
CUTANEOUS  APPENDAGES. 

A  Boil  or  Furuncle  is  a  localized  inflammation  of  the  skin,  usually 
terminating  in  suppuration,  due  to  infection  with  staphylococci  of 
a  hair  follicle  or  sebaceous  gland.  Experimentally,  a  plentiful  crop 
of  boils  can  be  produced  by  rubbing  a  culture  of  staphylococci  mto 
the  skin,  and  clinically  there  is  little  doubt  that  a  similar  mfection 
is  the  rnost  common  cause  of  this  condition.  The  secondary  or 
satellite  boils  which  form  around  a  primary  one  are  due  to  the 
friction  upon  the  healthy  integument  of  dressings,  covered  with  pus 
and  microbes. 

People  with  coarse  skins  and  a  tendency  to  comedones  are 
specially  liable  to  the  occurrence  of  boils,  but  some  depressing  con- 
stitutional condition,  such  as  chronic  Bright's  disease  or  diabetes, 
is  often  present  in  patients  who  suffer  from  recurrent  crops  of  boils. 
A  gangrenous  inflammation  ensues  after  infection,  resulting  in  the 
death  of  the  hair  follicle,  or  of  the  sweat  or  sebaceous  gland  in- 
volved, and  of  the  surrounding  connective  tissue,  and  the  slough 
thus  formed  is  cast  off  by  a  process  of  suppuration.  A  matured  or 
ripe  boil,  therefore,  consists  of  a  central  slough  or  core,  a  zone  of  pus 
around  it,  and  external  to  this  granulation  tissue  merging  into 
healthy  skin  and  connective  tissue. 

Signs.— A  boil  commences  as  a  small  red  irritable  pimple,  from 
which  a  hair  may  often  be  seen  to  protrude;  it  increases  gradually 
in  size,  becoming  more  and  more  painful,  until  it  forms  a  conical 
tumour,  deep  red  in  colour  and  exquisitely  tender.  A  small  whitish 
spot  appears  in  the  centre,  and  around  this  so-called  core  yellow  pus 
can  be  seen.  Finally  it  bursts,  discharging  the  pus,  and  subse- 
quently the  core  or  slough  comes  away.  The  process  is  then  at  an 
end,  and  the  wound  rapidly  heals  by  granulation.  Occasionally  the 
inflammation  extends  more  deeply  into  the  subcutaneous  tissues, 
constituting  a '  carbuncular  boil. '  Lymphangitis  sometimes  follows, 
and  the  neighbouring  lymphatic  glands  may  become  sympatheti- 
cally enlarged  and  painful,  but  rarely  suppurate.  A  boil  sometimes 
subsides  without  suppuration,  leaving  the  parts  thickened  and 
infiltrated,  the  condition  then  being  known  as  a  '  blind  boil' 

399 


400  A   MANUAL  OF  SURGERY 

Treatment. — Many  boils  may  be  left  to  burst  naturally,  though 
possibly  the  process  may  be  checked  by  painting  them  twice  daily 
with  iodine  (2  per  cent.)  and  applying  KIapj)'s  suction-glass  two 
or  three  times  a  day.  Where  pus  has  formed,  an  incision  is  made, 
and  the  suction-ball  persisted  in  till  the  slough  has  come  away.  In 
the  later  stages  the  skin  around  should  be  thoroughly  purilied, 
and  the  pus  and  core  received  on  })ortions  of  wool  soaked  in  carbolic 
lotion  (i  in  20),  and  the  cavity  lightly  swabbed  out  with  pure 
carbolic  acid.  A  small  collodion  dressing  is  then  a])j)lied.  Tonics, 
such  as  iron  and  quinine,  are  usually  recjuired,  except  in  plethoric 
individuals,  in  whom  a  spare  diet  and  abstinence  from  stimulants 
may  be  recommended.  A  change  of  air  to  a  bracing  seaside  place  is 
often  advisable,  especially  when  a  succession  of  boils  has  appeared. 
In  the  more  persistent  cases  a  staphylococcal  vaccine  may  be 
employed  with  advantage,  and  the  boils  will  probably  be  quickly 
cured  or  aborted  (p.  26). 

A  Carbuncle  is  a  more  extensive  infective  gangrene  of  the  sub- 
cutaneous tissues,  due  to  a  local  invasion  with  pyogenic  microbes, 
the  commonest  being  the  Staphylococcus  pyogenes  aureus.  It  occurs 
in  individuals  run  down  by  any  general  debilitating  condition,  such 
as  albuminuria  or  diabetes,  in  whom  the  germicidal  powers  of  the 
tissues  are  much  depreciated;  it  is  also  occasionally  met  with  as  a 
sequela  of  acute  fevers.  The  exciting  cause  may  be  some  blow  or 
squeeze,  resulting  in  extravasation  of  blood  or  some  local  diminution 
of  vitality;  into  this  area  cocci  are  implanted  either  by  auto-infec- 
tion, or  more  usually  through  the  sweat-glands  or  hair  follicles,  or 
through  some  slight  superficial  abrasion. 

Signs.- — A  carbuncle  commences  as  a  hard,  painful  infiltration  of 
the  subcutaneous  tissues,  the  skin  over  which  becomes  red  and  dusky. 
The  swelling  gradually  increases  in  size  in  all  directions,  until  a 
diameter  of  many  inches  may  be  reached.  As  it  extends  peripher- 
ally, the  central  parts,  which  were  formerly  brawny,  become  soft  and 
boggy,  and  the  overlying  skin  shows  evidences  of  yielding  to  the 
pressure  within.  Vesicles  form  on  the  surface,  and  finally  pustules; 
these  in  turn  burst,  and  allow  a  tardy  exit  to  the  ashy-gray  sloughs 
and  purulent  discharge  accumulated  below.  Fresh  openings  gradu- 
ally develop,  leading  to  a  cribriform  condition  of  the  cutis;  some  of 
these  apertures  enlarge  and  run  into  one  another,  producing  a  central 
irregular  crateriform  opening,  at  the  bottom  of  which  lies  the 
necrotic  tissue.  As  the  violence  of  the  inflammation  subsides,  the 
sloughs  gradually  separate,  leaving  a  clean  granulating  wound. 
Carbuncles  most  frequently  occur  on  the  back,  the  nape  of  the  neck, 
the  shoulders,  and  nates,  where  the  vitality  of  the  tissues  is  never 
very  active;  when  they  form  on  more  vascular  parts,  such  as  the 
face  and  lips,  the  consequences  may  be  even  more  serious,  since 
infective  thrombosis  of  the  large  veins  may  follow,  and  this  may 
quickly  spread  up  to  the  cavernous  sinus.  The  soft  and  spongy 
tissue  of  the  cheek  is  a  very  favourable  place  for  the  extension  of 


SURGICAL  DISEASES  OF  'THE  SKIN  4"^ 

the  necrotic  process,  and  there  may  be  a  wide  area  of  mischief  under 
an  apparently  insignificant  superficial  lesion.  A  carbuncle  is  usually 
single,  and  may  be  accompanied  by  lymphangitis  and  a  painful 
enlargement  of  the  nearest  lymphatic  glands. 

There  is  often  considerable  constitutional  chsturbance  of  an  as- 
thenic type,  although  the  temperature  is  not  necessarily  much 
raised.  A  temporary  glycosuria  is  sometimes  present,  and  dis- 
appears as  the  condition  improves,  but  occasionally  the  gravest 
symptoms  of  blood-poisoning  (pyaemia  or  septicemia)  may  super- 
vene. 

Treatment.— In  the  early  stages  Bier's  treatment  by  induced 
hyperemia  may  be  successful  in  preventing  suppuration,  but  where 
the  organisms  are  at  all  virulent  or  the  focus  large,  it  will  probably 
fail.  In  the  later  stages  the  most  satisfactory  treatment  is  to  lay 
the  carbuncle  freely  open  under  an  anaesthetic,  and  scrape  with  a 
sharp  spoon  or  cut  away  all  sloughs  until  healthy  tissue  is  reached, 
and  then  to  disinfect  the  cavity  thoroughly  with  pure  carbolic  acid 
or  peroxide  of  hydrogen  (lo  volumes).  The  hollow  thus  formed  is 
packed  with  gauze  soaked  in  an  iodoform  emulsion  (lo  per  cent.), 
and  allowed  to  heal  by  granulation.  Another  less  radical  proceeding 
is  to  make  a  free  crucial  incision,  and  allow  the  sloughs  to  separate 
naturally,  assisting  matters  by  antiseptic  fomentations  or  Klapp's 
suction-glass.  Good  food,  iron,  quinine,  and  alcohol  according  to 
judgment,  must  be  administered,  whilst  appropriate  medicine  {e.g., 
codeia  or  opium)  and  hmitation  of  diet  are  necessary  in  diabetic 
patients. 

A  Corn  [clavus]  is  a  localized  outgrowth  of  the  epidermic  layer  of 
the  skin,  together  with  a  central  ingrowth  of  a  hard,  horny  plug, 
which  compresses  and  causes  atrophy  of  the  underlying  papillae,  con- 
stituting a  cup-shaped  hollow,  whilst  the  surrounding  papillae  are 
hypertrophied.  It  is  the  presence  of  this  central  plug  that  consti- 
tutes the  difference  between  a  true  corn  and  a  simple  callosity  or 
diffuse  overgrowth  of  the  epidermis.  Any  abnormal  pressure  is 
capable  of  producing  either  condition,  granting  that  it  is  not  sufift- 
ciently  severe  or  intense  to  lead  to  ulceration;  but  it  is  rare  to 
find  corns  except  on  the  feet,  and  the  chief  cause  is  badly-fitting 
boots.  Two  kinds  of  corns  are  described,  viz.,  the  hard  and  the 
soft. 

The  hard  corn  usually  occurs  on  the  httle  toe,  or  over  the  head  of 
the  metatarsal  bone  of  the  great  toe,  or  over  the  heads  of  the  first 
phalanges  of  the  other  toes,  especially  if  there  is  any  tendency  to 
hammer-toe.  They  form  more  or  less  conical  swellings,  with  a  dark, 
dry,  central  plug,  and  are  often  very  painful,  especially  when  rain  is 
threatening.  Suppuration  sometimes  occurs  beneath  a  corn,  and  the 
pain  then  becomes  acute.  If  it  is  not  attended  to  early,  the  pus  may 
burrow  and  cause  necrosis  of  deeper  parts  or  a  destructive  arthritis. 
Treatment  consists  in  paring  the  corn,  after  softening  with  hot 
water  or  treating  with  salicyhc  acid  plaster  (lo  or  20  per  cent.),  or 


402 


A   MANUAL  OF  SURGERY 


painting  with  a  solution  of  salicylic  acid  in  collodion.*  A  ring  of 
felt  plaster  may  subsequently  be  worn,  but  attention  must  be 
directed  to  the  boots,  and  the  cause  of  the  trouble  removed.  Occa- 
sionally, where  the  toe  is  deformed,  or  disease  of  the  bone  or  joints 
has  dexcloped,  it  is  necessary  to  perform  amputation. 

A  soft  corn  occurs  between  the  toes,  and  owing  to  the  absorption 
of  sweat  the  surface  looks  white  and  sodden;  it  is  often  extremely 
painful.  Treatment  consists  in  removing  the  thickened  cuticle  after 
the  use  of  salicylic  acid.  The  parts  are  very  carefully  cleansed  night 
and  morning,  and  spirit  of  camphor  painted  on  at  night,  whilst 
cotton-wool  is  worn  between  the  toes  during  the  day.     Failing  this, 

the  corn  must  be  removed  by 
operation.  The  toes  are  held 
widely  apart,  and  the  incisions 
run  transversely  between  them,  so 
as  to  include  the  corn.  The  wound 
ran  be  readily  closed  bv  sutures. 

Perforating    Ulcer    of    the    Foot 

forms  on  some  part  of  the  sole  and 
progresses  deeply  so  as  to  involve 
sooner  or  later  the  bones  and 
joints.  It  is  usually  due  to  two 
main  factors,  viz.,  ancesthesia  of  the 
sole,  and  more  or  less  persistent 
traumatism,  such  as  arises  from 
wearing  a  tight  boot  or  from  the 
presence  of  a  nail,  which  is  not 
noticed  owing  to  the  concurrent 
anaesthesia.  It  is  therefore  likely 
to  be  met  with:  (i)  In  certain 
central  nervous  diseases — e.g.,  tabes 
dorsalis,  syringomyelia,  spina  bi- 
fida, etc. ;  (2)  in  diseases  such  as 
diabetes,  syphilis,  alcoholism,  etc., 
which  lead  to  peripheral  neuritis; 
and  (3)  as  a  sequence  of  traumatic  lesions  of  the  nerves  affecting 
any  portion  of  their  course  from  the  spinal  cord  downwards. 
(4)  Perforating  ulcer  is  occasionally  due  to  pure  plantar  lesions, 
apart  from  an}'  nervous  influence,  e.g.,  a  suppurating  wart  or  cf)rn, 

*   The  following  is  a  useful  formula: 

R.     Acidi  salicylici,  gr.  xv. 

Ext.  cannabis  ind.,  gr.  viii. 
Sp.  vini  rect.,  nixv. 
iEtheris,  mxl. 
Collodion  flexile,  iillxxv. 
M.  Ft.  pigm. 

Si",:  To  be  painted  on  with  a  brush  three  times  a  day  for 
a  week. — R.  Crocker. 


Fig.  130. — Perforating  Ulcer 
OF  Great-toe,  penetrating  to 
Bones  and  causing  Necrosis. 

The  scar  of  an  old  healed  ulcer[  of 
similarjtype  is  seen  on  the'outer 
side  of  the  foot. 


SURGICAL  DISEASES  OF  THE  SKIN  403 

or  even  a  chronic  epithelioma.  The  skin  under  the  head  of  the  first 
metatarsal  is  the  part  most  frequently  affected,  but  any  spot  to 
which  undue  pressure  is  directed  may  become  involved,  and  not  un- 
commonly several  such  sores  may  be  seen  on  the  same  foot.  A 
corn  or  callosity  first  forms,  and  under  this  a  bursa,  in  which  suppu- 
ration takes  place;  the  pus,  finding  a  difficulty  in  coming  to  the 
surface  owing  to  the  thickness  of  the  cuticle,  spreads  deeply  into 
the  soft  structures  of  the  sole,  and  the  suppuration  may  even  involve 
bones  and  joints.  A  typical  perforating  ulcer  presents  the  appear- 
ance of  a  sinus  passing  down  to  the  deeper  parts  of  the  foot,  and 
even  extending  through  to  the  dorsum;  the  orifice  is  surrounded  by 
heapcd-up  and  thickened  cuticle  (Fig.  136).  There  is  sometimes 
but  little  discharge  and  often  no  pain,  but  when  bones  or  joints  are 
aft'ected,  free  suppuration  may  occur.  If  allowed  to  progress  with- 
out treatment,  the  bones  and  joints  of  the  foot  may  be  destroyed  ex- 
tensively, or  may  be  welded  together  into  a  solid  painful  mass,  in 
either  case  necessitating  amputation.  A  cure  can  sometimes  be 
determined  in  the  early  stages  by  removing  the  thickened  mass  of 
cuticle  and  purifying  or  excising  the  sinus;  the  cavity  thereby 
formed  is  packed  with  gauze  and  allowed  to  heal  by  granulation. 
Should  this  fail,  or  if  bones  or  joints  are  involved,  amputation  will 
be  required. 

A  Wart  (verruca)  is  a  papillary  overgrowth  of  the  skin,  which  may 
manifest  itself  in  many  different  appearances.  The  common  wart  is 
a  horny  projection  about  the  size  of  a  split  pea,  usually  seen  on  the 
hands  of  young  people;  its  surface  may  be  smooth  or  irregularly 
filiform,  and  its  colour  varies  with  the  amount  of  dirt  ingrained  on 
the  surface.  When  smooth-topped,  they  are  sometimes  extremely 
numerous,  and  may  be  a  little  difficult  to  distinguish  from  lichen 
planus.  In  parts  where  there  is  a  certain  amount  of  moisture  warts 
become  soft  in  character,  and  form  large  vascular  masses — e.g., 
venereal  warts.  The  best  method  of  treating  ordinary  warts  is  to 
paint  them  with  glacial  acetic  acid,  or  some  other  caustic,  every  two 
or  three  days,  after  softening  and  removing  the  horny  crust  with 
salicylic  acid.     Ionic  treatment  with  salicylates  is  also  of  value. 

Verruca  Neerogenica  (see  p.  251). 

A  Chilblain  [pernio)  is  an  inflammatory  hyperemia,  usually  in- 
volving the  fingers,  toes,  or  ears,  and  determined  by  exposure  to  cold. 
It  is  generally  seen  in  young  people  with  defective  circulation,  whose 
fingers  and  toes  easily  go  dead.  After  the  period  of  anaemia  and 
pallor,  the  part  begins  to  itch  or  burn,  and  becomes  red,  swollen  and 
shiny.  Exudation  occurs  into  and  beneath  the  skin,  and  in  bad 
cases  a  blister  with  blood-stained  contents  forms;  when  this  bursts, 
troublesome  ulceration  ensues.  To  prevent  the  formation  of  chil- 
blains the  patient's  circulation  must  be  improved,  and  exposed 
parts  kept  warm.  In  the  earlier  stages  treatment  by  induced  hyper- 
aemia  is  most  valuable;  an  elastic  bandage  may  be  worn  for  six 


404  A   MANUAL  OF  SURGERY 

hours  or  so  daily,  whilst  locally  the  parts  may  bo  painted  with  tinc- 
ture of  iodine  or  a  solution  of  ichthyol.  When  the  chilblain  breaks, 
simple  antiseptic  precautions  may  suffice,  but  a  more  stimulating 
application  is  usually  required,  and  Peruvian  balsam  or  resin 
ointment  will  be  found  useful. 

Tuberculous  Af!ections  o£  the  Skin.  -Lupus  Vulgaris  is  a  chronic 
inflammation  of  the  skin  of  tuberculous  origin.  It  is  met  with  in 
children  and  young  adults,  rarely  commencing  after  the  age  of 
thirty.  Its  most  common  situation  is  the  face,  generally  starting  on 
the  nose  or  cheek.  It  is  rare  on  the  scalp,  but  fairly  frequent  on  the 
trunk  and  extremities.  The  mucous  membrane  of  the  nose  and 
mouth  is  also  attacked,  but  usually  by  extension  from  the  skin.  It 
is  not  often  symmetrical,  except  when  commencing  on  the  nose. 


Fig.   137. — Non-ulcerating  Lupus  of  Cheek.     (From  a  rHOTOGRAni.) 

Clinical  Features. — The  earliest  manifestation  of  lupus  consists  in 
the  formation  of  one  or  more  shot-like  nodules  in  the  deeper  layers 
of  the  skin,  which  are  surrounded  by  a  zone  of  hyper?emia  and  infil- 
tration. These  nodules  are  not  particularly  hard  to  the  touch,  but 
when  of  any  size  can  be  demonstrated  to  be  of  a  brownish-orange 
tint,  especially  if  they  are  devascularized  by  the  pressure  of  a  glass 
slide,  and  then  the  colour  somewhat  resembles  that  of  apple-jelly. 
Gradually  the  process  extends,  and  usually  more  rapidly  in  one 
special  direction,  following  the  course  of  the  vessels.  At  the  same 
time  the  integument  becomes  infiltrated  and  transformed  into 
granulation  or  cicatricial  tissue,  covered  by  a  layer  or  two  of  epi- 
thelium (Fig.  137),  and  owing  either  to  degeneration  of  the  tuber- 
culous nodules,  or  to  a  lack  of  vitality,  arising  from  compression  of 


SURGICAL  DISEASES  OF  THE  SKIN  4"5 

the  vessels  by  the  ccnitraction  of  this  new  formation,  ulceration  is 
very  liable  to  follow.  In  the  extremities  the  lupoid  growth  not  un- 
frequently  takes  on  a  warty  aspect,  somewhat  similar  to  the  ana- 
toinical  wart  '  occasionally  seen  on  the  knuckles  of  post-mortem 

porters  (p.  251).  .  -x  1,     1      +  ^-v,^ 

A  Lupoid  Ulcer  usually  spreads  at  one  margin  as  it  heals  at  the 
other,  and  hence  under  typical  circumstances  is  more  or  less  cres- 
centic  in  shape.  The  surface  is  covered  with  granulations,  often  ot 
a  protuberant  nature.  The  edges  are  raised  and  infiltrated,  and 
scattered  lupoid  tubercles  are  readily  distinguishable,  extending  into 
the  healthy  tissues,  which  are  usually  red  and  congested^  A  con- 
siderable amount  of  sero-pus  is  often  secreted,  and  this  by  drying 
forms  thick  scabs.  Any  cicatrix  which  results  from  natural  pro- 
cesses of  cure  is  thin  and  vascular,  easily  breaking  down  from  slight 
irritation.  The  process  extends  gradually,  with  or  without  inter- 
missions, from  the  seat  of  its  first  appearance;  it  is  as  a  rule  lirnited 
to  the  cutaneous  tissues;  but  when  it  attacks  the  nose,  the  cartilages 
are  often  involved  and  destroyed,  whilst  if  it  involves  the  palate  or 
septum  nasi,  perforation  is  very  hkely  to  ensue  The  disease  is 
practically  painless,  and  does  not  at  first  affect  the  gerieral  health. 
Neighbouring  lymphatic  glands  may  become  inflamed  and  ma 
few  instances  are  the  seat  of  a  tuberculous  deposit.  Lett  to  itseii, 
it  tends  sooner  or  later  to  come  to  an  end,  the  ulcerated  parts  cica- 
trizing, but  leaving  indelible  traces  of  its  ravages  m  the  shape  ot 
obvious  scars,  with  often  considerable  loss  of  substance  Occasion- 
ally it  persists,  in  spite  of  treatment,  and  then  an  epithelioma  may 
in  time  develop  on  the  site  of  the  mischief,  running  a  rapid  course 
owing  to  the  vascularity  of  the  part.  ■     ^  r     . 

Pathological  Anatomy.— The  characteristic  microscopical  feature 
of  lupus  lies  in  the  formation  of  nodules  around  the  smaller  vessels 
of  the  skin  (Fig.  138),  consisting  chiefly  of  a  mass  of  ro^nd  cells 
within  which  may  perhaps  be  observed  a  giant  cell  and  endothehoid 
cells,  arranged  in  the  same  way  as  in  tubercle.  The  structures 
around  are  infiltrated  and  hyperffimic;  as  the  disease  progresses,  ttie 
original  tissue  of  the  part  disappears,  and  is  replaced  by  granula- 
tion or  fibro-cicatricial  tissue.  The  bacilli  are  by  no  means  readily 
found,  and  are  always  few  in  number.  ,      ,       ^    .       .  •        a^^ 

'  The  Diagnosis  of  lupus  from  syphilitic  and  other  destructive  affec- 
tions of  the  skin  turns  on  the  presence  of  outlying  nodules  beyond 
the  spreading  edge  of  the  lesion,  together  with  the  apple-]  elly-iike 
granulations,  and  the  thin,  congested  character  of  any  cicatricial 
tissue  present,  whilst  the  slow,  though  continuous,  progress,  and  ttie 
tendency  to  heal  at  one  part  as  it  spreads  at  another,  are  also  sugges- 
tive of  its  presence.  The  age  and  constitution  of  the  individual,  and 
the  persistence  of  the  disease  in  spite  of  treatment,  must  also  be 

taken  into  account.  -..^    ,     r  +..00^= 

The  Treatment  of  lupus  has  been  greatly  modified  of  recent  years , 
owing  to  the  discovery  of  the  remedial  properties  of  F^^^en  iigtit, 
X  rays,  and  other  agents.     Of  course  where  practicable,  excision  ot 


4o6 


A    MANUAL  OF  SURGERY 


the  whole  area  of  disease  is  the  quickest  and  safest  cure;  but  it  is 
seldom  available. 

In  the  Finsen-light  cure  (p.  51)  each  sitting  lasts  for  one  and  a 
quarter  hours,  and  an  attendant  whose  eyes  are  shielded  by  dark 
glasses  controls  the  crystal  water-chamber,  keeping  it  firmly  against 
the  skin,  and  slightly  shifting  it  from  time  to  time  so  that  an  area 
about  as  large  as  a  shilling  shall  be  acted  upon  at  each  seance. 
Slight  inflammatory  phenomena  follow,  and  a  local  leucocytosis 
supervenes,  as  a  result  of  which  the  disease  disappears,  and  a  soft 


Fig. 


138. — Spreading  M.\rgix  of  a  Patch  of  Lupus.     (Zieglek.) 


a.  Normal  epidermis;  b,  normal  cerium  with  sweat-gland  (i) ;  c,  focus  of  lupoid 
tissue;  d,  vascular  nodule  surrounded  by  diffuse  cellular  infiltration; 
e,  non-vascular  nodule;/,  strings  of  cells  in  course  of  lymphatics;  g,  lupoid 
ulcer;  h,  proliferating  epithelium. 

supple  scar  is  produced,  which  is  very  little  obvious.  It  has  been 
found  of  most  value  where  ulceration  is  absent  and  the  ])atch  not 
of  great  size. 

X-ray  treatment  is  also  valuable.  Ihe  same  precautions  as  to 
protecting  healthy  parts  must  be  observed  as  in  treating  cancer^ 
(p.  57).  The  best  results  have  been  obtained  by  using  a  tube  of 
comparatively  low  vacuum,  and  by  working  for  a  definite  inflamma- 
tory reaction,  and  then  stopping  till  this  has  disappeared.  The 
length  of  the  treatment  necessarily  varies,  but,  as  a  rule,  three  to  six 
exposures  a  week  of  not  more  than  ten  minutes  each  will  suffice. 
The  X  rays  appear  to  act  best  on  the  ulcerative  and  fungating  forms 
of  lupus,  which  clear  up  and  heal ;  but  the  cure  is  only  up  to  a  point, 
as  the  scars  are  frequently  found  to  contain  small  nodules  over  which 
the  rays  have  no  further  influence.  For  these  the  Finsen  light  may 
be  employed  beneficially ;  but  in  the  absence  of  this  agent  they  should 
be  dealt  with  by  scraping  with  a  lupus  spoon,  and  subsequently 
applying    solid    nitrate   of   silver,   acid    nitrate  of   mercury   on    a 


SURGICAL  DISEASES  OF  THE  SKIN  407 

match   end,    chloride    of    zinc    as    a   paste,    or    even    the    actual 
cautery. 

In  some  bad  cases  with  much  ulceration  and  when  there  is  a  super- 
abundance of  granulations  it  may  be  wise  to  remove  these  with  a 
sharp  spoon  as  a  preliminary  measure,  and  then  hand  the  patient 
over  to  the  radiographer.  The  surgeon  must  remember,  however, 
that  he  is  not  operating  to  cure  the  disease,  but  merely  to  lay  bare  the 
deeper  tissues  in  order  that  the  rays  may  reach  them  more  effectively. 
He  must  not  include  in  the  scope  of  his  operation  healthy  tissues. 

Tuberculin  probably  renders  the  disease  more  amenable  to  local 
measures,  and  prevents  recurrence  after  its  destruction,  but  by  itself 
seldom  cures.-  The  patient's  health  also  must  be  attended  to,  and 
a  course  of  suitable  tonics  administered.  An  open-air  life,  as  nearly 
assimilated  to  the  sanatorium  type  as  possible,  is  also  desirable. 

Lupus  Erythematosus  is  a  disease  the  nature  of  which  is  not  yet 
satisfactorily  determined.  The  appearance  of  the  affection  is  toler- 
ably characteristic ;  it  is  usually  situated  on  the  face,  and  in  the  most 
typical  cases  symmetrical  patches  are  formed  over  the  root  of  the 
nose  and  cheeks,  corresponding  in  appearance  to  a  butterfly  with 
outspread  wings.  Ihe  condition  frequently  invades  the  forehead, 
ears,  and  scalp,'  and  occasionally  appears  on  the  trunk,  being  then 
unilateral.  It  appears  as  a  smooth  hyperaemic  surface,  covered  with 
a  branny  desquamation;  the  scales  consist  of  inspissated  sebum,  and 
are  continuous  with  deep  plugs,  which  can  be  traced  into  the  mouths 
of  enlarged  sebaceous  follicles.  As  the  disease  spreads  peripherally, 
the  older  and  central  portions  are  transformed  into  cicatricial  tissue 
of  a  pale,  thin  and  white  type,  in  marked  contrast  to  the  hyperaemic 
condition  of  the  advancing  margin.  It  is  usually  seen  in  adults,  and 
more  frequently  in  women  than  men.  Progress  is  exceedingly  slow, 
and  ulceration  uncommon,  except  when  the  ears  or  scalp  are  in- 
volved; in  the  latter  region  the  hair  is  often  lost.  Epithelioma  has 
also  been  known  to  follow  this  affection. 

The  Treatment  consists  in  attention  to  the  general  health,  together 
with  the  local  application  of  weak  tarry  and  mercurial  preparations. 
The  X  rays  and  Finsen  light  act  rapidly,  but  must  be  used  with  caution, 
since  the  inflammatory  disturbance  caused  by  them  is  considerable. 

The  so-called  Tuberculous  Ulcers  differ  from  the  lupoid  in  the  fact 
that  they  always  result  from  the  breaking  down  of  a  subcutaneous 
focus,  and  hence  may  be  connected  with  diseases  of  bones,  joints, 
lymphatic  glands,  or  simply  of  the  connective  tissues.  Their 
characters  and  treatment  have  been  already  indicated  (p.  183). 

Other  cutaneous  manifestations  of  tubercle  are  recognised,  but 
need  scarcely  be  mentioned  here. 

Ai¥ectious  of  the  Nails. 

A  Paronychia  (panaritium,  or  '  run  around  ')  is  a  condition  fre- . 
quently  seen  in  surgeons,  nurses,  or  others  who  have  to  expose  their 
hands  to  infective  material,  as  a  result  of  infection  of  the  semi- 


4o8  A   MANUAL  01-   SURGERY 

lunar  fold  at  the  base  of  a  nail.  It  is  often  preceded  by  a  '  hang- 
nail '  which  gives  entrance  to  the  organisms,  and  the  patient's 
general  condition  may  be  unsatisfactory ;  not  uncommonly,  however, 
it  is  seen  in  hospital  nurses  and  others  who  have  just  returned  from 
a  holiday,  suggesting  that  they  need  to  become  immunized  to 
their  surroundings.  1  he  skin  at  the  side  of  the  nail  becomes  swollen 
and  hyperremic,  and  on  pressure  is  tender  to  the  touch;  gradually 
the  pain  increases  and  is  particularly  troublesome  at  night,  perhaps 
preventing  sleep.  A  certain  amount  of  discharge  may  occur 
through  the  semilunar  fold,  but  a  sufficient  exit  is  rarely  given  by 
natural  processes.  Unless  effective  treatment  is  undertaken,  the 
suppuration  spreads  around  the  root  of  the  nail  to  the  other  side, 
and  also  burrows  beneath  the  nail,  separating  it  from  the  matrix. 
Granulations  spring  up  freely  from  the  semilunar  fold,  and  thereby 
discharge  is  often  prevented  from  escaping. 

Treatment  in  the  early  stages  is  by  fomentations  and  the  use  of  a 
Klapp's  suction-ball;  the  skin  at  the  side  of  the  nail  is  pared  down, 
and  if  pus  appears,  a  longitudinal  incision  parallel 
to  the  margin  of  the  nail  through  the  inflamed 
tissues  will  give  exit  to  the  pus,  and  often  sufiices 
to  cure  the  case.  If  the  pus  has  burrowed  beneath 
the  nail,  one  or  more  incisions  must  be  made 
radially  through  the  semilunar  fold  (Fig.  139),  so 
as  to  expose  the  base  of  the  nail,  and  permit  all 
the  loosened  portion  to  be  cut  away  from  the 
matrix  by  sharp  scissors ;  in  some  cases  all  the  base 
Fig.  139.— In-  of  the  nail  has  thus  to  be  sacrificed.  The  terminal 
cisioNs  FOR  portion  may,  however,  be  left,  as  it  is  serviceable 
Treatment  vvhile  the  new  nail  is  forming.  Abundant  granula- 
cHiA  "     ^^^^"^^   spring   up   from  the  matrix,  and  these  may 

need  to  be  kept  in  check  by  nitrate  of  silver. 
Onychia  Purulenta  is  the  term  applied  to  a  suppurative  lesion  of 
the  nail  matrix  which  results  in  the  destruction  and  separation  of 
the  whole  nail.  It  may  commence  on  one  side  as  a  paronychia,  or 
may  be  due  to  infection  of  the  matrix  by  penetrating  foreign  bodies. 
It  also  occurs  in  tuberculous  and  syphilitic  children  where  the 
matrix  is  transformed  into  granulation  tissue  with  but  little  sup- 
puration, and  the  whole  digit  becomes  swollen  and  bulbous  {onychia 
maligna).  Treatment  consists  in  avulsion  of  the  nail,  and  in 
syphilitic  cases  this  must  be  supplemented  by  the  administration 
of  mercury  generally,  and  the  application  of  an  oleate  of  mercury 
ointment  (5  per  cent.)  locally. 

Ingrowing  Toenail  is  an  ulcerated  condition  of  the  soft  parts  pro- 
jecting over  the  side  of  one  of  the  toenails  (usually  that  of  the  great- 
toe),  and  due  either  to  the  pressure  of  pointed  or  badly-fitting  boots, 
or  to  neglect  in  trimming  the  nails.  1  he  fold  of  skin  is  thus  pressed 
by  the  boot  over  and  against  the  nail  when  the  patient  walks,  and 
in  order  to  diminish  the  pain  and  irritation  caused  thereby,  he  often 
tuts  away  the  projecting  angle  of  the  nail,  but  leaves  a  deep  corner 


SURGICAL  DISEASES  OF  THE  SKIN  409 

which  still  further  irritates  the  soft  parts.  Ulceration  ensues,  ac- 
comi)anicd  by  an  offensive  discharge  and  so  much  pain  as  to  prevent 
the  patient  from  walking.  The  matrix  of  the  nail  may  also  become 
inflamed,  and  onychia  result.  In  the  earliest  stages,  further  progress 
can  often  be  prevented  by  careful  attention  to  the  nails,  by  the  use 
of  square-toed  boots  fitting  easily,  and  by  introducing  small  plugs  of 
aseptic  wool  to  press  back  the  overhanging  fold  of  skin.  A  cure 
can  sometimes  be  effected  by  excising  an  oval 
portion  of  skin  from  the  side  of  the  toe  and 
close  to  the  nail.  The  edges  of  the  incision 
are  drawn  together  by  horsehair,  and  thus 
the  overgrowing  fold  of  skin  is  drawn  away 
from  the  nail  (Fig.  140).     When  ulceration  is  _ 

actually  present,  the  best  treatment  is  the  ^fo^r°  ^iNcniowiNo 
removal  of  the  affected  half  of  the  nail,  giving  Toenail. 
special  attention  to  the  extraction  of  the  pro- 
jecting angle.  If  there  is  much  discharge,  it  is  also  wise  to  cut  away 
the  overhanging  fold  of  skin  with  scissors,  and  scrape  away  any 
granulations  present.  The  parts  are  then  dressed  antiseptically, 
and  in  a  few  days  the  patient  is  able  to  walk  about. 

The  term  Onychogryphosis  is  applied  to  a  hypertrophic  condition 
of  the  nails,  which  become  distorted  and  bent,  or  twisted  up,  per- 
haps simulating  a  ram's  horn.  It  is  usually  limited  to  the  great  toes 
of  elderly  people,  and  is  due  to  neglect.  The  nails  are  very  rough, 
and  often  covered  with  grooves  or  ridges,  whilst  beneath  them  is  an 
accumulation  of  soft,  offensive  epithelium.  The  only  treatment  is 
removal. 

AfEectious  of  the  Sebaceous  Glands. 

Sebaceous  Cysts  occur  on  any  part  of  the  surface  of  the  body,  but, 
especially  the  scalp,  and  are  due  to  obstruction  of  the  duct  of  a  seba- 
ceous gland.  They  are  rounded  swellings,  firm  and  elastic  to  the 
touch,  moveable  on  the  deeper  structures,  and  always  attached  at 
one  spot  to  the  skin.  On  careful  examination,  the  obstructed  mouth 
of  a  sebaceous  follicle  can  usually  be  seen,  and  possibly  some  of  the 
contents  of  the  sac  squeezed  through  this  opening.  The  cyst  wall  is 
formed  by  several  layers  of  epithelium,  surrounded  by  dense  fibro- 
cicatricial  tissue,  and  if  exposed  to  irritation  or  pressure,  as  when 
situated  on  the  back  or  shoulder,  and  rubbed  by  the  braces,  becomes 
very  firmly  adherent  to  the  surrounding  parts.  The  material  con- 
tained within  is  of  a  cheesy,  pultaceous  consistency,  with  a  peculiar 
stale  odour,  yellowish-white  in  colour,  and  under  the  niicroscope  is 
seen  to  be  composed  of  fatty  and  granular  debris,  epithelial  cells,  and 
cholesterine.  Left  to  themselves,  the  cysts  may  attain  considerable 
dimensions,  whilst  the  walls  and  contents  sometimes  become  calci- 
fied. Occasionally  the  exudation  oozes  through  the  duct,  and  dries 
on  the  surface,  with  just  sufficient  cohesion  to  prevent  it  from  falhng 
off;  layer  after  layer  of  this  desiccated  material  is  deposited  from 
below,  finally  giving  rise  to  what  is  known  as  a  Sebaceous  Horn. 


4IO  A   MANUAL  OF  SURGERY 

These  become  dark  in  colour  from  admixture  with  dirt,  and  are 
always  more  or  less  hbrillated  in  texture;  the  base,  to  which  they  are 
firmly  adherent,  is  infiltrated  and  hyperitmic.  Sebaceous  cysts 
sometimes  inflame  and  suppurate;  sooner  or  later  they  burst  or  are 
opened,  and  then  the  process  subsides.  They  are  sometimes  cured 
in  this  way,  but  more  frequently  the  cyst  fills  up  again,  and  the  same 
series  of  phenomena  are  repeated  after  an  interval.  Should  the 
contents  only  escape  partially,  the  remainder  is  liable  to  undergo 
putrefactive  changes,  giving  rise  to  an  offensive  ulcerated  surface 
with  raised  edges,  which  may  readily  be  mistaken  for  epithelioma. 
It  is  sometimes  known  as  Cock's  Peculiar  Tiumnir.  True  malignant 
disease  of  an  epitheliomatous  nature  is  said  occasionally  to  supervene. 

Diagnosis. — From  a  dermoid  cyst  it  is  known  by  the  facts  that  the 
dermoid  is  congenital  in  origin,  that  it  is  limited  to  certain  localities, 
whilst  it  is  hardly  ever  directly  attached  to  the  skin.  From  a  fatly 
tumour  it  is  recognised  by  its  rounded  shape,  its  fixity  to  the  skin, 
the  absence  of  lobulation,  and  by  its  more  solid  character,  whilst  a 
lipoma  is  softer  and  more  moveable.  From  a  chronic  abscess  it  is 
distinguished  by  the  dilated  orifice,  by  its  firmer  consistency,  and  by 
the  history,  but  it  is  sometimes  impossible  to  be  certain  before 
incising  it. 

Treatment. — A  sebaceous  cyst  should  be  entirely  and  completely 
removed  if  giving  rise  to  any  disfigurement,  inconvenience,  or  pain. 
In  the  scalp  all  that  is  needed  is  to  transfix  the  tumour,  squeeze  out 
the  cheesy  contents,  and  then  the  cyst  wall  can  be  readily  removed 
by  grasping  it  with  dissecting  forceps  and  pulling  it  away.  In  other 
situations  the  cyst  wall  may  require  to  be  dissected  out ;  but  even 
then  it  is  advisable  to  open  it  by  transfixion,  and  to  deal  with  the  sac 
from  within.  Horns  and  fungating  ulcers  should  be  excised  with  the 
surrounding  skin. 

Sometimes  a  true  sebaceous  adenoma  may  develop  in  connection 
with  these  cysts.  It  may  be  slowly-growing  and  of  a  firm,  solid  con- 
sistency; but  sometimes  it  is  much  more  vascular  and  grows  rapidly. 
The  latter  has  a  form  of  semi-malignancy  in  that  it  is  very  liable  to 
recurrence,  and  has  therefore  often  been  mistaken  for  a  sarcoma. 
On  microscopic  section  it  closely  resembles  a  rodent  ulcer,  but  its 
clinical  history  is  quite  distinct.  Its  most  frequent  situation  is  the 
scalp,  and  it  requires  to  be  removed  with  a  free  hand,  the  defect  in 
the  scalp  being  made  good  by  Ihiersch-grafting. 

Molluscum  Contagiosum. — This  affection  shows  itself  in  the  form 
of  a  number  of  firm  hemispherical  nodules,  a  little  larger  than  a  split 
pea,  usually  of  a  yellowish-white  colour,  and  very  definitely  umbili- 
cated.  The  depression  in  the  centre  may  be  occupied  by  dry  debris, 
and  from  the  larger  ones  a  waxy  mass  can  be  expressed.  They  are 
usually  seen  on  the  face,  but  may  involve  any  part  of  the  surface  of 
the  body.  There  seems  no  doubt  as  to  their  contagious  properties, 
this  being  perhaps  best  seen  in  the  development  of  growths  of  this 
nature  on  a  mother's  breast,  secondary  to  those  on  the  face  of  her 
baby,  but  the  cause  of  the  contagion  is  by  no  means  certain.    Patho- 


SURGICAL  DISEASES  OF  THE  SKIN 


411 


logically  the  tumours  consist  of  numerous  wedge-shaped  lobules  of 
polygonal  nucleated,  epitheUal  cells,  supported  by  a  fibrous  stroma. 
The  cells  towards  the  centre  undergo  a  waxy  or  hyahne  degeneration, 
and  in  them  are  seen  numerous  rounded  bodies,  which  have  been 
supposed  to  resemble  psorosperms.  Treatment  consists  m  cutting  or 
pulling  them  away,  or  in  cutting  them  across,  and  squeezing  the 
contents  out  from  the  well-defined  capsule. 

Rodent  Ulcer  is  a  special  variety  of  glandular  cancer,  commencing 
either  in  the  sebaceous  glands  or  in  the  basal  layer  of  the  rete 
Malpighii.  It  is  usually  met  with  in  elderly  patients,  though  occa- 
sionally observed  in  those  under  forty,  and  is  seen  with  special  fre- 
quency on  the  upper  two-thirds  of  the  face,  the  skin  below  the  inner 


Fig.  141. 


-Rodent  Ulcer  of  Many  Years'  Standing. 
(From  a  Photograph.) 


and  outer  canthi  being  the  chief  seats  of  election.  It  commences  ab 
a  papule  or  flat-topped  nodule  in  the  skin,  surrounded,  perhaps,  by 
an  area  of  hyperemia.  The  infiltration  extends  gradually  in  all 
directions,  but  the  ulceration  usually  keeps  pace  with  the  new 
growth  The  ulcer  has  a  smooth  but  somewhat  depressed  surface,  is 
perhaps  covered  with  granulations,  and  bounded  by  a  slightly  raised, 
indurated,  rolled-over  edge  (Fig.  141)  •  In  most  cases  one  can  detect 
evidences  of  the  new  formation  beneath  the  skm  beyond  the  edge. 
If  kept  aseptic,  there  is  but  Httle  discharge,  and  imperfect  attempts 
at  cicatrization  are  often  observed,  the  scar,  however,  readily  break- 
ing down-  but  when  septic,  the  surface  is  covered  with  sloughs  and 
an  abundant  offensive  discharge  escapes.  The  condition  ispamless 
neighbouring  lymphatics  are  not  enlarged,  and  the  general  healtn 
does  not  suffer,  except  in  the  later  stages.  The  progress  of  the  case 
is  slow,  but  continuous,  and  although  it  spreads  for  a  time  super- 


412 


A   MANUAIJOF  SURGERY 


ficially  rather  than  ck'ej)ly,  sooner  or  hiter  underlying  structures 
become  involved,  and  then  nothing  hinders  the  destructive  process, 
even  the  bones  of  the  skull  being  eroded,  and  the  dura  mater 
exposed. 

Microscopically,  the  growth  consists  of  interlacing  columns  of 
epithelial  cells,  interspersed  with  fibro-cellular  tissue  (Fig.  142).  The 
constituent  cells  are  small,  globular,  and  closely  packed,  never  of  the 
'  prickle-cell  '  type,  and  rarely  show  signs  of  keratinization;  hence 
'  cell-nests  '  are  uncommon,  although  they  are  sometimes  observed. 
The  cells  of  the  peripheral  layer,  however,  are  often  elongated,  and 
arranged  side  by  side  like  a  palisade.  The  deep  processes  spread 
laterally  rather  than  deeply  beneath  the  unaffected  skin,  the  papillie 


^,<^ 


Fig.  142. — Rodent  Ulcer.     (Photomicrograph,   x  30.) 


of  which  are  atrophied;  their  outline  is  clearly  defined,  and  fre- 
quently angular  on  section.  There  is  but  little  infiltration  of  round 
cells  around  the  epithelial  columns. 

The  Treatment  of  rodent  ulcer  has  been  considerably  modified  of 
late.  Formerly  the  method  of  choice  consisted  in  free  excision 
when  practicable,  a  margin  of  at  least  half  an  inch  being  allowed  all 
round,  and  the  defect  made  good  by  skin-grafting  or  by  some  plastic 
operation.  Where  this  could  not  be  undertaken,  the  ulcer  was 
thoroughly  scraped,  and  the  surface  treated  with  nitric  acid, 
chloride  of  zinc  paste,  or  some  other  caustic,  the  wound  being  allowed 
to  heal  by  granulation. 

The  discovery  of  the  therapeutic  value  of  the  X  rays  has  con- 
siderably diminished  the  number  of  cases  operated  on  for  this  dis- 
ease.    The  sore  or  nodule  is  exposed  to  the  influence  of  the  rays  for 


SURGICAL  DISEASES  OF  THE  SKIN  413 

about  ton  minutes  tlail}-,  and  a  reaction  of  variable  intensity  follows, 
which  results  in  many  cases  in  the  surface  of  the  sore  cleaning  up 
and  healing.  Recurrence  is  occasionally  observed,  but  the  recurrent 
nodules  can  be  treated  in  the  same  way.  Of  course,  surrounding 
parts  have  to  be  carefully  protected. 

Radium  bromide  has  also  proved  serviceable  in  some  cases.  It 
is  best  applied  in  a  lead  capsule  with  a  mica  window,  and  5  or  10 
milligrammes  is  the  usual  quantity  employed.  This  capsule  is 
enclosed  in  a  piece  of  sterilized  gutta-percha  tissue  and  fixed  over 
the  diseased  area  with  strapping.  It  may  be  applied  for  a  short 
time  (five  or  ten  minutes)  daily,  but  acts  equally  well  if  applied  for 
half  an  hour  once  a  week.  The  reaction  varies  considerably  with 
the  quality  of  the  radium,  but  sometimes  an  inflammatory  reaction 
of  some  intensity  follows.  Treatment  by  zinc  ions  (p.  54)  has  also 
been  found  useful,  especially  in  patients  who  can  only  come  for  treat- 
ment occasionally.  The  process  is  painful,  and  it  is  well  to  introduce 
cocaine  as  a  preliminary  by  moistening  the  positive  pad  with  a  solu- 
tion of  the  hydrochlorate.  The  rodent  ulcer  is  then  covered  with 
several  laj'ers  of  lint  wet  with  a  2  per  cent,  solution  of  sulphate  or 
chloride  of  zinc,  and  the  positive  electrode  is  applied  over  this. 

Our  present  experience  seems  to  indicate  that  superficial  growths 
are  best  treated  by  X  rays,  whilst  the  deeper  ones  are  more  amenable 
to  the  action  of  radium  or  zinc  ions.  The  scar  left  after  treatment 
by  any  of  these  agents  is  of  a  most  satisfactory  type,  being  soft, 
supple,  and  often  not  at  all  obvious,  and  hence  this  treatment  is 
particularly  indicated  when  the  disease  affects  the  eyelids  or  front  of 
the  face.  In  other  places  it  may  be  possible  to  remove  the  greater 
part  of  the  disease  with  the  knife,  and  the  rays  may  then  be  used  with 
advantage  to  the  raw  surface  before  grafting  is  undertaken.  When 
bone  or  cartilage  is  affected,  operation  is  the  only  hope,  as,  although 
improvement  follows  the  use  of  the  rays,  recurrence  is  almost 
invariably  the  rule. 


CHAPTER  XVIII. 
AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSiE. 

Injuries  of  Muscles  and  Tendons. 

Contusion. — Muscles  are  bruised  as  a  result  of  blows  or  falls,  leading 
to  more  or  less  extravasation,  with  possibly  some  rupture  of  the 
fibres.  The  part  becomes  tender  and  swollen,  and  any  active  con- 
traction gives  rise  to  pain;  passive  movement,  however,  is  tolerated, 
if  the  injured  fibres  are  not  thereby  put  on  the  stretch.  Fomenta- 
tions and  rest  may  be  needed  for  a  few  days ;  but  regular  massage, 
and  perhaps  elastic  support,  are  subsequently  necessary. 

Sprains  and  Strains,  due  to  violent  efforts  or  falls,  result  in  the 
tearing  or  stretching  of  some  of  the  fibres.  Considerable  stiffness 
follows,  especially  in  rheumatic  and  gouty  patients.  Rest  and  either 
hot  or  cold  applications  may  be  used  at  first ;  but  elastic  pressure 
and  regular  massage  will  be  needed  later.  In  individuals  predisposed 
to  the  development  of  tuberculous  disease,  special  precautions  must 
be  taken  to  ensure  complete  recovery. 

Rupture  of  the  Sheath  of  a  muscle  is  an  accident  occasionally  met 
with,  especially  in  the  adductors  and  rectus  abdominis.  The  belly 
of  the  muscle,  when  contracted,  protrudes  through  the  opening  as  a 
hernia,  constituting  a  soft  semi-fluctuating  swelling.  In  treating 
this  condition  the  limb  must  be  kept  at  rest  in  such  a  position  as  to 
'  relax  the  muscular  fibres  and  allow  the  rent  in  the  fascial  sheath  to 
heal.  In  old-standing  cases  it  is  justifiable  to  cut  down  upon  and 
expose  the  opening  in  the  muscular  sheath,  the  edges  of  which  are 
sutured  together,  or  if  this  cannot  be  effected  a  sterilized  sheet  of 
silver  foil  may  be  stitched  over  the  defect. 

Displacement  of  Tendons  rarely  occurs,  except  in  parts  where 
these  structures  pass  through  osseo-fibrous  canals,  and  particularly 
in  those  where  the  line  of  action  is  thereby  changed.  During  some 
violent  effort  the  patient  feels  a  sudden  localized  pain,  followed  by  a 
certain  amount  of  limitation  of  mobility.  This  accident  is  popularly 
known  as  a  '  rick.'  In  superficial  parts  the  displaced  tendon  can 
sometimes  be  distinctly  felt  in  an  abnormal  position,  and  this  be- 
comes more  evident  on  attempting  to  move  it.  Thus  the  long  tendon 
of  the  biceps  may  be  dislocated  from  the  bicipital  groove;   and 

414 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURS/E  415 

various  tendons  about  the  wrist  or  ankle,  especially  that  of  the 
pcroneus  longus,  may  similarly  suffer.  If  left  alone,  the  parts  settle 
down  more  or  less  comfortably,  but  some  permanent  weakness  may 
persist ;  recurrence  is  very  likely  to  ensue  if  movement  is  permitted 
before  the  newly-formed  connections  have  had  time  to  consolidate. 

Treatment  consists  in  fully  relaxing  the  muscles  and  replacing 
the  tendon,  if  possible,  by  manipulation.  The  parts  are  then  im- 
mobilized for  six  or  eight  weeks  by  a  plaster  of  Paris  splint  or 
strapping.  If  the  displacement  recurs,  it  is  sometimes  advisable  to 
expose  the  tendon,  and  stitch  it  back  into  position,  using  early 
passive  movement  to  prevent  the  formation  of  troublesome  adhe- 
sions. This  is  required  most  frequently  in  the  case  of  the  peroneus 
longus  tendon,  which  slips  forwards  from  its  groove  behind  the  ex- 
ternal malleolus.  The  external  annular  ligament  is  thereby  rup- 
tured, and  the  operation  consists  either  in  suturing  the  divided 
segments,  or  in  more  aggravated  cases  it  may  be  necessary  to  turn 
down  a  flap  of  periosteum  from  the  malleolus,  and  by  stitching  its 
apex  to  the  outer  side  of  the  os  calcis  secure  the  tendon  in  place. 

Rupture  of  Muscles  and  Tendons  is  by  no  means  uncommon,  re- 
sulting from  excessive  violence  of  a  sudden  and  unexpected  nature. 
Most  frequently  the  tendon  gives  way  at  its  union  with  the  muscular 
belly ;  less  often  the  belly  itself  yields,  whilst  occasionally  the  tendon 
may  snap,  or  the  point  of  bone  to  which  it  is  attached  may  be  torn 
off. 

Signs. — The  patient  at  the  moment  of  the  accident  "fexperiences  a 
sharp  and  severe  pain,  as  if  he  had  been  struck  with  a  whip ;  he  may 
also  feel  or  hear  a  snap.  Loss  of  function  follows,  together  with  a 
certain  amount  of  swelling  and  bniising,  which' is  more  evident  if  the 
muscular  fibres  have  been  torn  across  than  if  the  tendon  alone  has 
been  lacerated.  On  attempting  to  contract  the  affected  muscle,  the 
belly  rises  up  as  a  soft,  rounded,  semi-fluctuating  tumour,  drawn 
towards  the  uninjured  attachment,  if  the  union  between  the  tendon 
and  belly  has  given  way ;  whilst  if  the  lesion  has  been  through  the 
muscular  substance,  the  divided  halves  of  the  belly  become  similarly 
prominent,  and  a  distinct  gap  or  sulcus  can  be  felt  between  them. 

Repair  is  established  in  the  usual  way  by  the  formation  of  granu- 
lation, and  finally  of  cicatricial  tissue.  Where  a  muscular  belly  is 
involved  and  the  ends  are  much  separated,  a  long  and  weak  bond  of 
union  is  likely  to  form;  but  when  they  are  closely  apposed,  the 
cicatrix  is  short,  and  may  be  replaced  subsequently  by  true  mus- 
cular tissue.  When  a  tendon  has  been  divided  or  torn,  the  con- 
necting medium  is  at  first  attached  to  the  sheath,  and  if  this  ad- 
hesion persists,  it  may  lead  to  pain  and  weakness.  It  is  an  interest- 
ing fact  to  note  how  rapidly  this  tissue  becomes  strong;  a  rabbit's 
tendon  ten  days  after  division  requires  a  weight  of  56  lbs.  to  break 
it  (Paget). 

Treatment. — It  is  essential  to  relax  the  parts  tally  so  as  to  hmit 
the  separation  of  the  divided  ends,  and  to  maintain  them  in  this 
position  for  two  or  three  weeks.    Any  resulting  stiffness  is  combated 


4i6 


A   MANUAL  OF  SURGERY 


by  passive  movomonts  and  massage,  whilst,  if  need  be,  adhesions  arc 
broken  down  under  an  an;esthetir.  Tendons  aecidentally  divided  in 
ojx^n  wonnds  sliould  be  sutnred  together  by  silk  or  eatgut,  careful 
antiseptic  j^recautions  being  adopted  to  prevent  sn])puration  along 
the  tendon  sheaths.  Where  there  has  been  actual  loss  of  substance 
in  a  tendon,  one  may  be  split  longitudinally  in  such  a  way  as  to  leave 
a  thin  flap  attached  peripherally,  so  that  the  free  end  can  be  turned 
down  and  united  to  the  other  segment  (Fig.  143) ;  or  similar  flaps 
may  be  provided  from  each  end  (Fig.  I-14) ;  or  it  is  possible  to  remedy 
the  defect  by  grafting  a  portion  of  tendon  from  another  region  or 
person,  or  from  an  animal,  between  the  two  ends.     Care  must  be 

exercised  to  prevent  opposing 
muscles  from  dragging  on  and 
stretching  the  new  bond  of 
union,  as  thereby  considerable 
functional  disability  may  result. 
Thus,  a  young  man  had  his 
anterior  tibial  muscles  divided 
by  a  stab  with  a  knife;  they 
were  carefully  sutured  together, 
but  during  convalescence  the 
foot  was  allowed  to  drop,  the 
result  being  that  the  muscles 
and  tendons  were  stretched, 
and  hence  the  most  vigorous 
contractions  had  no  effect  in 
raising  the  toes,  which  dragged 
144-  along    the    ground.     A    second 


Fig.  143. 


Fig. 


Loss  OF  Tissue. 

In  Fig. 143  the  flap  is  taken  from  one  end 
only;  in  Fig.  144  from  both  ends. 


Method  of  Union  of  Tendon  after    operation   to   shorten    all    these 

structures  was  required. 

Muscular  bellies  which  have 
been  divided  longitudinally  or 
obhquely  are  easily  united  by 
sutures;  but  when  the  section  is  transverse,  the  stitches  tend  to 
cut  out',  unless  the  sheath  can  also  be  secured.  In  such  a  case  it 
is  advisable  to  encircle  with  a  ligature  a  bundle  of  muscular  fibres 
on  either  side  of  the  incision,  and  then  tie  the  two  threads  together. 
This  must  be  done  at  several  spots  in  the  cross-section. 

The  long  tendon  of  the  biceps  is  not  unfrequently  torn  from  the 
muscular  belly,  which,  on  attempting  to  bend  the  arm.  is  drawn 
down  towards  the  elbow,  constituting  a  soft  tumour,  somewhat 
resembhng  a  hpoma.  No  special  treatment  is  needed  beyond  keep- 
ing the  fore-arm  flexed  for  a  time.  If  the  tendo  AchiUis  is  ruptured, 
union  may  be  attained  by  keeping  the  knee  bent  and  the  heel  raised, 
as  by  securing  a  strap  to  the  back  of  a  slipper  below,  and  to  a  dog- 
collar  or  suitable  strap  passed  round  the  knee  above.  A  better 
result,  however,  would  follow  an  aseptic  incision  and  suture.  Simi- 
larly, if  the  ligamcntum  patella' \s  torn  across,  suture  through  an  open 
wound  gives  the  best  result.     'I  he  inner  head  of  the  gastrocnemius  is 


AFFECTIONS  OF  MUSCLES.   TENDONS.  AND  BURS/E         417 

sometimes  torn  in  wrenches  or  slips,  as  at  lawn  tennis,  and  the 
piantaris  is  similarly  affected.  Cooling  lotions  are  applied  for  a  few 
days,  and  the  parts  are  kept  at  rest  until  the  tenderness  and  swell- 
ing have  in  a  measure  subsided,  and  then  regular  massage  is  under- 
taken. The  adductor  longus  may  be  lacerated  in  violent  attempts 
to  maintain  a  seat  on  horseback,  and  constitutes  one  form  of  rider's 
sprain;  it  is  treated  by  rest  and  the  appUcation  of  a  firm  spica 
bandage,  but  in  bad  cases  operation  may  be  required. 

The  long  tendons  of  the  fingers  are  not  unfrequently  divided  acci- 
dentally, and  unless  they  are  effectively  sutured  considerable  im- 
painnent  of  function  will  result,  the  finger  remaining  in  a  position 
of  flexion  or  hyper-extension,  according  to  whether  the  extensors  or 
flexors  are  involved.  Operation  to  secure  the  divided  ends  should 
be  undertaken  at  the  earliest  possible  moment,  but  not  until  suitable 
aseptic  conditions  are  present.  Owing  to  the  existence  of  a  sheath 
the  flexor  tendons  retract  considerably,  and  a  longitudinal  incision  in 
the  middle  fine  of  the  finger  may  be  required  to  reach  the  proximal 
end.  Its  position  can  be  indicated  by  the  passage  of  a  probe  up  the 
sheath,  which  is  incised  only  opposite  the  retracted  end  of  the  tendon. 
A  suture  is  introduced  into  the  tendon  and  carried  dowm  the 
sheath,  and  thereby  the  retracted  tendon  is  drawn  again  to  the 
site  where  it  was  divided  and  secured  to  the  distal  end.  By  this 
manoeuvre  an  extensive  incision  of  the  sheath  is  avoided,  and  ad- 
hesions are  minimized.  The  finger  must  subsequently  be  kept  in 
a  spHnt,  and  active  movements  are  not  permitted  for  ten  days. 

The  extensor  tendons  have  no  syno\dal  sheath  on  the  fingers,  and 
hence  there  is  but  httle  difficulty  in  securing  them  by  suture,  except 
when  the  attachment  to  the  terminal  phalanx  is  torn  through,  a 
not  uncommon  accident.  The  aponeurosis  retracts  and  the  thickened 
di\aded  end  can  be  felt  opposite  the  centre  of  the  second  phalanx ; 
the  terminal  phalanx  is  bent  and  constitutes  the  condition  known 
as  a  mallet  finger.  Fixation  of  the  finger  in  a  position  of  extension 
is  useless  in  this  condition,  as  approximation  of  the  tendon  to  its 
point  of  attachment  is  not  effected.  Open  operation  is  often  un- 
satisfactory, since  the  tendon  is  torn  completely  away  from  the  bone, 
and  there  is  nothing  to  which  to  fix  it.  Good  results  are  often 
obtained  even  at  a  comparatively  late  stage  by  putting  up  the 
finger  with  the  metacarpo-phalangeal  and  first  interphalangeal 
joints  fully  flexed,  the  second  interphalangeal  joint  being  extended 
— an  uncomfortable  position  at  first.  The  extensor  aponeurosis  is 
so  attached  that  flexion  of  this  type  drags  it  downwards  and 
relaxes  its  terminal  segment  so  that  satisfactory  union  is  by  this 
means  much  more  likely  to  occur. 

It  is  sometimes  important  and  often  difficult  to  differentiate  between  a 
di\'ided  tendon  with  retraction  of  the  segments,  an  adherent  tendon,  and 
one  which  has  been  destroyed  hy  sloughing;  particularly  is  this  the  case  in 
connection  with  the  fiexors'of  the  fingers.  Division  of  a  tendon  involves  loss 
of  active  movement  alone ;  the  finger  can  be  moved  passively,  but  immediately 
springs  back  into  the  old  position.  Adhesion  of  a  tendon  to  its  sheath  or 
in  the  palm  involves  more  or  less  flexion  of  the  finger  and  stiffness ;  attempts 

27 


4i8  A   MANUAL  OF  SURGERY 

to  straighten  it  are  painful,  and  cause  the  tendons  above  the  wrist  to  be 
dragged  on.  Sloughing  of  the  flexor  tendon  results  in  flexion  from  contraction 
of  scar-tissue,  together  with  wasting  and  impairment  of  nutrition  of  the  flnger. 
Attempts  at  extension  produce  no  result  either  on  the  flnger  or  on  the  tendons 
above  the  wrist.  Sloughing  of  the  extensor  tendon  also  results  in  the  finger 
becoming  bent  from  unbalanced  action  of  the  flexors. 

The  persistence  of  any  of  these  conditions  is  followed  by  changes  in  the 
interphalangcal  joints  and  their  ligaments  which  may  invalidate  the  success 
of  subsequent  operations.  Under  such  circumstances  it  may  be  necessary 
to  include  a  resection  of  the  joint  at  the  same  time  as  the  tendons  are  reunited. 
Where  there  is  much  loss  of  substance,  tendon-grafting  may  be  required,  or 
the  finger  may  be  shortened  by  suitable  excision  of  bone. 


Diseases  oi  Muscles. 

Inflammation  of  Muscles  (Myositis)  ma}'  arise  from  a  variety  of 
circumstances,  but  the  chief  results  are  ahke,  whatever  the  cause, 
viz.,  a  more  or  less  painful  infiltration  of  the  muscle,  with  increased 
discomfort  on  attempting  movement.  The  part  feels  hard  and  rigid, 
and  may  be  tender  to  the  touch.  If  suppuration  ensues,  the  ordinary 
signs  of  an  abscess  subsequently  make  themselves  evident.  A 
certain  amount  of  contractile  tissue  is  thereby  destroyed,  and  the 
cicatricial  changes  induced  will  possibly  lead  to  deformity. 

Varieties. — i.  Simple  Traumatic  Myositis  results  from  contusion  or 
laceration  of  the  fibres,  and  is  merely  a  plastic  inflammation,  with 
or  without  haemorrhage,  running  on  to  resolution,  with  perhaps  a 
little  fibroid  thickening  of  the  part.  It  is  liable  in  some  cases  to 
become  chronic,  the  muscle  substance  becoming  shortened  and  re- 
placed by  fibrous  tissue  {M.  fibrosa),  and  this  fibrosis  may  extend 
beyond  the  limits  of  the  onginal  lesion.  The  induration  of  the 
sterno-mastoid  muscle  met  with  in  children  is  of  this  type,  and  may 
lead  to  torticollis. 

2.  Rheumatic  Myositis,  or  muscular  rheumatism,  is  a  condition 
often  met  with,  especially  in  middle-aged  men  of  rheumatic  or  gouty 
temperament  who  are  unable  or  unwilling  to  take  a  sufficiency  of 
exercise,  and  who  live  well.  The  condition  apparently  involves  the 
fibrous  tissues  mainly — e.g.,  the  fascise,  aponeuroses,  tendons,  and 
sheaths  of  muscles,  or  the  hgamentous  tissues  of  joints;  hence  the 
name  fibrositis  is  often  applied  to  it.  Some  forms  of  neuralgia 
result  from  a  similar  affection  of  nerve  sheaths  (perineuritis).  Any 
part  of  the  body  may  be  involved,  but  in  particular  may  be  noted 
lumbago,  in  which  the  fascia  lumboRim  is  affected,  the  patient 
walking  with  a  stiff  back  slightly  flexed;  the  pain  often  starts  sud- 
denly during  some  effort,  and  when  present  any  unexpected  move- 
ment eh  cits  a  sharp  spasm.  Rheumatic  wry-neck  is  a  similar 
condition,  and  may  be  induced  by  exposure  to  a  draught.  Pains 
in  many  joints — shoulders,  knees,  tendo  Achillis,  etc. — are  of  a  simi- 
lar nature,  and  sometimes  are  distinctly  influenced  by  climatic 
conditions. 

Treatment. — A  good  dose  of  calomel  is  in  many  cases  desirable 
at  the  start,  follow^ed  by  suitable  dietetic  or  medicinal  remedies 


AFFECTIONS  OF  MUSCLES.  TENDONS.  AND  BURS/E        419 

directed  to  the  rheumatic  or  gouty  basis  of  the  trouble.  Iodide  of 
potassium  is  by  some  authorities  looked  on  as  always  desirable. 
In  the  more  active  stages  the  part  must  be  kept  at  rest,  and  dry  or 
moist  heat  apphed  to  reUeve  pain,  whilst  aspirin  may  be  given  for 
a  similar  purpose.  Various  methods  of  applying  radiant  or  other 
forms  of  heat  have  been  already  alluded  to  (Chapter  III.).  Vibro- 
massage  is  in  many  cases  most  valuable.  Hydrotherapy,  when  it 
can  be  utihzed,  is  exceedingly  useful,  and  the  patient  must  be 
subsequently  instructed  to  take  more  exercise  and  to  hve  more 
simply. 

3.  Acute  Suppurative  Myositis  is  the  outcome  of  infection  with 
pyogenic  organisms,  either  from  without,  as  after  operation  wounds, 
penetrating  injuries,  etc.,  the  pus  in  such  cases  spreading  widely 
up  and  down  the  muscular  planes;  or  from  within  the  body,  as  in 
pyaemia;  or  by  extension  from  neighbouring  suppurative  foci,  as 
from  subperiosteal  abscesses;  it  may  also  arise  after  a  contusion 
or  sprain  by  auto-infection.  Great  cicatricial  deformity  is  hkely  to 
follow. 

4.  Chronic  Tuberculous  Myositis,  with  the  formation  of  a  chronic 
abscess,  is  not  an  uncommon  secondary  consequence  of  a  similar 
affection  of  neighbouring  bones  or  joints— e.g.,  a  psoas  abscess. 

5.  Syphilitic  Disease  is  usually  met  with  in  the  tertiary  period,  and 
takes  the  form  either  of  a  diffuse  sclerosis  or  of  a  localized  gumma. 
Any  muscle  may  be  affected,  but  perhaps  the  tongue  and  sterno- 
mastoid  are  those  most  frequently  involved.  Care  is  needed  in 
making  a  diagnosis,  since  these  conditions  resemble  tumours  in  their 
method  of  onset ;  but  the  presence  of  a  syphihtic  history,  the  slow 
growth,  the  hardness  with  subsequent  central  softening,  and  the 
rapid  disappearance  after  the  administrarion  of  iodide  of  potassium, 
should  suffice  to  determine  their  nature. 

Occasionally  gummata  appear  in  muscles  in  the  shape  of  small 
hard  and  shotty  nodules,  usually  arranged  more  or  less  longitudin- 
ally, which  are  painless  and  apparently  attached  to  the  fascial  sheath. 
They  react  readily  to  iodide  of  potassium. 

6.  Parasitic  Myositis,  arising  from  the  presence  either  of  the 
Trichina  spiralis  or  of  hydatids,  need  not  be  described  here. 

7.  Myositis  Ossificans  is  a  rare  disease,  in  which  various  muscles, 
especially  those  of  the  back,  are  transformed  into  bony  plates  or  rods, 
so  as  to  lead  to  extensive  ankylosis.  The  process  seems  to  be  one 
of  ossification  of  the  connective  tissue  associated  with  atrophy  of 
the  muscular  fibres,  and  is  sometimes  extremely  painful.  It  is  most 
commonly  seen  in  young  males,  and  is  possibly  rheumatic  in  origin. 
In  a  boy  under  observation  the  arms  were  immobihzed  by  ossifica- 
tion of  the  latissimus  dorsi  muscles  on  either  side,  whilst  the  pector- 
ahs  major  was  also  ossified  on  the  right  side.  The  erector  spina 
was  involved,  the  back  being  rigid,  and  the  right  trapezius  was 
undergoing  the  same  change.  This  disease  is  often  associated  with 
a  congenital  deformity  of  the  great  toes  in  which  the  proximal 
phalanx  is  absent  or  stunted.    No  treatment  has  proved  of  any  value. 


420 


A   MANUAL  OF  SURGERY 


Quite  distinct  in  nature  is  the  Traumatic  M.  Ossificans,  of  which 
two  varieties  are  described:  (i.)  The  new  formation  results  from 
persistent  and  repeated  irritation  of  muscles  or  tendons,  and  usually 
starts  from  the  periosteal  attachment .  The  '  rider's  bone  '  developed 
in  the  tendon  of  the  adductor  longus  is  of  this  description,  (ii.)  Less 
commonly  the  affection  follows  a  severe  injury  to  a  muscle  and  is 

often  secondary  to  a  fracture  or 
dislocation.  Extensive  haemor- 
rhage follows,  leading  to  the 
formation  of  much  fibrous  tissue, 
and  in  about  three  to  four  weeks 
the  presence  of  bone  can  be 
recognised  by  palpation  or  radio- 
graphy. Some  painful  limita- 
tion of  movement  may  ensue, 
but  if  possible  the  condition 
is  left  alone,  unless  the  dis- 
ability is  great,  and  then  re- 
moval must  be  undertaken. 
The  muscles  in  which  this  type 
of  inflammation  has  been  most 
commonly  observed  are  the 
quadriceps  femoris  and  the 
brachialis  anticus  (Fig.  145). 

Tumours  of  Muscles  are  not 
very  common.  Primary  growths 
consist  of  angioma,  lipoma, 
fibroma,  chondroma,  myxoma, 
or  sarcoma,  and  of  these  the 
majority  start  in  the  fibrous 
sheaths  or  the  interfibrillar  con- 
nective tissue.  Secondary  de- 
posits of  both  carcinoma  and 
sarcoma  also  occur.  Treatment 
is  conducted  on  ordinary  surgical 
principles.  If  sarcomatous,  the  whole  thickness  of  the  muscle 
should,  when  possible,  be  excised  for  some  distance  from  the 
growth,  since  the  lymphatics  run  in  the  direction  of  the  fibres,  but 
the  sheath  forms  a  hmit  not  early  overstepped.  Amputation  of 
the  limb  may,  however,  be  required. 

Diseases  of  Sheaths  of  Tendons. 

I.  Acute  Simple  Teno-Synovitis  often  follows  sprains  and  strains, 
and  is  most  commonly  seen  in  connection  with  the  extensor  muscles 
of  the  thumb.  A  puffy  swelhng  in  the  course  of  the  tendons  is 
produced,  painful  on  movement  and  perhaps  tender  to  the  touch, 
giving  a  characteristic  fine  crepitus  whenever  the  parts  are  moved. 

Treatment. — Immobilize  the  limb  for  a  few  days,  and  apply  fomen- 
tations.    As  soon  as  the  more  acute  symptoms  have  disappeared, 


Fig.  145. — Radiogram  of  Traumatic 
Myositis  Ossificans  involving 
THE  Brachialis  Anticus.  (Lent 
BY  Dr.   Knox.) 


AFFECTIONS  OF  MUSCLES.  TENDONS.  AND  BURSM        421 

massage  is  employed  to  hasten  the  absorption  of  the  fluid;  whilst 
active  and  passive  movements  are  undertaken  to  prevent  the  forma- 
tion of  adhesions. 

2.  Acute  Suppurative  Teno-Synovitis  may  result  from  a  punctured 
wound  of  the  synovial  sheath,  or  the  inflammation  ma}^  spread  to  it 
from  neighbouring  tissues.  The  thecal  variety  of  whitlow  (p.  253) 
is  of  this  nature.  Suppuration  may  extend  both  up  and  down  the 
sheath,  and  unless  promptly  treated  by  incision,  the  tendon  will 
slough,  or  may  contract  extensive  adhesions  to  neighbouring  parts; 
in  either  case  considerable  impairment  of  function  is  hkely  to  follow. 
When  the  tendon  survives,  active  and  passive  movements  must  be 
started  very  early  if  the  formation  of  serious  adhesions  is  to  be 
prevented.  The  suppuration  may  affect  neighbouring  articulations, 
leading  to  their  disorganization,  especially  in  the  case  of  the  tendon 
sheaths  around  the  wrist -joint. 

3.  Chronic  Simple  Teno-Synovitis  is  a  common  affection,  charac- 
terized by  a  passive  effusion  into  the  tendon  sheath  of  glairy  synovia, 
somewhat  resembling  uncooked  white  of  e^g.  An  elastic  fluctuating 
swelhng  forms  in  the  course  of  a  tendon,  usually  associated  with 
creaking.  In  the  more  limited  varieties  it  constitutes  one  form  of 
ganghon.  There  is  no  pain  or  tenderness,  but  the  affected  part 
feels  weak.  Treatment  consists  in  counter-irritation  and  pressure, 
as  by  Scott's  dressing;  faihng  this,  the  part  ma}^  be  freely  incised, 
the  synovia  removed,  and,  if  need  be,  the  cavity  washed  out.  In  the 
more  locahzed  forms  it  may  suffice  to  puncture  the  cyst-like  swelling 
and  squeeze  out  the  contents,  pressure  being  subsequently  applied. 

4.  Chronic  Tuberculous  Teno-Synovitis  is  of  two  types,  in  one 
the  sheath  is  lined  by  oedematous  granulation  tissue  of  some  thick- 
ness, containing  tuberculous  foci,  gi^nng  rise  to  a  soft  elastic  swelling 
along  the  course  of  a  tendon,  which  increases  slowly  in  size,  and  is 
but  slightly  painful  or  tender.  Suppuration  may  follow,  and  sub- 
jacent bones  or  joints  be  involved.  Treatment  consists  in  immobihz- 
ing  the  part,  pressure,  passive  hyperemia,  and  improvement  of  the 
general  health.  If  a  cure  is  not  quickly  established,  a  free  incision 
should  be  made  and  the  diseased  tissue  removed. 

The  other  form  of  tuberculous  disease  consists  in  a  passive  effu- 
sion into  the  syno\'ial  space,  the  lining  membrane  of  which  becomes 
thickened  by  the  deposit  thereon  of  fibrinous  material.  This  is  often 
detached,  and  b}'  the  movements  of  the  part  the  loose  fragments  of 
fibrin  are  moulded  into  various  shapes.  In  tendon  sheaths  they  are 
often  elongated,  and  constitute  the  so-called  melon-seed  bodies  ;  but 
when  they  occur  in  joints,  they  remain  somewhat  flattened,  whilst 
in  bursae  they  approximate  more  to  the  spherical.  On  examination, 
the}'  are  found  to  be  structureless,  though  sometimes  laminated. 
\\Tien  numerous,  they  give  rise  to  a  curious  and  characteristic  form 
of  crepitus.  That  they  are  of  a  tuberculous  nature  can  be  demon- 
strated by  inoculation  experiments;  the  bacilli  contained  therein 
are  not,  however,  in  a  very  active  state,  and  the  prognosis  of  this 
type  is  more  favourable  than  of  the  former. 


422  A   MANUAL  Ol-   SrRGI'h'Y 

Treatment  consists  in  immobilization  and  pressure  (as  by  the 
application  of  Scott's  dressing),  together  with  the  daily  application 
of  an  elastic  bandage,  so  as  to  induce  hyperemia.  Failing  this, 
the  part  should  be  opened,  the  effusion  removed,  including  fibrin 
and  melon-seed  bodies,  iodoform  gently  rubbed  in,  and  the  ca\nty 
closed,  after  filling  it  with  glycerine  and  iodoform  emulsion.  Should 
the  trouble  recur,  a  free  incision  and  removal  of  the  diseased  mem- 
brane may  be  required. 

A  Ganglion  is  the  term  given  to  a  localized  cyst-like  swelling  form- 
ing in  connection  with  a  tendon  sheath  or  joint.  It  is  most  com- 
monly met  with  at  the  back  of  the  wrist,  arising  from  the  tendons 
of  the  radial  extensors  of  the  carpus,  and  those  of  the  thumb  or 
index-finger,  but  it  sometimes  occurs  on  the  front  of  the  wrist  or 
in  the  foot  (Fig.  146).  It  varies  in  size  considerably,  and  contains 
a  clear,  transparent  gelatinous  or  colloid  substance.  A  rounded 
firm  elastic  swelling  is  produced,  usually  somewhat  moveable,  and 


Fig.  146. — Ganglion   of  Extensor  Tendon  of  Foot. 

neither  painful  nor  tender  at  first,  although  some  painful  weakness 
of  the  part  may  be  experienced  as  it  increases  in  size.  It  is  due  to 
one  of  several  causes:  thus,  it  may  result  from  a  chronic  localized 
teno-synovitis,  or  from  a  hernial  protrusion  of  the  synovial  mem- 
brane through  an  opening  in  the  tendon  sheath.  Others  seem  to 
originate  in  a  colloid  degeneration  of  the  cells  lining  the  synovial 
space;  whilst  certainly  some  few  arise  in  connection  with  subjacent 
articulations,  in  the  same  way  as  a  Baker's  cyst.  Little  difficulty 
arises  in  the  diagnosis,  although,  when  situated  deeph'  and  closely 
attached  to  a  bone,  they  have  been  mistaken  for  exostoses.  Treat- 
ment.— A  ganglion  may  often  be  ruptured  by  manipulation  and 
pressure  with  the  thumbs,  or  by  a  forcible  blow  with  a  book,  but  it 
is  apt  to  fill  again.  Failing  this,  a  rapid  cure  is  usually  obtained  by 
an  aseptic  puncture  of  the  ca\nty,  and  the  subseqvient  application 
of  firm  pressure.  In  some  cases  it  may  be  advisable  to  lay  the  part 
open  and  remove  the  cyst  wall  as  completely  as  possible;  such  treat- 


AFFECTIONS  OF  MUSCJ^ES,   TENDONS,  AND  BURSM         423 

mcnt    requires   absolute   asepsis,    sinec,    if   infection   occurs,    most 
serious  consequences  iTia\'  ensue. 

A  Compound  Palmar  Ganglion  consists  in  a  tuberculous  affection 
of  the  common  synovial  membrane  surrounding  the  flexor  tendons  of 
the  wrist,  the  cavity  being  distended  in  the  early  stage  with  a  glairy 
fluid,  usually  containing  many  melon-seed  bodies,  and  perhaps  later 
on  with  pus.  In  the  early  stages  all  that  is  noted  is  a  fulness  about 
the  front  of  the  wrist  and  palm,  the  normal  hollow  being  obliterated. 
Later  on  a  more  definite  swelling  is  observed,  and  this  is  found  to 
extend  into  the  thenar  eminence,  due  to  the  involvement  of  the 
tendon  sheath  of  the  flexor  longus  polhcis.  The  condition  is  painless 
at  first,  and  there  is  but  little  interference  with  the  mobility  of  the 
tendons ;  but  in  the  later  stages  of  repair  the  tendons  may  become 
matted  together,  and  the  movements  of  the  fingers  hampered;  or 
if  the  disease  ends  in  suppuration,  the  pain  and  disability  become 
more  marked.  In  all  stages  fluctuation  can  usually  be  detected 
above  and  below  the  annular  ligament,  being  transmitted  beneath 
it.  In  the  Treatment,  rest  and  pressure,  as  by  Scott's  dressing, 
together  with  induced  hypertiemia  and  suitable  constitutional 
remedies,  may  first  be  tried;  and  failing  this,  an  incision  is  made 
both  above  and  below  the  annular  ligament,  the  cavity  being  well 
washed  out,  and  all  melon-seed  bodies  and  fibrinous  debris  removed. 
The  cavity  is  then  filled  with  the  glycerine  and  iodoform  emulsion, 
some  of  which  may  be  gently  rubbed  into  the  pockets  of  the  wound ; 
both  incisions  are  firmly  sutured,  and  a  further  period  of  rest  main- 
tained. Should  the  skin  become  thin  and  undermined,  drainage 
may  be  required,  and  even  in  a  few  cases  division  of  the  annular 
hgament,  in  order  to  deal  effectively  with  the  trouble  by  the  sharp 
spoon.  The  results  in  such  cases  are  not  very  good,  as  the  tendons 
get  matted  together  and  adherent  to  the  skin,  and  the  movement 
of  the  fingers  is  thereby  hampered. 

Operations  on  Tendons. 

I.  By  Tenotomy  is  meant  the  division  of  a  tendon  through  an  open 
or  subcutaneous  wound  with  the  object  either  of  remedying  some 
deformity,  such  as  talipes  or  torticollis,  or  of  assisting  in  the  reduc- 
tion of  some  displacement,  as  in  setting  a  fracture.  It  is  accom- 
plished in  two  ways,  viz.,  by  subcutaneous  or  open  incision.  The 
subcutaneous  method  is  made  use  of  where  there  is  httle  hkehhood 
of  injuring  important  structures.  The  strictest  attention  tojasepsis 
is  desirable,  since  the  characters  of  the  wound,  viz.,  a  puncture,  and 
the  entire  absence  of  drainage,  are  most  favourable  to  the  develop- 
ment of  organisms,  if  entrance  is  once  given  to  them.  Moreover, 
the  s3movial  tendon  sheath  is  often,  though  undesignedly,  wounded, 
and  infection  spreads  rapidly  along  such  a  structure,  and  gives  rise 
to  serious  consequences.  The  operation  consists  in  inserting  a 
sharp-pointed  tenotome  through  the  skin  down  to  the  tendon. 
This  is  then  withdrawn,  and  a  blunt-pointed  knife  passed  along  the 


424  A   MANUAL  OF  SURGERY 

track  thus  made,  cither  superficial  to  or  beneatli  tlie  tendon.  'I  he 
cutting  edge  is  turned  towards  it,  and  the  tendon  divided  1)\'  a 
sawing  or  rocking  movement,  whilst  the  stnicture  is  put  on  the 
stretch.  It  is  undesirable  to  operate  through  the  synovial  sheath, 
since  even  if  the  wound  remains  aseptic,  the  tendon  often  retracts 
more  than  is  desirable,  and  in  heahng  gains  adhesions  to  the  sheath 
which  considerably  limit  the  subsequent  freedom  of  movement  of 
the  part.  Opinions  vary  as  to  whether  it  is  better  to  pass  the  knife 
above  or  below  the  tendon;  in  the  former  method  there  is  no  likeli- 
hood of  making  an  unduly  large  wound  in  the  skin,  and  there  is  less 
risk  of  dividing  the  lax  subjacent  structures  if  the  knife  is  turned 
towards  them.  On  the  other  hand,  if  the  knife  is  at  once  passed 
beneath  the  tendon,  and  any  subjacent  structures  are  by  mistake 
included,  their  division  is  a  matter  of  certainty.  Where,  however, 
there  is  any  risk  of  dividing  important  structures,  .such  as  the  ex- 
ternal popliteal  nerve  in  tenotomy  of  the  biceps  cruris,  it  is  wiser  to 
adopt  the  open  method.  In  this  an  incision  about  i  inch  in  length 
is  made  over  the  tendon,  which  can  thereby  be  exposed,  lifted  on  an 
aneurism  needle,  and  severed  without  danger.  There  is  no  haemor- 
rhage worth  mentioning,  and  the  wound  is  closed  by  suture,  dressed 
antiseptically.  and  firmly  bandaged  to  prevent  extravasation.  The 
malposition  is  at  once  corrected,  and  the  part  immobihzed  at  the 
time,  or  in  the  course  of  forty-eight  hours,  in  plaster  of  Paris. 
Passive  movements  may  usually  commence  at  the  end  of  twelve  to 
fourteen  days,  and  gradually  be  increased  in  vigour,  until  active 
movements  are  allowed. 

Tenotomy  of  the  Tendo  Achillis. — The  foot  is  placed  on  its  outer 
side,  and  the  tendon  relaxed  by  pointing  the  toes  downwards.  The 
tenotome  is  introduced  at  the  inner  margin  of  the  tendon,  about 
I  inch  above  its  insertion  (Fig.  log,  F),  either  superficial  to  or  be- 
neath it,  and  it  is  readily  divided  when  the  foot  is  dorsiflexed.  If 
the  surgeon  cuts  towards  the  skin,  he  must  not  divide  the  last  few 
fibres  too  rapidly,  otherwise  a  considerable  external  wound  may  be 
inflicted  by  the  suddenly  liberated  knife. 

The  Tibialis  Anticus  is  usually  divided  about  i  inch  above  its 
insertion,  as  it  crosses  the  scaphoid  (Fig.  iii,  C).  There  is  here  no 
synovial  sheath,  and  the  arteria  dorsalis  pedis  is  separated  from  it 
by  the  tendon  of  the  extensor  proprius  hallucis.  It  is  first  relaxed 
so  as  to  allow  of  the  introduction  from  the  outer  side  of  the  sharp- 
pointed  tenotome  beneath  it;  this  is  replaced  by  a  blunt-ended 
instrument,  and  the  section  is  accomplished  when  the  foot  is  ab- 
ducted. 

The  Tibialis  Posticus  is  usually  divided  together  with  the  flexor 
longus  digitomm  just  above  the  inner  malleolus,  at  a  spot  about  a 
finger's  breadth  from  the  tip  of  that  process  in  an  infant,  and  about 
i^  inches  from  it  in  an  adult  (Fig.  109,  E).  A  small  tubercle  can 
usually  be  felt  here,  and  the  section  is  made  just  above.  The  knife 
is  inserted  between  the  tibia  and  the  tendon,  and  if  correctly  placed, 
remains  fixed  without  the  support  of  the  hand,  being  grasped  between 


AFFECTIONS  OF  MUSCLES,   TENDONS.  AND  BURSJE        425 


the  tendon  and  the  bone.  The  bhmt-ended  tenotome  is  then  inti'o- 
duced,  and  the  edge  being  turned  towards  the  tendon,  the  latter 
structure  is  divided  when  the  foot  is  dorsiflexed.  The  posterior 
tibial  vessels  may  be  wounded,  but  a  httle  well-adjusted  pressure 
will  suffice  to  prevent  any  serious  consequences. 

The  Peronei  tendons  are  divided  just  above  the  base  of  the  outer 
malleolus,  at  a  spot  where  the  synovial  sheath  is  usually  absent 
(Fig.  no,  D).  The  tenotome  is  inserted  close  to  the  fibula,  between 
the  tendons  and  the  bone. 

The  Biceps  Cruris  tendon  is  best  divided  by  an  open  operation,  on 
account  of  the  close  propinquit}/  of  the  external  popliteal  nerve, 
which  has  often  been  wounded  in 
the  subcutaneous  operation.  An 
incision  is  made  in  the  direction 
of  the  tendon  just  above  its  inser- 
tion into  the  fibula.  It  is  then  lifted 
upon  an  aneurism  needle  and 
divided;  muscular  fibres  will  prob- 
ably be  found  quite  close  to  its 
lower  end. 

The  Semi-membranosus  and  the 
Semi-teiidinosus  tendons  are  dealt 
with  just  above  the  knee-joint,  and 
the  subcutaneous  operation  may  be 
conveniently  adopted  when  they  are 
prominent  and  tense.  For  division 
of  the  Sterno-mastoid,  see  p.  433. 

2.  Lengthening  a  Tendon  is  some- 
times required,  in  order  to  over- 
come the  deformity  which  results 
from  loss  of  substance  or  con- 
traction, where  simple  tenotomy 
does  not  seem  desirable.  It  may 
be  possible  to  utilize  the  method 
suggested  on  p.  416  for  the  union 
of  a  tendon  where  there  has  been 
loss  of  substance,  viz.,  by  bridging 

the  interval  by  a  flap  turned  down  from  one  or  both  ends.  Perhaps 
a  more  efficient  method  is  the  so-called  Z-operation  (Fig.  147) .  The 
tendon  is  spht  longitudinally  [be)  into  two  halves,  which  are  separ- 
ated one  from  the  other  by  cross  cuts  made  on  opposite  sides,  one 
at  each  end  {cib  and  cd) .  The  two  flaps  are  then  drawn  apart  for  a 
distance  corresponding  to  the  increase  in  length  required,  and 
sutured  together ;  the  resulting  bond  of  union  wifl  be  as  represented 
in  Fig.  148. 

3.  Shortening  a  Tendon  is  undertaken  in  some  forms  of  paralytic 
taUpes.  The  Z-method  may  also  be  employed  here,  the  two  halves, 
after  they  have  been  separated,  being  shortened  to  the  required 
amount,  and  then  stitched  together  (Fig.  149).     This  operation  will 


Fig.  147.      Fig.  i 


Fig.  149. 


Z-Operation  for  Lengthening 
OR   Shortening  of  Tendons. 

In  Fig.  147  the  method  of  divid- 
ing the  tendon  is  shown.  In 
Fig.  148  the  flaps  are  slipped 
downwards,  one  on  the  other,  so 
as  to  lengthen  the  tendon.  In 
Fig.  149  equal  portions  have 
been  cut  away  from  each  half 
and  the  remainders  sutured, 
so  as  to  shorten  it. 


426  A   MANI'AL  OF  SURGKRY 

probably  give  a  more  solid  bond  of  union  than  where  a  transverse 
or  an  oblique  seetion  is  removed  ;  in  such  the  sutures  are  much  more 
likely  to  cut  out. 

4.  Tenoplasty  is  the  term  applied  to  any  plastic  operation  on 
tendons  with  a  view  (i)  to  transfer  the  action  of  a  healthy  and 
strong  muscle  to  the  tendons  of  a  weakened  or  paralyzed  group, 
so  as  to  limit  the  deformity  or  disability  caused  thereby;  or  (2)  to 
displace  the  line  of  action  of  a  muscle  so  as  to  counteract  or  obviate 
some  deformity.  Clearly,  this  operation  finds  its  greatest  use 
in  paralytic  affections  such  as  talipes.  It  is  essential  to  study 
carefully  the  peculiar  features  of  each  case  where  such  a  procedure 
is  considered  desirable,  especially  as  to  the  electrical  reaction  and 
power  of  all  the  muscles  involved  and  the  relative  importance  of 
each  possible  movement.  Thus,  in  the  foot  plantar-flexion  is  of 
more  value  to  the  patient  than  dorsi-flexion,  and  the  latter  is  more 
useful  than  either  adduction  or  abduction,  whilst  of  the  two  last- 
mentioned  movements  adduction  is  more  important  than  abduction. 
Hence,  although  it  would  be  mechanically  correct  to  transplant  a 
healthy  abductor,  such  as  the  peroneus  longus,  into  a  paralyzed 
plantar  flexor,  such  as  the  tendo  Achillis,  so  as  to  improve  plantar- 
flexion  at  the  expense  of  abduction,  it  would  be  unwise  to  reverse 
the  proceeding.  It  is  desirable  that,  wherever  possible,  the  re- 
inforcing tendon  should  be  derived  from  a  synergic  and  not  from 
an  opposing  group,  although  with  careful  education  muscles  of 
opposing  function  may  be  utilized. 

Two  methods  of  tenoplasty  are  available:  (i)  Tendon  Implanta- 
tion consists  in  suturing  the  whole  or  part  of  the  proximal  end  of 
the  tendon  of  a  healthy  muscle  to  the  distal  end  of  the  divided 
tendon  of  a  paralyzed  muscle,  and  for  choice  the  latter  should  be 
divided  as  near  its  insertion  as  possible.  The  incision  should  be 
longitudinal,  or  a  suitable  flap  may  be  raised.  The  actual  inethod 
of  union  of  the  tendons  varies  with  circumstances,  but  the  best 
results  have  been  obtained  by  threading  the  healthy  tendon  through 
a  slit  in  the  recipient,  and  then  suturing  them  firmly  together. 
Direct  end-to-end  suture  of  two  tendons  is  less  satisfactory.  Occa- 
sionally merely  a  slip  from  the  stronger  tendon  is  employed,  which 
is  attached  to  the  weaker  one  so  as  to  fortify  the  latter  without 
destroying  the  power  of  either.  (2)  By  Tendon  Transplantation  is 
meant  the  total  detachment  of  a  tendon  from  its  point  of  insertion 
with  or  without  the  periosteum  or  bone  to  which  it  is  attached, 
and  its  transference  and  fixation  to  the  point  of  insertion  of  the 
tendon  of  a  paralvzed  muscle,  or  to  some  spot  where  it  can  act 
more  advantageously.  It  is  fixed  either  by  sutures  to  the  perios- 
teum, or  by  metal  staples,  or  by  drilling  a  hole  through  the  bone  and 
threading  the  tendon  through  it. 

The  greatest  care  must  be  taken  with  the  technique  of  these 
operations,  so  as  to  ensure  complete  asepsis  and  perfect  hsemostasis. 
Tendon  sheaths  must  be  closed  by  the  finest  catgut  or  silk  sutures. 
Deformities  should  be  corrected  before  the  tendons  are  united,  so 


AFFECTIONS  OF  MUSCLES.   TENDONS.  AND  BURSJE       427 

as  to  ensure  accurate  leii,i;t]i  of  the  new  stnicture.  The  after- 
treatment  is  in  the  first  place  directed  to  the  avoidance  of  undue 
tension  on  the  bond  of  union  for  fear  that  it  may  stretch.  The 
parts  should  be  kept  in  an  over-corrected  position  for  six  weeks  by 
splints  or  plaster  of  Paris.  Subsequently  a  supporting  instrument 
must  be  worn  for  six  months,  and  the  affected  muscles  are  treated 
by  massage,  electricity,  and  educative  exercises. 

Diseases  of  Bursae. 

Bursas  exist  as  normal  sti"uctures  in  many  parts  of  the  bod}"  ex- 
posed to  pressure,  their  object  being  to  diminish  friction  and  permit 
of  a  gliding  movement.  Similar  cavities,  known  as  abnormal  or 
Adventitious  Bursae,  are  developed  in  regions  where  exceptional 
pressure  is  brought  to  bear  on  some  prominent  structure;  they  con- 
sist of  a  fibrous  wall  lined  by  a  serous  membrane,  contain  a  small 
quantity-  of  serum,  and  are  formed  either  by  dilatation  of  lymphatic 
spaces,  or  as  a  result  of  a  localized  effusion  into  the  tissues.  Ex- 
amples of  this  are  met  with  in  men  following  special  occupations — 
e.g.,  over  the  vertebra  prominens  of  Covent  Garden  porters,  and  then 
known  as  a  '  hummy  ' ;  Billingsgate  fish-carriers  occasionally  have 
bursae  under  the  centre  of  the  scalp ;  and  deal-runners  often  present 
one  on  the  upper  part  of  the  shoulder.  They  occur  over  bony 
prominences  arising  from  malformation  or  displacement — e.g.,  over 
the  cuboid  in  talipes  equino-varus,  and  over  exostoses;  whilst  the 
false  joint  or  pseudarthrosis  which  occurs  in  unreduced  dislocations 
or  ununited  fractures  is  of  a  similar  nature. 

Wounds  of  bursae  mav  be  caused  by  penetrating  injuries,  or  some- 
times by  the  skin  over  them  splitting,  as,  e.g.,  in  a  fall  on  the  point  of 
the  olecranon.  The  escape  of  bursal  fluid  which  results  often  pre- 
vents healing,  and  then  it  will  be  necessary  either  to  excise  the  bursa, 
or  to  open  it  freely,  so  that  it  can  be  packed  and  allowed  to  heal 
from  the  bottom. 

Subcutaneous  injuries  are  followed  by  haemorrhage  constituting 
a  hasmatoma,  which  may  suppurate  or  become  absorbed;  in  the 
latter  case  adhesions  will  often  occur,  and  even  potypoid  fringes 
from  the  organization  of  the  blood-clot.  Treatment  consists  in 
keeping  the  part  at  rest,  unless  suppuration  is  threatening,  and 
then  an  incision  must  be  made.  It  is  always  well  to  make  certain 
that  no  fracture  is  present  beneath  a  h^ematoma  of  the  olecranon 
or  patellar  burss. 

The  following  are  the  morbid  conditions  which  arise  in  adven- 
titious as  well  as  normal  bursae: 

I.  Acute  Simple  Bursitis  results  from  moderate  injury  or  pro- 
longed irritation,  especially  in  gouty  or  rheumatic  indi\'iduals.  The 
part  becomes  swollen,  painful,  and  tender,  and  if  superficial  the  skin 
over  it  may  be  h\"peraemic.  Effusion  into  the  cavity  quickly 
occurs,  and  is  sometimes  mixed  with  blood.  Lymph  is  deposited 
on  the  serous  surface,  and  in  many  cases  results  in  the  formation 


428  A   MANUAL  OF  SURGERY 

of  adhesions,  and  possibly  obliteration  of  the  cavity.  Treatment 
consists  in  keeping  the  part  at  rest,  and  applying  fomentati(jns. 
If  the  effusion  persists,  aspiration,  or  removal  with  trocar  and 
cannula  under  strict  asepsis,  may  be  employed,  or  even  the  whole 
cavity  excised. 

2.  Acute  Suppurative  Bursitis  arises  from  infection  occurring 
either  from  without  or  within ;  it  not  uncommonly  follows  a  sub- 
cutaneous injury  of  a  chronically  inflamed  bursa,  leading  to  its 
distension  with  blood.  The  pus,  formed  at  first  within  the  bursa, 
may  travel  directly  to  the  surface,  or,  bursting  through  the  capsule, 
is  diffused  through  the  tissues.  Where  this  occurs,  the  characteristic 
features  suggesting  a  bursal  origin  of  the  abscess  may  be  masked. 
Thus,  in  suppuration  of  the  bursa  patellae,  the  pus  often  finds  its 
way  to  the  lateral  aspects  of  the  hmb,  allowing  the  patella  to  be 
distinctly  felt  through  the  skin;  the  case  might  then  be  mistaken 
for  suppuration  within  the  knee-joint,  but  is  easil}^  distinguished  by 
the  absence  of  the  more  acute  arthritic  sj^mptoms.  Implication  of 
subjacent  bones  and  joints  sometimes  occurs;  thus,  the  patella  or 
olecranon  may  become  carious,  or  necrose.  The  Treatment  of  sup- 
purative bursitis  resolves  itself  into  an  early  free  incision,  and 
drainage. 

3.  Chronic  Bursitis  with  Effusion  is,  perhaps,  the  most  common 
pathological  condition  met  with  in  connection  with  bursse.  The 
cavity  becomes  distended  with  a  serous  effusion  of  varying  amount, 
giving  rise  to  a  fluctuating  tumour.  The  walls  differ  in  thickness 
according  to  circumstances;  if  the  condition  is  one  of  long  standing 
with  frequent  recurrences,  the  bursal  wall  is  usually  reticulated  and 
dense,  and  adhesions,  papilliform  processes,  or  fibrous  cords  are  often 
produced.  Subacute  exacerbations  are  frequently  grafted  on  the 
more  chronic  variety.  Treatment  consists  in  rest  and  counter-irrita- 
tion, as  by  blistering  or  iodine  paint,  and  if  this  fails,  the  bursa 
should  be  dissected  out.  WTien  the  bursa  communicates  with  a 
joint,  such  as  that  under  the  semi-membranosus  tendon,  the  neck 
must  be  isolated,  and  its  communication  with  the  joint  shut  off  by 
ligature. 

4.  Chronic  Fibroid  Bursitis. — In  this  variety  the  walls  of  the  bursa 
are  much  thickened,  as  a  result  of  prolonged  irritation,  constituting 
a  hard  fibroid  tumour,  in  the  centre  of  which  is  a  small  cavity. 
Possibty  a  syphilitic  element  is  present  in  this  condition.  The  only 
Treatment  is  complete  removal. 

5.  Chronic  Tuberculous  Bursitis  usually  occurs  in  the  form  of  a 
fibrinous  deposit  on  the  inner  wall,  together  with  effusion  and  the 
presence  of  loose  fibrinous  bodies.  Less  frequently  the  lining  mem- 
brane is  transformed  into  granulation  tissue  of  a  tuberculous  type, 
perhaps  leading  to  the  formation  of  a  chronic  abscess.  Either  con- 
dition may  be  secondary  to  a  tuberculous  arthritis,  or  may  give  rise 
to  it,  when  the  bursa  communicates  with  a  joint.  If  total  removal 
is  impracticable,  Treatment  consists  in  laying  the  part  freely  open, 
scraping    away    all    tuberculous    tissue,    and    packing    the    cavity 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURS/E       429 

with  i;auzc  impregnated  with  iodoform.     Sometimes  it  is  possible 
to  filf  the  cavity  with   sterihzcd   iodoform   emulsion  and  close  it 

entirely. 

6.  Syphilitic  Changes  may  also  occur  in  bursas,  m  the  shape  either 
of  a  symmetrical  bursitis  in  the  early  stages,  or  later  on  as  a  gum- 
matous peri-svnovial  development. 

7.  Occasionally  Gouty  Deposits  are  observed  in  the  walls  of  bursae, 
constituting  tophi,  the  irritation  of  which  may  predispose  to  abscess 
formation,  pus  mixed  with  urate  of  soda  crystals  being  discharged. 
The  bursa  over  the  olecranon  is  said  to  be  most  frequently  affected  m 
this  way. 

Special  Bursse. 
The  hnrsa  patellce  (Fig.  150),  which  hes  over  the  lower  half  of  the 
bone  and  not  over  its  centre,  is  very  liable,  from  its  exposed  situa- 
tion, to  injury  or  any  of  the  above-mentioned  varieties  of  bursitis. 
In  its  simplest  form  it  constitutes  the  condition  known  as  '  house- 
maid's knee,'  and  is  due  to  kneehng.  Caries  of  the  patella  may 
follow  acute  suppuration,  and  the  more  chronic  varieties  may  lead 
to  osteoplastic  periostitis.     The  knee-joint  itself  usually  escapes. 


Fig.   150. — Enlarged  Bursa  Patella.     (From  a  Photograph.) 


The  bursa  beneath  the  ligamentum  patellce,  between  it  and  the  head 
of  the  tibia,  when  distended  with  fluid,  gives  rise  to  a  fluctuating 
sweUing  felt  on  either  side  of  the  tendon,  more  especially  when  the 
Hmb  is  extended;  when  the  leg  is  flexed,  the  swelling  diminishes. 
Chronic  enlargement  of  this  bursa  may  push  the  hgamenta  alaria 
backward  into  the  joint,  so  that  they  are  nipped  between  the  bones 
whenever  the  patient  attempts  to  stand  with  the  leg  extended;  the 
pain  thereby  induced  is  somewhat  similar  to  that  caused  by  a  dis- 
placed semilunar  cartilage,  or  by  a  loose  foreign  body  in  the  joint. 
The  presence  of  the  enlarged  bursa,  together  with  the  mabihty  to 
stand  with  a  straight  leg,  should  suffice  to  make  the  diagnosis  clear. 


430 


A   MANUAL  OF  SURGERY 


The  hurscv  in  the  popliteal  space  are  often  enlarged,  especially  that 
between  the  inner  head  of  the  gastrocnemius  and  the  semi-mem- 
branosus  (Fig.  151),  leading  to  a  rounded  tluctuating  swelling, 
sharply  limited  on  its  outer  aspect,  and  more  fixed  and  less  defined 
towards  the  inner.  The  sensation  imparted  to  the  fingers  varies 
according  to  the  position  of  the  limb,  the  swelling  being  tense  in 
extension  and  flaccid  in  flexion,  as  occurs  in  most  of  these  peri- 
articular bursae.  Owing  to  the  proximity  of  the  popliteal  vessels, 
pulsation  is  occasionally  detected,  but  is  not  expansile  in  character. 
Enlargement  of  this  bursa  is  often  secondary  to  an  articular  lesion, 

especially  tuberculous  disease 
or  osteo-arthritis,  and  before 
undertaking  treatment  the 
condition  of  the  joint  should 
be  ascertained.  If  the  joint 
is  healthy,  the  bursa  may  be 
removed  by  dissection,  the 
pedicle  being  closed  by  liga- 
ture or  suture. 

The  bursa  beneath  the  in- 
sertion of  the  semi-tendinosus 
and  gracilis  is  sometimes  in- 
flamed, and  is  very  liable  to 
cause  osteoplastic  periostitis 
of  the  subjacent  inner  surface 
of  the  tibia. 

The  bursa  beneath  the  tendo 
A  chillis,  if  enlarged,  presents 
a  fluctuating  swelling  on 
either  side  of  that  stmcture, 
somewhat  simulating  disease 
of  the  ankle  -  joint,  but 
necessarily  limited  to  the 
posterior  aspect  of  the  joint. 
Primary  tuberculous  disease 
is  sometimes  present. 

Distension  of  the  bursa 
beneath  the  psoas  tendon  gives  rise  to  a  fluid  swelling  which  usually 
projects  anteriorly,  presenting  either  on  the  outer  or  inner  side  of 
Scarpa's  triangle.  If  painful,  it  necessitates  flexion  of  the  thigh, 
and  thus  leads  to  symptoms  resembling  those  of  hip-joint  disease  or 
of  a  psoas  abscess.  It  must  not  be  forgotten  that  this  bursa  often 
communicates  with  the  joint. 

The  gluteal  bursa,  situated  between  the  insertion  of  the  gluteus 
maximus  and  the  great  trochanter,  is  not  uncommonly  the  seat  of 
tuberculous  disease.  It  presents  as  a  rounded  swelling,  obliterating 
the  hollow  behind  the  trochanter,  and  in  its  more  acute  manifesta- 
tions may  be  accompanied  by  abduction  and  eversion  of  the  limb,  in 
order  to  relax  as  far  as  possible  the  gluteus.     It  may  thereby  some- 


FiG.  151. — Enlarged  Semi-membranosus 
BuRS^  IN  Both  Legs  of  a  Boy. 


AFFECTIONS  OF  MUSCLES.   TENDONS,  AND  BURS/E       431 

what  resemble  the  earUer  stages  of  hip  disease,  but  is  recognised  by 
the  absence  of  flexion,  and  by  the  fact  that  passive  movements, 
including  even  the  so-called  test-movement  for  hi])  disease,  can  be 
undertaken  with  but  little  or  no  pain.  Should  suppuration  occur, 
the  pus  may  burrow  widely  beneath  the  gluteus.  Treatment  con- 
sists of  complete  excision,  if  possible,  or  incision  with  scraping  and 
disinfecting  the  interior,  and  allowing  it  to  heal  from  the  bottom. 
Necessarily  part  of  the  insertion  of  the  gluteus  maximus  will  require 
division,  and  must  be  subsequently  sutured. 

The  bursa  over  the  tuber  ischii,  if  inflamed,  gives  rise  to  the  condi- 
tion known  as  '  weaver's  bottom  ' ;  it  causes  great  discomfort  in 
sitting,  and  is  often  solid  and  symmetrical.  If  troublesome,  it 
should  be  removed. 

Enlargement  of  the  bursa  over  the  olecranon  constitutes  the  condi- 
tion known  as  '  miner's  elbow  ' ;  suppuration  within  it  is  not  un- 
common, leading  to  necrosis  of  the  underlying  bone;  the  elbow-joint 
is  but  rarely  affected. 

The  large  multilocular  subdeltoid  bursa  is  occasionally  enlarged; 
it  leads  to  prominence  of  the  deltoid,  and  expansion  of  the 
shoulder.  (For  diagnosis  from  effusion  into  the  shoulder- joint,  see 
Chapter  XXIIL) 


CHAPTER  XIX. 

THE  SURGERY  OF  DEFORMITIES. 

It  is  only  possible  in  a  text-book  of  this  character  to  deal  with  a  few 
of  the  more  notable  defects. 


Torticollis. 

Torticollis,  or  wry-neck,  is  a  deformity  produced  primarily  by 
contraction  of  the  sterno-mastoid  muscle,  although  in  old-standing 

cases  the  trapezius,  splenii, 
scaleni,  and  other  deep  mus- 
cles of  the  neck,  as  well  as  the 
deep  fascia,  are  affected.  It 
is  characterized  bj'  the  af- 
fected side  of  the  head  being 
drawn  down  towards  the 
shoulder,  whilst  the  face  is 
turned  towards  the  sound  side 

(Fig-  152). 

Several  different  types  are 
described,  in  particular  the 
acute  or  rheumatic,  the 
chronic,  which  is  usually  due 
to  cicatricial  changes  in  the 
muscle,  and  the  spasmodic. 

I.  The  Acute  or  Rheumatic 
variety  is  usually  the  result 
of  exposure  to  cold  or  to  sit- 
ting in  a  draught ;  it  comes  on 
suddenly,  and  is  extremely 
painful,  and  the  muscle  or 
muscles  affected  are  tender  to 
the  touch.  The  possibility  of 
mistaking  it  for  other  inflam- 
matory affections,  such  as 
acute  lymphadenitis  or  cellu- 
litis, must  not  be  overlooked ; 
in  them  the  neck  is  often  fixed  so  as  to  protect  the  inflamed 
structures.      Treatment  must  be  general  as  well  as  local;  aspirin 

432 


Fig.   152. — Chronic  Torticollis. 
(From  a  Photograph.) 

The  left  sterno-mastoid  is  contracted,  and 
the  corresponding  half  of  the  face 
atrophic. 


THE  SURGERY  OE  DEEORMITIES  433 

may  be  given  to  relieve  pain,  or  salicylates  to  counteract  the 
rheumatic  poison,  whilst  a  close  of  calomel  or  castor  oil  is  always 
beneficial.  Local  fomentations  should  be  applied  in  the  early 
stages,  and  subse(|uently  massage. 

2.  The  Chronic  form  of  torticollis  is  almost  always  due  to  cica- 
tricial changes  in  the  sterno-mastoid,  which  result  in  its  intrinsic 
shortening,  [a)  It  is  occasionally  congenital,  and  then  it  is  due  to 
malformation  or  malposition  in  lUero,  whereby  the  muscle  is  im- 
perfectly developed,  {b)  Most  commonly  it  follows  the  congenital 
induration  of  the  muscle  [q.v.],  due  to  laceration  of  its  fibres  during 
birth;  it  is  therefore  to  be  looked  on  as  a  myositis  fibrosa,  somewhat 
akin  to  Volkmann's  ischemic  contracture  (p.  489).  (c)  At  a  later 
date  contraction  of  the  muscle  may  result  from  suppuration  or 
gummatous  formation  within  the  sheath,  but  the  deformity  is  then 
less  marked. 

Most  commonly  the  sternal  portion  is  contracted,  whilst  the 
clavicular  half  may  be  quite  relaxed;  the  muscle  usually  stands  out 
as  a  hard  tense  band,  an  excess  of  fibrous  tissue  being  present,  or 
the  muscular  substance  almost  entirely  absent.  The  deep  fascia 
always  becomes  secondarily  contracted  and  shortened,  and  if  the 
deformity  has  lasted  long  the  posterior  cervical  muscles  are  similarly 
affected,  whilst  changes  in  the  shape  of  the  cervical  vertebrae  may 
also  be  induced,  the  bodies  becoming  wedge-shaped  and  thickest 
towards  the  convexity  of  the  curve.  A  secondary  compensatory 
curve  is  usually  present  in  the  dorsal  region  of  the  spine,  so  as  to 
maintain  the  horizontal  position  of  the  eyes.  In  children  the 
affected  side  of  the  head  and  face  also  becomes  atrophic.  The 
measurement  from  the  external  canthus  to  the  angle  of  the  mouth 
is  smaller,  the  eyebrow  is  less  arched,  the  nose  somewhat  flattened, 
and  the  cheek  less  full  than  on  the  sound  side.  These  phenomena 
are  probably  due  to  imperfect  vascular  supply,  resulting  from  the 
limited  mobility. 

The  Diagnosis  of  a  chronic  torticollis  is  readily  made  from  the  fact 
that  the  sterno-mastoid  muscle  is  evidently  contracted  and  stands 
out  as  a  tense  band  in  the  neck.  It  must  not  be  confounded  with 
cicatricial  contraction  of  the  skin  of  the  neck  following  burns,  or 
with  the  deformity  and  rigidity  of  the  neck  which  result  from  a 
rheumatic  inflammation  of  the  deeper  ligaments  and  muscles  of  the 
cervical  spine  (rheumatic  spondylitis),  or  from  tuberculous  disease 
of  the  cervical  vertebrje. 

Treatment. — Massage  and  manipulation  may  be  first  tried,  or 
even  some  form  of  mechanical  apparatus  directed  towards  stretching 
the  contracted  muscle  {ijide  infra),  but  in  the  majority  of  cases 
tenotomy  or  myotomy  will  give  a  more  satisfactory  result,  and  is 
less  tedious  and  troublesome. 

Two  methods  of  dividing  the  sterno-mastoid  have  been  employed: 
(i)  The  subcutaneous  operation  is  a  somewhat  undesirable  proceeding, 
on  account  of  the  important  structures  placed  immediately  beneath 
it.     There  is  but  httle  danger  or  difficulty  in  deahng  with  the  sternal 


434  A  MANUAL  OF  SURGERY 

head,  a  tenotome  being  passed  down  to  it  beneath  the  skin,  and  the 
incision  made  from  before  backwards;  the  tension  to  which  it  is 
exposed  suffices  to  draw  it  well  forwards  out  of  harm's  way.  The 
clavicular  portion,  on  the  other  hand,  should  always  be  divided 
through  an  open  incision.  (2)  '1  he  open  method  is  far  preferable,  as 
thereby  all  danger  is  obviated.  The  skin,  about  ^  inch  above  the 
clavicle,  is  incised  across  the  muscle,  its  anterior  and  posterior 
borders  are  defined,  and  its  fibres  completely  divided.  Tense  portions 
of  the  deep  cervical  fascia  on  its  deep  aspect  may  also  be  carefully  cut 
across,  keeping  in  view  the  importance  of  the  underlying  structures. 
Ihe  position  of  the  head  is  then  rectified,  and  fixed  by  plaster  of 
Paris  or  some  other  suitable  apparatus.  A  simple  and  satisfactory 
arrangement  consists  of  a  padded  leather  strap  passed  round  the 
forehead  and  occiput,  and  another  under  the  axillae.  A  chain  or 
elastic  band  is  secured  to  the  forehead  strap  above  the  mastoid 
process  of  the  side  which  is  not  affected,  and  traction  made  by  fixing 
it  to  the  front  of  the  lower  belt  on  the  opposite  side  of  the  body. 
Thus,  if  the  left  sterno-mastoid  is  contracted  and  has  been  divided, 
the  chain  is  attached  above  over  the  right  mastoid  process  and  below 
over  the  front  of  the  left  axilla,  traction  being  thus  made  in  the 
direction  of  the  weakened  right  sterno-mastoid  muscle.  In  some 
cases  more  efficient  support  is  necessary,  and  may  be  obtained  by  the 
use  of  Chance's  back  splint  (p.  441),  to  the  upper  end  of  wliich  arms 
are  attached,  bringing  pressure  to  bear  upon  each  side  of  the  head 
in  suitable  directions.  WTiere,  however,  osseous  changes  are 
present,  the  deformity  may  persist  to  a  great  extent,  in  spite  of 
combined  operative  and  mechanical  treatment. 

3.  Spasmodic  torticollis  is  a  condition  which  occurs  most  fre- 
quently in  women  about  thirty  years  of  age,  in  whom  there  is  often 
a  family  history  of  insanity  or  nervous  diseases,  such  as  epilepsy, 
etc.  It  is  characterized  by  clonic  spasms  of  the  various  muscles  of 
the  neck,  especially  the  sterno-mastoid  and  trapezius,  but  the  deep 
short  rotator  muscles  are  also  affected  in  many  cases.  The  head  is 
continually  being  twisted  and  jerked  into  a  position  of  torticollis, 
but  other  movements  are  often  associated.  The  cause  is  some 
lesion  of  the  nervous  supply  of  the  muscles,  probably  in  most  cases 
cortical.  In  a  few  instances  irritation  of  peripheral  nerves,  as  by 
inflamed  glands,  teeth,  etc.,  may  exert  some  temporary  influence, 
but  the  true  spasmodic  wry-neck  persists  in  spite  of  the  removal  or 
cure  of  such  causes.  The  prognosis  is  always  very  unfavourable, 
since,  even  if  the  localized  spasm  is  cured  by  appropriate  operative 
treatment,  other  parts  are  likely  to  become  affected. 

Treatment  in  these  cases  must  be  of  a  hygienic  and  tonic  character ; 
peripheral  sources  of  irritation  must  be  removed,  and  careful  in- 
vestigation made  to  ascertain  that  all  the  functions  of  the  body  are 
satisfactorily  performed.  Intestinal  toxaemia,  disorders  of  men- 
struation, and  any  other  possible  causes  of  irritation,  must  be  re- 
lieved. Local  applications  of  electricity  of  various  types  may  be 
employed,    as    also    various    hydro-therapeutic    remedies.     Where 


THE  SURGERY  OF  DEFORMITIES  435 

these  have  failed,  the  spinal  accessory  nerve  may  be  exposed,  and 
eUher  stretched  or  excised  (p.  386).     Not  ^^^^^^^^^'p  .^''l^^^' 
neriist  in  spite  of  this,  and  then  it  may  be  well  to  divide  the  pos- 
F    ^^rMrv^ral  nerves   as  they  he  on  the  semi-spmalis  colli  (Keen) 
Sd  «^s  flil."  may  beVstmable  to  deal  with    the    cortical 

""'nSerical  wry-neck  is  occasionally  seen,  and  must  be  carefully 
dife  nt' afed  from  the  above  varieties.     It  may  last  for  a  varying 
neriod  but  under  suitable  treatment  disappears  completely. 
^  A   Cer^cal  Rib  is   a   deformity  of   not  uncommon  occurrence, 
.eneralTy  noticed  about  the  age  of  puberty.     It  is  usually  bilateral 
and  arises  most  frequently  from  the  anterior  transverse  process  of 
the  seventh  cervical  vertebra,  but  a  similar  outgrowth  sometimes 
nrcurs  from  the  sixth.     It  is  composed  mainly  of  cartilage  at  first, 
but  a   age  advances  it  becomes  osseous.     It  may  be  short  and  have 
a  free  end  in  the  neck,  but  more  frequently  passes  down  to  unite 
with  the  first  rib  near  the  scalene  tubercle,  or  to  gam  attachment  to 
rhfsternum    occasionally  it  consists  of  two  portions,   an  upper 
A  fwpr  Ignited  together  by  a  synchondrosis.     No  symptoms  are 
and  a  lower,  .^"1^:^^^^^^^^^  encroaches  on  the  subclavian 

LTe'y'^ndTowe^aM  m^e^^  brachial  plexus.     The  vessel 

IS  Dushed  upwards  and  forwards,  and  becomes  so  prominent  as  at 
tiroes  to  be^mistaken  for  an  aneurism;  sometimes  the  pulse  is  im- 
paired when  the  arms  hang  down,  and  this  may  even  determine 
San^renTof  the  finger-tips  Nervous  symptoms  are  referable  to 
the  first  dorsal  and  eighth  cervical  nerve-roots,  and  appear  m  the 
orm  of  neuralgra  along  the  ulnar  border  of  the  fore-arrn  and  httle 
1  .  nr  of  naralvsis  inainlv  of  the  intrinsic  muscles  of  the  thumb. 
4'?ervicL  nb^pres^n^^^^^^  swelling  above  the  clavicle,  and  can 

be  relddy  recognised  by  radiography.  Nothing  should  be  done  to 
it  unless  pressure  symptoms  are  present,  when  removal  may  be 
reauked  ^ An  incision  is  made  parallel  to  the  anterior  border  of  he 
lower  portion  of  the  trapezius ;  the  nerves  and  vessels  are  separated 
l?rthe  mass  of  cartilage  and  drawn  aside,  and  the  growth  carefully 
excised  by  gouge,  chisel,  or  cutting  phers. 

Deformities  o£  the  Spine. 

Scoliosis  -By  scohosis  is  meant  a  lateral  curvature  of  the  spine 
accompamed  by  rotation  of  the  vertebrae.  Conditions  are  met  with 
inwS^he  spine  becomes  deflected  laterally  as  an  occasional  result 
of  Pott  s  dfsease.  or  in  fractures;  such,  however,  are  not  generally 
ronsidered  to  be  genuine  scoliosis.  .  , 

Mogy-Th?  following  are  the  chief  causes  of  scohosis:  (i)  It 
occurs  te?v  rarely  as  a  congenital  deformity,  owing  to  malformation 
of  The  veTtebrI      (2)  It  may  commence  m  young  children  as  a 

partly  to  their  irregular  growth.     It  is  probably  of^^^^.^"^^^^ 
the  children  being  always  carried  on  the  same  arm.     The  primary 


436 


A   MANUAL  OF  SURGERY 


curve  in  this  type  is  usually  one  directed  towards  the  left  in  the 
dorsi-lumbar  region.  A  similar  change,  due  to  the  so-called  '  ado- 
lescent rickets,'  may  also  occur  in  children  who  are  able  to  run 
about.  (3)  Any  condition  of  asymmetry  of  the  body  may  lead  to 
what  is  known  as  compcnsatoyy  scoliosis — e.g.,  congenital  shortness 
of  one  leg,  unilateral  dislocation  of  the  hip,  contractions  of  the  knee- 
or  hip-joint,  genu  valgmii,  falling  in  of  the  chest  wall  as  a  result  of 
empyema,  and  even  old-standing  torticollis.  If  one  leg  is  short 
(Fig.  153),  the  pelvis  is  tilted  down  on  that  side  in  order  to  bring 
the  foot  to  the  ground,  producing  a  lumbar  curve  with  the  con- 
vexity towards  that  side,  whilst  a  compensatory  dorsal  curve  in  the 
opposite  direction  is  subsequently  added  in  order  to  maintain  the 
general  axis  of  the  body  (A^).  If,  however,  the  short  leg  is  also 
persistently  adducted,  as  in  old  hip  disease  (Fig.  154,  B),  the  spine 
will  be  curved  in  the  opposite  direction  in  order  to  maintain  the  paral- 
lelism of  the  limbs  (B^).     \Mien  due  to  empyema,  a  primary  dorsal 


Fig.  153.- — Scoliosis  due  to 
Shortening  of  the  Left 
Leg. 


.^ 


Fig.  154. — Scoliosis  due  to 
Adduction  of  the  Left 
Hip. 


curvature  is  produced,  with  its  convexity  towards  the  sound  side. 
In  torticollis  the  cervical  curve  is  primary,  and  a  compensators- 
curve  in  the  opposite  direction  in  the  dorsal  region  usually  follows. 
(4)  The  most  common  type,  however,  is  the  scoliosis  of  adolescents, 
met  with  in  young  people  about  the  age  of  puberty,  or  a  little  older, 
who  are  in  a  weak  and  asthenic  condition,  often  as  a  result  of  rapid 
growth,  combined  possibly  with  improper  or  insufficient  food, 
defective  hygienic  surroundings,  or  exposure  to  hard  work,  whereby 
undue  muscular  fatigue  is  induced.  Young  women  of  an  anaemic 
type  who  suffer  from  amenorrhcea,  and  who  as  housemaids  or 
factor}^  hands  have  to  undertake  a  good  deal  of  lifting,  are  especially 
hable  to  this  condition.  It  is  due  to  a  relaxed  state  of  the  ligaments 
and  muscles,  which  have  not  developed  pari  passu  with  the  weight 
and  length  of  the  skeleton;  it  is  therefore  not  unfrequently  asso- 
ciated with  flat  foot  and  genu  valgum.  Prolonged  standing  in  a 
position  of  ease  or  rest,  in  which  the  weight  is  mamly  carried  on  one 


THE  SURGERY  OF  DEFORMITIES 


437 


leg,  may  determine  its  occurrence,  as  also  faulty  positions  occupied  by 
children  at  school,  owing  to  low  desks  and  want  of  support  to  the  feet. 
The  Phenomena  vary  considerably  according  to  the  character  and 
extent  of  the  lesion.  Sometimes  the  whole  spine  is  inv^olved  in  one 
curve  [total  scoliosis) ;  but  more  usually  two  curves  are  present,  one 
primary,  the  other  compensatory.  It  is  by  no  means  uncommon  for 
this  condition  to  be  associated  with  kyphosis,  but  the  absence  of  the 


vA    ^^^-^J'y 


Fig.   156. — Spine  in  Scoliosis  seen 
FROM  IN  Front.     (Tillm.\nns.) 


Fig.  155. — Photograph  of  Ordin- 
ary Type  of  Adolescent 
Scoliosis. 

The  apparent  asymmetry  of  the  legs  is  in  this  case  a  photographic  error ; 
in  reality  they  were  both  well  developed. 

latter,  in  what  is  sometimes  termed  the  '  fiat-backed  '  type,  is  no 
criterion  of  the  slightness  of  the  case.  The  most  usual  variety  is  that 
in  which  there  is  a  double  curve,  with  the  dorsal  convexity  to  the 
right  and  the  lumbar  to  the  left  (Fig.  155).  It  will  be  desirable  to 
describe  this  carefully,  whilst  for  the  opposite  condition  all  that  is 
necessary  is  to  transpose  the  words  '  right  '  and  '  left,'  or,  as  Hoffa 
has  put  it,  one  variety  is  the  '  mirror  picture  '  of  the  other. 


438 


A    MANUAL  OF  SURGERY 


In  addition  to  the  lateral  displacement,  the  bodies  of  I  he  vertehrce 
(Fig.  156)  are  always  rotated  towards  the  convexity  of  the  curves. 
This  is  probably  a  purely  mechanical  act,  and  due  to  the  more  firm 
support  given  to,  and  the  interlocking  of,  the  posterior  parts  of  the 
vertebrae.  As  a  result,  the  spinous  processes  are  directed  towards 
the  concavity,  and  hence  always  indicate  a  smaller  amount  of  dis- 
tortion than  really  exists.  Occasionally  there  may  be  some  back- 
ward projection  of  the  spines  at  the  junction  of  the  two  curves. 

The  thoracic  icalls  necessarily  participate  in  the  process,  and  the 
amount  of  thoracic  deformity  is  perhaps  the  best  measure  of  the 
degree  of  rotation  of  the  vertebra;.  The  ribs  on  the  right  side  become 
to  some  extent  separated  from  one  another,  and  project  posteriorly 
on  account  of  this  rotation  (Fig.  157) ;  the  amount  of  curvature  at 

the  angle  is  consequently  in- 


creased, whilst  the  front  of 
the  chest  on  this  side  of  the 
body  becomes  flattened.  On 
the  left  side  the  ribs  are 
huddled  together,  and  the 
curve  at  the  angle  diminished, 
the  ribs  being  therebv  opened 
out ;  consequently,  the  thorax 
is  flattened  posteriorlv  on  that 
side,  but  projects  in  front; 
the  left  breast  may  thus  be 
rendered  prominent.  In  fact, 
the  thorax  becomes  more  or 
less  rhomboidal  in  shape. 
The  sternum  also  is  somewhat 
displaced  towards  the  con- 
cavity, and  twisted  so  that 
the  anterior  surface  looks  to- 
wards the  right.  The  capacity 
of  the  thorax  is  not  as  a  rule 
affected  at  first,  but  in  the  later  stages  it  is  considerably  diminished, 
and  the  abdominal  viscera  may  even  be  displaced.  The  scapulce 
follow  the  thoracic  wall,  and  hence  the  right  shoulder  is  pushed 
upwards  and  outwards,  and  it  is  for  this  '  growing  out  of  the 
shoulder  '  that  the  majority  of  cases  come  under  observation. 
The  effect  on  the  waist  varies  with  the  situation  and  extent  of 
the  curves;  if  the  dorsal  and  lumbar  curves  are  nearly  equal,  then 
the  true  waist  on  the  right  side  becomes  more  marked  than  usual, 
corresponding  to  the  lumbar  concavity,  and  in  advanced  cases  a 
distinct  sulcus  may  be  present  between  the  lower  ribs  and  the 
crest  of  the  ilium.  On  the  left  side  the  hip  appears  to  project 
('  growing  out  '),  owing  to  the  deflection  of  the  trunk  toweirds 
the  right  side  (Fig.  155),  whilst  the  dorsal  concavity  higher  up 
may  simulate  a  false  waist.  The  erector  spina  muscle  'stands 
out    unduly   on   the   left    owing   to   the  rotation  of  the  vertebra:. 


Fig.  157. — Section  of  Thorax  in  Scolio- 
sis.    (After  Holmes  and  Hulke.) 


THE  SURGERY  OF  DEFORMITIES  439 

whilst  the  transverse  processes  on  this  side  may  be  unusually 
evident. 

In  the  early  stages  the  characteristic  deformity  disappears  on  ex- 
tension of  the  trunk,  as  by  hanging  from  a  trapeze,  or  on  bending  for- 
wards ;  but  as  it  progresses,  the  spine  becomes  more  and  more  fixed, 
and  but  little  alteration  is  produced  by  suspension  of  the  patient. 
In  the  worst  cases,  especially  when  associated  with  kyphosis,  the  de- 
formity becomes  so  marked  as  to  simulate  the  '  hump  '  formed  in 
Pott's  disease,  and  the  patient's  stature  becomes  dwarfed  and  stunted. 

Subjective  symptoms,  such  as  neuralgic  pain  and  weakness,  are 
also  present,  but  usually  they  are  not  very  prominent  features. 

Anatomical  Changes. — The  structure  of  the  spinal  column  is  at 
first  not  manifestly  altered,  but  as  soon  as  the  deformity  becomes 
chronic,  the  individual  vertebrse  become  mis-shapen.  The  bodies 
become  wedge-like  on  section,  being  thicker  on  the  convex  than 
on  the  concave  side.  The  intervertebral  discs  are  similarly  changed, 
whilst  the  articular  processes  are  unduly  pressed  together  on  the  con- 
cave side,  and  separated  from  one  another  on  the  convex.  The 
transverse  and  spinous  processes  are  also  approximated  to  one 
another  on  the  side  of  the  concavity,  and  often  curved.  The  liga- 
ments, which  in  the  early  stages  are  relaxed,  becomes  secondarily 
shortened  on  the  concave  side,  and  may  indeed  disappear,  the 
bodies  of  the  vertebrse  being  ankylosed.  The  muscles  accommodate 
themselves  to  the  altered  curves  of  the  spine,  and  hence  are  con- 
tracted on  the  concave  side  and  stretched  on  the  convex. 

It  is  most  essential  that  a  correct  Diagnosis  be  made  as  soon  as 
possible,  since  so  much  depends  upon  early  treatment.  A  thorough 
examination  should  be  made  with  the  clothes  stripped  to  below  the 
waist,  so  that  the  whole  back  can  be  seen.  The  patient  should  be 
made  to  sit  straight  up  on  a  stool  or  chair  placed  sideways,  and  the 
surgeon  stands  behind  her.  The  general  appearance  is  first  noted, 
and  then  the  spinous  processes  are  marked  out  one  after  another  with 
a  spot  of  ink  or  with  a  flesh  pencil.  The  shape  of  the  thorax,  the 
curvature  of  the  ribs,  and  the  position  of  the  scapulae,  are  also  ascer- 
tained, and  the  length  of  the  legs  is  measured.  The  patient  is  then 
made  to  stand,  to  hang  from  a  bar,  and  to  bend  forwards,  and  the 
effects  of  these  respective  movements  noted;  by  this  means  some 
idea  can  be  obtained  of  the  extent  and  nature  of  the  deformity. 
There  can  be  but  little  risk  of  mistaking  it  for  Pott's  disease,  since 
the  rigidity,  deformity,  and  localized  pain  of  the  latter  are  so  charac- 
teristic; in  those  cases  of  scoliosis,  however,  where  there  is  a  pro- 
jection of  the  spinous  processes  backwards,  a  mistake  might  easily 
arise  if  only  a  careless  examination  were  made. 

The  Prognosis  necessarily  varies  with  the  stage  which  the  affection 
has  reached.  In  early  days,  before  the  deformity  has  become  set, 
and  when  it  disappears  on  extension  of  the  spine,  it  is  almost  certain 
to  be  entirely  cured,  if  suitable  precautions  are  taken.  Later  on  it 
can  be  improved  to  some  extent,  but  in  bad  cases  all  that  can  be 
expected  is  to  prevent  it  from  getting  worse. 


440  A    MANUAL  OF  SURGERY 

In  tlie  Treatment  oi  scoliosis,  the  cause  of  the  trouble  must  not  be 
oveiiooked,  since  in  many  cases  the  deformity  may  be  remedied,  or 
at  any  rate  prevented  from  increasing,  by  attending  to  this.  Thus, 
inequality  in  the  length  of  the  limbs  necessitates  the  wearing  of  a 
high-heeled  boot,  whilst  contractions  of  the  knee-  or  hip-joints 
should,  if  possible,  be  corrected.  In  that  variety  which  occurs  in 
young  people  from  constitutional  or  local  debility,  the  general 
health  must  be  improved  by  a  visit  to  the  seaside,  or  the  administra- 
tion of  tonics  such  as  iron  and  arsenic.  Carefully-ri'gulated  rest 
and  exercise  must  also  be  recommended,  so  as  to  improve  the 
muscular  tone  of  the  back  without  unduly  fatiguing  the  patient; 
for  a  similar  reason  massage  and  cold  baths  are  beneficial.  All 
errors  of  position  must  be  corrected,  and  suitable  desks,  forms,  and 
chairs  utilized.  In  the  slighter  cases  it  often  suffices  to  order  the 
patient  to  rest  in  the  supine  position  on  an  inclined  board  for  an 
hour  or  two  daily,  the  head  being  thus  raised  and  the  spine  extended. 
Calisthenic  movements  and  gymnastic  exercises,  especially  on  the 
horizontal  bar  and  trapeze,  constitute  the  most  important  element 
of  treatment,  which  may  be  looked  on  as  curative  in  early  and 
moderate  cases,  and  as  palliative  in  the  advanced  stage.  Of  these 
exercises,  the  details  of  whicli  vary  with  each  patient,  some  are 
arranged  so  as  to  extend  and  render  mobile  the  spine,  and  gener- 
ally to  improve  the  tone  of  the  spinal  muscles;  others 
are  devised  so  as  to  undo  the  abnormal  curves  present. 
Space  forbids  us  describing  them  here,  and  we  must 
refer  readers  to  special  text-books. 

A  spinal  support  is  often  useful,  but  should  not  be 
worn  continuously,  except  in  bad  cases,  as  it  renders 
the  muscles  of  the  back  weak  from  disuse.  All  that  is 
needed  in  the  early  stages  is  the  support  of  a  firm,  care- 
fully-fitted corset;  but  should  the  deformity  increase, 
stronger  steel  instruments  may  be  employed  in  which 
springs  are  incorporated,  whereby  it  is  hoj)ed  that  correc- 
tion of  the  curvature  may  be  brought  about.  In  the 
worst  cases,  where  the  deformity  is  irremediable,  much 
can  be  done  by  a  skilful  mechanism  to  hide  the  deformity 
and  prevent  its  increase. 

Kyphosis.^ — By  this  term  is  meant  a  condition  of  in- 

FiG.    158. creased  dorsal  convexity  of  the  back  (Fig.  158),  which  is 

Kypho-sis.    often  associated  with  loss  of  the  lumbar  concavity,  so 
that  the  whole  spine  is  arched  backwards.     Occasionally, 
however,  a  marked  lumbar  lordosis  is  present  as  a  com]xmsatory 
condition. 

Ihe  chief  varieties  of  kyphosis  are  as  follows: 

I.  Kyphosis  from  defective  growth  or  habit.  This  may  occur 
{a)  in  children  under  the  age  of  four,  resulting  from  rickets;  (b)  in 
adolescents  up  to  the  age  of  sixteen  (round  shoulders),  from  a 
continuous  habit  of  stooping,  as  in  reading  or  writing,  especially 
in  those  suffering  from  myo])ia;  (c)  various  forms  oi  occupation, 
which  involve  the  carrying  of  hea\-y  weights,  or  stooping  over  work. 


THE  SURGERY  OF  DEFORMEriES 


441 


w 


lead  to  its  appt'arance  in  adults,  as  in  porters  and  cobblers  (Fig-  159); 
((/)  in  old  men  it  results  from  senile  atrophy. 

2.  Kyphosis  from  general  diseases  of  the  spine  is  a  marked 
feature  in  spondylitis  deformans,  osteitis  deformans,  osteomalacia, 
h3'pertrophic  osteo-artlu\)pathy,  and  acromegaly.  In  the  latter 
disease  the  condition  is  limited  to  the  dorsal  region. 

3.  Kyphosis  from  localized  injury  or  disease  of  the  spine  is  some- 
times described,  although  it  is  more  commonly  known  by  the  con 
tradictory   term  '  angular  curvature.'     It 
results    from     fractures.    Pott's    disease, 
gumma,  or  cancer  [q.v.). 

Treatment  is  impossible  in  the  majority 
of  cases,  but  the  round  shoulders  of  young 
people  come  so  commonly  under  obser- 
vation that  a  little  more  notice  of  the  con- 
dition is  needed. 

Round  Shoulders  occur  most  frequently 
in  girls  who  have  grown  rapidly,  and  per- 
haps developed  precociously.  The  con- 
dition is  often  due  to  defective  habits  of 
sitting  and  standing,  especially  at  school, 
and  may  be  induced  by  faulty  desks  and 
chairs,  whilst  other  intrinsic  conditions, 
such  as  mvopia  or  adenoids,  may  also  be 
primarily  responsible.  The  spine  becomes 
bent  forwards  in  the  cervico-dorsal  region ; 
at  first  the  deformity  can  be  voluntarily 
corrected,  but  not  so  later  on. 

Treatment. — In  the  first  place  the  cause 
must  be  ascertained,  and  if  possible,  re- 
moved; in  particular,  chairs  and  desks 
must  be  arranged  so  as  to  ensure  that  the 
child  sits  in  a  good  position,  and  does  not 
stoop  whilst  writing,  reading,  or  playing 
the  piano.  In  particular,  the  back  should 
be  supported  whilst  reading,  and  the 
feet  should  not  be  allowed  to  dangle.  The  muscles  of  the  back, 
especially  the  trapezii,  the  erectores  spinae,  the  rhomboidei,  and  the 
serrati,  must  be  strengthened  by  massage,  electricity,  and  exercises, 
the  latter  necessarily  directed  towards  extension  of  the  back. 
The  girl  should  never  be  allowed  to  fatigue  herself  unduly,  and  must 
rest  on  her  back  two  or  three  times  a  day  for  half  an  hour.  At 
night  she  should  lie  on  her  back,  without  a  bolster,  and  with  a 
pillow  beneath  the  curve.  The  general  nutrition  and  health  must 
also  be  attended  to,  and  a  course  of  suitable  tonics  prescribed  In 
bad  cases  where  the  deformity  is  marked  and  it  is  feared  it  may 
be  progressive,  a  light  support  may  be  required;  a  Chance's  splint* 

*  Many  modifications  of  Chance's  original  splint  have  appeared,  but  the 
essential  features  of  all  are  the  presence  of  a  metal  pelvic  band,  from  which 


Fig.  159. — Acquired  Oc- 
cupation Kyphosis  in  a 
Young  Man,  from  Exces- 
sive Weight-carrying. 


42 


A   MANUAL  OF  SURGERY 


will  do  as  well  as  an}-,  but  of  course  the  exercises  must  be  persisted 
in. 

Lordosis  (l^g.  160)  is  almcjst  invariably  a  secondary  or  compensa- 
tory conditi(jn,  and  consists  in  an  increased  anterior  curvature  of 
the  spine  in  the  lumbar  region.  It  is  usually  produced  by  continued 
fiexion  of  the  hip,  whether  due  to  congenital  disi)lacement,  unre- 
duced dislocation,  malunited  fracture,  or  to  hip  disease,  and  in  such 
cases  it  is  irremediable  unless  the  malposition  of  the  femur  can  be 
corrected. 

It  is  seen  as  a  temporary  condition  in  pregnancy,  and  as  a  more 
persistent  phenomenon  in  bad  cases  of  uterine  fibroids,  owing  to 
the  increased  weight  of  the  uterus  or  its  contents,  necessitating 
backward  displacement  of  the  upper  part  of  the 
spine  in  order  to  adjust  correctly  the  centre  of 
gravity  of  the  body.  The  same  may  be  noticed  in 
persons  with  large,  fat,  and  pendulous  abdomens. 

It  is  occasionally  present  in  progressive  muscular 
atrophy  where  the  lumbar  and  abdominal  muscles 
are  weakened,  and  usually  in  pseudo-hypertrophic 
paralysis  from  loss  of  power  in  the  gastrocnemii 
and  other  muscles  engaged  in  maintaining  the 
erect  posture. 

Spondylo-listhesis  is  the  term  applied  to  a  curious 
and  somewhat  uncommon  deformity,  in  which  the 
lumbar  vertebra  slip  forwards  and  downwards  from 
the  top  of  the  sacrum.  It  arises  from  fracture 
of  the  articular  processes  of  the  lumbo-sacral  syn- 
chondrosis, or  from  imperfect  development  of  the 
laminae  or  pedicles  of  the  lowest  lumbar  vertebra, 
as  a  result  of  which  the  pressure  of  loads  carried  on 
the  shoulders  or  the  weight  of  a  pregnant  uterus  brings  about  the  dis- 
placement. In  the  latter  instance  the  enforced  lordosis  aggravates 
this  tendency.  The  effects  produced  are  shortening  of  the  stature, 
together  with  the  formation  of  a  marked  hollow  above  the  sacrum, 
whilst  the  lumbar  vertebrae  are  unduly  prominent  anteriorly.  The 
condition  is  accompanied  by  neuralgic  pain  and  weakness.  The  only 
treatment  is  prolonged  rest  in  the  recumbent  posture,  and  possibly 
the  application  of  a  leather  jacket,  moulded  to  the  pelvis,  and 
supplied  with  crutches,  so  as  to  carry  part  of  the  weight  downwards 
from  the  axillae  to  the  pelvic  support  without  utilizing  the  spine. 


Fig.  160. — Lor 

DOSIS. 


Deformities  of  the  Upper  Extremity. 

In  Congenital  Elevation  of  the  Scapula  (Sprengel's  Shoulder)  the 
scapula  may  be  normal  in  size  or  a  little  smaller  than  usual,  but  is 
situated  above  its  proper  position,  and  rotated  so  that  its  lower 

rises  a  single  or  double  bar  of  malleable  iron,  fitted  to  the  back,  and  capable 
of  having  its  curve  altered.  Lateral  supports  spring  from  the  central  bars  or 
bar,  and  straps  to  fix  it  in  position  are  also  provided. 


THE   SURGERY  OF  DEFORMITIES  443 

angle  is  approximated  to  the  middle  line.  The  muscles  attached 
to  "its  upper  border  are  prominent;  in  a  few  instances  a  cartilaginous 
or  osseous  band  has  replaced  them,  passing  between  the  upper 
angle  of  the  bone  and  the  seventh  cervical  vertebra.  The  lower 
third  of  the  trapezius  is  often  defective,  as  also  the  serratus  magnus. 
The  disability,  which  is  usually  slight,  depends  on  the  condition  of 
these  muscles,  but  the  affected  arm  is  sometimes  smaller  than  its 
fellow.  A  slight  degree  of  scoliosis  develops  as  a  compensatory 
phenomenon.  The  only  active  treatment  consists  in  dealing  with 
the  affected  muscles  by  removing  the  cartilaginous  or  osseous  band ; 
otherwise  massage  and  exercises  are  required. 

A  Winged  Scapula  is  a  condition  characterized  by  projection  back- 
wards of  the  vertebral  border  and  lower  angle  of  that  bone  when  the 
arm  is  thrust  forwards  (Fig.  i6i).     It  is  due  to  paralysis  of  the 


Fig.   i6i. — Winged  Scapula. 


serratus  magnus  and  rhomboids,  resulting  from  neuritis  or  trauma 
of  the  roots  of  the  fifth  and  sixth  cervical  nerves,  or  of  the  special 
branches  to  these  muscles;  the  nerve-roots  are  not  unfrequently 
tender  on  pressure.  Treatment  consists  in  massage  and  faradism, 
whilst,  if  persistent,  a  suitable  apphance  may  correct  the  deformity. 
Various  types  of  Club-hand  occur,  in  which  the  hand  is  deflected  to 
one  or  the  other  side,  or  is  hyper-extended  or  flexed.  Perhaps  the 
most  frequent  cause  is  a  congenital  absence  of  the  radius,  under  which 
circumstances  the  hand  is  radially  abducted  to  a  marked  degree,  the 
ulna  is  shortened  and  curved,  and  its  lower  epiphysis  expanded, 
so  as  to  articulate  with  the  carpal  bones.  Where  the  bones  are 
normal,  the  hand  is  usually  flexed  and  adducted  towards  the  ulnar 
side.  In  any  of  these  deformities  radiography  should  be  employed, 
so  as  to  ascertain  the  exact  relation  of  the  bones  to  each  other. 


444  ■'    MANUAL  OF  SURGF.IiY 

Congenital  Deformities  oi  the  Finger  arc  much  more  common,  iind 
the  account  licrc  given  of  such  defects  of  the  uj^per  extremity  applies 
with  equal  force  to  those  which  occur  in  the  lower.  The  following 
\arieties  may  be  alluded  to: 

Polydactylism  consists  in  the  presence  of  supernumerary  fingers 
and  toi's.  There  may  be  from  one  to  seven  additicnial  digits,  and 
the  condition  is  usually  symmetrical.  One  case  is  on  record  with 
twelve  and  thirteen  lingers  on  the  hands,  and  twelve  toes  on  each 
foot.  The  accessory  digits  are  often  stunted,  and  smaller  in  size 
than  the  normal,  but  may  be  of  average  dimensions.  Usually  they 
are  separated  from  the  true  digits,  but  now  and  then  may  be  blended 
with  them.  The  correct  number  of  metacarpal  or  metatarsal 
bones  may  be  present,  or  they  also  may  be  multiplied.      In  one  of 


Fig.   162. — Magrodactyly  and  Syndactyly. 

In  this  case  a  child,  aged  two  and  a  half  years,  had  the  ring  and  niidiUc  fingers 
united  laterally  into  a  large  mass  which  projected  far  beyond  the  others. 
The  middle  finger  was  normal  in  size,  the  ring  finger  was  hypertrophic. 
A  fruitless  attempt  was  made  to  save  the  middle  finger,  but  both  had 
finally  to  be  amputated. 

our  cases  there  were  six  digits  and  six  metatarsal  bones;  but  the 
last  two  digits  were  supported  by  an  accessorv  metatarsal  apparently 
springing  from  the  outer  side  of  the  fourth.  The  condition  is 
frequently  inherited.  1  he  Treatment  consists  in  removing  the  super- 
numerary digits,  if  useless,  obtrusive,  or  troublesome.  Sometimes 
the  patients  are  proud  of  their  abnormalitv,  and  refuse  to  part 
with  it. 

Ectrodactylism,  or  the  absence  of  one  or  more  of  the  digits,  is 
occasionally  seen,  as  also  partial  arrests  of  development  of  fingers  or 
toes,  or  intra-uterine  amputation  at  a  higher  level. 

Macrodactyly  (Fig.  162)  consists  in  a  congenital  overgrowth  of  one 
or  more  lingers  or  toes.  The  structures  are  perfectly  normal  in 
character,  and  merely  gigantic  in  size  for  the  age  of  the  individual 


THE  SURGERY  OF  DEFORMITIES 


445 


Aniinitation  or  excision  mav  be  needed  in  these  cases,  as  the  de- 
formed parts  grow  out  of  all' proportion  to  the  neighbouring  tissues. 
1  hus,  an  infant  with  enormous  overgrowth  of  the  second  toe  of  the 
right  foot  was  successfully  treated  by  excision  of  the  digit,  together 
with  a  V-shaped  portion  of  the  foot,  which  was  by  this  means 
reiluced  to  normal  shape  and  size. 

Syndactylism,  or  webbed  hngers,  is  a  condition  in  which  two  or 
more  fingers  are  joined  together  laterally,  either  by  a  thin  web  con- 
sisting mainly  of  skin,  or  by  a  thick  fleshy  bond  of  union.     In  the 
foot   no   treatment   is   required,    but   in   the 
hand   the    fingers   must    be    separated.      If 
there   is   merely   a   thin  web,   this   may  be 
divided  by  scissors;   but  to  prevent  its  re- 
formation from  above  downwards,  as  healing 
proceeds,    a    flap    of    skin    must    be    trans- 
planted into  the  angle  between  the  fingers, 
or  an  opening  in  the  base  of  the  web  may 
be    made    and   maintained,    and   the    edges 
allowed   to   cicatrize  before    the  web   itself 
is  divided.     Where  the  union,   however,  is 
thick  and  fleshy,  a  more  extensive  operation 
is  needed.     Iwo   flaps  of    skin   as   long   as 
the  web,  and  half  the  width  of  a  finger,  are 
respectively  raised  from  the  dorsal  aspect  of 
one  finger  (Fig.  163,  A)  and  from  the  palmar 
aspect  of   the  other  (B),  in  such  a  manner 
that,   after  the  web  has  been  divided,  the 
denuded  surfaces  can  be  covered  by  wrappmg  the  flaps  round  ttie 
lateral  aspects  of  the  fingers  and  suturing  them  m  position.     An 
additional  flap  of  skin  must  also  be  fixed  in  the  angle  between  the 
separated  digits.  j  r        -4. 

Congenital  Contraction  o£  the  Fingers  is  not  a  very  rare  deformity 
being  frequentlv  inherited ;  it  is  usually  limited  to  the  little  finger  and 
may  be  associated  with  congenital  hammer-toe.  It_  is  due  to  con- 
traction of  the  central  prolongation  of  the  palmar  fascia  m  the  finger 
whereas  Dupuytren's  contraction  involves  the  palmar  fascia  itselt 
and  its  lateral  prolongations  into  the  fingers.  Moreover,  m  the 
congenital  variety  the  first  phalanx  is  hyper-extended,  and  the 
second  and  third  flexed,  whereas  in  the  acquired  form  the  first  and 
second  phalanges  are  flexed  and  the  third  is  hyper-extended. 
Treatment.— It  often  suffices  to  use  massage  and  apply  a  splint, 
but  in  bad  cases  division  of  the  fascial  bands  may  be  needed. 

Acquired  Deformities  of  the  Hand.— After  burns  the  hands  may  be 
contracted  into  a  useless  mass  in  which  the  fingers  are  drawn  into 
the  palm  and  united  by  cicatricial  tissue  to  the  palmar  structures,  so 
that  all  treatment  is  hopeless.  .        .^ 

Spring-,  Jerk-,  or  Snap-finger  is  a  condition  m  which,  when  the 
patient  attempts  to  open  his  hand,  one  finger  or  the  thumb  remains 
flexed,  and  on  extending  it  with  the  other  hand  it  flies  open  with  a 


Fig.  163.  — Operation 
FOR  Syndactyly. 


446  A   MANUAL  OF  SURGERY 

jerk  or  snap.  Slight  tenderness  is  usually  felt  near  the  metacarpo- 
phalangeal articulation,  and  the  cause  of  the  trouble  is  some  ob- 
struction to  the  free  working  of  the  long  tendons  under  the  trans- 
verse ligament  at  the  root  of  the  fingers,  or  between  the  sesamoid 
bones  of  the  thumb.  In  a  few  cases  a  ganglion  has  been  present 
here,  but  in  most  instances  the  condition  is  due  to  an  increase  in 
size  of  the  sesamoid  bone  which  ra(li(>gra]:)hy  has  taught  us  occurs 
constantly  in  this  situation.  Treatment  consists  in  an  aseptic 
incision  to  remove  the  cause  of  the  obstruction. 

A  Mallet  Finger  is  one  in  which  the  terminal  phalanx  is  maintained 
in  a  state  of  flexion  owing  to  some  damage  to  the  extensor  aponeu- 
rosis. Its  treatment  in  the  early  stage  has  been  already  alluded  to 
(p.  417) ;  should  tlie  deformity  be  persistent,  an  incision  is  made 
on  the  posterior  aspect  of  the  finger,  and  the  weak  tendon  isolated 
and  stitched  down  in  such  a  way  as  to  give  it  a  better  attachment 
to  the  bone. 


Fig.   164. — Dupuytren's  Contraction. 

Contraction  of  the  Palmar  Fascia  (Dupuytren's  Contraction). — This 
condition  is  usually  met  with  in  middle-aged  individuals  of  a  gouty 
temperament,  more  often  in  men  than  women,  and  not  unfrequently 
on  both  sides  of  the  body.  It  may  or  may  not  be  associated  with 
direct  irritation  of  the  palm,  as  by  leaning  much  on  a  round-headed 
cane,  or  from  the  constant  use  of  some  instrument,  such  as  an  awl, 
whilst  heredity  is  an  important  causative  factor.  Pathologically,  it 
is  due  to  a  chronic  overgrowth  and  contraction  of  the  fascia,  inflam- 
matory in  nature,  and  cirrhotic  or  sclerosing  in  type.  It  commences 
as  an  indurated  subcutaneous  nodule  in  the  palm  of  the  hand,  about 
the  situation  of  the  most  marked  transverse  crease,  and  affects  most 
commonly  the  ring  and  little  fingers  first,  the  other  fingers  and  thumb 
being  less  often  involved.  The  induration  spreads  slowly  both  up 
and  down  the  fascial  bands  into  the  fingers,  which,  as  it  increases, 
are  graduall}^  drawn  into  the  palm  and  fixed,  so  that  extension 
becomes  impossible  (Fig.  164).     The  flexion  is  limited  to  the  first 


THE  SURGERY  OF  DEFORMITIES  447 

and  second  phahinges,  the  third  remaining  extended,  and,  indeed, 
sometimes  assuming  a  position  of  hyper-extension,  owing  to  the 
injudicious  appUcation  of  a  spUnt.  The  skin  over  the  indurated 
masses  is  sooner  or  later  incorporated  with  them,  and  may  become 
dimpled  or  creased  by  the  traction  of  the  subcutaneous  connecting 
bands. 

The  Diagnosis  of  Dupuytren's  contraction  is  exceedingly  easy,  the 
only  condition  for  which  it  is  likely  to  be  mistaken  being  the  con- 
genital contraction  already  noted,  and  the  flexion  of  the  finger  due 
to  contraction,  division,  or  destruction  of  the  long  tendons.  In  the 
latter  case  there  is,  as  a  rule,  no  palmar  induration,  but  there  will 
be  a  history  of  injury  or  inflammation,   and  some  scarring  (see 

P-  417)- 

'i  he  only  satisfactory  Treatment  is  by  operation,  and  the  following 

methods  are  those  which  are  most  successful:  [a]  Adams'  subcu- 
taneous section  of  the  fascia  and  its  prolongations  consists  in  dividing 
the  indurated  bands  by  a  tenotome  in  several  places,  where  they 
can  be  felt  tense.  Orie  puncture  and  division  must  be  made  in 
the  centre  of  the  palm ;  a  second  divides  the  same  band  as  near  the 
finger  as  possible,  whilst  the  third  and  fourth  deal  with  the  lateral 
prolongations  at  the  sides  of  the  finger;  if  other  bands  still  exist, 
they  are  treated  similarly,  the  tenotome,  if  possible,  in  all  cases 
being  inserted  between  the  skin  and  the  fascia.  The  improvement 
thus  produced  must  be  maintained  and  increased  by  the  subsequent 
use  of  suitable  apparatus  and  passive  movements,  but  the  final 
results  are  not  very  satisfactory,  {b)  Kocher's  method  consists  in 
the  total  extirpation  of  the  thickened  bands  and  their  prolonga- 
tions through  longitudinal  incisions.  The  fingers  are  at  once 
straightened,  and  subsequent  contraction  is  prevented  by  mechanical 
appliances.  Many  excellent  and  lasting  cures  have  resulted  from 
the  latter  operation. 

Deformities  of  the  Lower  Extremity. 

Congenital  Dislocation  of  the  Hip  is  by  no  means  rare,  although  its 
causation  is  still  quite  uncertain.  It  is  frequently  bilateral,  though 
more  commonly  unilateral ;  it  occurs  much  more  often  in  girls  than 
in  boys.  It  may  pass  unnoticed  until  the  child  begins  to  walk, 
and  then  the  characteristic  signs  become  evident.  The  limb  is 
shortened  and  flexed  on  the  pelvis,  owing  to  the  traction  of  the  ilio- 
psoas muscle,  resulting  in  a  considerable  amount  of  lordosis  (Fig.  166) , 
whilst  scohosis  is  well  marked  in  one-sided  cases.  Since  the  head 
of  the  femur  is  displaced  from  the  middle  line,  a  gap  is  usually 
noticed  between  the  thighs  close  to  the  perineum.  Considerable 
adduction  of  the  lower  end  of  the  femur  is  present  (Fig.  165),  and 
in  bilateral  cases  a  scissor-leg  deformity  may  ensue.  The  patient's 
gait  is  of  a  curious  waddling  character,  which  becomes  very  marked 
if  one  side  alone  is  affected.  Since  the  head  of  the  bone  is  only 
maintained  in  position  by  its  ligamentous  and  muscular  attachments. 


448  A   MANUAL  OF  SURGERY 

it  can  often  be  drawn  down  at  first,  and  the  leg  thus  lengthened  to 
the  extent  of  an  inch  or  two ;  moreover,  it  is  often  easy  to  reduce  the 
displacement  and  put  the  head  of  the  bone  in  the  acetabulum  in 
children  that  have  not  walked  much.  At  a  subsequent  date  strains 
to  the  limb  are  almost  entirely  borne  by  the  ligamentous  tissues, 
and  hence  attacks  of  synovitis  are  common. 

The  Pathological  Anatomy  varies  consideral)ly  according  to  whether 
or  not  the  child  has  walked.  At  birth  the  head  and  neck  are  some- 
times nearh'  normal  in  shape,  and  located  near  the  acetabulum ; 


^- 


Fig.  165.  Fig.  166. 

Congenital  Dislocation  of  Both  Hips  in  a  Girl  of  Fifteen  Years,  seen 
FROM  the  Front  and  Side.  (From  Photographs  kindly  lent  by 
Mr.  J.  Jackson  Clarke.) 

generally,  however,  the  head  is  rather  small  and  perhaps  flattened 
at  the  spot  where  it  rests  against  the  innominate  bone,  and  the  neck 
is  short  and  stunted.  The  ligamentum  teres  is  long,  thin,  and  band- 
like. 1  he  acetabulum  is  smaller  and  more  shallow  than  usual ;  it 
can  often  receive  the  head  of  the  bone,  though  it  cannot  retain  it.  The 
capsule  is  large  and  room}^  After  the  child  has  walked,  sundry  modi- 
fications make  themselves  evident.  The  head  of  the  bone  becomes 
more  and  more  displaced,  so  that  finally  it  may  lie  well  above  the 
acetabulum  on  the  dorsum  ilii  (Fig.   167).     The  capsule  becomes 


THE  SURGERY  OF  DEFORMITIES 


449 


Stretched  over  the  displaced  head,  and  much  thicker  than  usual ;  the 
ligamentum  teres  is  elongated.  The  head  of  the  bone  is  consider- 
ably altered  and  often  much  deformed;  the  acetabulum  becomes 
triangular  in  shape,  owing  chiefly  to  want  of  growth  of  the  iliac 
portion;  whilst  the  muscles  are  necessarily  modified  as  to  their 
length.  A  new,  but  ver\'  imperfect,  acetabulum  forms  on  that 
portion  of  the  dorsum  ilii  where  the  head  of  the  bone  rests. 

Treatment  is  usually  dela^-ed  until  the  child  is  two  or  three  years 
old,  and  able  to  walk.  In  the  meantime,  if  a  diagnosis  is  made,  the 
head  of  the  bone  is  drawn  down  into  the  socket  night  and  morning 


Fig.   i6: 


-Radiogram  of  Double  Congenital  Dislocation  of  the 
Hip-Joint. 


The  noticeable  points  are  the  absence  of  the  acetabular  cavities  and  the  dis- 
placement upwards  and  distortion  of  the  heads  of  the  femora. 


(a  matter  of  no  diflficulty,  as  a  rule),  and  worked  about  therein,  with 
massage  to  the  surrounding  muscles.  Some  surgeons  recommend 
the  use  of  prolonged  traction  even  at  this  early  period. 

At  a  later  age  (up  to  five  or  six  years)  Lorenz's  bloodless  method  of 
treatment  may  be  employed  with  some  hopes  of  a  successful  issue,  at 
any  rate,  in  unilateral  cases,  (i)  The  head  of  the  bone  is  first  drawn 
down  to  the  level  of  the  acetabulum.  Some  surgeons  recommend 
this  to  be  effected  by  gradual  extension;  others  do  it  at  one  sitting 
under  an  aucesthetic.  The  adductor  muscles  are  the  chief  hindrance, 
and  will  require  a  good  deal  of  kneading,  or  even  possibly  section 
with  a  tenotome.  The  anterior  and  posterior  muscles  must  also  be 
fully  stretched  by  forcible  flexion  and  hyper-extension  of  the  limb. 
(2)  The  head  of  the  bone  is  to  be  replaced  in  the  acetabulum,  and 

29 


450  A   MANUAL  OF  SURGERY 

as  this  cavity  is  small  and  chink-like,  and  sometimes  covered  in  by 
the  front  of  the  capsule,  a  good  deal  of  difficulty  may  be  here  ex- 
perienced. The  limb  is  fully  flexed  and  then  firmly  abducted, 
extended  and  everted;  upward  pressure  from  behind,  as  by  the 
fingers  or  the  insertion  behind  the  trochanter  of  a  leather-covered 
wedge  (Lorenz),  may  be  of  assistance.  The  head  of  the  bone  can 
sometimes  be  felt  to  slip  into  the  acetabulum,  and  the  manoeuvre 
should  be  repeated  several  times,  as  it  were,  grinding  the  head  of  the 
femur  into  the  cavity.  (3)  The  limb  is  then  put  up  in  plaster  of  Paris 
from  the  pelvis  to  the  knee  in  a  position  of  abduction  and  slight 
eversion,  and  with  the  leg  hyper-extended.  It  is  maintained  in  this 
position  for  ten  or  twelve  weeks,  and  it  is  well  to  ascertain  by 
radiography  that  the  bone  has  not  slipped.  At  the  end  of  that  period 
it  will  probably  be  found  that  a  less  degree  of  abduction  will  suffice 
in  order  to  keep  the  bone  in  place,  and  a  fresh  case  of  plaster  is 
applied  with  the  limb  in  this  new  position,  the  extension  and  out- 
ward rotation  being  maintained.  As  soon  as  possible  the  child  is 
encouraged  to  walk  on  the  limb  in  this  position  of  abduction,  so  as  to 
force  the  head  of  the  bone  still  deeper  into  the  acetabulum ;  crutches 
are  required  at  first,  but  he  will  soon  do  without  them.  The  plaster 
casing  is  usually  needed  for  six  months,  and  then  massage  and  exer- 
cises will  be  required. 

Where  actual  reduction  has  failed,  benefit  is  often  obtained  by 
forcing  the  head  of  the  bone  forwards  into  the  neighbourhood  of  the 
anterior  superior  spine;  the  gait  is  manifestly  improved  by  diminish- 
ing the  tilting  of  the  pelvis  and  the  lordosis. 

In  older  children  (from  five  to  ten  years)  treatment  by  open  opera- 
tion can  be  undertaken.  The  joint  is  opened  from  the  back  or  front, 
the  head  of  the  bone  is  shaped  up,  the  acetabulum  enlarged  so  that 
the  head  can  be  replaced  in  it,  and  any  tense  structures  divided 
which  prevent  reduction.  The  limb  is  subsequently  immobilized  in  a 
position  of  eversion  and  abduction,  but  for  as  short  a  time  as  possible. 
Even  if  ankylosis  results,  the  patient's  gait  is  considerably  improved. 

Coxa  Vara,  or  incurvation  of  the  neck  of  the  femur  (Fig.  168) ,  is  a 
condition  in  which  the  neck  of  the  bone,  instead  of  passing  obliquely 
upwards,  is  horizontal,  or  in  bad  cases  directed  downwards,  whilst 
shortening  from  interstitial  absorption  also  occurs,  and  the  head 
becomes  mushroom-shaped.  At  first  the  osseous  tissue  is  softened, 
but  after  a  while  sclerosis  supervenes.  It  is  met  with  in  children  as 
a  result  of  rickets,  or  perhaps  more  frequently  in  young  adults,  when 
it  is  sometimes  due  to  the  adolescent  form  of  the  same  disease. 
Certainly  it  is  seen  most  frequently  in  those  who  have  to  do  much 
walking  or  carrying  of  heavy  weights.  In  some  cases  it  results  from 
a  gradual  slipping  down  or  traumatic  separation  of  the  epiphysis, 
which  constitutes  the  head  of  the  bone,  or  from  a  fracture  of  the  neck 
in  a  child,  followed  by  yielding  of  the  callus. 

The  Symptoms  commence  with  pain  in  the  region  of  the  hip, 
followed  by  a  distinct  limp.  As  the  neck  of  the  bone  becomes 
absorbed  or  curved,  the  trochanter  rises  above  Nelaton's  line,  and 


THE  SURGERY  OF  DEFORMITIES 


451 


real  sliortening  of  the  limb  occurs,  even  up  to  i\  inches.  The  hmb 
is  also  everted  and  the  trochanter  increasingly  prominent,  especially 
on  flexing  the  thighs.  Internal  rotation  and  abduction  of  the  joint 
are  limited,  the  latter  being  practically  impossible  in  the  more  severe 
cases,  owing  to  the  base  of  the  trochanter  hitching  against  the  lip  of 
the  acetabulum.  On  flexing  the  limb,  the  thigh  sometimes  lies 
across  the  sound  one,  whilst  in  the  later  stages  the  adduction  may  be 
so  marked  as  to  constitute  a  scissor-legged  condition.  As  distin- 
guishing features  may  be  mentioned:  the  absence  of  local  swelling 
or  tenderness  on  pressure,  as  also  of  the  up-and-down  movement  on 
traction,  so  well  marked  in  congenital 
dislocation,  whilst  suppuration  never 
follows,  and  thickening  of  the  tro- 
chanter is  not  observed. 

Treatment. — In  the  early  stages  rest 
is  the  essential,  and  thereby  any  in- 
crease in  the  deformity  already  exist- 
ing is  prevented;  local  massage  and 
manipulation  are  also  advisable,  whilst 
in  children  prolonged  extension  with 
inversion  may  do  good.  In  the  later 
stages,  sub-trochanteric  osteotomy,  in 
order  to  alter  the  axis  of  the  bone,  is 
perhaps  the  best  measure  to  undertake, 
although  a  cuneiform  osteotom}'  of  the 
neck  is  recommended  by  some.  The 
subsequent  shortening  may  be  dealt 
with  by  means  of  a  thick  sole  on  the 
under  surface  of  the  boot. 

Coxa  Valga  is  the  term  applied 
to  the  opposite  deformity,  in  which 
the  axis  of  the  neck  of  the  femur 
approaches  more  to  that  of  the 
shaft,  and  the  angle  of  inclination  between  the  two  is  greater 
than  the  normal  125°.  It  is  usually  secondary  to  congenital  dislo- 
cation or  infantile  paralysis,  and  largely  due  to  the  absence  of  the 
transmission  of  the  body-weight.  The  limb  is  usually  abducted  and 
rotated  outwards,  and  there  is  some  limitation  of  adduction  and 
internal  rotation.  The  trochanter  is  flattened  and  displaced  below 
Nelaton's  line.  Treatment,  if  necessary,  is  usualty  directed  to  the 
cause;  but  if  the  resulting  limp  is  seriously  noticeable,  a  sub- 
trochanteric osteotomy  may  be  desirable. 

Congenital  Affections  of  the  knee  are  mainly  connected  with  the 
patella,  which  is  sometimes  absent,  and  then  other  deformities  are 
associated  with  its  non-development.  The  extensor  tendon  passes 
down  the  front  of  the  knee  as  a  thick  band,  and  the  function  of  the 
joint  is  not  much  impaired. 

Congenital  Dislocation  of  the  Patella  may  be  present  as  a  persistent 
lesion,  the  bone  lying  to  the  outer  side  of  the  joint;  but  more  com- 


FiG.   168. — Coxa  Vara. 

The  dotted  lines  represent  the 
normal  neck  of  the  femur. 


452 


A   MANUAL  OF  SURGERY 


monly  tlie  displacement  only  occurs  at  intervals,  and  then  produces 
acute  pain  followed  by  synovial  effusion.  Replacement  is  easy  when 
the  joint  is  extended.  '1  he  cause  of  the  trouble  is  either  an  imperfect 
development  of  the  external  condyle  of  the  femur  or  abnormal 
laxity  of  the  capsule.  Genu  valgum  may  be  associated  with  the 
former,  and  paralysis  of  the  extensor  muscles  with  the  latter. 
Treatment  consists  either  in  tightening  up  the  capsule  and  synovial 

membrane  by  excising  a 
portion  on  the  inner  side 
of  the  patella,  or  in  correct- 
ing the  genu  valgum.  Some 
surgeons  have  cliiselled  off 
the  tubercle  of  the  tibia  with 
the  attached  ligamentum 
patellae,  and  refixed  it  on 
the  inner  surface  of  the  tibia. 
Genu  Valgum,  or  knock- 
knee,  is  a  deformity  in  which, 
if  the  knees  are  allowed  to 
touch  with  the  patelUe  look- 
ing forwards,  the  malleoli 
are  separated  one  from  the 
other — i.e.,  it  is  a  condition 
of  fixed  abduction  of  the 
legs  from  the  middle  line, 
with  some  external  rotation 
(Fig.  169).  One  or  both 
limbs  may  be  affected,  but 
if  due  to  general  causes  the 
double  form  is  more  common. 
Occasionally     genu     valgum 


Fig.   169.- 


-Genu  Valgum  of  Rachitic 
Origin. 


The  patient  was  a  child  aged  twelve  years, 
and  the  cause  of  the  deformity  was 
rickets.  The  femora  were  curved  antero- 
posteriorly,  but  radiography  demon- 
strated that  the  trouble  in  the  right  leg 
was  as  much  tibial  as  femoral  in  origin. 
Cuneiform  osteotomy  of  both  tibia  and 
iemur  was  needed  on  the  right  side, 
whilst  simple  osteotomy  of  the  femur 
sufficed  to  correct  the  left  side. 


occurs  in  one  leg,  whilst  the 
other  is  in  a  condition  of 
genu  varum. 

1  here  are  two  main  varieties 
of  the  disease,  viz.:  (i)  The 
rachitic  genu  valgum  of 
young  children,  and  (2)  the 
static  form  occurring  in  ado- 
lescents. 

The  genu  vaLgnm  of  young 
children  arises  from  the  ir- 
regular epiphyseal  development  induced  by  rickets.  Increased  growth 
occurs  on  the  inner  side  of  the  joint,  and  this  may  involve  equally 
the  femur  and  tibia,  although  most  frequently  the  former  is  mainly 
affected.  When  once  the  axis  of  the  limb  is  altered,  the  weight  of 
the  trunk  is  transmitted  chiefly  through  the  outer  portion  of  the 
joint,  and  development  on  this  side  is  thereby  hindered.  In  not  a 
few  cases  an  antero-lateral  rachitic  curvature  of  the  diaphysis  of  the 
femur  is  an  important  element. 


THE  SURGERY  OF  DEFORMITIES  453 

The  Static  genu  valgum  of  adolescents  occurs  most  commonly  in 
voung  people  of  relaxed  constitution,  and  particularly  m  those  who 
have  to  carry  heavy  weights.     Thus,  anemic  girls  who  act  as  nurse- 
maids, and  young  "bricklayers,  smiths,  and  porters,  are  very  hable 
to  it      The  method  of  origin  is  probably  as  follows:  In  the  erect 
posture  the  femur  is  normally  set  at  an  angle  to  the  tibia  (which  is 
Vertical)  in  such  a  way  that  the  weight  of  the  trunk  passes  rather 
through  the  outer  than  the  inner  condyle,  whilst  the  latter  structure 
is  lengthened  in  order  to  keep  the  plane  of  the  knee-]omt  horizontal. 
1  his  position  naturally  throws  a  certain  amount  of  strain  and  tension 
on  the  internal  lateral  ligament,  even  in  a  healthy  person  (hence  its 
insertion  into  the  shaft  and  not  merely  into  the  upper  epiphysis  oi 
the  tibia) ;  and  this  strain  is  increased  when  the  natural  position  of 
rest— ^  e.  with  the  feet  separated  and  slightly  abducted— is  adopted. 
A  long  continuance  of  this  posture  tires  those  muscles  on  the  inner 
side  of  the  hmb  which  tend  to  counterbalance  this  strain  especially 
if  a  certain  amount  of  additional  weight  has  to  be  carried,  and  par- 
ticularly in  those  whose  bones  have  rapidly  increased  m  length  and 
weight  "without  any  coincident  increase  in  power  of  muscles  or 
ligaments.      Hence  the  internal  lateral  ligament  becomes  more  and 
more  stretched,  and  not  unfrequently  a  certain  amount  of  lateral 
mobihty  of  the  knee  is  noticed  in  the  early  stages.     Subsequently 
the  outer  condyle  becomes  atrophied  from  more  weight  being  trans- 
mitted through  it,  and  the  inner  condyle  becomes  lengthened  from 
overgrowth.     Flat-foot   and  lateral  curvature  of  the  spme  often 
accompany  this  form  of  genu  valgum,  the  former  being  also  usual  y 
due  to  ligamentous  relaxation,  whilst  the  latter  may  be  merely 
compensatory  if  the  deformity  in  the  knee  is  unilateral. 

Occasionally  genu  valgum  is  due  to  traumatic  causes  such  as 
fracture  of  the  tibia  or  femur  close  to  the  joint,  or  lateral  dislocation 
of  the  knee;  whilst,  again,  it  may  be  caused  by  atrophy  consequent 
on  interference  with  the  epiphysis  from  local  injury  or  diseases  other 
than  rickets.  It  is  sometimes  observed,  as  a  result  of  ridmg,  m  those 
with  long  legs,  as  in  cavalry  soldiers;  short-legged  individuals,  such 
as  iockevs,  are  more  liable  to  develop  a  condition  of  genu  varum. 

The  Physical  Condition  of  the  parts  about  the  knee  may  be  sum- 
marized as  follows:  [a)  The  inner  condyle  of  the  femur  is  elongated 
and  prominent;  the  increase  in  size  is  mamly  m  the  vertical  ana 
•  transverse  directions,  and  but  very  little  antero-posteriorly,  so  that, 
on  flexion  of  the  joint,  the  deformity  to  a  large  extent  disappears, 
(b)  impaired  growth  and  atrophy  of  the  outer  femoral  condyle  and 
tibial  tuberosity  are  present  owing  to  the  weight  of  the  body  being 
transmitted  more  directly  through  these  structures;  (c)  relaxation  ot 
the  hgamentous  and  muscular  tissues  takes  place  on  the  inner  side 
of  the  joint;  this,  however,  is  not  constant,  especially  m  the  later 
stages,  or  in  cases  which  are  stationary;  {d)  the  tendons  and  liga- 
ments on  the  outer  aspect  of  the  joint  are  contracted  and  shortened 
especially  the  external  lateral  ligament,  the  iho-tibial  band,  and  the 
tendon  of  the  biceps;  {e)  the  patella  tends  to  be  thrown  outwards. 


454  A   MANUAL  OF  SUIiGERY 

and  in  bad  cases  recurring  dislocation  is  sometimes  observed;  (/)  in 
rachitic  cases  a  localized  bony  outgrowth  can  usually  be  detected  on 
the  inner  surface  of  the  tibia  about  2  or  3  inches  from  the  joint,  and 
probably  due  to  a  localized  periostitis  at  the  point  of  attachment  of 
the  internal  lateral  ligament. 

The  feet  are  displaced  outwards,  or  occasionally  inwards,  as  best 
suits  the  convenience  of  the  patient  in  obtaining  as  good  a  footing  as 
possible;  the  bones  of  the  legs  and  of  the  thighs  are  often  bent; 
whilst,  if  unilateral,  scoliosis  may  result.  In  well-marked  cases  the 
gait  of  the  patient  is  of  a  rolling  or  waddling  type,  and  very  charac- 
teristic. 1  he  legs  are  partially  flexed,  and  as  tiie  condyles  t(juch  or 
overlajx  tliey  have  to  be  separated  at  each  step  to  allow  of  progression. 

Treatment. — In  rachitic  cases,  the  infant  requires  the  adoption  of 
dietetic  and  therapeutic  measures  suitable  to  the  condition  present. 
For  the  local  deformity  absolute  rest  in  bed  is  enforced;  the  limbs 
are  well  rubbed  daily,  and  such  manipulation  and  pressure  employed 
as  will  help  to  straighten  the  limb.  By  perseverance  slow  but 
appreciable  progress  may  be  made  until  the  deformity  is  corrected. 
In  older  children,  splints  ma\'  be  applied  on  the  outer  side  of  the 
limbs,  reaching  from  the  waist  or  axilla  down  to  the  outer  malleoli, 
or,  if  they  are  to  be  kept  off  their  feet,  beyond  them.  These  are 
retained  in  position  by  water-glass  bandages,  put  on  firmly  enough 
to  draw  the  knees  outwards.  Such  an  arrangement  is  often  sufficient 
in  early  cases  to  bring  about  a  cure  in  the  course  of  a  few  months. 

In  static  cases  the  administration  of  tonics,  such  as  iron  and 
arsenic,  combined  with  rest,  massage,  and  possibly  a  change  of  air, 
will  frequently  suffice  to  determine  a  cure  in  the  early  stages. 
Suitable  apparatus  must  be  adopted  when  the  patient  is  allowed  to 
walk;  that  usually  employed  consists  of  an  outside  iron  stem,  jointed 
at  the  knee,  fixed  below  into  a  slot  in  the  heel  of  a  well-made  boot, 
and  attached  above  to  a  pelvic  band.  From  it  several  well-padded 
straps  pass  round  the  limb,  and  at  the  knee  itself  a  much  broader 
one  covers  the  projecting  inner  condyle;  by  tightening  these,  the 
limb  is  drawn  out  towards  the  rod,  and  any  increase  of  the  deformity 
is  prevented. 

When,  however,  the  osseous  deformity  is  fixed,  and  the  patient  of 
such  an  age  as  to  preclude  the  hope  of  a  cure  by  mechanical  means, 
osteotomy  will  be  required,  and  the  operation  devised  by  Macewen,  or 
some  modification  of  it,  is  that  generally  employed.  It  consists  in 
the  division  of  the  femur  transversely  about  a  finger's  breadth 
above  the  upper  border  of  the  external  condyle,  so  as  to  be  well 
away  from  the  epiphyseal  cartilage.  Macewen  himself  uses  an 
osteotome*  for  the  purpose,  introducing  it  through  an  incision  made 
J  inch  in  front  of  the  tendon  of  the  adductor  magnus,  and  turning 
it  so  as  to  lie  at  right  angles  to  the  long  axis  of  the  shaft ;  he  divides 
the  bone  for  three-quarters  of  its  diameter,  and  breaks  the  re- 
mainder.    A  similar  method  maj'  be  employed  from  the  outer  side, 

*  An  osteotome  dilters  from  a  chisel  in  the  fact  that  the  former  is  bevelled 
on  both  sides,  whilst  the  latter  is  merely  bevelled  on  one  side. 


T?IE  SURGERY  OF  DEFORMITIES 


455 


\ 


the  force  used  in  breaking  the  inner  layer  of  compact  bone  com- 
minuting and  compressing  that  portion,  and  so  diminishing  the 
deformity.  Man}^  surgeons,  however,  prefer  to  divide  the  bone 
with  a  saw,  previously  making  a  track  for  it  along  the  front  of  the 
femur,  and  we  certainly  consider  that  such  an  operation  is  simpler, 
and  equally  efficacious.  The  limb,  having  been  straightened,  is 
either  put  up  at  once  in  plaster 
of  Paris,  or,  perhaps,  at  first  in  a 
Gooch's  splint,  which  allows  the 
wound  to  be  looked  at  and  dressed, 
and  subsequently  in  plaster.  Union  .. 
is  complete  in  six  weeks,  but  an 
immoveable  apparatus  should  be  kept 
on  for  three  months. 

In  a  few  cases  due  to  rickets  it 
may  be  necessary  to  divide  the  tibia 
just  below  the  tubercle  in  addition  to 
dealing  with  the  femur.  This  is  best 
accomplished  as  a  first  step,  and  the 
fibula  will  also  have  to  be  divided. 
WTien  these  wounds  have  consohda- 
ted,     the    femur    is    dealt    with,    if 


Fig.  170. 


—Bilateral    Genu 

Varum. 


necessary. 

Genu  Varum  is  a  less  common  con- 
dition, characterized  by  a  fixed  separa- 
tion of  the  knees  when  the  ankles 
are  in  contact  (Fig.  170).  It  arises 
from  three  chief  causes:  (i.)  Occupa- 
tion, and  particularly  that  of  a  jockey, 
the  short  legs  being  constantly  apposed 
to  the  sides  of  the  horse;  (ii.)  trau- 
matism, especially  if  directed  to  the 
femoral  condyles;  and  (iii.)  rickets, 
the  lesion  usually  present  being  a 
well-marked  excurvation  of  the 
femoral  shafts,  with  possibly  a 
similar  curve  of  the  tibise  {bow-leg). 
The  condition  is  usually  bilateral  and 
sjmimetrical,  but  occasionally  one 
side  only  is  affected,  whilst  the  other 
leg  is  in  a  state  of  genu  valgum.  Treatment  in  the  early  stage  is  by 
splints,  in  the  latter  by  operation,  which  consists  either  in  simple 
osteotomy  above  the  knee,  or  in  cuneiform  osteotomy  of  the 
shaft  of  the  femur. 

Genu  Recurvatum,  or  back-knee,  is  a  deformity  occasionally  met 
with,  in  which  the  joint  is  hyper-extended,  the  limb  describing  a 
curve  with  the  concavity  forwards ;  it  is  necessarily  associated  with 
relaxation  or  stretching  of  the  crucial  ligaments,  and  is  usually 
due  to  a  congenital  displacement,  possibly  the  result  of  the  limbs 


The  patient  was  a  girl  of  thir- 
teen years,  who  had  devel- 
oped this  condition  during 
two  years,  and  was  the  sub- 
ject of  adolescent  rickets. 
Enlargement  of  the  epiphyseal 
ends  of  the  radius  and  ulna, 
and  of  the  costo-chondi^al 
junctions,  was  also  present. 


456 


A   MANUAL  OF  SURGERY 


not  being  flexed  in  utero,  but  extended  with  the  feet  under  the 
chin.  It  is  sometimes  the  result  of  paralysis  of  the  extensor  muscles, 
and  is  then  due  to  the  necessity  for  the  patient  to  keep  his  knee 
fully  or  hyper-extended  if  it  is  to  be  a  basis  of  support ;  in  time  the 
posterior  ligaments  give  way,  and  deformity  results.  Genu  recur- 
vatum  may  also  arise  from  irregular  growth  along  the  epiphyseal 
line,  possibly  as  a  sequela  of  tuberculous  or  other  disease  of  limited 


Fig.  171. — Radiogram  of  Rachitic  Curvature  of  Both  Femora  in  a 
Child,  aged  Nine  Years,  who  had  suffered  in  Consequence  from 
Many  Fractures.  The  Tibi.^  also  showed  Typical  Rachitic 
Deformities. 

extent  in  that  region,  and  sometimes  as  a  result  of  the  disorganization 
of  the  joint  in  Charcot's  disease.  It  has  also  been  known  to  occur  as 
an  acquired  accomplishment  in  fakirs  and  contortionists.  Treatment 
must  be  suited  to  the  special  requirements  of  the  individual  case. 

Rachitic  Deformities  of  the  Bones  of  the  Leg  arc  not  unfrequent,  if 
in  the  course  of  an  attack  of  rickets  a  child  is  allowed  to  11m  about. 
The  trouble  may  involve  both  segments  of  the  limb,  and  give  rise 
to  a  general  excurvation,  constituting  what  is  known  as  hoxv-lcgs,  the 


THE  SURGERY  OF  DEFORMITIES  457 

knees  being  widely  separated  the  one  from  the  other,  and  the 
antero-posterior  curve  being  exaggerated.  The  femora  are  bent 
antero-posteriorly  with  the  convexity  of  the  curve  forwards  and 
outwards;  the  main  convexity  of  the  curve  usually  occurs  about 
the  junction  of  the  upper  and  middle  fourths,  and  here  it  may  be 
so  marked  as  to  be  a  cause  of  spontaneous  fracture.  We  have  had 
a  case  of  this  nature  under  our  observation  for  some  years,  where 
both  femora  had  been  frequently  broken  as  a  result  of  extreme 
rachitic  distortion  (Fig.  171).  The  tibia  and  fibula  participate  in 
this  deformity,  or  are  separately  affected;  the  antero-postenor 
curve  is  usually  increased,  and  some  amount  of  abduction  or  adduc- 
tion may  also  be  present.  The  bones  in  these  cases  are  flattened 
from  side  to  side,  presenting  a  sharp  edge  in  front,  with  a  buttress- 
hke  support  or  strut  reaching  along  the  concavity;  they  become 
exceedingly  dense  and  sclerosed.  .       .       , 

Treatment  in  the  early  stages  consists  of  rest  and  constitutional 
treatment,  and  in  the  application  of  suitable  apparatus  to 
reduce  the  deformity.  Where  the  femora  are  seriously  affected, 
it  may  be  necessary  to  provide  the  patient  with  apparatus 
(somewhat  like  a  Thomas's  knee-splint),  which  fits  closely  round 
the  pelvis,  and  carries  the  weight  to  the  ground  by  lateral 
metal  rods  which  also  maintain  continuous  extension.  In  the 
worst  cases  operation  will  be  required,  but  never  uiitil  all  signs 
of  active  disease  have  passed.  The  bones  may  be  divided  at  their 
most  prominent  part,  or,  if  necessary,  a  wedge-shaped  portion  may 
be  removed  {cuneiform  osteotomy),  the  sections  being  made  at  nght 
angles  to  the  upper  and  lower  segments  of  the  bone  respectively. 
Careful  and  prolonged  after-treatment,  including  the  use  of  suitable 
splints,  is  required,  especially  where  the  femora  have  been  divided, 
in  order  to  prevent  a  reappearance  of  the  deformity. 

The  tibia  and  fibula  also  become  distorted  and  curved  antero- 
posteriorly  as  the  result  of  inherited  syphiUs ;  this  usually  comes 
under  notice  at  a  later  date  than  the  rachitic  change,  and  is  due 
to  a  deposit  of  new  bone  under  the  periosteum  rather  than  to 
bending.  The  deformity  is  purely  antero-posterior,  without  lateral 
deviation,  whilst  the  subcutaneous  margin  of  the  tibia  is  rounded, 
and  not  sharp  as  in  rickets.  Moreover,  the  curve  generally  involves 
the  centre  of  the  bone,  whilst  in  rickets  the  chief  deformity  occurs 
either  near  the  knee  or  a  little  above  the  ankle. 

Talipes. 

By  tahpes,  or  club-foot,  is  meant  a  deformity  of  the  foot  due  to 
muscular,  hgamentous,  or  osseous  causes,  the  displacement  occurring 
mainly  at  the  ankle  and  mid-tarsal  joints. 

Causes. — Tahpes  may  be  congenital  or  acquired. 

Congenital  malformation  is  responsible  for  a  certain  percentage  of 
the  cases  resulting  from  imperfect  formation  of  the  bones  of  the  foot, 
occasionahy  from  absence  of  the  lower  end  of  the  tibia  or  fibula, 


458  A   MANUAL  OF  SURGERY 

or  very  rarely  from  intra-uterine  paralysis  of  central  origin.  Other 
cases  are  due  to  malposition  of  the  feet  in  ntcro,  possibly  resulting 
from  a  deficient  amount  of  liquor  amnii,  as  a  result  of  which  the  feet 
are  abnormally  compressed  and  held  in  one  position.  Naturally 
the  legs  of  the  foetus  are  in  a  state  of  flexion,  and  the  feet  usually  in 
a  position  corresponding  to  that  of  tahpes  varus;  it  is  easy  then  to 
understand  that  in  an  unusually  small  uterus  this  position  may 
become  fixed.  Spina  bifida  in  the  lumbar  region  is  occasionally 
associated  with  congenital  tahpes,  which  is  then  probably  due  to 
impairment  of  nervous  control.  The  congenital  variety  is  often 
hereditary,  and  may  occur  in  several  members  of  the  same  family, 
or  be  transmitted  through  many  generations. 

The  acquired  varieties  arise  from  some  derangement  of  the  equi- 
librium normally  maintained  between  opposing  groups  of  muscles,  in 
consequence  of  which  the  more  powerful  group  draws  the  foot  into 
an  abnormal  position.  Thus  it  may  be  due  to:  {a)  Paralysis  of 
central  origin,  one  of  the  commonest  causes  of  tahpes;  in  young 
children  this  form  is  usually  the  result  of  infantile  palsy  (anterior 
poho-myelitis),  whilst  a  similar  affection  is  occasionally  seen  in 
adults,  [h]  Cicatricial  contraction  of  muscles  from  diffuse  suppura- 
tion, or  arising  from  burns  or  disease  of  neighbouring  bones;  thus 
necrosis  or  caries  of  the  tibia  may  lead  to  the  formation  of  an  abscess 
in  the  sheaths  of  the  tibiahs  anticus  or  posticus,  and  contraction  of 
one  or  both  of  these  muscles  may  cause  tahpes  varus,  (c)  Essential 
muscular  shrinking,  resulting  from  a  chronic  myositis  fibrosa,  is 
occasionally  met  with  in  elderly  people,  [d]  Affections  of  the  main 
peripheral  nerve-trunks  of  the  leg  also  lead  to  talipes.  If  the  in- 
ternal pophteal  -nerve  is  involved,  tahpes  calcaneo-valgus  will  ensue, 
whilst  a  lesion  of  the  external  popliteal  nerve  produces  tahpes 
equino-varus,  but  never  to  any  marked  degree,  {e)  Certain  diseases 
of  the  cord  of  a  sclerosing  type  occasionally  cause  a  spastic  variety 
of  tahpes.  (/)  Shortening  of  the  leg  from  hip  or  knee  mischief  often 
induces  a  compensatory  talipes  equinus,  whilst  injuries  or  diseases 
of  one  of  the  epiphyses  of  the  leg  bones  may  stop  its  grow^th,  and 
then  the  continued  development  of  the  other  bone  forces  the  foot 
to  one  side  or  the  other,  (g)  It  is  a  question  whether  the  condition 
known  as  flat-foot,  arising  from  prolonged  standing,  is  to  be  classed 
as  a  form  of  tahpes ;  some  surgeons  draw  but  little  difference  between 
it  and  talipes  valgus,  [h)  Finally,  prolonged  maintenance  of  the 
foot  in  a  bad  position  may  lead  to  permanent  deformity,  a^^in  the 
variety  known  as  talipes  decubitus. 

Four  primary  forms  of  talipes  are  described,  viz.:  T.  Equinus,  in 
which  the  heel  is  drawn  up,  the  patient  walking  on  the  toes  (plantar- 
flexion)  ;  T.  Calcaneus,  in  which  the  toes  are  raised  from  the  ground 
(dorsi-flexion) ;  T.  Varus,  in  which  the  anterior  half  of  the  foot  is 
adducted  and  inverted,  and  the  inner  side  of  the  foot  is  raised,  the 
patient  walking  on  the  outer;  and  T.  Valgus,  due  to  abduction  and 
eversion  of  the  anterior  half  of  the  foot,  or  to  yielding  of  the  longi- 
tudinal arch  on  the  inner  side.     Not  unfrequently  mixed  forms  occur, 


THE  SURGERY  OF  DEFORMITIES 


459 


due  to  the  association  of  two  of  the  above — e.g.,  T.  equino-varus,  or 
T.  equino-valgus,  or  T.  calcaneo-valgus. 

As  to  the  relative  frequency  of  these  different  forms,  there  is  not  the 
shghtest  question  that  T.  equino-varus  is  by  far  the  commonest. 
If,  however,  we  exclude  congenital  cases  and  fiat-foot,  T.  equinus  is 
in  all  probability  the  variety  most  frequently  observed. 

Talipes  Equinus  (Fig.  172,  A,  B,  and  C)  is  almost  always  acquired  ; 
as  a  congenital  lesion  it  is  very  uncommon.  It  is  usually  due  to 
paralysis  of  the  extensor  muscles,  either  from  infantile  palsy  or 
injury  to  the  anterior  tibial  nerve;  secondary  contraction  of  the  calf 
muscles  follows,  the  tendo  Achillis  being  tense  and  rigid.  It  also 
occurs  as  a  compensatory  manifestation  where  the  limb  has  been 
shortened,   as  after  hip  disease,   and  may  result  from  prolonged 


A  B  C 

Fig.  172. — -Various  Forms  of  Talipes  Equinus. 


pressure  of  the  bed-clothes  on  the  dorsum  of  the  foot  of  a  bed- 
ridden patient  (T.  decubitus). 

In  the  slightest  cases  all  that  is  noticed  is  that  the  foot  cannot  be 
dorsi-fiexed  beyond  a  right  angle  (right-angled  contraction  of  the 
ankle) .  When  more  marked,  the  heel  is  drawn  up,  and  the  patient 
walks  on  the  heads  of  the  metatarsal  bones  and  on  the  toes,  which  are 
usually  hyper-extended.  In  neglected  cases  due  to  paralysis,  the 
toes  sometimes  become  plantar-flexed,  the  patient  walking  on  their 
upper  surface  (Fig.  172,  C) ;  the  whole  dorsum  of  the  foot  may  even 
in  time  be  turned  downwards.  The  astragalus  is  displaced  forwards 
from  under  the  malleolar  arch,  only  the  posterior  part  of  the  articular 
surface  being  in  contact  with  the  tibia.  In  the  paralytic  type  the 
anterior  segment  of  the  foot  drops  at  the  mid-tarsal  joint,  so  that  the 
head  of  the  astragalus  and  scaphoid  constitute  a  marked  prominence 
beneath  the  skin.  In  all  cases  the  sole  of  the  foot  is  shortened  by 
contraction  of  the  plantar  fascia  and  of  the  short  plantar  muscles 
(pes  cavus),  and  a  certain  amount  of  varus  is  frequently  present. 


460 


A   MANUAL  OF  SURGERY 


In  this,  as  in  all  forms  of  talipes,  callosities,  and  perhaps  bursse 
beneath  them,  form  over  points  of  pressure — viz.,  under  the  heads 
of  all  the  metatarsal  bones. 

Talipes  Varus,  or,  as  it  is  most  frequently  termed,  Equino-varus, 
is  the  commonest  variety  of  congenital  club-foot,  and  is  then  often 


Fig.  173. — Double  Talipes  Equixo- 
VARUS  OF  Congenital  Origin. 


Fig.   174. — The  Same,  seen  from 
Behind. 


bilateral,  and  may  be  accompanied  by  other  congenital  defects — 
e.g.,  hare-Hp  or  spina  bifida.  As  an  acquired  deformity,  T.  varus  is 
not  a  very  unusual  result  of  infantile  palsy  affecting  the  extensor 
and  peroneal  muscles;  other  cases  are  due  to  a  primary  spastic 
contraction  of  these  muscles. 

The  heel  is  drawn  up,  and  the  anterior  half  of  the  foot  adducted 

and  drawn  inwards  (Figs.  173  and 
174).  The  inner  border  of  the  foot 
is  concave,  and  a  well-marked  trans- 
verse crease  crosses  the  sole  on  a  level 
with  the  mid-tarsal  joint  ;  the  outer 
border  is  convex,  and  in  adults  who 
have  walked  a  thick  bursal  formation 
is  usually  present  over  the  cuboid. 
In  neglected  cases  the  patient  may 
even  stand  on  the  dorsal  aspect  of 
the  latter  bone  (Fig.  175).  The  sole 
of  the  foot  is  arched  from  secondary 
contraction  of  the  plantar  fascia  and 
short  muscles  of  the  sole,  and  a  longi- 
tudinal crease  may  run  dowTi  the 
centre  of  the  sole,  owing  to  doubling 
over  of  the  outer  metatarsal  bones. 

The  most  marked  anatomical  changes 
in  the  congenital  type  are  found 
in  the  astragalus,  the  neck  of  which  is  elongated  and  inclined 
inwards  at  an  angle  of  50°  or  more  to  the  body  of  the  bone; 
the  bone  also  projects  forwards  from  under  the  tibio-fibular 
arch,  the  posterior  portion  of  the  upper  articular  facet  alone  re- 


FiG.   175. — Neglected    Case 
of  Talipes  Varus. 


THE  SURGERY  OF  DEFORMITIES  461 

maining  in  contact  with  it.  The  scaphoid  is  displaced  to  the  inner 
side  of  the  head  of  the  astragalus,  and  its  tubercle  is  usually  in  close 
proximity  to,  or  may  even  touch,  the  inner  malleolus.  The  os  calcis 
and  other  tarsal  bones  are  also  modified  in  position  and  shape  to 
correspond  with  these  changes.  The  dorsal  tendons  are  displaced 
inwards,  usually  occupying  the  centre  of  the  concavity  between  the 
foot  and  the  leg.  The  hgaments  on  the  inner  side  of  the  foot  are 
contracted,  especially  the  anterior  portion  of  the  deltoid,  the 
inferior  calcaneo-scaphoid,  and  to  a  less  extent  the  long  and  short 
plantar  ligaments. 

The  following  table  (shghtly  modified  from  Mr.  Tubby's  work  on 
Deformities*)  indicates  the  chief  diagnostic  points  between  con- 
genital and  paralytic  T.  equino-varus : 

Congenital.  Paralytic. 

History Affection  has  existed     Affection    not    developed 

from  birth.  till  the  second  or  third 

year,  and  ushered  in  by 

convulsions,  fever,  etc. 

Feet  affected Usually  bilateral.  More  often  unilateral. 

Circulation    Good.  Feeble ;  limb  is  sometimes 

cold,  blue,  and  clammy. 

Muscles But  little  wasting.  Extreme  wasting. 

Electrical  Reactions      Not  much  impaired.      Almost  entirely  absent  in 

paralyzed  muscles. 
Growth  of  Bones    .  .       Much  as  usual.  Considerably  diminished. 

Creases  in  Sole   ....       Present.  Absent. 

Talipes  Calcaneus  is  an  unfrequent  variety  of  the  deformity,  and 
may  be  either  congenital  or  acquired.  In  the  congenital  form 
(Fig.  176)  the  toes  are  draw^n  upwards  so  that  the  heel  alone  comes 


Fig.  176. — Congenital  Talipes      Fig.  177. — Paralytic  Talipes  Calcaneus, 
Calcaneus.  with  Well-marked  Hallux  Flexus. 


into  contact  with  the  ground,  the  sole  pointing  forwards.  The 
extensor  tendons  are  contracted,  but  the  toes  may  be  flexed  owing 
to  the    tension  of  the  flexor  longus  digitorum.     It  is  sometimes 

*  Macmillan,  1896,  p.  398. 


4^2 


A   MANUAL  or  SURGERY 


associated  with  deviation  of  the  foot  inwards  or  outwards,  consti- 
tuting a  condition  of  T.  calcaneo-varus  or  -valgus.  The  acquired 
variety  (Fig.  177)  is  generally  due  to  infantile  palsy  of  the  calf 
muscles,  or  occasionally  to  overstretching  of  the  tendo  Achillis 
after  tenotomy.  The  longitudinal  arch  of  the  foot  is  increased 
(pes  cavus),  partly  from  the  development  of  a  large  pad  of  fat  over 
the  calcaneal  tuberosities,  but  mainly  from  the  dropping  of  the 
anterior  half  of  the  foot  from  the  mid-tarsal  joint. 

Tahpes  Valgus  is  a  condition  seldom  met  with  as  a  congenital  de- 
formity, except  in  association  with  T.  equinus.  In  it  the  foot 
is  abducted  and  everted,  owing  to  contraction  of  the  peronei 
muscles.  The  sole  becomes  flattened,  and  the  inner  border  of  the 
foot  comes  in  contact  with  the  ground  (Fig.  178).  Considerable 
pain  is  usually  experienced  after 
walking     a    short     distance.      This 


Fig.  178. — Talipes  Valgus  (Congenital), 
WITH  a  Little  Tendency  to  Calcaneus. 


Fig. 


179. — Paralytic  Tali- 
pes Valgus. 


deformity  is  occasionally  due  to  absence  of  the  fibula.  The  acquired 
variety,  which  is  not  uncommon  (Fig.  179)  results  from  paralysis 
of  the  tibial  muscles,  or  from  spastic  contraction  of  the  peronei, 
the  condition  in  these  cases  closely  simulating  fiat-foot. 

The  Diagnosis  of  the  different  varieties  of  tahpes  is,  as  a  rule, 
easily  made,  although  the  cause  of  the  deformity  is  not  always  so 
readily  ascertained.  In  paralytic  cases  the  limb  is  generally 
atrophied,  bluish  in  colour,  and  feels  cold  and  clammy.  Trophic 
lesions  are  not  uncommon  in  the  form  of  recurrent  ulceration,  and 
even  ulcers  of  the  perforating  type  may  develop,  especially  in  cases 
due  to  nerve  lesions,  whether  central  or  peripheral.  The  trouble 
is  often  unilateral,  and  the  muscles  are  wasted  and  flabby.  In  con- 
genital cases  the  condition  is  usually  symmetrical,  and  of  course 
present  from  birth;  considerable  resistance  is  felt  on  any  attempt 
being  made  to  correct  the  deformity,  and  the  hmbs  look  healthy, 
are  well  nourished,  at  any  rate  at  first,  and  free  from  trophic  lesions. 
In  spastic  cases  (most  frequently  T.  equinus)  spasm  or  contraction 
of  other   parts  is  usually   present,   which    renders    the  diagnosis 


THE  SURGERY  OF  DEFORMITIES 


463 


obvious;  one  or  both  limbs  may  be  affected;  the  reflexes  are  ex- 
aggerated; the  gait  is  characteristic;  and  the  muscles,  at  first 
fninly  contracted,  may  finally  atrophy. 

The  Treatment  of  talipes  is  always  tedious,  demanding  care  and 
patience  on  the  part  of  all  concerned.  In  the  congenital  variety  no 
time  should  be  lost  in  correcting  the  deformity,  and,  in  fact,  treat- 
ment should  commence  as  soon  after  birth  as  possible.  The  nurse 
must  be  instructed  to  manipulate  the  foot  into  a  good  position, 
holding  it  there  for  some  time  daily,  and  the  medical  attendant 
may  attempt  more  forcible  correction  two  or  three  times  a  week. 
At  the  same  time  the  muscles  on  the  offending  side  of  the  limb  should 
be  rubbed  and  stimulated.  In  the  early  stages  of  the  paralytic 
variety  friction  and  faradization  of  the  paralyzed  muscles  must  be 
regularly  undertaken.  At  a  somewhat  later  date  treatment  by  the 
apphcation  of  suitable  mechanical  apparatus  may  suffice  to  restore 
the  foot  to  its  normal 
position.  If  this  is  un- 
successful, division  of  the 
contracted  tendons,  liga- 
ments, and  fasciae  will  be 
necessary,  whilst  in  severe 
and  neglected  cases  more 
extensive  operations  in  the 
shape  of  tarsectomy  '  or 
tarsotomy  may  have  to  be 
performed. 

Talipes  equinus,  if  secon- 
dary to  hip  disease,  should 
not,  as  a  rule,  be  interfered 
with.  In  other  early  cases 
it  may  be  remedied  by 
what  is  known  as  Sayre's  apparatus  (Fig.  180).  This  consists  in 
the  application  of  a  plantar  splint  which  projects  slightly  beyond 
the  toes,  and  from  the  anterior  end  of  which  a  piece  of  adhesive 
strapping  is  carried  to  just  below  the  knee,  to  which  it  is  applied 
and  fixed  by  a  firm  bandage.  Each  day  the  bandage  is  carried 
a  little  lower  down  the  limb,  and  as  the  traction  X)f  the  strapping 
is  thereby  increased,  the  foot  is  gradually  extended.  In  the  more 
serious  varieties  tenotomy  of  the  tendo  Achillis  may  be  required, 
accompanied,  if  necessary,  by  division  of  the  plantar  fascia,  whilst 
in  neglected  cases,  or  where  tenotomy  has  failed,  excision  of  the 
astragalus  gives  most  excellent  results,  the  patient  being  able  to 
walk  subsequently  with  a  plantigrade  foot. 

Congenital  T.  equino-varus  may  be  treated  in  the  early  stages  by 
applying  to  the  foot  a  carefully-fitted  malleable  splint  (Fig.  181), 
the  shape  of  which  is  gradually  altered  so  as  to  bring  it  in  time  to 
a  normal  position,  or  by  a  series  of  casings  of  plaster  of  Paris,  a 
little  improvement  being  obtained  at  each  change.  By  care  and 
patience  many  a  cure  will  thus  be  obtained.     In  some. cases,  the 


Fig.  180. — Sayre's  Apparatus  for  Talipes 
Equinus. 

The  upper  figure  shows  how  the  strapping 
is  fixed  to  the  plantar  splint. 


464 


A   MANUAL  OF  SURGERY 


tendo  Achillis  and  plantar  fascia  may  be  divided  and  the  equinus 
and  cavus  elements  cured,  thereby  rendering  the  varus  condition 
more  amenable  to  pressure. 

In  cases  where  such  early  treatment  has  not  been  undertaken,  or 
where  the  deformity  has  not  been  improved  thereby,  forcible  correc- 
tion may  be  attempted.  The  child  is  placed  under  an  anaesthetic, 
and  the'foot  is  forcibly  wrenched  and  moulded  into  a  good  position, 
a  Thomas's  wrench  being  employed,  if  need  be.  It  is  essential  that 
the  foot  should  remain  in  good  position  when  all  force  is  removed 
from  it.     Possibly  division  of  the  tibial  tendons  may  assist  in  this 

procedure,  as  also  section  of  the 
tense  ligaments  on  the  inner  side 
of  the  foot  [syndesmotomy)  ,h\x\.  if 
such  can  be  avoided,  so  much  the 
better.  The  foot  is  then  placed 
in  plaster  of  Paris  for  five  or  six 
weeks,  and  subsequently  mas- 
sage and  suitable  exercises  are 
employed  before  walking  is 
allowed. 

It  is,  however,  only  in  the 
early  stages  that  such  treatment 
is  advisable.  At  the  age  of 
eighteen  to  twenty-four  months 
considerable  growth  of  the  limb 
has  determined  such  osseous  de- 
velopment as  almost  forbids  one 
to  expect  benefit  from  it,  with- 
out the  exercise  of  undue  force. 
Hence,  if  treatment  is  not  com- 
menced till  the  child  is  two 
years  of  age,  and  still  more  if 
the  child  has  walked  or  is 
older,  other  methods  must  be 
employed.  Of  these,  two  chief 
plans  have  been  advocated,  viz.,  tarsectomy  and  Phelps'  operation. 
I.  In  tarsectomy,  a  wedge-shaped  portion  of  bone  is  removed  from 
the  outer  aspect  of  the  foot.  This  is  accomphshed  through  a  semi- 
lunar incision  on  the  outer  aspect  of  the  foot ;  the  thick  subcutaneous 
structures,  including  the  bursa,  are  removed,  and  the  extensor 
tendons,  already  somewhat  displaced  inwards,  are  stripped  from 
the  bones  and  held  aside.  The  tarsus  is  divided  by  a  chisel  in  two 
places  in  such  a  way  that  a  wedge  of  bone  can  be  removed,  the  base 
being  on  the  outer  aspect,  and  the  apex  on  the  inner.  The  position 
of  the  joints  need  not  be  taken  much  into  consideration,  and  as  far 
as  possible  the  sections  are  made  at  right  angles  to  the  anterior  and 
posterior  segments  of  the  foot  respectively,  sufircient  bone  being 
removed  to  allow  the  foot  to  come  into  good  position  without 
difficulty.     After  closing  the  wound,  the  foot  is  kept  in  position,  at 


Fig.  181. —  Malleable  Splint  for 
Treatment  of  Congenital  Talipes 
Equino-varus. 

It  consists  of  two  plates  of  metal,  shaped 
to  fit  the  sole  of  the  foot  and  the  lower 
part  of  the  leg  respectively;  these  are 
united  by  a  malleable  curved  bar  of 
copper.  The  foot-piece  is  first  fixed, 
and  then  the  foot  brought  into  asgood 
a  position  as  possible,  and  the  leg- 
piece  bandaged  on.  Each  week  the 
foot-piece  is  bent  a  little  more  to- 
wards the  normal  position. 


THE  SURGERYIOF  DEFORMITIES  465 

first  by  ordinary  splints  and  subsequently  by  plaster  of  Paris  for 
six  or  eight  weeks.  The  results  are  excellent,  the  foot,  although  a 
little  shortened,  being  firm  and  plantigrade.  2.  Phelps'  operation 
consists  in  dividing  all  the  structures  on  the  inner  aspect  of  the  foot 
through  a  vertical  incision,  starting  above  just  in  front  of  the 
internal  malleolus.  The  mid-tarsal  joint  is  usually  opened,  tendons 
and  ligaments  are  divided,  and  the  foot  put  up  in  a  good  position 
with  the  wound  gaping.  HeaUng  may  be  accelerated  by  skin 
grafting.  The  results  are  at  first  quite  as  good  as  those  attained  by 
tarsectomy,  but  the  deformity  is  likely  to  recur  as  cicatrization 
advances.  In  successful  cases  the  longitudinal  arch  of  the  foot  is 
lost,  and  the  cosmetic  result  is  anything  but  perfect,  whilst  the 
patient  usually  requires  an  instep  support.  In  our  opinion  tar- 
sectomy is  much  the  better  operation,  and  even  when  undertaken  in 
children  need  not  interfere  with  the  subsequent  growth  bi  the  foot. 
In  paralytic  Talipes  varus  the  foot  will  probably  remain  weak 'arid 
flail-like  in  spite  of  treatment,  and  a  suitable  boot  with  leg  irons  to 
steadv  it  will  be  required.  The  character  of  the  treatment  neces- 
sarilv  varies  with  the  extent  of  the  paralysis,  but  occasionally  help 
is  obtained  by  displacing  the  attachment  of  a  healthy  tibialis 
anticus  from  the  inner  to  the  outer  side  of  the  foot.  In  very  bad 
cases  arthrodesis  of  the  ankle  {i.e.,  its  fixation  by  removal  of  the 
articular  cartilage  and  subsequent  synostosis)  may  secure  to  the 
patient  a  firm  basis  of  support. 

In  congenital  Talipes  calcaneus  all  that  may  be  needed  is  di\asion 
or  lengthening  of  the  extensor  tendons ;  but  in  the  paralytic  variety 
some  form  of  apparatus  must  always  be  worn.  Where  the  tendo 
AchiUis  is  thin  and  attenuated,  a  portion  of  it  may  be  excised,  and 
the  ends  united  by  suture;  or  the  tubercle  of  the  os  calcis  into  which 
the  latter  is  inserted  may  be  sawn  off  and  re-attached  by  a  nail  or 
peg  to  the  bone  at  a  lower  level  (Walsham) ;  but  the  prognosis  in 
all  forms  due  to  paralysis  is  unsatisfactory.  ^ 

Talipes  valgus,  if  unreKeved  by  the  apphcation  of  suitable  boots;- 
may  need  di\nsion  of  the  peroneal  tendons,  or  in  severer  cases 
wrenching  the  foot  into  position,  and  fixation  in  plaster  of  Paris. 
Removal  of  a  wedge-shaped  portion  of  bone  from  the  inner  aspect' 
of  the  foot  may  be  undertaken,  but  is  not  very  successful. 

Flat-foot  {syn.  :  Splay-foot  or  Spurious  Valgus)  is  a  condition  fre-' 
quently  seen  in  young  adults  whose  occupation  exposes  them  to ' 
over-fatigue,  or  the  carrying  of  heavy  weights — e.g.,  in  nurse-girls  or 
shop-boys.  It  occurs  as  a  natural  condition  in  many  of  the  negro 
races,  and  is  more  often  seen  in  long  than  in  short  feet.  -  Tt  also 
results  from  rupture  of  the  inferior  calcaneo-scaphoid  ligament, 
fracture  of  the  neck  of  the  astragalus,  of  the  sustentaculum  tab,  or; 
of  the  greater  process  of  the  calcaneum  {traumatic  flat-foot). 

Mechanism. — In  thfe  majority  of  non-traumatic  cases  it  is  due  t6- 
relaxation  of  the  inferior  calcaneo-scaphoid  ligament,  which  sup- 
ports the  under  surface  of  the  head  of  the  astragalus,  and  thus  keeps 
up  the  longitudinal  arch  of  the  foot.     This  in  its  turn  is  braced  up  by 

30 


466  A   MANUAL  OF  SUIiGERY 

the  tendon  of  the  tibialis  posticus  and  an  expansion  backwards  there- 
from to  the  OS  calcis,  as  also  by  the  plantar  fascia  and  ligaments, 
and  by  the  short  muscles  of  the  sole.  A  rapid  increase  in  the 
length  and  weight  of  the  skeleton  ai)art  from  an  equivalent  in- 
crease in  strength  of  muscles  and  ligaments  throws  undue  strain 
upon  this  structure,  especially  if  the  patient  is  suddenly  exposed 
to  long  hours  of  standing  or  weight-carrying.  The  ligament  stretches, 
the  head  of  the  astragalus  sinks,  the  anterior  portion  of  the  foot 
becomes  abducted  at  the  mid-tarsal  joint,  and  the  typical  splay- 
foot results.  The  tibialis  posticus  is  often  relaxed  or  even  paretic, 
and  the  peronei  tendons  are  in  the  later  stages  contracted.  Occa- 
sionally the  deformity  is  due  to  a  gonorrhreal  inflammation  of  the 
inferior  calcaneo-scaphoid  ligament,  which  becomes  relaxed  and 
yields  under  the  weight  of  the  body.  However  produced,  the  de- 
formity is  tolerably  characteristic  (Figs.  182  and  114).  The  sole  of 
the  foot  is  flat,  and  in  well-marked  cases  comes  in  contact  with  the 

ground  throughout  the 
whole  of  its  extent.  The 
inner  border  is  convex  and 
somewhat  lengthened, 
whilst  the  anterior  half 
is  abducted.  The  head 
of  the  astragalus  is  felt 
a  little  in  front  of  and 
below  the  internal  mal- 
leolus, whilst  the  sus- 
tentaculum tali,  which  is 
normally  distinguishable 
about  I  inch  below  the 
Fig.  182. — Flat-Foot.  malleolus,    is   buried    by 

this  displacement.  The 
tubercle  of  the  scaphoid  is  less  evident  than  usual,  being  situated 
below  and  in  front  of  the  head  of  the  astragalus.  In  the  early 
stages  the  patient  complains  of  a  sensation  of  fatigue  or  weakness 
along  the  inner  side  of  the  leg,  foot,  or  ankle,  increased  by 
exertion.  Later  on,  the  gait  becomes  somewhat  shuftling,  and 
severe  pain  is  experienced,  not  only  in  the  sole,  but  also  on 
the  dorsum  over  the  astragalo-scaphoid  joint.  Sometimes  it  is 
extremely  marked  in  the  metatarso-phalangeal  joint  of  the  great 
toe,  which  may  be  enlarged  and  inflamed,  owing  to  an  associated 
chronic  arthritis  {vide  Hallux  rigidus). 

Treatment. — In  the  earliest  stages,  when  the  deformity,  though 
threatening,  has  not  yet  actually  developed,  all  that  is  required  in 
many  cases  is  rest,  so  as  to  allow  the  overstrained  muscles  and  liga- 
ments to  recover  themselves;  at  the  same  time  the  parts  should  be 
massaged,  and  tonics  administered  to  improve  the  general  health. 
Square-toed  boots  without  high  heels  must  be  used,  so  as  to  check 
any  tendency  to  a  valgoid  position  of  the  foot,  and  the  heels  may 
sometimes  be  slightly  thickened  on  the  inner  side.     The  patient 


THE  SURGERY  OF  DEFORMITIES 


467 


must  walk  with  the  toes  pointed  forwards  or  even  inwards  and  in 
some  cases  assistance  may  be  obtained  by  ordering  him  to  sit  cross- 
kneed,  in  the  tailor  position,  so  as  to  ^^ercise  a  certain  amount  of 
constant  pressure  inwards  upon  the  front  of  the  feet.  Regular 
exercises  ought  to  be  instituted,  such  as  raising  the  body  on  tip  oc 
with  the  feet  inverted;  such  can  only  be  undertaken  for  a  short 
time  at  first,  but  as  the  muscles  regain  their  tone  a  longer  period 
can  be  tolerated.  In  a  later  stage  elastic  tension  apphed  to  the 
sunken  arch  is  sometimes  useful;  Golding-Bird  s  sling  can  be  em- 
ploved  for  this  purpose.  It  consists  of  a  loop  of  soft  webbmg 
passed  round  the  ankle  and  then  under  the  instep,  its  free  end  being 
drawn  uo  on  the  inner  side  and  attached  to  an  elastic  accumulator 
which  is'connected  with  a  steel  garter-piece  (Figs.  183  and  iS4). 

In    worse    cases    a    metal    spring 
or  instep  pad  may   be  required  to 


Fig. 


■The  Sling  applied. 


Fig.  183. — Mr.  Golding-Bird's  Sling 
OF  Soft  Webbing  for  Supporting 
THE  Arch  of  the  Foot. 

support  the  foot  whilst  walking,  but  it  must  be  remembered  that 
it  has  no  curative  function,  and  indeed  by  its  pressure  tends  still 
further  to  weaken  the  structures  on  the  inner  side  of  the  foot,  it 
must  fit  the  instep  accurately  and  be  made  to  pattern  for  each  par- 
ticular case,  extending  from  the  root  of  the  toes  to  the  heel. 

When  the  affection  has  reached  a  later  stage,  and  the  deformity 
cannot  be  remedied  by  ordinary  manipulation,  forcible  rectification 
under  an  aucesthetic  may  be  employed.  The  foot  is  hrmly  grasped 
in  the  two  hands  or  in  a  i  homas's  wrench  (Fig.  185) ,  and  the  anterior 
portion  is  forced  mwards  and  backwards  m  such  a  way  as  to  draw 
the  scaphoid  round  the  head  of  the  astragalus  as  a  fulcrum,  and  thus 
restore  the  arch.  Probably  a  number  of  adhesions  m  the  astragaio- 
scaphoid  and  other  joints  will  be  felt  to  give  way  during  this  manipu- 
lation Tenotomy  of  the  peronei  is  sometimes  required  before  recti- 
fication of  the  position  is  possible.  The  foot  is  then  put  up  m  plaster 
of  Paris  and  kept  at  rest  for  some  weeks.  Satisfactory  results  have 
followed. 


468 


A   MANUAL  OF  SURGERY 


In  neglected  cases  operative  proceedings  may  be  necessary  for  the 
relief  of  pain.  The  removal  of  a  wedge-shaped  section  from  the 
inner  side  of  the  foot,  and  the  production  of  bony  ankylosis  between 
the  scaphoid  and  astragalus  (as  recommended  by  Ogston),  is  the  only 
operative  procedure  worthy  of  consideration.  Prolonged  rest  and 
a  suitable  course  of  exercises  and  massage  will  be  required  sub- 
sequently, whilst  an  instep  pad  may  still  have  to  be  worn. 

Pes  Cavus  (Hollow  or  Claw  Foot)  is  a  condition  characterized  by 
increased  concavity  of  the  plantar  arch,  so  that  when  the  individual 
stands  there  is  a  greater  interspace  than  usual,  if  not  an  absolute 
break,  between  the  impressions  produced  by  the  anterior  and  pos- 
terior segments  of  the  foot  (Fig.  172,  B).  Corresponding  to  the 
plantar  concavity,  there  is  a  marked  dorsal  convexity,  whilst  the  toes 
are  generally  in  a  condition  to  be  immediately  described  as  hammer- 
toe; the  heads  of  the  metatarsal^ bones  are  unduly  prominent  below, 
and  callosities  often  form  beneath  them,  causing  considerable  pain. 


Fig.   185. — Thomas's  Wrench.     (Down  Bros.) 

The  two  cro.ss-bars  are  protected  by  thick  indiarubber,  and  can  be  approxi- 
mated or  separated  by  rotation  of  the  handle.  The  anterior  portion  of 
the  foot  is  firmly  grasped  between  them,  one  being  placed  on  the  dorsal 
and  one  on  the  plantar  aspect,  and  forcible  wrenching  movements  can 
then  be  carried  out. 


The  condition  is  almost  always  associated  with  a  slight  degree  of 
talipes  equinus  (right-angled  contraction),  and  its  method  of  pro- 
duction from  this  cause  is  as  follows:  The  weight  is  normally 
carried  to  the  ground  mainly  through  the  heel,  but  also  partly 
through  the  toes;  in  these  cases  it  is  only  transmitted  through  the 
toes  and  front  of  the  foot,  and  since  the  anterior  extensor  muscles 
are  probably  weak,  the  short  flexors  act  at  an  advantage,  and  by 
contracting  draw  the  heel  downwards  so  as  to  reach  the  ground,  and 
thus  the  arch  is  increased.  It  is  also  seen  in  the  paralytic  form  of 
T.  calcaneus.  Treatment  in  the  early  stages  consists  in  friction 
applied  to  the  weakened  muscles  of  the  leg,  together,  possibly,  with 
the  application  of  a  splint  to  the  sole.  In  more  marked  cases  divi- 
sion of  the  tendo  Achillis  is  needed,  together  with  subcutaneous 
section  of  the  tense  plantar  fascia.  The  deformity  of  the  toes  usuall}' 
disappears  when  the  equinus  is  corrected. 

Hallux  Rigidus  {syii.  :  H.  flexus)  is  a  painful  condition  of  the  great 
toe,  due  to  a  chronic  arthritis  of  its  metatarso-phalangeal  articula- 
tion. It  usually  occurs  in  young  males  with  fiat  feet.  The  foot  is 
abnormally  long ;  its  circulation  is  defective;  the  toe  itself  may  be  in 


THE  SURGERY  OF  DEFORMITIES  469 

good  position,  but  not  unfrequently  the  first  phalanx  is  flexed 
(Fig.  177)  and  the  distal  one  hyper-extended.  It  is  probably  due 
to  abnormal  pr«^ssure  owing  to  the  valgoid  position  of  the  foot,  and 
possibly  to  wearing  too  short  a  boot.  Treatment. — In  the  early 
stages  correct  the  flat-foot,  and  see  that  suitable  boots  are  worn. 
Failing  this,  careful  strapping  with  Scott's  dressing  may  give  relief, 
but  in  bad  cases  excision  of  the  head  of  the  metatarsal  may  be 
required. 

Hallux  Valgus  (Fig.  186)  consists  in  a  displacement  outwards  of 
the  great  toe  from  the  median  line  of  the  body,  as  a  result  of  which 
the  other  toes  are  huddled  together, 
and  in  extreme  cases  the  hallux 
is  placed  over  or  under  them.  It  is 
present  in  the  majority  of  people  in 
some  measure,  owing  to  the  usual 
shape  in  which  boots  are  made;  but 
in  its  severer  forms  it  generally  occurs 
in  adult  women,  and  is  due  to  a  chronic 
arthritis  of  the  metatarso-phalangeal 
joint,  the  greater  power  of  the  adductor 
group  of  muscles  explaining  the  de- 
formity. The  cartilaginous  surface  of 
the  head  of  the  first  metatarsal  bone 
becomes  inflamed  owing  to  the  partial  p^,.^_  iS6.— Hallux  Valgus 
dislocation  of  the  toe  and  the  pressure  with  Bunion-. 

of  the  boot;   its  structure  and  shape 

are  thereby  altered,  and  the  joint  is  more  or  less  disorganized. 
Two  other  conditions  are  associated  with  this  deformity,  viz., 
bunion  and  hammer-toe. 

A  bunion  consists  in  the  formation  of  a  bursa  over  the  head  of  the 
first  metatarsal  bone,  which  becomes  inflamed  from  cold  or  injury, 
and  may  even  suppurate,  the  abscess  often  communicating  with 
the  joint,  and  leading  to  its  disorganization.  A  marked  bony  out- 
growth is  usually  found  under  the  bursa,  springing  from  the  inner 
side  of  the  head  of  the  bone,  and  due  to  a  localized  chronic  periostitis. 

The  Treatment  of  hallux  valgus  in  its  earliest  stages  consists  in 
the  use  of  correctly-shaped  boots,  with  the  inner  border  straight  from 
toe  to  heel,  whilst  the  sock  or  stocking  should  have  a  separate  com- 
partment for  the  great  toe.  The  introduction  of  a  toe-post  between 
the  great  toe  and  its  neighbour  is  sometimes  effective  in  giving 
relief.  In  more  severe  types  excision  of  the  projecting  head  of  the 
metatarsal  bone  gives  admirable  results.  The  operation  is  best 
conducted  by  turning  up  a  flap  of  skin  and  subcutaneous  tissues 
over  the  inner  aspect  of  the  head  of  the  metatarsal  with  its  con- 
vexity forwards.  The  bone  is  then  divided  by  a  chisel,  and  the  head 
removed,  allowing  the  toe  to  be  easily  replaced  in  a  normal  position. 
The  skin  is  then  laid  down  in  place,  and  if  need  be  shortened  to  meet 
the  requirements  of  the  case.  Very  rarely  ought  the  second  toe  to 
be  removed  for  this  condition,  as  the  lateral  support  of  the'great  toe 


470 


A   MANUAL  OF  SURGERY 


is  thus  weakened,  and  the  deformity  is  probably  aggravated.  An 
injlamcd  bunion  is  treated  by  removing  all  local  pressure,  and  apply- 
ing fomentations.  If  the  joint  is  involved  in  sujipurative  disease, 
excision  of  the  head  of  the  bone,  or  amputation  of  the  t(je,  may  be 
required.  In  less  serious  cases  it  may  suffice  merely  to  remove  the 
thickened  bursa,  and  to  chisel  away  the  projecting  portion  of  the 
bone. 

Hammer-Toe. — This  deformity  is  constituted  by  hyper-extension  of 
the  tirst  phalanx,  marked  flexion  to  an  acute  angle  of  the  second, 
and  either  flexion  or  extension  of  the  terminal  phalanx,  so  that  the 
first  inter-phalangeal  joint  projects  under  the  upper  leather  of  the 
boot,  whilst  the  patient  walks  on  the  extremity  of  the  ungual 
phalanx,  or  even  on  the  nail  (Fig.  187).     Callciities  form  upon  the 


Fig.  187. — Hammer-Toe  Deformity  of  All 
Toes  of  Both  Feet  with  Marked  Cal- 
losities OVER  THE  Heads  of  the  First 
Phalanges. 

In  this  case  the  patient,  a  girl  of  seventeen 
years,  was  quite  crippled.  Operation  was 
performed  on  all  the  toes,  the  heads  of  all 
the  first  phalanges  being  removed,  and  an 
excellent  functional  result  followed. 


Fig.   188. — Hammer-Toe. 
(After  Keen  and  White.) 

[ ,  Callosity  over  head  of  meta- 
tarsal bone  in  sole;  2,  cal- 
losity- over  end  of  toe;  3,  cal- 
losity or  corn  over  head  of 
first  phalanx;  4,  adventitious 
bursa  over  the  same  bony 
point. 


points  of  pressure  (Fig.  188,  i,  2,  and  3),  especially  on  the  dorsal 
aspect,  and  a  subcutaneous  bursa  over  the  head  of  the  first  pha- 
lanx (4),  giving  rise  to  great  pain  and  inconvenience.  The  second 
toe  is  that  most  frequently  affected,  with  or  without  the  others,  but 
it  is  uncommon  for  the  hallux  to  be  thus  deformed.  The  extensor 
tendons  often  stand  out  very  evidently  beneath  the  skin.  The 
flexion  of  the  second  phalanx  on  the  first  is  carried  to  such  a  degree 
that  the  former  bone  is  semi-dislocated.  The  prolongations  of  the 
plantar  fascia  on  either  side  are  much  shortened,  and  the  lower  portions 
of  the  lateral  ligaments  of  these  articulations  are  also  contracted. 

Causes. — It  is  occasionally  congenital,  but  more  often  acquired, 
and  then  [a]  it  may  be  secondary  to  hallux  valgus;  {b)  it  may  result 
from  wearing  short  and  pointed  boots,  or  very  high  heels;  in  either 
case  the  toes  are  crowded  together  and  drawn  up  out  of  the  way  of 


THE  SURGERY  OF  DEFORMITIES  471 

pressure ;  (c)  it  follows  contraction  of  the  plantar  fascia,  and  is  then 
associated  with  pes  cavus  and  talipes  cquinus. 

Treatment  may  be  commenced  by  the  use  of  correctly-shaped 
boots,  but  the  case  has  usually  progressed  to  such  an  extent  when  the 
patient  is  first  seen  that  no  palliative  measures  are  of  any  avail. 
Operation  is  then  necessary,  and  probably  the  second  phalanx  is  so 
much  displaced  that  nothing  short  of  removal  of  the  head  of  the 
first  phalanx  holds  out  any  prospect  of  permanent  relief.  An  in- 
cision is  made  longitudinally  over  the  joint,  the  extensor  tendon 
being  split  down  the  middle;  the  head  of  the  bone  is  then  cleared 
by  the  raspatory,  and  nipped  off  by  cutting  pliers.  No  splint  is 
required,  as  the  pressure  of  the  dressings  suffices  to  keep  the  toes  in 
good  position.  Sometimes  there  is  but  little  room  between  the  great 
and  third  toes,  so  that  even  if  one  corrected  the  deformity  of  the 
second  toe  there  is  no  space  for  it  to  lie  comfortably;  amputation 
should  then  be  performed. 

Metatarsalgia,  or  Morton's  Disease,  is  characterized  by  severe  pain 
of  a  neuralgic  type  located  primarily  about  the  head  of  one  or  more  of 
the  metatarsal  bones,  usually  the  fourth,  but  also  radiating  thence  up 
and  down  the  limb.  It  often  occurs  in  gouty  or  rheumatic  subjects, 
and  ma}^  be  attributed  to  some  injury ;  a  slight  degree  of  flat-foot  and 
the  wearing  of  tight  boots  certainly  predispose  to  it.  It  is  probably 
due  to  compression  of  the  digital  nerves  between  the  heads  of  the 
metatarsal  bones  and  the  ground.  The  foot  is  found  to  be  broader 
than  usual,  and  the  anterior  transverse  arch  formed  by  the  heads 
of  the  metatarsals  flattened  out.  Marked  callosities,  or  corns,  are 
observed  on  the  under  surface  close  to  the  heads  of  the  bones,  one 
or  more  of  which  may  be  unduly  prominent  below.  In  a  few  cases 
small  bony  enlargements  have  projected  from  the  heads  of  the  meta- 
tarsal bones,  and  in  others  definite  fibrous  growths  have  been  found 
in  the  subcutaneous  tissues;  in  other  cases  a  simple  peripheral 
neuritis  may  explain  the  manifestations.  The  pain  is  generally 
induced  by  w^alking,  and  comes  on  in  characteristic  paroxysms. 
Lateral  pressure  over  the  bases  of  the  metatarsal  bones  often  relieves 
the  pain,  but  similar  pressure  over  the  heads  usually  increases  it. 
Occasionally  evidences  of  osteo-arthritis  are  manifested  in  one  of 
the  neighbouring  joints. 

Treatment  consists  in  resting  the  foot,  W'hilst  suitable  diet  and 
drugs  are  ordered  to  combat  any  gouty  or  rheumatic  tendency. 
At  the  end  of  a  few  weeks  the  patient  may  be  allowed  to  walk  again 
with  boots  which  are  low-heeled,  thick-soled,  and  broad  anteriorly. 
An  instep  pad  may  be  employed,  if  flat-foot  is  present,  and  an 
attempt  made  to  relieve  pressure  on  the  heads  of  the  metatarsals 
by  treating  the  callosities  on  the  sole  of  the  foot,  and  applying 
a  transverse  strip  of  felt  plaster  (J  inch  thick)  behind  the  heads. 
Morton's  recommendation — viz.,  excision  of  the  head  of  the  project- 
ing metatarsal  bones — may  be  reserved  for  the  more  aggravated  and 
serious  forms;  it  is  best  effected  through  a  longitudinal  dorsal  in- 
cision running  parallel  to  the  extensor  tendons. 


CHAPTER  XX. 

INJURIES  OF  BONES     FRACTURES. 

Contusion  of  a  Bone  and  of  its  periosteum  is  usually  a  matter  of  no 
great  moment,  although  the  part  becomes  painful  and  swollen. 
Occasionally  a  subacute  periostitis  is  caused  in  people  liable  to 
rheumatism  or  gout,  or  in  the  subjects  of  syphilis;  whilst  in  those 
who  "are  thoroughly  out  of  health,  and  with  low  germicidal  power, 
acute  infective  periostitis  or  osteo-myelitis,  resulting  in  necrosis, 
may  supervene.  The  Treatment  of  an  uncomplicated  case  consists 
merely  in  the  use  of  cooling  lotions  or  of  a  bandage,  whilst  if  peri- 
osteal thickening  results,  iodide  of  potassium  may  be  given,  and 
iodine  paint  applied  locally. 

Bending  of  Bone  may  or  may  not  be  associated  with  fracture. 
Bending  witliout  fracture  occurs  mainly  in  children,  and  in  adults  is 
only  the  result  of  some  local  disease.  More  commonly  a  partial  or 
green-stick  fracture  is  produced  (p.  474),  and  in  this  the  deformity 
can  generally  be  corrected  without  much  difficulty. 

Fractures. 

A  fracture  may  be  defined  as  a  sudden  solution  of  continuity  in  a 
bone,  usually  resulting  from  external  violence. 

Predisposing  Causes  of  Fracture — Age.- — From  two  to  four  frac- 
tures are  not  uncommon,  owing  to  the  unsteady  gait  and  frequent 
falls  to  which  little  children  are  liable ;  from  four  to  six  the  bones 
often  bend  so  as  to  cause  green-stick  fractures;  up  to  the  age  of 
eighteen  years  injuries  near  joints  induce  separation  of  epiphyses; 
from  six  years  onwards  fractures  increase  in  frequency,  reaching 
their  maximum  between  thirty  and  forty  years  of  age;  old  people 
are  liable  to  this  form  of  accident,  owning  to  the  bones  becoming 
atrophic  or  brittle. 

S^ex.- — As  might  be  expected,  fractures  are  more  common  in  the 
male  sex  during  boyhood  and  adult  life;  but  up  to  the  age  of  four  or 
five  they  are  equally  frequent  in  the  two  sexes,  whilst  after  forty- 
five  they  are  more  common  in  women,  owing  to  their  great  liability 
to  intracapsular  fracture  of  the  cervix  femoris  and  to  Colles's 
fracture. 

472 


INJURIES  OF  BONES— FRACTURES  473 

Morbid  Conditions  of  the  Bones  predispose  to  fracture  in  a  marked 
manner,  often  leading  to  what  is  known  as  S pontaneons  Fracture,  in 
which  the  determining  force  cannot  be  recognised  or  is  very  slight. 
Under  this  heading  may  be  included:  (i)  Atrophy  of  bone,  which 
may  be  of  the  senile  type,  as  manifested  especially  in  the  cervix 
femoris;  or  is  due  to  want  of  use,  as  in  a  paralyzed  limb  or  from  an 
ankylosed  joint.  (2)  Patients  afflicted  with  certain  mental  or  ner- 
vous diseases,  such  as  general  paralysis  or  tabes  dorsalis,  are  unduly 
liable  to  fracture,  which  may  result  from  atrophy,  but  may  also 
occur  in  apparently  healthy  bones.  Thus,  a  man  suffering  from 
tabes  was  sitting  with  his  thigh  abducted  and  everted  in  order  that 
he  might  examine  and  dress  a  perforating  ulcer  on  the  sole  of  the 
foot,  when  the  shaft  of  the  femur,  subsequently  shown  to  be  of 
normal  dimensions,  and  apparently  of  normal  density,  snapped  in 
two.  (3)  Fragilitas  ossium  or  osteo-psathyrosis  consists  in  an  in- 
herited tendency  to  spontaneous  fracture.  It  results  in  a  multi- 
plicity of  fractures,  occurring  even  in  children;  thus,  a  girl,  aged 
twelve  and  a  half  years,  had  suffered  from  forty-one  fractures  since 
the  second  year  of  life.  No  explanation  of  this  condition  is  known ; 
the  lesions  often  unite  perfectly,  though  sometimes  with  a  good  deal 
of  deformity.  (4)  General  bone  diseases,  such  as  rickets  and  osteo- 
malacia, also  predispose  to  fracture;  in  the  latter  affection  the  bones 
often  bend  considerably  before  breaking,  and  there  is  usually  but 
httle  attempt  at  repair.  (5)  Local  bone  disease  may  also  constitute 
an  important  predisposing  factor  by  weakening  its  structure.  Thus, 
sarcoma  and  secondary  cancer  of  bone  are  often  first  recognised  by 
causing  a  spontaneous  fracture ;  the  erosion  of  an  aneurism  and  the 
destruction  of  the  para-epiphyseal  region  in  acute  osteo-myehtis 
may  lead  to  a  similar  result. 

The  Exciting  Causes  of  Fracture  are  threefold:  (i)  Direct  violence, 
the  fracture  occurrmg  at  the  spot  struck,  and  being  often  transverse, 
not  unfrequently  comminuted,  and  sometimes  complicated  with 
injuries  to  the  adjacent  soft  parts.  (2)  When  due  to  indirect  violence, 
the  accident  is  usually  produced  by  the  compression  or  bending  of 
the  bone  with  such  force  as  to  exceed  the  limits  of  its  natural 
elasticity,  so  that  it  yields  at  the  weakest  spot.  Thus,  when  a 
person  jumps  from  a  height,  the  leg  bones  are  compressed  between 
the  weight  of  the  body  and  the  resistance  of  the  ground,  and,  if  the 
violence  is  excessive,  a  fracture  occurs  at  some  point  of  mechanical 
'  isadvantage.  If  the  stress  falls  chiefly  on  the  shaft,  an  oblique 
fracture  ensues,  often  with  much  longitudinal  displacement,  and 
possibly  becoming  compound;  if  an  element  of  torsion  is  present,  as 
by  forced  inversion  or  eversion  of  the  foot,  the  fracture  is  likely  to 
become  spiral  in  type.  If,  on  the  other  hand,  the  violence  expends 
itself  on  a  mass  of  cancellous  tissue,  such  as  the  os  calcis,  astragalus, 
or  upper  end  of  the  tibia,  the  bone  may  be  fissured  in  various  direc- 
tions, comminuted,  or  even  '  pulped  ' ;  such  a  condition  is  sometimes 
termed  a  compression  fracture.  (3)  Muscular  action  is  most  com- 
monly the  cause  of  fracture  of  small  bones  or  of  osseous  prominences. 


474 


A  MANUAL  OF  SURGERY 


Fig.  189.  —  Obstetric 
Fracture  ofHumerus 
IN  A  Baby  Four 
Weeks  Old 


into  which  powerful  muscles  are  inserted.  The  patella  and  ole- 
cranon arc  not  unfrcquently  broken  in  this  way,  the  former  often 
occurring  from  sudden  and  vigorous  efforts  to  avert  a  fall.  Occa- 
sionally one  of  the  long  bones,  such  as  the  humerus  or  clavicle,  has 
been  broken  by  violent  muscular  exertion, 
as  by  throwing  a  cricket-ball. 

Intra-uterine  Fractures  are  caused  by 
blows  upon  the  mother's  abdomen,  or  by 
abnormal  or  violent  uterine  contractions, 
especially  if  the  liquor  amnii  is  deficient  in 
amount,  or  if  the  formation  of  bone  is  defec- 
tive, as  in  osteogenesis  imperfecta  (p.  586). 
Ihey  are  usually  followed  by  considerable 
deformity,  which  must  be  clearly  distin- 
guished from  that  due  to  imperfect  develop- 
ment. Obstetric  fractures  also  occur  as  a 
result  of  undue  violence  used  by  the  accou- 
cheur during  delivery,  usually  affecting  the 
shaft  of  the  femur  or  humerus  (Fig.  189). 

Varieties. — A  Simple  Fracture  is  one  in 
which  the  skin  is  unbroken  or,  at  any  rate, 
where  the  external  air  has  no  admission  to 
the  site  of  injury.  A  Com- 
pound Fracture  is  present 
when  the  skin  or  mucous 
membrane  is  so  lacerated  that  there  is  direct  or 
indirect  communication  between  the  fracture  and 
the  external  air.  In  the  base  of  the  skull,  a  frac- 
ture may  open  up  one  of  the  deeper  air-sinuses, 
and  thus  it  becomes  compound  without  any 
apparent  external  lesion.  These  terms,  though 
sanctioned  by  the  approval  of  centuries,  are  neither 
of  them  good,  subcutaneous  and  open  being  prefer- 
able. A  subcutaneous  fracture  is  often  anything 
but  a  simple  injury,  and  may  result  in  the  most 
disastrous  consequences,  whilst  an  open  fracture 
may  be  a  matter  of  comparatively  little  importance. 
Indeed,  with  our  present  appliances  and  methods 
of  treatment  open  fractures  often  give  better  results 
than  those  that  are  called  simple. 

Fractures  are  complete  or  incomplete,  according 
to  whether  or  not  the  continuity  of  the  bone  is  pj^  190.— Green- 
entirely  interrupted.  Various  forms  of  Incom-  stick  Fracture 
plete  Fracture  are  described,  and  indeed  the  intro-  of  Radius. 
duction  of  radiography  has  shown  that  they  are 
much  more  common  than  was  formerly  supposed.  A  green-stick 
fracture  (Fig.  190)  is  one  which  only  occurs  in  young  children,  and 
most  often  in  those  that  are  rickety;  curved  bones,  such  as  the 
clavicle,  are  usually  affected,  and  the  fracture  merely  involves  the 


INJURIES  OF  BONES—FRACTURES 


475 


con\-exity  of  the  curve,  whilst  the  concave  half  is  bent,  just  as  when 
a  green  bough  or  twig  is  partially  broken.  Depressions  of  the  skull 
may  be  similarly  incomplete  when  the  outer  table  is  driven  in  with- 
out fracture  and  the  inner  table  alone  splintered.  Fissured  fractures 
also  are  often  only  partial.  A  sub- periosteal  fracture  is  one  in  which 
the  periosteum  remains  intact,  although  the  bone  is  broken;  dis- 
placement does  not  occur,  and  therefore  the  injury  is  likely  to  be 
overlooked,  apart  from  radiography- 

Complete  Fractures  mav  be  transverse,  though  this  is  not  very 
common:  oblique,  arising  usually 
from  indirect  violence ;  spiral,  when 
the  force  acts  in  a  rotary  direction 
as  well  as  longitudinally;  it  occurs 
most  frequently  in  the  tibia  or  femur, 
and  the  lower  fragment  often  has  a 
sharp  triangular  upper  end,  giving 
it  somewhat  the  appearance  of  the 
mouthpiece  of  a  clarionet  (fracture 
en  bee  de  flute  ;  Fig.  191).  Not  un- 
commonly a  second  fissure  runs 
downwards  from  the  main  line  of 
fracture,  separating  off  a  long  narrow 
fragment  of  the  shaft.  A  longi- 
tudinal fracture  is  one  due  to  fissur- 
ing  or  splitting  of  the  bone  in  its 
long  axis ;  it  is  most  common  as  the 
result  of  gunshot  injuries.  If  it  is 
combined  with  a  transverse  fissure, 
it  is  often  termed  T-shaped.  Com- 
minuted is  a  term  used  to  describe 
the  condition  when  the  bone  is 
broken  into  more  than  two  pieces; 
impacted,  when  one  fragment  is 
driven  into  the  other;  multiple, 
when  more  than  one  fracture  exists ; 
complicated,  when  important  struc- 
tures, such  as  an  artery  or  joint, 
are  damaged  as  well  as  the  bone. 

The  Separation  of  an  Epiphysis 
results  in  young  people  from  vio- 
lence directed  to  the  ends  of  the  bones,  but  occasionally  from 
pathological  affections  of  the  epiphysis  or  of  the  adjacent  portion 
of  the  diaphysis — e.g.,  from  inherited  syphiHs,  rickets,  scurvy, 
suppurative  osteo-myelitis,  or  tuberculous  epiphysitis.  The  femur, 
humerus,  or  radius  are  the  bones  most  often  affected.  The  line  of 
cleavage  usually  runs  through  the  soft  spongy  tissue  on  the  dia- 
physeal side  of  "the  cartilage,'  so  that  there  is  cartilage  wdth  spicules 
of  bone  on  one  side,  and  spongy  bone  on  the  other.  In  very  young 
children,  w^here  the  epiphysis  is  entirely  or  mainly  cartilaginous. 


Fig.  191. — Fracture  OF  THE  Tibia: 
'  EN  Bec  de  Flute.' 

There  was  but  little  shortening  in 
this  case ;  it  was  impossible,  how- 
ever, to  reduce  the  deformity 
even  under  an  anaesthetic,  and 
operation  was  required. 


476  A  MANUAL  OF  SURGERY 

the  lesion  is  almost  always  a  pure  separation  of  the  epiphysis  from 
the  shaft ;  but  at  a  later  date  it  not  unusually  extends  in  part  through 
the  adjacent  end  of  the  diaphysis  (Fig.  221).  A  marked  feature  is 
the  stripping  up  of  the  periosteum,  which,  though  loosely  attached 
to  the  shaft  and  easily  separated  from  it  in  children,  is  hrmly  ad- 
herent to  the  epiphyseal  cartilage,  and  hence  retains  its  connection 
with  it,  thus  frequently  limiting  displacement.  If,  however,  the 
force  is  sufficient,  the  end  of  the  shaft  penetrates  the  periosteum, 
which  may  grasp  it  closely,  and  this  periosteal '  sleeve  '  may  seriously 
hinder  reduction.  Union  usually  occurs  by  means  of  bone,  and  arrest 
of  the  longitudinal  growth  may  follow  if  the  parts  are  not  replaced 
in  exact  apposition.  This  is  a  matter  of  importance  when  one  of 
the  bones  of  the  leg  or  fore-arm  is  affected,  since  deformity  of  the 
hand  or  foot  results  if  the  injured  bone  ceases  to  grow  and  the 
uninjured  one  continues  its  development.  Suppuration  some- 
times occurs  as  a  sequela  in  unhealthy  children,  or  when  the 
accident  is  compound,  and  may  result  in  acute  osteo-myelitis  and 
necrosis. 

Partial  detachment  of  an  epiphysis  (the  juxta-epiphyseal  strain  of 
Oilier)  often  occurs,  giving  rise  to  phenomena  similar  to  those  of  a 
sprain ;  if  overlooked  and  neglected,  it  is  Hkely  to  prove  a  fertile 
source  of  tuberculous  disease,  or  may  interfere  with  the  growth  of 
the  hmb.  The  essential  feature  is  a  more  or  less  tender,  but  very 
distinct  swelling  of  the  bone  close  to  the  epiphysis,  but  the  neigh- 
bouring joint  remains  unaffected.  Treatment  consists  in  immobi- 
lization in  plaster  of  Paris. 

Signs  of  Fracture. — The  history  usually  given  by  the  patient  is 
that,  as  the  result  of  some  accident,  he  felt,  or  perhaps  heard,  some- 
thing give  way  with  a  snap,  and  experienced  sharp  pain  which 
became  much  intensified  on  attempting  to  move  the  limb.  On 
examining  the  injured  part  and  contrasting  it  with  the  opposite 
side,  the  following  points  are  usually  noticed: 

1.  The  signs  of  a  local  trauma,  viz.,  pain,  brviising,  and  swelling, 
as  a  result  of  the  effusion  of  blood  from  the  torn  and  lacerated  struc- 
tures. The  amount  of  this  may  be  so  great  as  to  obliterate  all  the 
ordinary  bony  prominences  and  landmarks.  Blebs  and  bullae 
sometimes  form  over  the  surface  in  the  course  of  a  day  or  two, 
and  these  should  be  carefully  protected  from  infection.  The  dis- 
coloration continues  for  some  time,  and  may  spread  to  parts  far 
removed  from  the  original  mischief.  This  infiltration  of  the  parts 
with  blood  often  leads  to  considerable  subsequent  thickening,  and 
possibly  to  serious  adhesions  and  limitation  of  movement.  It  is 
unusual  for  suppuration  to  occur  after  a  simple  fracture,  unless 
the  patient  is  very  debilitated  and  with  diminished  germicidal 
powers. 

2.  Preter-natural  mobility  in  tJie  continuity  of  the  bone  may  be 
demonstrated  by  manipulation,  but  never  unnecessarily.  Im- 
paction or  non-separation  of  the  fragments  prevents  its  occurrence. 

3.  Partial  or  complete  loss  of  function  also  follows. 


INJURIES  OF  BONES—FRACTURES  477 

4.  Crepitus*  can  only  be  felt  when  the  fragments  are  moveable 
and  can  be  brought  into  contact,  but  not  when  there  is  wide  separa- 
tion or  impaction. 

5.  Change  in  shape  of  the  limb  or  deformity  from  displacemeni 
results  from  three  chief  factors,  viz.,  the  direction  of  the  violence, 
the  weight  of  the  limb,  and  the  contraction  of  muscles,  whilst 
injudicious  movement  or  rough  handling  may  aggravate  it.  It 
is  always  more  marked  in  oblique  than  in  transverse  fractures, 
and  hence  is  usually  greater  in  those  due  to  indirect  violence. 
Various  types  of  displacement  are  described,  viz. :  Angular,  generally 
due  to  the  unequal  action  of  powerful  muscles;  lateral,  where  the 
displacement  is  merely  to  one  or  the  other  side,  and  most  common 
in  transverse  fractures;  longitudinal,  when  one  fragment  overlaps 
the  other  or  is  forcibly  driven  into  it,  causing  shortening  of  the 
limb ;  it  may  also  occur  in  the  form  of  wide  separation  of  the  frag- 
ments, as  from  contraction  of  the  quadriceps  in  fracture  of  the 
patella;  rotatory,  when  one  fragment  is  twisted  on  the  other,  as  in 
fractures  of  the  femur,  where  the  weight  of  the  limb  causes  eversion 
of  the  lower  end.  In  flat  bones — e.g.,  the  skull — deformity  may 
exist  in  the  shape  of  depression  or  elevation. 

Radiography  has  proved  of  the  greatest  service  both  in  connection 
with  the  diagnosis  and  the  treatment  of  fractures.  Many  a  case 
which  would  formerly  have  been  called  merely  a  sprain  can  now  be 
demonstrated  to  be  really  a  fracture  (especially  about  the  wrist),  and 
the  constant  use  of  this  procedure  has  revolutionized  our  ideas  as 
to  the  relative  frequency  and  also  as  to  the  nature  of  many  such 
lesions.  The  following  points  must,  however,  be  noted  if  the 
practitioner  is  not  to  be  misled:  In  the  first  place,  an  assured  diag- 
nosis can  never  be  made  with  the  screen  alone:  the  limb  must  be 
photographed,  and  for  choice  stereoscopically ;  otherwise  the  radio- 
grams should  be  taken  in  two  directions,  antero-posteriorly  and 
laterally. .  The  importance  of  this  latter  precaution  is  indicated 
by  a  study  of  Figs.  226  and  227,  or  of  Figs.  258  and  259.  Then  it 
must  be  remembered  that  all  radiograms  are  more  or  less  exaggera- 
tions, owing  to  the  proximity  of  the  tube  to  the  limb,  and  that  a 
deformity  which  is  very  obvious  in  the  radiogram  may  in  reality 
be  comparatively  slight.  Moreover,  too,  the  exact  position  of 
the  tube  and  its  angular  relationship  to  the  limb  must  not  be 
neglected,  as  otherwise  misleading  interpretations  may  be  given  of 
the  appearances  presented.  Finally,  it  must  be  remembered  that 
callus  is  for  a  considerable  time  pervious  to  the  X  rays,  so  that, 

*  The  term  Crepitus  is  applied  to  five  different  conditions  which  may  pro- 
duce a  creaking  or  grating  sensation  to  the  examining  hand,  i .  Bony  crepitus; 
results  from  the  rubbing  together  of  the  fragments  in  a  fracture,  or  of  the  ends 
of  bones  in  a  joint  when  denuded  of  their  articular  cartilage.  2.  A  softer 
variety  of  bony  crepitus  is  obtained  when  an  epiphysis  is  detached.  3.  An 
effusion  of  blood  into  the  tissues  gives  rise  to  a  soft  crackling  sensation  on 
handling.  4.  Effusion  into  tendon  sheaths,  bursas,  and  joints  also  causes  a 
soft  crepitant  sensation,  varying  in  different  cases.  5.  Air  in  the  tissues 
causes  surgical  emphysema  and  a  characteristic  form  of  crepitus. 


478  A   MANUAL  OF  SURGERY 

although  the  fracture  is  firmly  united,  it  may  ])c  still  visible  in  the 
radiogram. 

General  or  Constitutional  Effects. — Shock  is  greater  or  less  accord- 
ing to  the  amount  of  violence  and  the  seat  of  injury.  It  varies  from 
a  mere  passing  faintness  to  the  severest  prostration.  If  the  bones 
of  the  head  or  spine  are  injured,  special  symptoms  due  to  con- 
cussion of  the  brain  or  injury  to  the  spinal  cord  may  also  be  pro- 
duced. 

Hcemorrhage  is  rarely  sufficient  to  give  rise  to  general  effects  unless 
the  fracture  is  compound,  and  involves  some  important  vessel. 

Fracture  fever  (aseptic  traumatic  fever,  p.  268)  is  met  with  in  the 
majority  of  cases,  commencing  twenty-four  hours  after  the  accident 
and  lasting  two  or  three  days.  As  a  rule,  it  is  not  severe,  the 
temperature  rarely  rising  above  100°  F.  in  uncomplicated  cases.  In 
compound  fractures  where  asepsis  is  not  attained,  any  form  of 
wound  infection  may  result,  and  even  general  septicaemia  or  pya-mia. 

Delirium  tremens  is  a  not  unusual  complication  of  fractures  of  the 
leg  in  debilitated  individuals  or  habitual  drinkers.  The  general 
characters  and  treatment  of  the  disease  are  dealt  with  elsewhere 
(p.  270).  As  regards  local  treatment,  the  limb  must  be  fixed  by 
splints  or  encased  in  plaster  of  Paris,  and  suspended  in  a  Salter's 
swing  so  as  to  prevent  the  patient  from  moving  the  upper  fragment 
independently  of  the  lower. 

Fat  embolism  results  from  the  absorption  of  broken-up  fat  globules 
after  any  injury  which  causes  contusion  or  laceration  of  fatty  tissue; 
when  this  is  accompanied  by  tension  from  effusion  of  blood,  as  in 
fractures,  this  process  is  more  likely  to  occur.  Usually  the  great 
mass  of  the  fat  is  filtered  off  by  the  lungs  or  ehminated  by  the 
kidneys  (as  can  be  demonstrated  after  death  by  staining  with  osmic 
acid),  and  no  harm  results.  The  pulmonary  obstruction  may^  how- 
ever, become  so  great  as  to  lead  to  a  fatal  issue  from  dyspnoea; 
whilst  if  the  cerebral  vessels  are  blocked,  syncope,  or  even  coma, 
may  be  induced.  The  symptoms  are  gradual  in  their  onset,  and 
usually  commence  about  the  third  day,  but  may  not  be  evident 
for  a  week. 

The  Union  of  Fractures  is  brought  about  by  a  series  of  changes 
analogous  to  those  which  we  have  already  seen  occur  in  other 
wounds,  except  that  they  do  not  terminate  in  the  formation  of 
cicatricial  tissue,  but  go  on  to  the  further  development  of  bone. 

When  a  fracture  has  occurred,  the  broken  ends  of  the  bone 
are  left  rough,  spiculated,  and  more  or  less  separated  one  from  the 
other;  the  periosteum  is  torn,  but  the  rupture  is  not  always  com- 
plete, a  '  periosteal  bridge  '  perhaps  persisting  and  playing  an 
important  part  in  the  reparative  process,  especially  if  the  fracture 
is  not  accurately  set.  Ihe  muscles  and  neighbouring  tissues  are 
lacerated,  and  a  varying  amount  of  blood  is  extravasated,  occupying 
the  interstices  of  the  wound.  In  the  course  of  a  few  hours  after 
the  parts  have  been  immobilized,  the  process  of  repair  is  in- 
augurated by  the  blood-clot  becoming  invaded  by  leucocytes,  and 


INJURIES  OF  BONES— FRACTURES  479 

after  a  time  it  is  absorbed,  the  haemoglobin  passing  through  various 
stages  of  degeneration,  and  thereby  staining  the  surrounding  tissues. 
At  the  same  time  there  is  an  exudation  of  plasma  into  all  the 
injured  and  lacerated  soft  parts  around,  and  the  connective  tissue 
cells  proliferate  actively.  The  periosteum  becomes  thickened  and 
more  vascular,  and  its  connection  with  the  bone  is  loosened  for  a 
short  distance  on  each  side  of  the  fracture.  The  blood-clot,  occupy- 
ing the  space  beneath  the  loosened  periosteum,  is  gradually  trans- 
formed into  granulation  tissue,  which  unites  with  that  derived 
from  surrounding  torn  structures  and  from  the  bone  itself,  and  this 
ovoid  mass  binding  the  fractured  ends  together  is  known  as  the 
provisional  or  ensheathing  callus  (Fig.  192). 

The  ossification  of  the  callus  is  the  next  stage  in  the  process.  This 
is  brought  about  by  the  activity  of  the  cells  in  the  deeper  part  of  the 
granulation  tissue,  which  are  derived  from  the  osteoblastic  cells  set 
loose  by  the  injury  and  the  resulting  rarefaction.  These  retain  their 
bone-producing  potentialities,  and  hence  bony  spicules  develop  in 
the  substance  of  the  deeper  parts  of  the  granulation  tissue,  as  also 
from  the  surface  of  the  uncovered  ends  of  the  fragments,  and  from 
the  under  side  of  the  periosteum.  This  latter  membrane  when  it  is 
stripped  from  the  underlying  bone  draws  with  it  certain  bone  cells, 
accompanying  the  small  vessels  which  pass  from  the  membrane 
into  the  Haversian  canals,  and  from  these  the  bone  develops.  Ossi- 
fication thus  starts  from  many  foci,  and  the  callus  is  quickly  con- 
verted into  a  mass  of  bone,  which  is  at  first  soft  and  spongy,  but 
after  a  time  becomes  firm.  When  a  periosteal  bridge  has  been  left, 
bone  formation  commences  on  its  under  surface,  and  not  unf requently 
in  radiograms  a  fine  of  newly-formed  bone  can  be  seen  passing  from 
one  fragment  to  the  other,  and  evidently  due  to  this  cause. 

The  medulla  becomes  hyperaemic  for  some  distance  from  the  seat 
of  fracture  and  is  transformed  into  granulation  tissue,  which  unites 
with  that  springing  up  from  the  opposite  fractured  surface.  Fine 
spicules  of  bone  gradually  permeate  the  granulation  mass  until  the 
whole  is  ossified,  constituting  the  internal  callus,  or,  better,  the 
medullary  -plug. 

Naturally,  the  compact  bony  tissue  is  the  last  to  engage  in  these 
changes.,  and  the  denser  the  bone,  the  longer  they  are  in  being  com- 
pleted. The  fractured  ends  become  hyperaemic  and  rarefied,  the 
bone  cells  prohferating,  the  medullary  contents  of  the  Haversian 
canals  increasing  in  amount,  and  the  actual  osseous  substance  being 
absorbed,  until  the  rough  and  spiculated  surface  becomes  smooth 
and  covered  with  granulations.  These  unite  with  the  medullary 
plug,  of  which  they  may  indeed  be  looked  on  as  an  extension,  and 
finally  give  rise  to  the  annular  bond  of  union  between  the  two  layers 
of  compact  bone,  to  which  was  originally  apphed  the  name  definitive 
or  permanent  callus. 

It  will  thus  be  obvious  that  the  continuity  of  a  bone  is  restored 
long  before  repair  is  completed,  and  that  it  mainly  depends  on  the 
ossification    of   the  provisional  callus,  the  amount  of  which  is  to 


480 


A   MANUAL  OF  SURGERY 


some  extent  proportional  to  the  degree  of  m()l)ilityof  the  fragments. 
A  certain  amount  of  cartilage  is  often  developed  in  tlic  process  of 
bone-formation,  especially  in  young  people,  and  where  there  is 
much  mobility;  it  is  present  chiefly  in  the  early  stages,  and  mainly 
in  the  ensheathing  callus.  The  newly-formed  osseous  tissue  is  at 
first  soft  and  spong^^  but  gradually  becomes  denser;  at  first  it  is 
easily  detachable  from  the  underlying  bone,  but  later  on  becomes 
continuous  with  it.  As  the  so-called  definitive  callus  becomes 
stronger,  the  ensheathing  callus  diminishes,  and  finally,  if  the  ends 
are  in  good  position,  may  vanish  entirely,  whilst  the  medullary 
plug  may  also  be  totally  removed.  Thus  it  is  possible  for  the  bone, 
under  these  circumstances,  to  be  restored  so  absolutely  as  to  show, 
no  signs  of  its  having  been  fractured. 

When  the  ends  of  the  bones  partially  overlap  (Fig.  193),  the 
amount  of  ensheathing  callus  is  considerably  increased,  and  fills 
up  all  the  spaces  left  by  the  overlapping  of  the  fragments.     The 


Fig.   192. 


Fig. 


Fig. 


193.  i<iG.  194. 

Diagrams  to  represent  Union  of  Fractures:  Fig.  192,  when  the  Ends 
ARE  IN  Close  Apposition;  Fig.  193,  when  the  Ends  are  only  Par- 
tially Apposed;  and  Fig.  194,  when  the  Fractured  Surfaces  are 
not  in  Contact  at  all. 

projecting  edges  of  bone  become  rounded  off,  and  the  medullary 
cavities  closed  by  plates  or  plugs.  Thejmain  bond  of  union  is  the 
ensheathing  mass,  a  considerable  portion  of  which  persists.  Some 
deformity  is  sure  to  remain,  and  it  is  unusual  for  the  medullary  canal 
to  be  restored. 

If  the  fractured  ends  overlap  completely,  but  remain  in]^contact 
(Fig.  194),  the  union  is  secured  by  a  large  mass  of  ensheathing  callus, 
whilst  the  medullary  cavity  of  each  fragment  is  closed  by  a  plate  of 
internal  callus. 

If  the  fractured  ends  overlap  and  are  kept  from  contact  by  the 
interposition  of  muscular  tissue,  union  rarely  takes  place,  and  an 
ununited  fracture  results.  The  same  occurs  if  the  fragments  are 
widely  separated,  as  in  the  patella. 

Where  comminution  has  occurred,  the  splintered  fragments  are 
matted  together  by  an  abundant  formation  of  granulation  tissue, 
which  is  subsequently  transformed  into  callus.- 


INJURIES  OF  BONES— FRACTURES  481 

The  soft  tissues  around — muscles,  tendons,  etc. — are  repaired  in 
the  usual  way,  but,  owing  to  the  infiltration  of  the  parts  with  blood 
and  their  laceration,  the  muscles  become  matted  together  and  often 
lose  their  power  of  independent  movement;  tendons  may  become 
adlierent  to  their  sheaths  and  surrounding  structures;  nerves  and 
veins  may  be  compressed  in  the  cicatricial  tissue,  so  that  the 
functional  result  may  be  most  disappointing. 

The  removal  of  the  clot  and  the  formation  of  granulation  tissue 
usually  take  about  a  week  or  ten  days,  and  new  bone  formation 
commences  about  the  end  of  the  first  week.  By  the  third  or  fifth 
week,  according  to  the  size  and  vascularity  of  the  bone  and  the 
recuperative  power  of  the  individual,  the  fracture  will  be  consoli- 
dated, but  in  the  lower  hmb  it  is  often  eight  weeks  before  the  patient 
can  bear  any  weight  upon  it.  Months  may,  however,  pass  before 
the  final  stage  of  complete  repair  is  attained. 

In  conclusion,  one  must  allude  to  the  fact  that  a  sarcoma  some- 
times develops  at  the  site  of  fracture  within  a  comparatively  short 
time  of  the  accident. 

The  Treatment  of  a  simple  fracture  is  always  to  be  considered  as 
a  task  of  some  difficult}',  inasmuch  as  it  involves  not  only  the  union 
of  the  bony  fragments,  but  also  the  complete  restoration  of  the  limb 
to  functional  utihty,  and  that  without  deformity  or  unnecessary 
delay. 

First  Aid. — -In  mo\ang  the  patient  from  the  spot  where  the  accident 
happened,  it  is  necessary  to  secure  the  limb  temporarily  in  as  good 
a  position  as  possible;  sphnts  have  often  to  be  improvised  from 
sticks,  umbrellas,  newspapers,  and  so  forth.  In  a  railway  accident 
the  splintered  debris  of  the  carriages  may  be  employed  for  this 
purpose,  and  the  upholstery  of  the  seats  as  padding.  A  broken 
leg  may  also  be  firmly  tied  to  the  other  limb,  which  is  thus  con- 
verted into  a  temporary  splint. 

The  Local  Treatment  consists,  first,  in  setting  the  Hmb,  i.e.,  in 
reducing  the  deformity,  and  replacing  the  fractured  ends  in  a  normal 
position ;  then  in  fixing  the  fragments  and  Hmb  so  as  to  prevent  a 
recurrence  of  the  deformity;  and,  finally,  in  using  such  further 
means  as  massage  and  manipulation  in  order  to  secure  the  ultimate 
functional  usefulness  of  the  limb. 

Reduction  of  a  fracture  is  usually  accompHshed  by  a  combination 
of  traction  or  extension  appHed  to  the  lower  segment  of  the  Hmb, 
with  manipulation  of  the  fractured  ends,  counter-extension  being 
at  the  same  time  maintained  by  an  assistant.  In  some  cases  it  is 
necessary  to  relax  particular  muscles  in  order  to  facilitate  reduction ; 
thus,  in  the  leg,  the  calf  muscles  may  be  relaxed  by  flexing  the  knee, 
or  even  by  division  of  the  tendo  AchilHs.  Rotation  must  also  be 
corrected,  and  shortening  reduced  to  a  minimum.  It  is  important 
that  the  other  Hmb  should  be  uncovered  to  serve  as  a  standard  of 
comparison. 

The  manipulation  is  painful,  and  so  much  muscular  spasm  is  often 
ehcited  by  it  that  the  setting  of  the  fracture  becomes  almost  im- 

31 


482  A   MANUAL  OF  SURGERY 

possible  without  an  ansesthetic.  Reduction  slunikl  always  be  accom- 
plished as  early  as  possible,  so  as  to  anticipate  the  stiffness  and  in- 
filtration which  soon  develop  in  the  affected  parts.  At  the  same 
time  it  may  be  wise  to  delay  a  few  hours,  so  as  not  to  give  an  anaes- 
thetic on  a  full  stomach,  or  without  the  previous  administration 
of  an  enema;  but  if  practicable,  a  fracture  should  never  be  left 
unreduced  for  more  than  twelve  hours. 

The  Fixation  of  the  fracture  in  a  good  position  is  provided  for  by 
the  application  of  suitable  splints  made  of  wood,  leather,  zinc,  poro- 
plastic,  etc.,  according  to  the  rccjuisites  of  the  case.  If  of  wood, 
zinc,  or  tin,  they  are  usually  made  according  to  some  general  pattern, 
and  fitted  to  the  patient  by  means  of  pads.  If  formed  of  leather 
or  poroplastic,  they  can  be  shaped  so  as  to  meet  any  peculiarities 
of  the  part.  A  paper  pattern  is  first  fitted  to  the  opposite  limb, 
and  the  splint  is  then  cut  to  the  desired  shape;  it  is  softened  by 
immersion  in  hot  or  cold  water,  moulded  to  the  part,  and  allowed 
to  dry.  Where  leather  is  employed,  the  addition  of  a  little  vinegar 
to  the  water  assists  in  rendering  it  soft  and  supple.  The  edges 
and  corners  are  finally  rounded,  and  the  interior  padded  with  wool 
or  lint.  In  fractures  of  the  shafts  of  long  bones  the  joints  both 
above  and  below  the  site  of  fracture  should,  as  far  as  possible,  be 
immobilized,  and  the  splints  must  be  sufficiently  large  to  encase 
the  part  firmly,  or  if  flat,  to  project  a  little  beyond  it,  so  that  the 
limb  may  be  fixed  by  the  splint,  and  not  the  splint  by  the  limb. 
In  all  cases  careful  attention  must  be  given  to  the  padding  so  as 
to  prevent  irritation  or  sloughing  of  the  skin.  In  out-patient 
practice,  where  the  patients  are  not  too  careful  as  to  personal  cleanli- 
ness, it  is  advisable  to  pad  the  splint  with  some  antiseptic  material, 
such  as  boracic  lint,  in  order  to  prevent  the  development  of  vermin; 
but  it  is  a  wise  precaution  to  shave  and  purify  the  limb  in  all  cases, 
and  to  dust  it  over  with  boric  acid  and  starch.  When  blebs  or 
blisters  have  developed,  a  dry  aseptic  dressing  should  first  be 
applied.  The  splints  may  often  with  advantage  be  fixed  to 
the  limb  by  one  or  two  turns  of  strapping,  and  then  secured  by 
ordinary  calico  bandages;  these  must  not  be  applied  too  tightly 
at  first,  since  the  swelling  of  the  limb  not  unfrequently  increases 
afterwards,  and  undue  constriction  resulting  in  gangrene  might 
ensue.  Moreover,  a  limb  ensheathed  in  bandage  must  never  be 
flexed,  but  the  flexion  should  always  be  made  bef  oreh3  nd ;  if  this  is  not 
attended  to,  the  bandage  may  cut  into  the  soft  tissues,  and  by  com- 
pression of  the  vessels  cause  gangrene.  It  is  sometimes  advisable 
to  bandage  the  whole  of  the  limb  from  the  fingers  or  toes  upwards, 
so  as  to  prevent  oedema  from  the  pressure  of  the  apparatus  obstruct- 
ing the  venous  return.  The  patient  should  always  be  seen  on  the 
day  following  the  application  of  the  spHnts,  and  the  condition  of 
the  fingers  or  toes  carefully  examined ;  if  they  look  at  all  bhie,  or 
feel  numb  and  cold,  the  bandages  must  be  slightly  relaxed. 

It  is  also  desirable  that  a  radiogram  be  taken  after  the  application 
of  the  splints,  so  that  the  actual  position  of  the  fragments  can  be 


IX JURIES  OF  BONES— FRACTURES  483 

estimated.  If  it  is  found  to  be  unsatisfactory,  a  further  attempt 
should  be  made  to  improve  it,  and  faiUng  that  the  question  of  opera- 
tion should  be  raised. 

Various  forms  of  Fixed  Apparatus  are  used  in  the  treatment  of 
fractures,  especially  in  children.  The  materials  most  commonly 
employed  are  starch,  water-glass,  and  plaster  of  Paris. 

The  starch  bandage  is  utilized  only  in  cases  where  great  strength 
and  rigidity  are  not  required.  The  limb  is  carefully  padded  with 
cotton  wool,  and  over  this  are  apphed  thin  strips  of  cardboard  soaked 
in  starch  so  as  to  fit  the  limb.  These  are  firmly  secured  by  a 
bandage,  the  meshes  of  which  are  well  impregnated  with  a  starch 
solution,  and  over  all  may  be  placed  another  bandage,  the  under 
surface  of  which  is  also  rubbed  with  starch.  WTien  this  dries,  it 
produces  a  firm  mass,  sufficient  to  immobihze  the  hmb.  Should  it 
become  loose,  it  can  easily  be  readjusted  by  slitting  up  and  paring 
awav  a  portion  on  one  or  both  sides. 

The  icaier-glass  bandage  is  appfied  by  first  swathing  the  hmb  with 
a  padding  of  cotton  wool,  or  bandaging  it  with  boracic  hnt ;  around 
this  a  coarse  canvas  bandage  is  apphed,  soaked  in  a  solution  of 
sihcate  of  soda  of  the  consistency  of  treacle;  several  thicknesses 
of  the  bandage  are  required  in  order  to  give  it  the  necessary  strength. 
This  material  is  hght,  easily  apphed,  and  makes  very  little  mess, 
but  is  slow  in  dr\dng,  taking  fully  twenty-four  hours  to  become 
firm. 

Plaster  of  Paris,  though  rather  messy  and  increasing  considerably 
the  weight  of  the  limb,  is  one  of  the' best  means  of  securing  pro- 
longed immobihzation.  {a)  The  dried  plaster  may  be  rubbed  mto 
a  coarse  canvas  bandage,  which  prior  to  use  is  soaked  for  a  few 
minutes  in  cold  water,  to  which  a  little  salt  or  alum  is  added  in 
order  to  hasten  its  setting ;  it  is  then  wound  round  the  hmb,  which 
has  been  pre\aously  enswathed  in  boric  hnt  or  wool,  and  on  the 
exterior  of  this  fresh  plaster  of  the  consistency  of  cream  is  applied. 
To  make  this  cream  of  the  right  strength  the  dried  powder  is  cast 
in  spoonfuls  into  a  bowl  of  cold  water,  or  a  weak  solution  of  alum, 
until  it  no  longer  sinks  immediately,  but  remains  floating  on  the 
surface.  The  mixture  is  then  stirred  with  an  iron  spoon,  and  is 
ready  for  use.  WTien  the  casing  is  sufficiently  thick,  the  outer 
surface  is  smoothed  dowm  with  wet  hands,  or  a  strip  of  wet  bandage ; 
the  date  mav  be  ad\'isablv  marked  on  it,  and  the  part  is  slung  up 
to  dry.  A  Gigh  saw,  smothered  with  vasehne,  may  be  incorporated 
in  the  dressing  beneath  the  plaster,  if  it  is  desired  to  remove  it  early 
for  the  sake  of  massage,  etc. ;  by  this  means  it  is  easily  cut  into  two 
pieces,  which  can  be  re-applied  daily  after  the  rubbing. 

(b)  Ordinary  house-flannel  fomis  the  basis  of  various  methods  of 
apph-ing  plaster— g.g.,  Croft's,  the  Bavarian,  etc.  In  the  former, 
the  limb,  protected  bv  boric  hnt  or  wool,  has  apphed  to  one  side  of 
it  one  or  two  thicknesses  of  flannel,  suitably  cut  to  shape,  soaked 
in  plaster,  and  with  perhaps  a  httle  extra  plaster  rubbed  in;  it  is 
fixed  to  the  hmb  by  a  mushn  bandage.     WTien  this  is  dry,  a  similar 


484  A   MANUAL   OF  SURG  FRY 

splint  is  placed  on  the  other  side  of  the  limb,  and  again  bandaged 
on.  Division  of  the  bandage  down  the  front  permits  the  removal 
of  the  appliance,  the  bandage  over  the  junction  of  the  two  portions 
behind  serving  as  a  hinge.  If  necessary,  thin  strips  of  wood  or  tin 
may  be  incorporated  in  any  of  these  arrangements,  so  as  to  add  to 
their  strength. 

Early  immol)ilization  by  means  of  plaster  of  Paris,  reinforced  by 
strips  of  wood  or  tin,  has  been  advocated  by  certain  authorities, 
constituting  the  so-called  ambulatory  treaimenl,  and  so  much  con- 
fidence have  they  in  it  that  even  fractures  of  the  femur  are  dealt 
with  in  this  way  within  a  few  days  of  the  accident,  and  the  ])atient 
allowed  to  walk  about. 

A  most  valuable  adjuvant  in  the  treatment  of  fractures  is 
Massage,  advocated  so  forcibly  by  the  late  Professor  Lucas-Cham- 
pionniere,  whilst  in  some  cases  Early  Mobilization  is  also  desirable. 
It  has  long  been  recognised  that  after  a  fracture  the  limb  remains 
for  some  considerable  period  weak  and  stiff,  owing  partly  to  atrophy 
of  muscles,  partly  to  cicatricial  adhesions  between  various  divided 
structures,  and  in  part  to  contraction  of  ligaments  in  neighbouring 
joints,  and  that  these  disabilities  increase  in  direct  ratio  to  the 
length  of  time  that  the  limb  is  kept  at  rest.  It  is  the  object  of 
massage  to  prevent  or  obviate  these  disabilities.  In  a  fracture  with 
displacement  through  the  shaft  of  a  long  bone,  the  part  is  immobi- 
Hzed  by  spUnts  for  a  sufficient  time  to  ensure  the  non-recurrence 
of  the  displacement  (say,  two  or  three  weeks  for  most  bones,  a  little 
longer  for  the  femur).  Massage  is  then  commenced,  and  is  con- 
ducted methodically  day  by  day,  the  splints  being  removed  for  the 
purpose  and  re-applied  subsequently;  neighbouring  joints  will  also 
be  rubbed,  and  gentle  passive  movements  undertaken.  Possibly 
some  pain  may  be  noticed  at  first,  but  it  soon  disappears,  and  the 
patient  experiences  a  sense  of  comfort.  Repair  is  hastened,  but  of 
course  the  patient  must  not  put  any  strain  on  the  bone  until  it  is 
quite  consolidated.  In  fractures  near  joints  or  through  the  articular 
ends  of  bones,  it  is  sometimes  possible  to  discard  splints  entirely, 
or  at  any  rate  to  use  them  only  for  a  short  time,  steadying  the  i)art 
by  some  simple  contrivance,  such  as  a  sUng  or  strapping;  massage 
is  commenced  within  a  few  days  and  regularly  persisted  in.  Ihis 
method  of  treatment  is  specially  applicable  to  such  injuries  as  frac- 
ture of  the  anatomical  neck  of  the  humerus,  the  simpler  varieties 
of  Colles's  or  Pott's  fracture,  and  for  some  fracture-dislocations  in 
the  neighbourhood  of  the  elbow.  At  the  same  time  it  is  necessary 
to  point  out  that  active  movements  should  not  be  encouraged  too 
early  in  cases  where  powerful  muscles  acting  on  one  of  the  frag- 
ments might  overcome  the  resistance  of  the  callus  and  reproduce 
the  deformity. 

'ihe  increasing  success  of  modern  aseptic  surgery  has  given  con- 
siderable impetus  to  the  Early  Operative  Treatment  of  fractures  in 
order  to  secure  complete  fixation  and  the  restoration  of  function  in 
as  short  a  space  of  time  as  possible.     At  first  this  plan  was  only 


INJURIES  OF  BON ES—FRACTU NILS  485 

utilized  [or  such  bones  as  the  patella  or  olecranon,  but  at  the  present 
day  there  is  no  valid  reason  for  refusing  operation  in  suitable  cases. 
The  excellent  results  following  operation  in  compound  fractures,  as 
compared  with  those  gained  by  the  treatment  of  simple  fractures 
by  prolonged  immobilization,  emphasize  this  statement.  It  is 
often  impossible  to  co-apt  accurately  the  fragments  apart  from 
operation,  whilst  the  infiltration  of  the  soft  tissues  with  blood  leads 
to  much  fibrosis  and  the  formation  of  many  adhesions;  moreover, 
the  more  lengthy  immobilization  results  in  greater  atrophy  of  muscles 
and  stiffness  of  joints,  and  hence  the  commercial  value  of  a  working 
man  after  a  fracture  of  the  thigh  or  leg  is  very  considerably  de- 
preciated, owing  partly  to  persistent  deformity,  partly  to  the  joints 
being  stiff,  whilst  the  period  of  convalescence  is  reckoned  by  months 
rather  than  weeks.  Should  such  a  case  be  operated  on,  the  blood 
being  removed,  and  the  ends  of  the  bone  freed  from  intervening 
tissues  and  securely  fixed,  repair  is  rapidly  effected;  the  bone 
retains  its  normal  length;  early  massage  of  the  muscles  and  joints 
above  and  below  becomes  practicable,  owing  to  the  fixity  of  the 
limb,  and  thus  atrophy  on  the  one  hand,  and  stiffness  on  the  other, 
are  avoided. 

The  actual  selection  of  cases  for  operation  must  necessarily  vary 
with  the  views  of  the  particular  surgeon  as  to  the  justifiability  of 
the  procedure,  but  most  surgeons  agree  that  the  following  cases  cer- 
tainly demand  operation  :  i .  Fractures  of  small  bones  or  of  processes 
which  are  not  easily  retained  in  position  by  external  appliances, 
and  where  healing  apart  from  operation  is  slow  and  often  defective 
■ — e.g.,  in  the  patella,  olecranon,  etc.  2.  Fractures  involving  joints, 
where  fragments  are  displaced,  as  when  the  condyles  of  the  femur 
or  humerus  are  detached.  3.  Fractures  of  the  shafts  of  long  bones 
which  are  oblique  or  spiral,  with  much  longitudinal  displacement, 
and  perhaps  overlapping,  and  with  the  sharp  ends  of  the  fragments 
impacted  in  muscular  or  other  tissues.  Effective  reduction  in  such 
cases  is  often  difficult  even  with  the  tissues  laid  open,  and  is  practi- 
cally impossible  apart  from  operation. 

As  to  the  technique,  the  incision  to  expose  the  bone  should  be 
extensive,  so  as  to  give  plenty  of  room  and  allow  exit  to  as  much 
of  the  extravasated  blood  as  possible.  The  ends  of  the  fragments 
are  then  cleared,  brought  into  correct  position  with  as  little  handling 
as  possible,  and  held  by  suitable  forceps,  whilst  arrangements  are 
made  for  fixing  them.  Various  contrivances  are  available,  and  it 
is  not  always  easy  to  determine  which  to  employ.  Sometimes  it 
suffices  to  hold  the  fragments  together  by  silver  wire  of  appropriate 
thickness — e.g.,  for  the  patella  (Fig.  256),  or  for  some  oblique  frac- 
tures of  the  shafts  of  long  bones  (Fig.  195).  When  the  fracture 
extends  through  masses  of  cancellous  tissue,  it  may  be  possible  to 
fix  the  fragments  by  nails,  screws  (Fig.  250),  or  ivory  pegs  driven 
into  them. 

For  fractures  through  the  shafts  of  long  bones,  Lane's  plates 
(Fig.  196)  have  been  largely  employed,  and  often  with  great  benefit. 


486 


A   MANUAL  OF  SURGERY 


but  increasing  experience  has  demonstrated  that  the  results  of 
their  employment  are  not  always  perfect,  (i)  They  consist  of  flat 
metal  plates  with  holes  for  screws.  For  a  tibia  two  screws  must  be 
introduced  both  above  and  below  the  line  of  fracture;  for  a  femur 
three,  if  not  four,  must  be  similarly  employed.  The  use  of  so  many 
screws  invohes  increasing  length  of  the  plates,  and  a  corresponding 
interference  with  the  nutrition  of  the  bone.  (2)  The  absolute  fixity 
of  the  fractured  ends  does  not  conduce  to  rapid  union;  repair  is 
more  rapidly  and  satisfactorily  effected  when  slight  movement  is 
possible  between  the  fragments.  Thus  in  the  ribs,  where  fixity 
is  impossible,  non-union  is  unknown.  Many  cases  of  delayed 
union  and  even  of  non-union  have  been  observed  after  "  plating  " 
a  fracture  of  the  tibia.  (3)  The  actual  effect  of  the  screws  on  the  bone 
in  which  they  are  embedded  is  to  cause  a  rarefactive  change,  which 


Fig.   195. — Fixation   of   Oblique 
Fracture  by  Silver  Wire  Loop 

TRAVERSING   THE   WhOLE   THICK- 
NESS OF  THE  Bone. 


Fig.  196. — Lane's  Plate  applied 
for  Tr.\nsverse  Fr.\cture  with 
Diagrammatic  Longitudinal  Sec- 
tion. 


results  in  them  becoming  loose  in  a  comparatively  short  time.  If 
splints  or  other  retentive  apparatus  are  removed  too  early,  and 
powerful  muscles  allowed  to  act,  the  plate  may  be  drawn  from  its 
attachment  and  deformity  reproduced.  Thus  a  fracture  of  the 
upper  third  of  the  femur  was  plated,  and  the  limb  was  in  perfect 
position  at  the  end  of  three  weeks;  without  permission  or  consulta- 
tion the  splints  were  removed,  and  in  a  week's  time  the  powerful 
adductors  had  bent  the  six-screwed  plate  and  detached  it  from  the 
upper  fragment,  and  had  pulled  the  lower  fragment  into  a  position 
of  marked  adduction  and  complete  external  rotation,  necessitating 
the  opening  of  the  perfectly  healed  wound  to  remove  the  plate,  and 
the  forcible  restoration  of  the  limb  to  a  normal  position  by  manipula- 
tion. Especiall}'  important  is  the  rarefying  effect  of  the  introduc- 
tion of  nails,  etc.,  in  the  case  of  fractures  near  the  ends  of  the  long 
bones  in  children.     Silver  wire  has  less  effect  in  determining  bone 


INJURIES  OF  BONES— FRACTURES  487 

atrophy,  but  in  many  cases  it  is  wise  to  avoid  metallic  sutures 
entirely,  and  trust  merely  to  the  temporary  fixation  of  fragments 
by  silk  or  catgut ;  if  the  fragments  can  be  kept  in  position  for  a  few 
days,  it  is  unlikely  that  they  will  be  displaced  if  the  limb  is  suitably 
fixed  in  splints  or  plaster  of  Paris.  (4)  It  is  doubtful  whether  it 
is  ever  wise  to  employ  plates,  screws,  etc.,  in  compound  fractures, 
especially  of  superficial  bones  such  as  the  tibia.  If  asepsis  can  be 
assured,  their  employment  may  be  justifiable;  but  where  asepsis 
is  uncertain,  plates  should  be  avoided. 

Complications  of  Fractures — i.  Implication  of  a  Joint. — When  the 
fracture  extends  through  the  articular  cartilage,  the  joint  becomes 
distended  with  blood  and  synovial  fluid,  but  this  is  subsequently 
absorbed,  and  the  fissure  in  the  cartilage  closed  by  plastic  lymph, 
which  develops  into  scar  tissue.  If  the  fragments  are  in  perfect 
apposition  no  harm  results,  although  the  joint  remains  stiff  for  a 
little  while.  If,  however,  the  apposition  is  imperfect,  adhesions  of 
a  more  serious  type  develop,  and  considerable  limitation  of  move- 
ment results.  It  is  thus  comprehensible  that  one  of  the  chief 
indications  for  the  operative  treatment  of  fractures  is  when  they 
involve  joints.  In  elderly  people  injuries  of  this  type  may  result 
in  a  chronic  traumatic  arthritis,  particularly  in  the  shoulder  or  hip. 
The  patient  complains  of  great  pain,  and  the  development  of  osteo- 
phytes  causes  limitation  of  movement. 

2.  The  same  violence  that  causes  the  fracture  may  at  the  same 
time  produce  a  Dislocation  in  a  neighbouring  joint,  and  particu- 
larly in  connection  with  the  elbow  and  shoulder.  Treatment 
should  always  be  undertaken  as  soon  as  possible.  Should  the 
fracture  involve  or  be  close  to  the  articular  end  of  the  bone,  an 
attempt  should  be  made  to  reduce  the  deformity  by  manipulation 
under  an  anaesthetic;  failing  this,  or  if  the  deformity  recurs,  open 
operation  should  be  undertaken  if  the  conditions  as  to  surgical 
cleanliness  permit.  In  most  cases  the  dislocation  is  reduced  after 
removing  the  extravasated  blood,  and  the  fracture  fixed ;  but  some- 
times, when  the  displaced  articular  fragment  is  small,  it  may  be 
better  to  remove  it  entirely.  When  the  fracture  is  further  away 
from  the  joint,  it  is  sometimes  possible  to  command  the  fragments 
by  splints,  and  then  the  limb  may  be  manipulated  in  the  usual  way, 
and  the  dislocation  reduced  under  an  anaesthetic.  Should  this  fail, 
the  surgeon  may  either  fix  the  fracture  by  operation  and  repeat  the 
attempt  to  reduce  the  dislocation,  or  he  may  open  the  joint  and 
perform  an  open  reduction.  The  exact  method  adopted  must 
necessarily  vary  with  the  particular  condition  present.  Should 
immediate  treatment  be  impracticable,  the  limb  should  be  fixed 
in  splints  so  as  to  allow  union  of  the  fracture,  and  at  a  later  date  the 
unreduced  dislocation  should  be  treated. 

3.  The  Main  Artery  may  be  compressed,  contused,  punctured,  or 
ruptured,  giving  rise  to  thrombosis,  aneurism,  or  haemorrhage.  In 
the  former  case  dry  gangrene  may  result  if  the  terminal  vessels  are 
unhealthy;  in  the  latter  moist  gangrene  may  be  produced  by  the 


488  A   MANUAL  OF  SURGERY 

pressure  of  the  extravasatcd  blood  on  the  veins.  This  is  most 
frequently  observed  in  fractures  of  the  lower  end  of  the  femur, 
where  the  femoral  or  popliteal  artery  may  be  involved.  Treatment 
has  been  discussed  elsewhere  (p.  120).  Here  it  may  only  be 
mentioned  that  in  the  case  of  a  ruptured  artery  operation  should,  if 
possible,  involve,  not  only  the  removal  of  the  blood-clot  and  the 
securing  of  the  arter3%  but  also  the  fixation  of  the  fracture. 

4.  Laceration  of  Veins  results  in  extravasation  of  blood,  which 
is  not  so  extensive  as  when  an  artery  is  wounded,  since  thrombosis 
occurs  more  easily ;  the  distal  part  of  the  limb  may  become  congested 
and  cedematous,  and  this  may  require  for  its  removal  firm  bandaging 
and  massage.  Pulmonary  embolus  is  an  occasional  sequence  of 
venous  thrombosis. 

5.  The  Nerves  of  a  limb  may  be  injured  at  two  different  periods. 
(a)  Immediate  injury  is  due  to  laceration  or  rupture,  either  of  the 
whole  trunk,  or,  as  is  more  common,  of  the  nerve  fibrillse,  without 
loss  of  continuity  of  the  sheath,  {b)  Secondary  symptoms  result 
from  inclusion  and  compression  of  the  nerve  in  the  callus,  or  from 
injudicious  splint  pressure.  Irritative  symptoms  in  the  shape  of 
neuralgia  and  muscular  spasms  are  first  manifested,  followed  by 
paralysis  and  anaesthesia.  This  usually  occurs  three  or  four  weeks 
after  the  accident,  and  may  disappear  in  a  month  or  two,  or  persist. 
Treatment  is  always  for  a  time  of  the  expectant  type,  even  when 
the  paralysis  is  immediate,  since  total  rupture  of  a  nerve  is  rare, 
and  restoration  of  function  the  rule  rather  than  the  exception. 
When,  however,  the  sjmptoms  persist,  the  parts  must  be  laid  open, 
the  nerve  freed  from  adhesions,  or  exuberant  callus  removed,  and 
such  measures  taken  as  will  best  secure  the  nerve  from  further 
compression. 

Complications  arising  during  Treatment. — (i)  If  an  elderly  patient 
is  kept  in  bed  for  any  length  of  time  in  the  recumbent  posture, 
hypostatic  pneumonia  is  likely  to  ensue.  It  occurs  most  commonly 
after  intracapsular  fractures  of  the  cervix  femoris,  and  non-union 
often  results,  since  the  patients  must  be  allowed  to  get  about  on 
crutches  at  an  early  date  with  the  limb  fixed  by  a  suitable  splint. 
(2)  Bedsores  (p.  120)  are  very  liable  to  supervene  in  old  people  with 
fractures  which  need  treatment  in  the  recumbent  posture.  {3)  Crutch 
palsy  is  the  result  of  compression  of  the  brachial  nerves  between  the 
head  of  the  humerus  and  the  pad  of  a  crutch.  It  may  affect  all  the 
nerves  of  the  upper  extremity,  or  may  pick  out  any  one  of  them, 
and  then  most  commonly  the  musculo-spiral.  It  can  usually  be 
prevented  by  the  use  of  spring-padded  crutches  with  cross-pieces 
for  the  hands,  so  as  to  allow  the  patient  partially  to  relieve  the 
axillary  pressure  by  supporting  the  weight  of  the  body  by  means  of 
the  arms.  When  it  has  occurred,  the  use  of  crutches  must  be 
discontinued,  and  faradism  and  massage  employed  to  the  affected 
muscles.  (4)  Occasionally  a  peculiar  induration  occurs  in  the 
muscles  in  the  neighbourhood  of  a  fracture,  resulting  in  a  rapidly 
developed  shortening.     It  is  usually  seen  in  children  following  frac- 


INJURIJCS  OF  BONES —FRACTURES  489 

turcs  of  the  fore-ann  or  lower  end  of  the  humerus,  the  flexor  muscles 
being  involved,  and  manifests  itself  by  the  fingers  becoming  flexed 
and  clawed,  and  by  hyper-extension  of  the  wrist.  The  deformity 
of  the  fingers  disappears  on  flexing  the  wrist,  demonstrating  thereby 
that  no  adhesions  of  tendons  to  sheaths  are  present.  It  is  recog- 
nised from  the  results  of  a  nerve  lesion  by  the  absence  of  sensory 
or  trophic  phenomena.  This  so-called  Volkmann's  Ischemic  con- 
traction has  been  attributed  to  splint  pressure  upon  the  muscles  of 
the  forearm,  but  it  has  also  been  observed  when  splints  have  not 
been  employed;  probably  it  is  due  to  a  necrobiosis  of  the  muscular 
tissue  due  to  deprivation  of  blood  resulting  from  tight  bandaging, 
and  this  is  foHowed  by  a  spreading  myositis  fibrosa.  Treatment 
consists  in  exposing  and  lengthening  the  contracted  tendons,  if 
massage  fails,  or  in  shortening  the  bone  or  bones  of  the  limb.  The 
outlook  is,  however,  not  very  promising.  Another  muscular  com- 
plication consists  in  a  deposit  of  bony  tissue  therein,  a  result  of  a 
myositis  ossificans  (p.  420).  (5)  Gangrene  may  arise  from  fractures 
in  a  variety  of  ways:  (i.)  From  the  immediate  effects  of  the  injury, 
either  by  its  direct  action  on  the  tissues,  or  by  causing  arterial 
thrombosis  in  a  limb  with  atheromatous  vessels,  or  from  rupture 
of  the  artery  with  consequent  venous  thrombosis,  owing  to  the 
pressure  of  the  extravasation;  (ii.)  by  the  supervention  of  spreading 
gangrene  in  a  compound  fracture;  (iii.)  from  errors  in  the  course  of 
treatment,  as  by  bandaging  the  limb  too  tightly,  so  as  to  constrict 
the  vessels;  or  by  the  bandage  becoming  unduly  tight,  owing  to  the 
subsequent  sweUing  of  the  limb ;  or  by  flexing  a  joint  after  bandaging 
it,  the  bandage  cutting  into  the  soft  tissues;  or  by  the  localized 
pressure  of  a  splint  which  has  been  insufficiently  padded.  Moist 
gangrene  is  the  type  met  with  in  all  cases,  except  when  the  limb 
has  been  previously  drained  of  its  fluids  by  an  atheromatous  con- 
dition of  its  vessels.     (For  rules  of  treatment,  see  Chapter  VIL) 

Compound  Fractures. 

A  compound  fracture  is  one  in  which  there  is  a  communication 
between  the  external  air  and  the  site  of  injury.  It  is  produced  by 
direct  or  indirect  violence,  the  solution  of  continuity  of  the  skin 
being  produced  in  the  former  from  without,  and  in  the  latter  by 
the  penetration  of  a  bony  fragment  from  within.  It  is  also  some- 
times secondary  to  treatment,  the  skin  over  the  fracture  sloughing 
as  a  result  of  pressure  or  irritation.  The  bone  may  be  but  little 
displaced,  or  may  protrude  through  a  small  opening  in  the  skin; 
or  the  bone  may  be  crushed  and  comminuted,  and  a  large  fleshy 
wound  may  be  associated  with  it.  In  some  of  the  injuries  produced 
by  motor-cars,  the  skin  and  muscles  are  violently  torn  across,  and 
the  underlying  bone  may  be  pulped,  whilst  road-dust  and  dirt  are 
ground  into  the  tissues. 

The  chief  dangers  of  compound  fractures  are,  firstly,  hcsmorrhage, 
the  blood,   instead  of  collecting  within  the  tissues  of  the  limb. 


490  A    MANUAL  OF  SURGERY 

escaping  externally  if  a  sufficient  opening  is  present ;  and,  secondly, 
the  advent  of  infection,  which  may  lead  t(j  the  gravest  consequences. 
Portions  of  muscle  and  periosteum,  which  in  a  simple  fracture 
would  be  absorbed  or  incorporated  in  the  callus,  slough;  detached 
fragments  of  bone  necrose,  whilst  acute  osteo-myelitis  may  develop. 
Acute  sup])urative  arthritis  ma}-  result,  and  secondary  haemorrhage 
may  follow  an  infective  peri-arteritis.  Toxaemia  to  a  variable 
degree  is  certain  to  be  present,  and  sometimes  pyamia  occurs. 

The  Method  of  Union  of  a  compound  fracture  is  much  the  same 
as  that  occurring  in  simple  fractures.  If  the  wound  can  be  rendered 
aseptic,  it  may  be  closed  by  suture,  and  the  fracture  is  thus  con- 
verted into  a  simple  one,  and  repaired  accordingly.  If,  however, 
suppuration  occurs,  it  is  probably  attended  with  a  greater  or  less 
amount  of  necrosis,  and  possibly  diffuse  inflammation  and  sloughing 
of  the  soft  parts;  the  wound  will  therefore  remain  open  for  a  time, 
varying  with  the  severity  of  the  local  phenomena.  Healing  occurs 
by  granulation,  which  extends  from  below  upwards,  and  inasmuch 
as  the  deepest  part  of  this  granulation  tissue  is  derived  from  bone 
and  contains  osteoblastic  elements,  it  will  be  transformed  into 
callus,  and  finally  into  true  osseous  tissue.  Repair  is  obviously 
much  slower  under  these  circumstances  than  in  a  simple  fracture. 

In  the  Treatment  of  compcmnd  fractures,  the  main  object  is  to 
render  the  wound  aseptic  and  to  give  efficient  exit  to  the  discharges. 
For  this  purpose  the  patient  should  in  all  cases  be  anaesthetized,  the 
limb  shaved  and  thoroughly  purified,  and  the  wound  enlarged  and 
thoroughly  washed  out  with  some  reliable  antiseptic.  It  may  be 
advisable  to  excise  torn  and  dirty  fragments  of  skin,  muscle,  and 
tendon,  especially  when  dirt  has  been  ground  into  them.  Loose 
fragments  of  bone  are  removed,  and  portions  denuded  of  their  perios- 
teum may  be  taken  away  lest  necrosis  should  ensue ;  where  fragments 
retain  any  considerable  connection  with  the  soft  parts,  they  may  be 
left  without  fear.  When  a  sharp  end  of  one  of  the  fragments  is  pro- 
truding through  a  small  opening  in  the  skin,  it  is  first  purified 
thoroughly  before  attempting  its  reduction,  and  then  replaced,  after 
enlarging  the  wound  in  the  skin,  or  a  portion  is  sawn  off.  Haemor- 
rhage is  dealt  with  in  the  usual  way,  and  the  fragments  are  placed 
as  nearly  as  possible  in  their  normal  position.  It  is  undesirable  to 
fix  them  by  any  metalHc  mechanical  appHance  unless  they  cannot 
otherwise  be  kept  in  position.  Where  the  ends  of  the  bone  are  much 
comminuted,  the  small  portions  must  be  arranged  in  position  as  well 
as  possible,  and  no  attempt  made  to  wire  them.  A  good-sized 
drainage-tube  is  inserted,  and,  if  need  be,  counter-openings  are 
made ;  the  external  wound  is  closed  or  not  according  to  circumstances 
and  dressed,  and  suitable  splints  are  then  applied.  Under  such  a 
regime  the  majority  of  cases  do  well.  Immoveable  apparatus  may 
be  used  after  a  time,  windows  being  left  in  the  plaster  casing  to 
allow  wounds  to  be  dressed. 

In  compound  fractures  which  have  been  attended  with  complica- 
tions directed  to  vessels,  nerves,  and  neighbouring  soft  parts  or  joints. 


INJURIES  OF  BONES^FRACTURES 


491 


the  prognosis  and  course  of  the  case  may  be  considerably  modified ; 
treatment  suitable  to  each  of  these  conditions  must  be  adopted. 

The  question  of  Amputation  will  necessarily  be  raised  in  the  more 
serious  cases ;  but  it  is  unnecessary  to  add  anything  here  to  what  has 
been  already  stated  (p.  244). 

Ununited  Fractures. 

Three  varieties  of  ununited  fracture  have  been  described:  (i)  Ahso- 
liite  non-union,  when  no  attempt  at  repair  is  made,  rarely  occurs 
except  when  some  definite  bone  disease  exists,  such  as  sarcoma  or 
osteo-malacia,  or  when  in  a  very  debihtated  patient  the  Hmb  has  not 
been  fixed.  (2)  Fihrous  Union 
consists  in  the  development  of 
a  more  or  less  firm  mass  of 
connective  tissue  as  the  bond 
of  union  between  the  ends  of 
the  bones,  which  are  either 
rounded  off  and  closed  by  a 
thin  plate  of  bone  or  cartilage, 
or  are  sometimes  atrophic  and 
pointed.  (3)  A  false  joint,  or 
pscudartkrosis,  is  a  condition 
in  which  the  ends  of  the  frag- 
ments are  covered  either  by 
bone  or  cartilage,  and  more  or 
less  altered  in  shape,  so  as  to 
form  a  shallow  ball  -  and  - 
socket  joint,  the  capsule  being 
represented  by  the  surround- 
ing fibrous  tissue,  and  the 
syno\nal  cavity  by  an  adven- 
titious bursa,  which  results  from 
the  friction  of  the  two  ends 
(Fig.  197). 

The  most  common  situations 
for  ununited  fractures  are  pro- 
jecting processes  of  bone  to 
which  powerful  muscles  are 
attached,  such  as  the  patella, 
olecranon,  coracoid  process,  posterior  half  of  the  os  calcis,  etc.; 
whilst  in  long  bones  the  middle  of  the  shaft  of  the  humerus  and  the 
upper  and  lower  thirds  of  the  femur  are  the  favourite  sites. 

Causes.— (i)  Want  of  apposition  of  the  bony  ends,  owing  to 
muscular  action — e.g.,  in  the  patella,  when  the  two  fragments  are 
widely  separated,  or  in  the  femur,  where  they  may  overlap ;  (2)  the 
interposition  of  muscular  or  aponeurotic  tissue,  or  detached  frag- 
ments of  compact  bone ;  (3)  want  of  rest,  one  of  the  most  common 
causes,  as  in  the  middle  of  the  shaft  of  the  humerus,  where,  unless 
the  elbow  is  well  supported,  complete  immobility  cannot  be  obtained, 


Fig.  917. — Radiogram  of  Ununited 
Fracture  of  the  Bones  of  the 
Fore-arm.     (Dr.  Knox.) 


492  A   MANUAL  OF  SURGERY 

and  non-union  is  likely  to  result ;  {4)  defective  blood-supply  to  one 
or  both  fragments,  as  by  injury  to  the  nutrient  artery,  or  as  in  intra- 
capsular fracture  of  the  cervix  fcmoris,  where  the  only  source  of 
supply  to  the  upper  fragment  is  a  small  twig  derived  from  the 
obturator  artery  running  along  the  ligamentum  teres;  (5)  local 
affections  of  the  bone,  such  as  malignant  tumours,  or  the  undue 
pressure  of  pads  upon  the  newly-formed  callus;  (6)  general  bone 
disease,  as  osteo-malacia ;  and  (7)  general  constitutional  weakness 
or  debihty,  sometimes  due  to  definite  diseases,  such  as  scurvy  or 
severe  syphihs,  sometimes  to  general  asthenia  or  alcoholism.  It 
has  been  proved  that  senility,  pregnancy,  and  the  cancerous  cachexia 
do  not,  as  used  formerly  to  be  stated,  predispose  to  this  condition. 

The  Signs  of  an  ununited  fracture  are  usually  obvious,  mobility 
between  the  fragments  being  easily  obtained  in  some  directions, 
though  perhaps  not  in  all;  of  course  crepitus  is  absent. 

The  Prognosis  is  fairly  good  if  suitable  treatment  is  adopted,  and 
the  local  or  general  conditions  do  not  prohibit  reunion.  Even  opera- 
tion is  not  always  successful,  especially  if  the  soft  parts  have  to  be 
extensively  interfered  with  in  order  to  secure  reposition  of  the  frag- 
ments; in  children  under  such  circumstances  the  outlook  is  poor, 
the  ends  of  the  bone  becoming  atrophic,  rounded,  and  covered  by 
cartilage;  in  such  the  final  resource  is  not  unfrequentlv  amputation. 

Treatment. — (i)  If  in  good  position,  the  parts  should  be  refixed, 
and  a  course  of  passive  venous  congestion  carried  out.  A  Bier's 
elastic  bandage  is  applied  to  the  Hmb  above  the  fracture  for  three 
or  four  hours  daily.  Excellent  results  often  follow.  At  the  same 
time  the  general  health  is  improved  by  a  stay  at  the  seaside  or  the 
administration  of  tonics.  (2)  Failing  this,  operative  measures  must 
be  undertaken.  If  tfie  bone  is  tolerably  superficial,  and  the  ends 
not  very  far  apart,  they  should  be  exposed,  sawn  into  shape,  fitted 
together  (preferably  by  a  dove-tailing  process),  and  secured  by  stout 
silver  wire,  plates,  screws,  or  pegs.  If,  however,  the  bones  are  deeply 
placed,  so  that  it  is  difficult  to  expose  the  ends  and  fit  them  together, 
it  may  be  wiser  to  leave  them  in  their  bad  position,  and  fix  them  by 
the  insertion  of  screws  or  ivory  pegs.  Thus,  in  the  upper  end  of  the 
femur  non-union  is  usually  associated  with  overlapping  of  the  ends 
of  the  bone  to  a  considerable  extent.  To  expose  and  fit  these 
together  would  necessitate  a  very  extensive  dissection;  it  may  be 
desirable  in  such  cases  merely  to  cut  down  in  front  upon  the  upper 
anterior  fragment,  drill  two  holes  in  different  directions  through 
both  fragments,  and  into  these  insert  suitable  pegs  or  screws.  Two 
holes  should  always  be  employed,  to  prevent  shpping  of  the  frag- 
ments during  the  necessary  manipulations;  whilst  one  drill  is 
removed  for  the  insertion  of  the  peg,  the  other  holds  the  bone  steady. 
Their  presence  causes  the  formation  of  a  large  amount  of  callus,  and 
by  this  means  the  fracture  is  consolidated.  (3)  When  there  is  loss 
of  substance  between  the  bone  ends  and  other  operative  measures 
fail,  various  methods  of  hone  graf ling  may  be  employed.  Thus,  in  an 
ununited  fracture  of  the  tibia  in  a  child  it  may  be  possible  to  secure 


INJURIES  OF  BONES—FRACTURES 


493 


continuity  of  the  bone  by  the  employment  of  a  graft  cut  from  the 
othiM"  sound  tibia,  or  consisting  of  a  portion  of  the  sound  fibula 

Vicious  Union  (Fig.  198)  of  fractures  results  either  from  imperfect 
adjustment  of  the  ends  of  the  bone,  or  from  the  parts  not  being  kept 
at  rest,  and  hence  becoming  subsequently  displaced.  Various  kinds 
of  deformity  and  disfigurement, 
accompanied  or  not  by  loss  of 
function,  may  result  from  this 
accident,  and  if  these  are  serious, 
means  must  be  taken  to  remedy 
matters.  If  observed  early,  when 
the  callus  is  not  too  consoli- 
dated, it  is  not  difficult  forcibly 
to  readjust  the  parts  by  manipu- 
lation under  an  anaesthetic,  if 
necessary,  refracturing  the  bone. 
In  some  cases  powerful  mechanical 
apphances,  or  osteoclasts,  are  em- 
ployed for  this  purpose,  but  care 
must  be  exercised  not  to  damage 
unduly  the  soft  parts.  The  open 
method  is  certainly  preferable,  cut- 
ting down  on  the  bone,  redividing 
it,  removing  redundant  callus,  and 
fixing  the  fragments  by  silver  wire, 
pegs,  or  screws. 

Disunited  Fracture  is  the  term 
applied  to  a  rare  condition,  in  which 
a  fracture  which  had  been  firmly 
united  becomes  separated  again. 
It    is    only    met    with    when    the 

individual  develops  some  extremely  debilitating  disease,  such  as 
scurvy,  and  may  be  recovered  from  under  suitable  treatment 
directed  to  the  cause,  and  by  fixation  of  the  parts. 


Fig.  198. — Vicious  Union  with 
Marked  Deformity  after 
Fracture  of  Femur.  (King's 
College  Hospital  Museum.) 


Special  Fractures. 

Bones  of  the  Face. — The  Nasal  bones  are  broken  as  a  result  of  direct 
violence — ^by  the  fist,  a  cricket -ball,  stick,  etc.  The  fracture  is  gener- 
ally transverse,  and  situated  just  above  their  free  margins ;  occasion- 
ally, when  greater  force  is  used,  it  occurs  close  to  the  root  of  the  nose, 
and  may  then  be  associated  with  fracture  of  the  frontal  bone  or  base 
of  the  skull.  In  young  people  the  cartilages  alone  may  be  separated. 
There  is  usually  considerable  deformity  from  depression  or  lateral 
displacement  of  the  fragments,  although  it  may  at  first  be  masked 
by  the  amount  of  bruising.  Severe  epistaxis,  surgical  emphysema, 
and  cerebral  symptoms,  are  sometimes  met  with  as  complications. 
The  fracture  very  readily  becomes  consohdated,  and  the  deformity 
is  thus  often  irremediably  fixed,  unless  its  presence  is  determined  at 


494 


A   MANUAL  OF  SURG  FRY 


once,  and  suitable  treatment  adopted.  The  Septum  is  some- 
times broken  and  depressed,  in  association  witli  or  apart  from  the 
above  injiiry.  Lateral  displacement  occurs,  causing  imilateral  nasal 
obstruction  and  some  amount  of  obvious  deformity.  The  Treatment 
of  these  cases  consists  in  immediate  replacement  of  the  bones, 
advisably  under  an  anaesthetic;  this  may  be  accomplished  by  the 
pressure  of  some  blunt  instrument,  such  as  a  pair  of  dressing- 
forceps,  the  blades  of  which,  covered  with  rubber,  are  introduced 
within  the  nostril.  A  pad  of  lint  or  gauze  soaked  in  carbolized  oil 
is,  if  necessary,  inserted  to  maintain  the  position,  and  a  gutta-percha 
or  zinc  spUnt  moulded  to  fit  the  bridge.  This  dressing  should  be 
changed  at  least  every  twenty-four  hours,  and  the  nose  irrigated 
In  old-standing  cases,  where  there  is  much  depression,  but  little  can 
be  done  by  operation,  but  subcutaneous  injections  of  paraffin  may 
improve  the  appearance  (p.  814).  Lateral  displacement  can  usually 
be  remedied  by  mechanical  appliances  or  operation. 

The  Lachrymal  bone  has  been  broken  by  direct  violence,  the  frac- 
ture usu'ally  extending  from  the  nasal  bone  to  the  lateral  mass  of  the 
ethmoid.  Interference  with  the  flow  of  tears  and  surgical  emphy- 
sema are  the  two  most  marked  symptoms. 

The  Malar  bone  is  but-rarely  broken  without  the  other  bones  of  the 
face  being  involved;  fracture  is  almost  always  associated  with 
damage  to  the  anterior  wall  of  the  antrum  and  considerable  depres- 
sion of  the  fragments.  An  attempt  should  be  made  to  replace  the 
parts  by  pressure  from  within  the  mouth. 

The  Zygoma  is  fractured  by  direct  violence  apphed  from  without; 
the  broken  portion  may  be  depressed  below  the  surface,  but  vertical 
displacement  is  limited  by  the  attachment  of  the  masseter  below  and 
of  the  temporal  fascia  above.  Reposition,  either  by  manipulation 
from  within  the  mouth,  or  even  by  operation,  is  essential  in  order  to 
prevent  interference  with  the  subsequent  mobiUty  of  the  jaw.  Per- 
haps the  simplest  plan  to  adopt  is  to  encircle  the  zygoma  subcu- 
taneously  with  a  loop  of  silver  wire  and  drag  it  up  to  its  natural  level. 

The  Superior  Maxilla  is  invariably  broken  as  a  result  of  direct 
injury,  such  as  a  blow  or  gunshot  wound ;  it  is  almost  always  com- 
pound, and  often  bilateral.  The  alveolar  portion  is  either  partially 
or  entirely  detached,  or  a  transverse  fissure,  extending  as  far  as  the 
pterygoid  processes  on  each  side,  may  render  the  whole  palate  and 
lower  part  of  the  facial  skeleton  moveable.  More  frequently  all  the 
bones  of  the  face  are  smashed  and  comminuted,  severe  haemorrhage 
sometimes  resulting  from  wounds  of  the  terminal  branches  of  the 
internal  maxillary  artery.  Treatment  consists  in  merely  keeping  the 
patient  quiet  and  applying  cooling  lotions;  union  occurs  with  great 
readiness,  but  is  sometimes  associated  with  suppuration  and  necrosis. 
The  patient  must  be  fed  by  a  tube,  and  a  carefully-fitted  dental  plate 
should  be  applied  to  a  broken  alveolus. 

The  Inferior  Maxilla  is  usually  fractured  by  direct  violence,  applied 
from  in  front  as  by  a  fall  or  a  '  punch  '  on  the  chin ;  more  rarely  the 
force  acts  from  the  side,  and  then  the  bone  may  break  in  the  middle 


INJURIES  OF  BONES—FRACTURES 


495 


line.  Most  frequently,  however,  the  lesion  is  a  little  in  front  of  the 
mental  foramen  (Fig.  199),  this  being  a  weak  spot  at  the  junction  of 
two  strong  parts,  viz.,  the  symphysis  menti,  and  the  alveolar  process 
carrying  the  molar  teeth ;  the  bone  is  further  weakened  by  the  long 
narrow"  alveolus  which  lodges  the  canine  tooth.  This  fracture  is 
occasionally  bilateral  when  great  violence  has  been  applied  to  the 
symphysis.  A  solution  of  continuity  sometimes  occurs  close  to  the 
angle  behind  the  molar  teeth,  whilst  the  coronoid  process  and  con- 
dyle have  also  been  broken,  the  former  only  as  a  result  of  severe 
direct  force — e.g.,  a  gunshot  wound — ^the  latter  from  either  direct 
or  indirect  violence. 

The  Signs  of  fracture  are  very  evident  if  the  lesion  is  situated 
anteriorly;  but  when  behind  the  teeth,  diagnosis  may  be  much  more 
difficult.  The  usual  variety  is  almost  always  compound,  owing  to 
the  firm  attachment  of  the  muco-periosteum  to  the  alveolar  border. 
Laceration  of  the  gums,  the  blood-stained  sahva  soon  becoming 


Fig.  igg. — Lower  Jaw,  indicating  the 
Most  Common  Sites  of  Fracture. 


Fig.  200. — Application  of 
Four-Tailed  Bandage  for 
Fracture  of  Lower  Jaw  . 


foetid,  the  irregularity  in  the  hne  of  the  teeth,  some  of  which  are 
loose,  and  the  easily  elicited  crepitus,  all  constitute  a  typical  picture. 
There  is  often  considerable  pain,  owing  mainly  to  the  tearing  of  the 
mucous  membrane,  but  possibly  due  to  implication  of  the  inferior 
dental  nerve.  The  main  trunk,  however,  generally  escapes,  owing 
to  the  position  of  the  fracture  in  front  of  the  mental  foramen,  whilst 
in  those  behind  there  is  but  little  displacement.  Smart  haemorrhage 
sometimes  occurs  from  laceration  of  the  accompanying  artery.  The 
posterior  fragment  is  usually  raised  and  displaced  outwards,  whilst 
the  anterior  portion  is  depressed  by  the  action  of  the  hyoid  muscles, 
and  may  overlap  the  other.  In  a  bilateral  fracture  the  loose  central 
fragment  is  displaced  downwards  by  the  causative  blow  and  held  in 
that  position  by  the  muscles,  whilst  the  posterior  fragments  are 
drawn  upwards  and  outwards  by  the  temporal  and  masseter  muscles. 
When  situated  at  the  angle  or  in  the  vertical  ramus,  there  is  such  equal 
muscular  support  on  the  two  sides  that  but  little  displacement 
results.     When  the  fracture  passes  through  the  neck  of  the  condyle. 


496 


A   MANUAL  OF  SURGERY 


that  process  is  drawn  forwards  and  inwards  by  the  external  pterygoid, 
whilst  the  body  of  the  bone  is  freely  moveable  antero-postcriorly, 
and  displaced  towards  the  fractured  side.  WHien  the  coronoid 
process  is  detached,  it  is  dragged  upwards  by  the  temporal  tendon, 
but  no  great  displacement  can  occur,  owing  to  the  extensive  attach- 
ment of  the  tendinous  fibres. 

Treatment. — Seeing  that  in  the  majority  of  these  cases  the  fracture 
is  compound,  the  greatest  care  must  be  taken  to  try  and  keep  the 
mouth  clean  and  free  from  infection  by  the  use  of  antiseptic  lotions; 
failure  in  this  direction  may  result  in  necrosis  of  the  ends  of  the 
fragments,  together  with  suppuration,  an  abscess  perhaps  pointing 
beneath  the  jaw,  whilst  pneumonia  or  even  general  pyaemia  may 
ensue.  The  condition  of  the  teeth  must  be  carefully  considered, 
and  in  any  case  the  co-operation 
of  a  skilled  dentist  is  desirable. 
Teeth  that  are  merely  loosened  in 
their  sockets  may  often  be  left, 
and  will  become  refixed  ;  but 
teeth  that  are  quite  loose,  as 
also  septic  roots,  should  be  re- 
moved, especially  if  encroaching 
on  the  line  of  fracture. 


Fig.  20I. — Leather  Splint 
FOR  Lower  Jaw. 


Fig.  202. — Leather  Splint 

APPLIED. 


1.  As  a  temporary  measure,  and  indeed  as  a  permanent  appliance 
in  simple  cases  without  much  displacement  of  the  fragments  and 
where  dental  assistance  is  not  to  hand,  all  that  is  needed  is  an  efficient 
four-tailed  bandage.  This  is  made  by  taking  a  piece  of  calico  4  inches 
wide  and  i  yard  m  length,  and  splitting  each  end  into  two,  leaving 
about  8  inches  undivided,  in  the  centre  of  which  a  small  longitudinal 
cut  is  made  for  the  insertion  of  the  chin.  The  two  lower  tails  are 
then  drawn  up  and  tied  over  the  vertex,  whilst  the  two  upper  ends 
are  secured  behind  the  occiput,  and  then,  to  prevent  slipping,  are 
knotted  to  the  ends  of  the  former  (Fig.  200).  The  bandage  is 
maintained  firmly  in  position  for  three  weeks,  the  patient  being  fed 
through  a  tube  passed  between  the  teeth  or  through  the  gap  behind 
the  last  molar,  and  all  movement  of  the  jaw  prohibited.  The  mouth 
should  be  frequently  washed  out  with  some  antiseptic  lotion.  Union 
is  usually  secured  in  five  weeks. 

2.  If  there  is  any  difficulty  in  maintaining  the  parts  in  good 
position,  alight  poroplastic  or  leather  splint  may  be  applied,  made 
m  the  shape  indicated  in  Fig.  201,  the  upper  portion,  which  should 


INJURIES  OF  BONES— FRACTURES 


497 


reach  to  the  posterior  border  of  the  vertical  ramus,  being  folded 
back,  and  the  lower  portion  drawn  up  around  the  bone.  It  is  hned 
with 'lint,  and  secured  by  bandages  or  tapes  passed  through  holes, 
and  tied  as  shown  in  Fig.  202.  ,  u    a      i 

3.  Where  there  is  much  displacement,  the  fragments  must  be  hxed. 
Wire  sutures  passed  around  or  between  adjacent  teeth  and  tied  are 
distinctly  objectionable,  causing  the  teeth  to  become  loose  and  per- 
haps diseased.  Hammond's  wire  splint  is  the  best  apparatus  to 
employ.  It  consists  of  a  firm  wire  collar  or  framework  (Fig.  203),  which 
encircles  the  whole  series  of  teeth  in  the  lower  jaw.  It  is  accurately 
fitted  by  a  dentist,  firstly,  to  a  cast  of  the  jaw,  subsequently  to  the 
jaw  itself,  and  is  fixed 
by  several  wires  passing 
from  one  half  to  the  other 
between  the  teeth. 

4.  In  cases  where  a 
Hammond's  sphnt  fails 
in  remedying  the  dis- 
placement, or  where  the 
teeth  are  defective,  a 
Kingsley's  apparatus 
may  be  used  with  ad- 
vantage. It  consists  of 
a  vulcanite  splint  fitted 
over  the  teeth  or  al- 
veolar process  of  the 
mandible,  and  extending 
for  a  sufftcient  distance 
on     each     side     of     the 


Fig.  203. — Hammond's  Splint  for 
Fracture  of  Lower  Jaw. 


fracture    to     steady    the  -,        ^  i  u 

fragments.  To  the  front  of  this  are  attached  curved  metal  bars, 
which  extend  sideways  from  the  angles  of  the  mouth  over  the 
cheeks.  It  is  kept  in  position  by  passing  a  bandage  over  the  bars 
and  under  the  chin,  and  secures  thereby  excellent  immobihzation 
of  the  fragments,  even  when  the  mouth  is  opened. 

S  Wiring  of  the  fragments  together  may  be  required  m  a  few  cases. 
The  wires  must  be  passed  either  through  the  bone  below  the  teeth— 
a  task  not  easy  to  accomplish  without  an  external  wound--or 
through  the  empty  alveoh  of  neighbouring  teeth,  which  are  extracted 

for  the  purpose.  ,  .^  i.     1     j  + 

WTien  septic  inflammation  occurs  of  such  seventy  as  to  lead  to 
necrosis,  it  is  best  to  delay  all  operative  treatment  until  the  seques- 
trum has  been  detached,  and  the  parts  are  more  healthy,  the 
patient's  mouth  in  the  meantime  being  frequently  cleansed  with 
antiseptic  lotions.  Wiring  of  the  fragments  may  then,  if  necessary, 
be  undertaken  with  good  hope  of  success. 

Fracture  of  the  Hyoid  Bone  is  uncommon,  arising  usually  trom 
direct  violence,  such  as  a  forcible  grasp  or  the  constriction  of  the 
neck  in  hanging.     Either  the  body  may  be  broken,  or  one  of  the 


498  A   MANUAL  OF  SURGERY 

cornua  separated.  The  s^Tnptoms  produced  are:  Pain  on  attempt- 
ing to  move  the  tongue,  jaw,  or  neck ;  a  husky  voice ;  and  deformity, 
which  can  sometimes  be  detected  from  without.  Occasionally  the 
mucous  membrane  is  perforated,  and  bleeding  into  the  pharynx  may 
occur,  whilst  oedema  of  the  glottis  may  super\'ene.  The  fragments 
should  be  approximated  as  well  as  possible  by  manipulation  between 
one  finger  in  the  mouth  and  the  hand  outside,  and  the  neck  then 
fixed  by  a  poroplastic  collar. 

Fracture  of  the  Ribs  may  arise  in  two  distinct  ways:  (i)  By  direct 
violence,  as  by  blows  or  stabs,  the  fragments  being  driven  inwards, 
and  damage  to  the  underlying  pleura,  lungs,  liver,  or  diaphragm, 
being  very  likely  to  occur;  or  (2)  much  more  frequently  by  indirect 
violence,  as  when  the  chest  is  compressed  between  a  cart-wheel  and 
the  ground,  or  between  a  wall  and  the  back  of  a  waggon.  The  ends 
of  the  ribs  are  then  approximated  beyond  the  hmits  of  natural 
plasticity,  and  they  give  way  at  the  most  convex  part — i.e.,  near  the 
angle.  The  viscera  may  be  contused,  but  less  often  than  in  the 
former  class,  although  haemothorax  from  rupture  of  the  parietal 
pleura  is  not  uncommon.  As  a  rule  more  than  one  rib  is  broken, 
but  the  displacement  is  rarely  marked,  except  in  cases  due  to  direct 
violence,  where  several  ribs  have  been  '  staved  in.'  The  fifth  to  the 
eighth  ribs  are  those  usuall}^  injured,  being  more  prominent  and 
fixed  at  both  ends ;  the  first  and  second  ribs  are  so  well  protected  by 
the  clavicle  as  to  be  seldom  broken  by  direct  injury,  although  great 
violence  from  above  downwards  to  the  outer  end  of  the  clavicle  may 
lead  to  such  an  accident:  the  lower  ribs  often  escape  on  account  of 
their  greater  mobility.  Elderly  women  and  persons  suffering  from 
various  mental  diseases,  such  as  general  paralysis,  are  specially  prone 
to  this  fracture. 

The  Symptoms  are  tolerably  obvious,  viz.,  a  sensation  of  something 
snapping  or  giving  way,  a  sharp  localized  catching  pain  at  the  site  of 
the  injury,  increased  on  deep  breathing  and  coughing^  and  possibly 
some  local  extravasation  and  swelHng.  Pain  is  ehcited  by  a  local 
examination,  and  also  by  conjoined  pressure  upon  the  sternum  and 
spinal  column,  whilst  the  fracture  may  be  evident  on  palpation,  or 
crepitus  detected  when  the  patient  coughs  or  on  auscultation.  When 
several  ribs  are  driven  in,  a  marked  depression  results,  but  if  a  single 
bone  is  broken  in  a  fat  individual,  the  diagnosis  may  be  extremely 
obscure.  For  the  chnical  history  of  the  pulmonary  or  pleural  com- 
plications, see  p.  gi8. 

Treatment.— The  affected  side  should  be  firmly  strapped  with 
broad  strips  of  adhesive  plaster,  so  as  to  limit  its  movements.  The 
strips,  i|  to  2  inches  wide,  should  extend  beyond  the  middle  line, 
both  front  and  back,  and  are  applied  from  below  upwards,  whilst 
the  chest  is  in  a  state  of  forcible  expiration,  each  strip  overlapping 
the  preceding  one  and  crossing  the  direction  of  the  ribs  (Fig.  204). 
A  firm  woollen  bandage  should  then  be  applied  over  all.  If  the 
ends  of  the  bone  are  driven  inwards,  strapping  can  rarely  be  borne, 
as  it  tends  still  further  to  irritate  or  compress  the  lung.     Under  such 


INJURIES  OF  BONES— FRACTURES 


499 


circumstances  all  constriction  of  the  chest  must  be  avoided,  the 
patient  being  confined  to  bed  with  a  sandbag  between  the  shoulders, 
and  the  arm  bound  to  the  side.  When  the  lower  ribs  are  broken, 
tight  applications  are  generally  contra-indicated,  since  the  dia- 
phragm is  likely  to  be  irritated,  and  troublesome  hiccough  may 
result.  Ribs  unite  readily,  but  with 
a  considerable  amount  of  callus,  owing 
to  the  mobihty  of  the  fragments. 

Separation  of  a  Costal  Cartilage 
sometimes  occurs,  giving  rise  to  the 
same  symptoms  and  requiring  the 
same  treatment  as  a  broken  rib. 
Occasionally  the  cartilage  itself  may 
be  fractured.  In  each  case  the  re- 
sulting bond  of  union  is  osseous. 

Fracture  of  the  Sternum  is  almost 
always  due  to  direct  violence,  but  is 
occasionally  caused  by  forcible  flexion 
of  the  body,  and  is  then  generally 
associated  with  fracture  of  the  spine. 
The  Hne  of  fracture  is  usually  trans- 
verse, the  bone  giving  way  either 
between  the  manubrium  and  gladi- 
olus or  a  httle  below  this  level.  The  fragments  may  remam 
in  situ  or  the  upper  portion  be  displaced  backwards,  the 
deformity  in  such  cases  being  very  evident,  and  great  dyspnoea 
resulting.  As  a  late  effect,  aneurism  of  the  arch  of  the  aorta 
may  occur.  Treatment.— The  patient  should  be  kept  in  bed  with 
a  pillow  between  the  shoulders,  and  the  chest  strapped  as  for 
fractured  ribs.  If  the  patient  cannot  bear  this  position,  he  should 
be  allowed  to  sit  up  with  the  body  leaning  forwards.  Reposition 
can  sometimes  be  effected  by  manipulation  and  extension,  but  the 
possible  co-existence  of  a  fractured  spine  must  not  be  overlooked. 


Fig. 


204. — Method  of  Strap- 
ping Broken  Ribs. 


Fractures  of  the  Upper  Extremity. 

Fracture  of  the  Clavicle.— No  bone  in  the  body,  with  the  exception 
of  the  radius,  is  broken  more  frequently  than  the  clavicle ;  this  is  due 
to  its  exposed  position  and  its  buttress-hke  action  in  keeping  out  the 
point  of  the  shoulder,  so  that  every  shock  to  the  arm  is  transmitted 
through  it  to  the  trunk.  Hence,  although  sometimes  broken  by 
direct  violence,  fracture  is  usually  due  to  force  directed  to  the  hand 
or  shoulder,  such  as  a  fall  from  a  horse.  It  is  more  common  m  men 
than  in  women,  and  in  children  is  often  of  a  greenstick  nature.  The 
bone  may  yield  in  four  different  situations,  viz.: 

I.  At  the  Sternal  End,  an  unusual  occurrence,  due  to  direct  or 
indirect  violence.  The  displacement  vanes  with  the  hne  of  frac- 
ture •  if  transverse,  it  is  sHght ;  but  if  obhque,  and  this  is  most  usual, 


500 


A   MANUAL  OF  SURGERY 


the  outer  fragment  is  drawn  downwards  and  forwards  as  in  the  next 
variety,  though  to  a  less  degree. 

2.  Through  the  Greater  Convexity,  the  commonest  situation. 
The  l)one  \ields  about  its  centre,  or  a  httle  external  to  it,  and  the 
line  of  fracture  is  slightly  oblique,  running  from  before  backwards, 
downwards,  and  inwards.  The  displacement  is  quite  characteristic, 
and  is  present  in  any  fracture  situated  between  the  rlujmboid  liga- 
ment on  the  inner  side  and  the  coraco-clavicular  ligaments  on  the 
outer,  being  less  marked,  however,  when  the  fracture  is  nearer  the 
extremities  than  in  the  centre  of  this  space.  The  patient  gives  a 
history  of  injury  and  severe  pain,  supports  the  elbow  with  the  other 

hand,  the  head  being  bent  over 
to  the  affected  side  to  relax 
the  muscles  of  the  neck,  and 
the  arm  is  powerless.  The 
point  of  the  shoulder  is  less 
prominent  than  usual,  being 
approximated  to  the  middle 
line,  and  on  a  lower  level  than 
the  other,  whilst  at  the  seat 
of  fracture  the  inner  fragment 
projects.  This  deformity  is  ac- 
counted for  by  a  displacement 
of  the  whole  outer  fragment 
downwards,  forwards,  and  in- 
wards (Fig.  205);  the  outer 
end  being,  however,  more  dis- 
placed than  the  inner.  This  is 
mainly  due  to  the  weight  of 
the  arm  acting  upon  the  outer 
fragment  when  the  buttress-like 
action  of  the  bone  is  gone ;  mus 
cular  action  has  but  little  effect. 
The  position  of  the  inner  fragment  is  probably  but  little  altered, 
since  it  is  held  in  place  by  the  rhomboid  ligament ;  the  apparent 
projection  of  its  outer  end  is  mainly  due  to  the  depression  of  the  . 
outer  fragment. 

3.  Between  the  Coraco-clavicular  Ligaments,  usually  arising  from 
direct  violence,  and  with  but  little  displacement,  owing  to  the 
tension  of  the  hgaments  and  to  the  fact  that  the  periosteum  is  not 
torn  across.  The  signs  of  local  trauma  and  crepitus  are,  however, 
present,  though  not  very  obvious. 

4.  At  the  Acromial  End,  external  to  the  trapezoid  ligament,  and, 
again,  generally  produced  by  direct  violence.  The  inner  fragment 
retains  its  position  unaltered,  but  the  outer  fragment  is  dragged  down 
by  the  weight  of  the  arm,  and  forwards  by  the  action  of  the  muscles, 
so  that  it  sometimes  lies  at  right  angles  to  the  rest  of  the  bone. 

Complications  arise  most  frequently  in  cases  produced  by  direct 
violence.     The  subclavian  vein  may  be  injured,   or  the  brachial 


Fig.  205. — Fracture  of  Clavicle 
THROUGH  Greater  Convexity. 

,  Sterno-mastoid ;  2,  subclavius;  3,  pec- 
toralis  minor;  4,  pectoralis  major; 
5,  latissimus  dorsi. 


INJURTES  OF  BONES—FRACTURES  501 

plexus ;  and  oven  tlie  dome  of  tlio  pleura  and  the  subjacent  lung  have 
been  wounded.  Gangrene  of  the  arm  has  been  caused  by  obstruction 
to  the  vessels.  Great  violence  has  resulted  in  fracture  of  the  first 
rib. 

Treatment. — Where  there  is  little  or  no  displacement,  all  that  is 
needed  is  to  immobilize  the  arm  in  a  shng  and  to  keep  the  patient 
quiet.  In  a  greenstick  fracture,  the  deformity  must  be  remedied 
by  manipulation,  and  the  arm  subsequently  bandaged  to  the  side. 

For  fractures  with  displacement  many  different  plans  of  treatment 
have  been  adopted.  In  order  to  replace  the  fragments,  the  surgeon 
should  stand  behind  the  patient,  who  is  seated,  with  his  knee  be- 
tween the  scapulas;  traction  is  then  made  upon  the  shoulders,  and 
the  point  of  the  acromion  is  drawn  upwards  and  backwards.  To 
maintain  the  fractured  ends  in  apposition  the  following  methods 
have  been  recommended:  {a)  The  simplest,  which  can  always  be 
apphed  in  emergency  cases,  is  that  known  as  the  three-handkerchief 


•^^nti 


Figs.  206  and  207. — Sayre's  Method  of  Strapping  for  Fractured 

Clavicle. 

plan.  Two  large  handkerchiefs,  folded  double  and  rolled  into  bands, 
are  placed  vertically,  one  over  each  shoulder  and  under  each  axilla ; 
each  is  lightly  knotted  behind,  and  the  ends  firmly  tied  to  the  oppo- 
site handkerchief  across  the  middle  Hne.  By  this  means  the  point 
of  the  shoulder  is  kept  outwards  and  backwards.  The  third  hand- 
kerchief is  now  folded  crosswise  and  used  as  a  shng  to  support  the 
elbow,  which  is  drawn  well  forwards,  the  hand  being  placed  over  the 
sound  clavicle.  If  this  apparatus  is  employed  permanently,  the 
knots  must  be  examined  every  few  days,  especially  at  first,  as  the 
handkerchiefs  always  stretch  a  little  and  require  occasional  tighten- 
ing, [b)  Sayre's  method  is  very  useful,  especially  in  treating  chil 
dren.  A  long  strip  of  adhesive  plaster,  3^  inches  wide  or  less,  accord- 
ing to  the  size  of  the  patient,  is  passed  round  the  arm  a  little  below 
the  axilla,  as  a  loop,  with  the  sticky  side  out,  and  then  around  the 
body  with  the  adhesive  side  inwards,  the  arm  being  drawn  well  back, 
and  the  loop  and  end  secured  by  stitches  (Fig.  206).     If  this  has 


502  A   MANUAL  OF  SURGERY 

been  applied  firmly,  it  may  now  be  used  as  a  fulcrum,  so  that  as 
the  elbow  is  drawn  forwards,  the  point  of  the  shoulder  is  directed 
backwards  and  outwards,  and  thus  the  main  deformity  is  overcome. 
Another  strip  of  a  similar  width  is  applied  over  the  elbow  (a  small 
hole  being  cut  to  receive  the  point  of  the  olecranon),  and  by  this 
means  the  elbow  is  raised  and  drawn  forwards  (Fig.  207)  so  that  the 
hand  can  be  placed  on  the  opposite  shoulder,  and  the  desired 
position  is  thus  maintained.  In  children  more  than  one  strip  of 
plaster  will  be  needed  in  order  to  secure  the  arm,  whilst  an  additional 
bandage  is  also  useful.  Excellent  results  follow  this  plan  of  treat- 
ment, (c)  In  ladies,  where  even  the  slightest  deformity  is  un- 
desirable, it  is  better  to  confine  them  to  bed  for  three  weeks;  the 
head  is  kept  low  without  a  pillow,  and  a  sandbag  placed  between  the 
scapulae,  the  arm  being  bandaged  to  the  side. 

Union  is  probably  attained  in  four  weeks,  but  the  movements  of 
the  arm  should  be  restricted  for  some  time  longer.  A  considerable 
amount  of  callus  is  usually  formed,  and  there  is  very  hkely  to  be 
some  slight  persistent  deformity. 

Fractures  of  the  Scapula. — i.  The  Acromion  Process  may  be 
broken  by  direct  violence  applied  to  the  point  of  the  shoulder.  The 
arm  hangs  powerless,  supported  by  the  other  hand,  and  the  shoulder 
is  flattened.  The  irregularity  of  the  bone  can  be  readily  detected, 
and  crepitus  can  be  eUcited  by  raising  the  elbow  and  rotating  the 
arm.  Occasionally  the  tip  alone  is  detached,  and  then  the  above 
signs  will  not  be  present.  Treatment  consists  in  raising  the  elbow, 
and  bandaging  the  arm  to  the  side. 

2.  The  Coracoid  Process  is  rarely  fractured,  and  then  only  by  direct 
violence.  There  is  but  little  displacement,  on  account  of  the  power- 
ful ligaments  attached  to  it,  and  all  the  treatment  needed  is  to  raise 
the  elbow  by  a  sling  and  keep  the  arm  to  the  side. 

3.  The  Body  of  the  scapula  is  broken  as  a  result  of  considerable 
direct  violence,  which  is  often  primarily  received  by  the  spine. 
There  is  but  little  displacement  when  the  fracture  is  comminuted  or 
transverse  just  below  the  spine.  A  longitudinal  fracture  may,  how- 
ever, result  in  the  inner  or  vertebral  fragment  being  drawn  upwards 
and  outwards  in  front  of  the  axillary  portion  by  the  serratus  magnus 
and  levator  anguli  scapulae.  The  diagnosis  is  sometimes  difficult 
owing  to  the  presence  of  a  large  haematoma,  but  can  usually  be  made 
by  detecting  crepitus  on  grasping  the  bone  firmly,  and  mo\nng  one 
fragment  on  the  other,  or  by  radiography.  Treatment  consists  in 
bandaging  the  arm  to  the  side,  and  possibly  applying  strapping  to 
support  the  fragments. 

4.  Fracture  of  the  Neck  is  usually  due  to  great  violence  directed  to 
the  shoulder,  but  is  uncommon.  A  portion  of  the  articular  surface 
is  broken  off  and  displaced  downwards  in  some  few  cases  of  dislo- 
cated shoulder  (Fig.  208,  A) ;  or  the  fracture  has  been  known  to  run 
through  the  anatomical  neck  (Fig.  208,  B),  either  condition  causing 
some  flattening  of  the  shoulder,  slight  lengthening  of  the  arm,  and 
displacement  downwards  of  the  head  of  the  humerus,  so  that  the 


INJURIES  OF  BONES— FRACTURES 


503 


appearance  somewhat  resembles  that  of  a  dislocation .     Treatment. — ■ 
The  arm  must  be  kept  to  the  side  and  raised. 

More  commonly,  however,  the  fracture  involves  the  Surgical  Neck 
(Fig.  208,  C),  extending  from  the  suprascapular  notch  above  (o  just 
below  the  origin  of  the  triceps  muscle,  so  that  the  detached  fragment 
includes  the  coracoid  process.  Flattening  of  the  shoulder  results, 
with  prominence  of  the  acromion,  lengthening  of  the  arm  as 
measured  from  the  acromion  to  the  external  condyle,  and  crepitus 
on  raising  and  rotating  the 
hmb.  Treatment. — -The 
bone  is  replaced  by  pressure 
in  the  axilla,  if  necessary 
under  chloroform,  and  fixed 
by  an  axillary  pad  or  a 
n -shaped  leather  splint, 
whilst  the  arm  is  kept  to 
the  side. 

Fractures  of  the  Upper 
End  of  the  Humerus. — 
I.  Of  the  Anatomical  Neck, 
the  so-called  '  Intracapsular 
Fracture'  (Fig.  209).  This 
is  usually  due  to  blows  or 
falls  on  the  shoulder,  less 
commonly  to  indirect  vio- 
lence, and  occurs  more  often 
in  elderly  people  than  in 
the  young.  The  shoulder 
becomes  greatly  swollen 
from  effusion  of  blood;  pain 
on  movement  is  severe,  but 
crepitus  may  perhaps  be 
felt  on  rotating  the  arm; 
there  is  usually  about  half 
an  inch  of  shortening.  In 
most  cases  the  upper  frag- 
ment is  not  totally  de- 
tached, but  remains  con- 
nected with  the  rest  of  the  bone  by  a  few  shreds  of  capsule, 
and  thus  necrosis  is  prevented;  it  is  sometimes  impacted  into 
the  lower  fragment,  and  marked  deformity  of  the  head  of  the 
bone  results,  which  can  be  detected  occasionally  by  palpation  from 
the  axilla.  If  it  is  completely  detached,  the  small  upper  fragment  is 
often  rotated  on  its  own  axis,  and  even  dislocated  into  the  axilla. 
Examination  must  be  conducted  with  great  care  lest  impaction  be 
disturbed,  or  any  capsular  attachments  broken  through ;  the  routine 
use  of  radiography  in  all  serious  lesions  of  the  shoulder  renders  such 
manipulation  less  necessary  than  formerly.  Repair  takes  place 
mainly  from  the  lower  end,  and,  owing  to  the  difficulty  of  apposing 


Fig.  208. — Fractures  of  the  Neck  of 
THE  Scapula. 

A,  Through  the  glenoid  fossa;  B,  through 
the  anatomical  neck;  C,  through  the 
surgical  neck. 


504 


A   MANUAL  OF  SURGERY 


and  immobilizing  the  fragments,  a 
usually  formed.  Treatment. — ^WTien 
nothing  more  is  required  than  to  rai 
to  the  side  by  a  suitable  liandage, 
support  is  given  by  placing  a  pad  i 
menced  early — about  the  fourth  or 
ments  a  few  days  later  J  In  the  more 
splint  isfplaced  in  the  axilla,  and 
bandage  or  handkerchief  passing  ov 


considerable  mass  of  callus  is 
there  is  but  little  displacement, 
se  the  elbow  and  keep  the  arm 
though  a  comfortable  sense  of 
n  the  axilla.  Massage  is  com- 
fifth  day — and  passive  move- 
serious  cases  a  pad  or  n-^li'^^pcd 
retained  in  position  by  a  soft 
er  the  top  of  the  shoulder,  and 


Fig.  209. — Impacted  Fracture  of  the 
Anatomical  Neck  of  the  Humerus. 


Fig.  210. — Fracture  of  Sur- 
gical Neck  of  Humerus 
in  a  Young  Person  after 
Reduction  of  the  De- 
formity. 


tied  under  the  opposite  axilla;  this  assists  in  raising  the  arm,  which 
is  also  supported  by  an  elbow-sling.  Finally,  a  comfortable  poro- 
plastic  or  leather  cap  is  fitted  over  the  shoulder  and  buckled  on. 
Union  generally  occurs  in  about  six  weeks,  but  often  results  in  great 
stiffness,  unless  massage  and  manipulation  are  suitablv  employed ; 
they  must  commence,  however,  a  little  later  than  in  the  simpler 
cases  mentioned  above.  At  first  the  splints,  etc.,  arc  restored  to 
position  after  the  daily  rubbing,  but  are  gradually  discarded,  so  that 
by  the  end  of  three  weeks  or  so  the  arm  is  merely  supported  by 
a  sling. 


INJURIES  OF  BONES—FRACTURES 


505 


If  dislocation  of  the  small  fragment  has  occurred,  or  if  radiography 
indicates  that  it  has  been  rotated  or  seriously  displaced,  the  surgeon 
ma}^  advisably  raise  the  question  of  operation,  with  a  view  to 
removing  the  fragment  entirely. 

2.  Fracture  of  the  Surgical  Neck,  the  '  Extracapsular  Fracture  ' 
(Fig.  210).  The  bone  yields  in  this  case  below  the  muscles  attached 
to  the  tuberosities,  but  above  the  insertions  into  the  bicipital  groove 
and  its  margins  of  the  latissimus  dorsi,  pectorahs  major,  and  teres 
major.  It  results  from  violence  applied  directly  below  the  point 
of  the  shoulder,  or  from  falls  on  the  hand  or  elbow,  and  is 
usually  more  or  less  transverse.  The  displacement  of  the  upper 
fragment  varies  somewhat,  and  is  often  not  very  great,  but  in  other 
cases  it  is  abducted  considerably.  The 
lower  fragment  is  drawn  inwards  by 
the  muscles  attached  to  the  bicipital 
groove,  and  upwards  by  the  deltoid, 
coraco-brachialis,  biceps,  and  triceps 
(Fig.  211).  The  appearance  of  the 
patient  is  sufficiently  characteristic;  the 
head  of  the  bone  is  still  in  the  glenoid 
cavity,  so  that  there  is  no  loss  of  the 
fulness  of  the  shoulder  (Fig.  212,  C), 
although  there  is  a  depression  just  be- 
low, unless  it  is  obliterated  by  the 
extensive  haemorrhagic  effusion.  The 
elbow  is  directed  away  from  the  side, 
and  the  axis  of  the  lower  fragment  is 
upwards  and  inwards.  Crepitus  can  be 
obtained  b}^  extending  and  rotating  the 
arm,  which  is  shortened  an  inch  or 
more.  This  fracture  is  often  very  pain- 
ful from  pressure  of  the  upper  end  of 
the  lower  fragment  against  the  brachial 
nerves.  If  impaction  occurs,  the  signs 
are  much  less  evident,  and,  indeed,  may 
be  very  equivocal;  the  lower  fragment  is  usually  driven  into  the 
upper,  and  only  slight  shortening  or  displacement  may  be  present. 

Complications. — ^The  axillary  vessels  may  be  seriously  damaged, 
or  more  commonly  some  of  the  nerves  sustain  injury,  especially  the 
circumflex,  which  winds  round  the  neck  of  the  bone  close  to  the  site 
of  the  fracture. 

Treatment. — Immobilization  of  the  fragments  is  absolutely  neces- 
sary in  this  fracture.  It  may  be  secured  in  the  simpler  cases  by 
the  application  of  an  axillary  pad  and  a  shoulder-cap,  whilst  the  arm 
is  kept  to  the  side,  and  the  hand  well  supported  by  a  sUng.  INIiddel- 
dorpf's  triangle  (Fig.  214)  may  be  used  with  advantage  in  this  frac- 
ture. \^Tien  the  fracture  is  obhque  and  the  fragments  overlap,  the 
patient  must  be  put  to  bed,  and  continuous  traction  made  in  an 
abducted  position  of  the  limb.     An  extension  apparatus  (p.  535)  is 


Fig.  211. — Fracture  of  Sur- 
gical Neck  of  Humerus. 

S,  Subscapularis;  L.D.,  latissi- 
mus dorsi ;  D,  deltoid ;  P.M.. 
pectoralis  major. 


5o6 


A   MANUAL  OF  SURGERY 


applied  to  the  arm  from  the  elbow  upwards,  and  a  weight  of  from 
5  to  10  pounds  attached,  the  cord  passing  over  a  pulley  at  the  side 
of  the  bed.  Counter-extension  is  made,  if  need  be,  by  a  sheet 
passed  round  the  body.  Massage  is  employed  from  the  first  in 
order  to  assist  absorption  of  the  effused  blood  and  to  allay  muscular 
spasm.  At  the  end  of  a  fortnight  the  patient  is  allowed  up  with  a 
simple  retentive  apparatus,  but  daily  massage  and  movements  are 
maintained  for  some  time.  Firm  union  usually  results  in  four  and 
a  half  to  six  weeks,  but  with  the  formation  of  a  good  deal  of  callus. 
3.  Separation  of  the  Upper  Epiphysis  occurs  up  to  the  age  of 
eighteen  to  twenty  years,  and  involves  the  head  and  both  the  tuber- 
osities. The  upper  end  of  the  shaft  is  somewhat  conical  in  shape, 
the  apex  of  the  cone  fitting  into  a  depression  in  the  middle  of  the 


Fig.  212. — Outlines  of  Shoulder. 

A,  Normal  shoulder;  B,  dislocation  of  shoulder;  C,  fracture  of  surgical  neck 

of  humerus. 


epiphysis  (Fig.  213).  The  lesion  usually  follows  the  line  of  the  car- 
tilage; but  the  displacement  is  often  incomplete,  partly  from  the 
conical  projection  hitching  against  the  inner  edge  of  the  epiphysis 
(a  doubtful  occurrence),  but  mainly  from  the  persistence  of  a  well- 
marked  periosteal  sleeve  or  bridge  on  the  outer  and  posterior  side. 
The  shaft  usually  travels  forwards,  its  upper  end  projecting  so  as  to 
be  felt  or  even  seen  beneath  the  skin  an  inch  or  more  below  the  cora- 
coid  process;  occasionally  a  well-marked  inward  displacement  is 
superadded,  so  that  the  condition  somewhat  resembles  a  subcoracoid 
dislocation.  The  presence  of  the  head  of  the  bone  in  the  glenoid 
cavity  should  prevent  this  mistake,  whilst  the  softness  of  the  crepitus 
distinguishes  it  from  a  fracture. 

Treatment. — It  is  most  important  to  reduce  this  displacement, 
since  otherwise  interference  with  the  growth  of  the  limb  is  almost 
certain  to  ensue.     This  may  be  effected  by  traction  upon  the  arm 


INJURIES  OF  BONES— FRACTURES  507 

under  an  anaesthetic,  assisted  perhaps  by  sHght  rotary  movements 
or  abduction;  but  should  these  manoeuvres  not  be  successful,  opera- 
tion should  be  undertaken  to  restore  the  parts  to  their  correct 
position.  After  reduction  the  limb  is  treated  as  for  a  fracture  of 
the  neck.  Should  union  occur  in  the  displaced  position,  considerable 
limitation  of  movement  results  from  the  projecting  edge  of  the 
diaphysis;  this  may  be  improved  by  cutting  down  and  chiselling  it 
away- 

4.  The  Great  Tuberosity  is  occasionally  torn  off  as  a  result  of  direct 
or  muscular  violence,  or  as  a  complication  of  fracture  through  the 
neck.  If  the  whole  tuberosity  is  separated,  there  is  marked  de- 
formity, resulting  in  a  great  increase  in  the  breadth  of  the  shoulder. 
The  fragment  is  displaced  upwards  and  backwards  by  the  unopposed 
action  of  the  supra-  and  infra-spinatus,  whilst   the   shaft  of   the 


Fig.  213. — Separation  of  the  Upper  Epiphysis  of  the  Humerus. 

humerus  is  drawn  forwards  and  partially  dislocated  (or  subluxated) 
by  the  subscapularis  and  other  muscles.  A  distinct  sulcus  is  felt 
between  the  two  bony  masses,  and  if  they  can  be  brought  together, 
crepitus  is  obtained.  Treatment. — There  can  be  no  question  that 
when  displacement  has  occurred,  the  most  efficacious  plan  is  to  cut 
down  on  the  fragment  and  fix  it  in  position  by  wire,  screw,  or  peg. 
This  is  best  effected  by  cutting  through  and  turning  down  the  del- 
toid from  above.  Excellent  results  follow,  if  asepsis  is  maintained. 
Failing  operative  treatment,  the  patient  must  be  kept  in  bed,  with 
the  arm  elevated  and  extended,  supported  by  pillows — a  most  un- 
comfortable position — until  union  has  occurred. 

5.  Fracture  of  the  Upper  End  of  the  Humerus  combined  with  Dis- 
location of  the  head  of  the  bone  is  not  a  very  common  accident. 
The  fracture  is  usually  more  or  less  oblique,  and  passes  through  the 
greater  tuberosity  or  involves  the  surgical  neck. 


5o8 


A   MANUAL  OF  SURGERY 


It  is  usually  produced  by  severe  direct  violence,  such  as  by  a 
person  pitching  with  great  force  on  the  shoulder.  The  head  of 
the  bone  is  first  forced  into  the  axilla  through  a  rent  in  the  capsule, 
the  tendons,  attached  to  the  tuberosities  being  stretched  or  torn,  and. 
secondly,  the  violence  being  unexpended,  fracture  of  the  neck  of  the 
bone  follows.  Unless  seen  early,  ha.*m()rrhage  and  serous  effusion 
make  diagnosis  difficult,  and  from  time  immemorial  mistakes  have 
occurred  in  diagnosis  and  treatment.  Stereoscopic  radiography 
should,  where  practicable,  be  used  as  soon  as  possible.  At  the  same 
time  the  tension  of  the  deltoid  and  the  absence  of  the  head  from  the 
glenoid  cavity  and  its  presence  elsewhere  should  suffice  to  guide  the 

surgeon  to  a  correct  opinion. 
If  unreduced,  the  displaced 
head  of  the  bone  may  remain 
loose,  or  union  may  occur  with 
much  deformity  and  the  pro- 
duction of  man}'  adhesions, 
which  may  involve  the  vessels 
and  nerves,  and  lead  to  serious 
after-trouble  in  the  limb. 

Treatment.* — I  he  reduction 
of  the  dislocation  is  a  matter 
of  considerable  d'fficulty,  but 
the  head  of  the  bone  should, 
if  possible,  be  manipulated 
back  through  the  rent  in  the 
capsule  without  delay,  whilst 
steady  traction  is  made  upon 
the  shaft  of  the  limb  either 
downwards  or  at  right  angles 
to  the  trunk.  This  reposition 
can  hardly  be  hoped  for  apart 
from  complete  anaesthesia.  If 
successful,  the  fracture  is 
treated  in  the  usual  way, 
suitable  apparatus  to  maintain 
end-to-end  apposition  of  the 
fragments  being  applied.  If, 
however,  reposition  is  not  effected,  operative  measures  should  be 
undertaken.  The  parts  are  laid  open  from  the  front,  the  head  of 
the  bone  is  replaced,  and  the  fracture  wired  or  screwed  into  accurate 
end-to-end  union.  Failing  that,  and  especially  if  any  loose  frag- 
ments due  to  breaking  up  the  globular  head  exist,  they  should  be 
excised.  McBurney  has  devisee!  a  special  hook,  which  can  be  intro- 
duced through  a  hole  in  the  bone  so  as  to  exercise  traction  to  facili- 

*  For  an  interesting  series  of  radiograms  of  this  condition,  see  an  article  by 
Robert  Jones,  British  Medic-al  Journal,  June  i6,  1906.  The  subject  is  also 
ably  dealt  with  in  Bransby  Cooper's  (1S42)  edition  of  Sir  Astley  Cooper's 
treatise  on  '  Dislocations  and  Fractures  of  the  Joints.' 


Fig.    214.  —  Middeldorpf's    Triangle 
FOR  Fractured  Humerus. 

For  the  sake  of  clearness,  the  bandages, 
etc.,  have  been  represented  as  much 
smaller  than  would  be  the  case  in  the 
living  subject;  a  Gooch  splint  may 
also  with  advantage  be  applied  to  the 
fore-arm. 


INJURIES  01'   BONES— FRACTURES  509 

tatc  the  open  reduction  of  the  dislocation  or  the  division  of  liga- 
ments if  excision  is  required.  r  f 

Fractures  of  the  Shaft  of  the  Humerus  may  arise  from  any  form  of 
violence  whether  direct  or  indirect,  and  even  from  muscular  violence, 
as  e.s.,  in  throwing  a  cricket-ball.  The  signs  of  the  injury  are  very 
obvious,  and  most  typical.  The  displacement  depends  largely  on 
the  position  of  the  fracture.  If  it  occurs  above  the  insertion  of  the 
deltoid  but  below  that  of  the  muscles  inserted  into  or  around  the 
bicipital  groove,  the  upper  fragment  is  drawn  inwards,  and  the  lower 
upwards  and  outwards.  If,  however,  it  is  below  the  deltoid  the 
upper  fragment  is  drawn  outwards,  and  the  lower  upwards  and  in- 
wards As  the  line  of  fracture  approaches  the  elbow,  the  displace- 
ment tends  to  become  more  antero-posterior  than  lateral,  owing  to 
the  change  in  shape  of  the  bone.  The  most  common  complication 
is  injury  to  the  musculo-spiral  nerve  which  winds  round  the  shatt 
close  to  its  centre. 

Treatment.— An  internal  angular  splint  reaching  from  the  axilla  to 
the  wrist  must  be  applied,  together  with  three  small  lateral  splints  to 
fix  the  fragments,  or  a  piece  of  Gooch  or  kettle-holder  sphnt;  the 
Hmb  is  kept  to  the  side  in  the  sling.     Union  is  usually  complete  m 

five  weeks.  ^  ^         ^      ^  .   ,       .      ,.    , 

Some  authorities  recommend  the  use  of  four  short  lateral  splints, 
the  outer  one  of  which  is  prolonged  upwards  to  constitute  a  shoulder- 
cap,  and  downwards  as  an  external  angular  sphnt.  The  lore-arrn 
is  kept  midway  between  pronation  and  supination;  and  the  hand 
points  directly  forwards,  so  as  not  to  rotate  the  lower  fragment 

A  useful  apphance  for  all  fractures  of  the  humerus  is  the  Middel- 
dorpf  triangle  (Fig.  214).  It  is  carefully  padded  so  that  the  angles 
and  edges  are  protected,  and  applied  so  that  its  base  is  m  con- 
tact with  the  body-wall  and  its  obtuse-angled  apex  m  the  elbow. 
It  is  fixed  by  a  strap  or  bandage  passed  from  the  axillary  angle  over 
the  same  shoulder  and  under  the  opposite  axilla,  as  also  by  a  sheet  or 
bandage  round  the  trunk.  Pieces  of  Gooch  sphnting  can  be  apphed 
to  the  arm,  thus  completely  immobihzing  the  humerus,  and  the  tore- 
arm  is  also  fixed.  The  fingers  are  left  free,  or  if  there  is  any  swelling 
they  are  bandaged.  This  apparatus  is  even  more  efficacious  when 
the" patient  is  standing  than  when  he  is  recumbent. 

It  is  not  at  all  uncommon  to  meet  with  an  ununited  fracture  of  the 
shaft  of  this  bone;  this  is  probably  due,  not  to  any  anatomical 
reasons,  but  simply  to  the  fact  that  the  necessity  for  fixing  and 
supporting  the  elbow- joint  has  not  been  appreciated,  the  fore-arrn 
being  allowed  to  hang  loose  on  the  false  plea  of  tending  to  diminish 
the  shortening.  ,,     ,      .  .  , 

In  oblique  fractures,  or  where  there  is  difficulty  m  securing  exact 
reposition,  operation  may  be  undertaken  and  the  fragments  fixed 
by  some  suitable  mechanical  appliance.  Care  must  be  taken  to 
place  the  incision  so  as  to  avoid  the  musculo-spiral  nerve. 

Fractures  of  the  Lower  End  of  the  Humerus.— In  deahng  with  any 
injury  in  the  vicinity  of  the  elbow,  it  is  absolutely  essential  that  the 


5IO 


A  MANUAL  OF  SURGERY 


relative  position  of  the  bony  points,  which  can  there  be  felt,  should 
be  accurately  established,  and  a  comparison  made  witli  those  of  the 
opposite  side.  Normally  four  bony  prominences  can  be  detected, 
viz.,  the  two  condyles,  the  olecranon,  and  the  head  of  the  radius. 
The  relation  of  the  olecranon  to  the  condyles  varies  with  the  position 
of  the  elbow.  If  the  fore-arm  is  extended,  the  tip  of  the  olecranon 
just  touches  the  intercondyloid  line,  but  is  placed  nearer  the  inner 
than  the  outer  condyle,  whilst  in  flexion  of  the  fore-arm  it  lies  below 
that  line.  The  head  of  the  radius  in  all  positions  of  the  arm  is 
immediately  below  the  outer  condyle,  and  can  be  felt  rotating  be- 
neath a  dimple  in  the  skin  which  appears  at  that  spot.  When  the 
fore-arm  is  flexed  to  a  right  angle,  the  tip  of  the  olecranon  is  a  little  in 
front  of  the  posterior  surface  of  the  arm,  so  that  a  ruler  placed  along 


Fig. 


215. — -Outlines  of  Upper  Extremity  to  show  A,  Normal  Carrying 
Angle  {a  =  15°);  B,  Cubitus  Varus;  C,  Cubitus  Valgus. 


that  surface  misses  the  olecranon;  this  is  a  useful  guide  in  ascertain- 
ing if  the  bones  of  the  fore-arm  have  been  displaced  backwards  or 
forwards,  together  with  or  apart  from  the  lower  end  of  the  humerus. 

Another  important  feature  depends  on  the  fact  that  the  axis  of  the 
fore-arm  does  not  correspond  with  that  of  the  arm,  the  former  being 
in  a  position  of  slight  abduction  (about  15°),  constituting  what  is 
known  as  the  '  carrying  angle  '  (Fig.  215,  A).  Lateral  deviation 
following  fractures  in  the  neighbourhood  of  the  elbow  results  in 
modifications  of  this  angle,  and  if  these  are  allowed  to  persist, 
conditions  of  cubitus  varus  or  valgus  (Fig.  215,  B,  C)  ensue,  which 
much  interfere  with  the  utility  of  the  limb. 

I.  Transverse  Supracondyloid  Fracture,  involving  the  shaft  about 
I  or  2  inches  above  the  joint,  is  due  either  to  a  fall  on  the  hand  with 
the  arm  bent,  when  the  lower  fragment  is  usually  displaced  back- 


INJURIES  OF  BONES— FRACTURES 


5it 


wards,  or  much  less  commonly  to  a  fall  on  or  violence  directed  to  the 
point  of  the  elbow,  when  the  displacement  is  either  forwards  or  back- 
wards. When  the  lower  fragment  is  displaced  backwards,  it  is  also 
drawn  up  by  the  action  of  the  triceps  upon  the  olecranon,  a  certain 
amount  of  angular  as  well  as  vertical  deformity  being  thus  produced; 
when  displaced  forwards,  apparent  lengthening  of  the  fore-arm 
results,  with  a  loss  of  prominence  of  the  olecranon.  The  former  of 
these  conchtions  is  likely  to  be  mistaken  for  a  dislocation  of  both 
bones  backwards  at  the  elbow  (c/.  Fig.  216,  A  and  B),  but  may  be 
recognised  by  the  following  facts:  {a)  The  relative  position  of  the 
bony  points  at  the  elbow  is  unimpaired;  in  a  dislocation  they  are 
necessarily  disturbed.     (&)  The  length  of  the  arm  measured  from  the 


Fig.  216. — Fracture  of  Lower  End  of  Humerus  (B)  compared  with  Dis- 
location OF  Radius  and  Ulna  Backwards  at  Elbow  (A).     (Tillmanns.) 

deltoid  tubercle  which  can  be  easily  felt  at  the  back  of  the  acromion 
to  the  outer  condyle  is  diminished  in  a  fracture,  but  remains  un- 
altered in  a  dislocation.  On  the  other  hand,  the  length  of  the  fore- 
arm, as  measured  from  the  external  condyle  to  the  styloid  process  of 
the  radius,  is  shortened  in  a  dislocation,  but  remains  unaltered  in  a 
fracture,  (c)  The  forward  projection  of  the  lower  end  of  the  upper 
fragment  is  felt  above  the  crease  of  the  joint,  whilst  in  a  dislocation 
it  corresponds  with  it.  {d)  The  deformity  is  easily  reduced  with 
crepitus,  but  readily  reappears;  in  a  dislocation  the  bones  are  re- 
placed with  difficulty,  but  after  replacement  they  usually  remain  in 
position.  Lateral  deviation  sometimes  occurs,  and  the  restoration 
of  the  normal '  carrying  angle  '  must  always  be  aimed  at.  It  may  be 
difficult  and  at  times  almost  impossible  to  recognise  this  condition 
at  once,  apart  from  radiography,  owing  to  the  amount  of  swelling  and 
ecchymosis  present ;  the  application  of  a  cooling  lotion  for  a  few  days 
will  so  reduce  this  as  to  permit  a  thorough  examination,  but  the 


512  A   MANUAL  OF  SVliGERY 

delay  may  be  fraught  with  serious  consequences,  and  in  all  clDubtlul 
cases  radiography  must  be  empl()\ed  at  once. 

Much  care  is  needed  in  the  Treatment  of  these  cases  in  order  to 
prevent  ankylosis  or  deformity,  and  the  stereotyped  aj)plication  of  an 
internal  angular  splint  is  by  no  means  desirable.  To  correct  the 
backward  deformity  the  elbow  must  be  placed  in  a  position  of  full 
flexion,  whilst  the  fore-arm  is  completely  supinated.  It  usually 
suffices  to  maintain  this  position  by  means  of  bandages  or  strapping 
without  splints,  a  layer  of  aseptic  wool  covered  with  dusting  powder 
being  placed  between  the  adjacent  surfaces  of  the  arm  and  fore-arm. 
In  case  of  necessity,  the  best  splint  to  use  is  a  moulded  gutter-shaped 
posterior  splint  reaching  well  above  and 
below  the  elbow,  whilst  a  shorter  anterior 
splint  reaches  down  to  the  bend  of  the  joint. 
In  these  fractures  the  elbow-joint  is  not  as 
a  rule  involved,  and  therefore  passive  move- 
ment is  not  commenced  too  early  for  fear  of 
deformity,  owing  to  yielding  of  the  callus. 
At  the  same  time,  it  must  not  be  delayed 
too  long,  as  if  the  olecranon  and  coronoid 
fossae  are  involved,  they  become  filled  by 
callus,  and  if  this  is  allowed  to  consolidate, 
the  movements  of  the  arm  will  be  sub- 
sequently limited.  In  displacements  of  the 
Fig.  217. —  Fractures  lower  fragment  forwards  an  anterior  angular 
OF    Internal   Con-       gpUnt  should  be  employed,  and  possibly  a 

DYLE      AND     EpICON-  f        ,  ,        •  -^       ■\^■^.■ 

DYLE  OF  Humerus.       short  posterior  one  m  addition. 

(Tillmanns.)  2.  T- or  Y-shaped  Fracture  usually  occurs 

as  a  result  of  direct  injury.  The  T-shaped 
variety  is  a  condition  in  which  a  longitudinal  fissure  extends  into  the 
joint  through  the  centre  of  the  lower  fragment  of  a  supracondyloid 
fracture  ;  in  a  Y-shaped  fracture  the  fissure  starts  at  the  articular 
line  and  bifurcates  above  so  as  to  detach  both  condyles.  Some- 
times the  fragments  are  not  completely  detached,  and  then  there 
will  be  much  bruising  and  pain,  but  no  crepitus;  at  other  times  the 
condyles  are  separated  completely  and  will  move  on  each  other 
with  crepitus,  the  elbow  being  increased  in  breadth.  Great  swelling 
and  ecchymosis  are  rapidly  developed,  and  diagnosis  is  often 
difficult.  If  there  is  no  separation  of  the  fragments,  treatment  as 
for  the  transverse  supracondyloid  fracture  suffices;  but  when  they 
are  completely  detached,  it  is  often  wise  to  operate  so  as  to  remove 
the  blood  and  enable  the  fragments  to  be  manipulated  into  position 
and  fixed  there. 

Excessive  violence  may  lead  to  comminution  of  the  lower  frag- 
ment, and  then  it  may  be  advisable  completely  to  remove  it. 

3.  Fracture  of  the  Condyles  usually  results  from  direct  injury, 
though  the  outer  is  sometimes  broken  by  indirect  violence,  such  as  a 
fall  on  the  hand,  since  the  laxity  of  the  elbow-joint  on  this  side  allows 
considerable  mobility  between  the  radial  head  and  the  capitellum  of 


INJURIES  OF  BONES—FRACTURES 


513 


the  humerus.  Fracture  of  the  external  condyle  (Fig.  218)  always 
involves  the  elbow-joint,  and  is  more  common  than  that  of  tlie  inner. 
The  line  of  fracture  runs  from  the  condyloid  ridge  downwards  and 
inwards  so  as  to  separate  the  capitellum,  or  even  encroach  upon 
the  trochlear  surface.  The  fragment  is  rotated  forwards,  and  can 
be  felt  to  move  independently  with  crepitus,  which  may  also  be 
produced  by  rotation  of  the  hand  and   radius.     The   accident  is 


Fig. 


!. — Fracture    of   the    Exter- 
nal Condyle. 


Fig.  219. — The  Same  Fracture 
AFTER  Operation. 


Fig.  218  is  a  good  illustration  of  the  deceptive  appearance  which  may  result 
from  radiography.  It  appears  as  if  the  condyloid  fragment  were  displaced 
outwards;  as  a  matter  of  fact,  it  was  merely  rotated  forwards,  but  as 
the  radiogram  was  taken  slightly  from  the  inner  side,  the  shadow  of  the 
fragment  overlapped  that  of  the  shaft.  The  patient  was  a  girl  of 
fifteen  years,  who  fell  on  the  elbow  from  her  bicycle. 


associated  with  much  pain  and  ecchymosis.  Fracture  of  the 
internal  condyle  may  be  intra-  or  extra-capsular.  The  extra- 
articular variety  (Fig.  217)  consists  of  a  mere  displacement  of  the 
tip  of  the  condyle  (or  epicondyle),  and  in  young  people  is  probabty 
a  separation  of  the  epiphysis,  which  remains  distinct  from  the 
shaft  till  the  age  of  eighteen  or  nineteen  years.  The  small  frag- 
ment is  drawn  a  Httle  downwards  by  the  muscles  attached  to  it, 
and  may  be  associated  with  injury  of  the  ulnar  nerve.     The  intra- 

33 


514 


A   MANUAL  OF  SURGERY 


arliailar  form  is  the  more  common,  and  extends  from  the  condyloid 
ridge  to  the  trochlear  surface,  implicating  the  coronoid  and  ole- 
cranon fossa;.  The  fragment  is  displaced  a  little  upwards  and 
backwards,  the  ulna  usually  accompanying  it,  so  that  on  extending 
the  elbow  the  olecranon  appears  unduly  prominent,  the  lower 
end  of  the  humerus  projects  anteriorly,  and  the  fore-arm  is  slightly 
adducted  (cubitus  varus).  The  ulnar  nerve  may  also  be  injured 
in  this  case. 


A 


8  "•' 


Fig.  220. — A  and  B,  Lower  End 
OF  THE  Humerus  at  Three 
Years  and  Fifteen  Years  of 
Age.       (Semi   -  diagrammatic  ; 

AFTER    OUAIN's    '  AnATOMY.') 

In  A  there  is  only  one  centre  of  ossi- 
fication; in  B  all  the  centres  in 
the  lower  epiphysis  have  joined 
together  with  the  exception  of 
that  for  the  internal  condyle. 


\^' 


Fig.  221. — Separation  of  the 
Lower  Epiphysis  of  the  Hu- 
merus IN  AN  Infant  under 
Three  Years.  (Museum  of 
Royal  College  of  Surgeons.) 

A,  Epiphysis,  including  both  con- 
dyles; B,  small  portion  of  the 
diaphysis  detached  with  epiphysis; 
C,  diaphysis;  D,  loose  periosteal 
bridge. 


Treatment. — Flexion  of  the  fore-arm  will  sometimes  suffice  to 
restore  the  fragment  to  its  normal  position ;  but  this  must  be  demon- 
strated by  radiography.  The  limb  under  such  circumstances  is 
placed  in  an  angular  splint,  and  massage  and  passive  movements 
are  started  early.  Failing  reposition  by  flexion,  operation  must  be 
undertaken,  and  the  fragment  secured  m  position  bv  wire  or  screw 
(Fig.  219). 

4.  Separation  of  the  Lower  Epiphysis  of  the  Humerus  is  a  very 
common  accident  in  children.     At  birth  and  fur  some  }-ears  after- 


INJURIES  OF  BONES— FRACTURES 


515 


wards  the  i'i)i])liysis  consists  of  a  single  mass  of  cartilage,  including 
the  two  condyles  as  well  as  the  articular  surface,  and  these  are  all 
involved  in  any  separation,  together  possibly  with  a  fragment  of  the 
diaphysis  (Fig.  221).  As,  however,  growth  and  ossification  proceed, 
the  shaft  encroaches  rapidly  upon  the  inner  portion  of  the  epiphysis, 
so  that  the  epiphyseal  line  becomes  almost  rectangular  (Fig.  220,  B), 
the  internal  condyle  being  isolated  from  the  rest  of  the  epiphysis. 
As  a  result  of  this,  separation  of  the  epiphysis  after  puberty  does  not 
include  the  internal  condyle;  the  lesion  at  this  period  is  situated 


Fig.  222. — Separation  of  Lower 
Epiphysis  and  a  Portion  of 
THE  Diaphysis  in  a  Child  of 
Twelve  Years. 

The  radiogram  is  taken  from  the 
side.  The  displacement  is  back- 
wards. The  dark  black  spots 
represent  tin-tacks  in  the  wooden 
splint  on  which  the  arm  was 
resting.  The  dark  area  around 
the  end  of  the  bone  represents 
the  sub-periosteal  effusion  of 
blood. 


Fig.  223. — Separation  of  the 
Lower  Epiphysis  of  the  Hu- 
merus, WITH  Displacement  Out- 
wards, IN  A  Young  Person  a 
little  over  the  Age  of  Puberty. 

The  outer  condyle  has  been  broken 
off,  as  well  as  the  epiphysis,  and 
displaced  upwards  and  outwards; 
above  this  fragment  is  seen  a 
shadow  caused  by  the  stripping 
up  of  the  periosteum.  The  ulna 
and  radius  accompany  the  lower 
epiphysis  of  the  humerus  out- 
wards. 


relatively  much  nearer  the  joint  than  in  infants,  and  consequently 
is  more  likely  to  be  followed  by  impairment  of  movement.  The 
displacement  is  generally  backwards  (Fig.  222),  with  some 
amount  of  lateral  displacement  or  deviation  (Fig.  223).  Treatment. 
— Reduction  can  usually  be  accomplished  by  flexion  with  some 
amount  of  traction.  In  young  children  it  is  best  to  avoid  splints, 
and  merely  to  trust  to  keeping  the  limb  in  a  state  of  full  flexion 
the  hand  being  well  supinated.  Where  there  is  much  swelling  from 
haemorrhage,  it  may  not  be  possible  to  gain  complete  flexion  at  once, 
but  as  the  swelling  subsides  it  can  be  gradually  increased.     In  a 


5i6  A   MANUAL  OF  SURGERY 

few  cases  it  may  be  desirable  to  make  an  incision  through  the  peri- 
osteum on  one  or  both  sides  of  the  bone  so  as  to  allow  the  blood  to 
escape,  and  enable  the  epiphysis  to  be  manipulated  into  position; 
but  even  then  it  is  better  not  to  attempt  lixation  by  nails,  screws, 
or  wire,  but  merely  to  trust  to  the  flexion.  Massage  and  passive 
movements  should  commence  about  the  eighth  day.  Parents 
should  be  warned  from  the  first  that  a  perfect  restoration  of  func- 
tion cannot  be  guaranteed,  as  the  fossa  at  the  lower  end  of  the 
humerus  are  encroached  on  and  are  liable  to  be  filled  up  with  bone, 
and  hence  complete  flexion  or  extension  may  be  hindered,  whilst  the 
involvement  of  the  epiphysis  may  impair  the  growth  of  the  limb 
and  lead  to  a  condition  of  cubitus  varus  or  valgus. 

Fractures  of  the  Ulna. — i.  The  Olecranon  is  frequently  broken  by 
direct  violence,  the  patient  falling  on  the  bent  elbow,  but  occasionally 
by  muscular  action.  The  line  of  fracture  usually  runs  through  the 
base  of  the  process  at  its  attachment  to  the  shaft,  and  is  for  the  most 
part  transverse.  Should  the  tendinous  and  periosteal  coverings  of 
the  bone  remain  intact,  there  is  but  little  separation;  but  if  the 
fracture  is  complete,  the  detached  fragment  is  drawn  up  by  the 
ti"iceps  and  tilted  backwards  (Fig.  224),  whilst  the  bones  of  the  fore- 
arm are  subluxated  forwards.  Great  swelling  in  and  around  the 
joint  comes  on  early;  on  examination,  the  detached  fragment  can  be 
readily  distinguished,  and  between  it  and  the  shaft  a  sulcus,  which 
increases  on  flexing  and  diminishes  on  extending  the  fore-arm.  If 
the  fragments  are  not  brought  accurately  into  apposition,  fibrous 
union  occurs,  and  although  the  new  cicatricial  tissue  may  stretch 
considerably,  a  useful  elbow  sometimes  results;  in  some  cases  the 
fragment  is  drawn  up  and  fixed  to  the  humerus,  and  a  false  joint  is 
developed  below  it.  If,  however,  the  fragments  are  brought  in 
contact,  bony  union  follows,  though  even  then  some  impairment 
of  function  may  result  from  the  formation  of  adhesions.  In  all 
cases  the  ulnar  nerve  is  exposed  to  injury,  though  it  is  rarel}' 
affected. 

Treatment. — The  arm  must  be  kept  fully  extended  on  a  suitable 
splint,  and  an  effort  made  to  bring  the  fragment  into  apposition 
with  the  end  of  the  ulna  by  a  pad  and  strapping.  Gentle  passive 
movements  and  massage  are  commenced  at  the  end  of  ten  days  or 
a  fortnight,  but  active  movements  should  be  deferred  for  another 
fortnight.  When,  however,  the  olecranon  has  been  completely 
separated,  the  most  satisfactory  plan  consists  in  laying  the  parts 
open,  freeing  the  joint  of  blood-clot,  removing  shreds  of  tendon 
which  may  be  placed  between  the  fragments,  and  then  wiring  them 
together,  the  wire  just  extending  down  to  the  articular  cartilage 
(Fig.  225).  Passive  movements  may  usually  be  started  in  ten 
days,  and  active  after  a  fortnight.  A  similar  plan  should  be  adopted 
in  all  compound  cases,  and  in  those  where  loose  fibrous  union  has 
occurred  with  a  resulting  weak  and  relaxed  elbow;  in  the  latter 
instance  the  new  fibrous  tissue  must  be  entirely  dissected  away  and 
the  bony  surfaces  freshened. 


INJlfRIES  OF  BONES— FRACTU RES 


517 


2.  The  Coronoid  Process  is  so  deeply  placed  and  so  well  protected 
that  fractures  must  necessarily  be  very  uncommon,  except  as  an 
accompaniment  of  dislocation  of  the  ulna  backwards.  The  signs 
relied  on  in  making  a  diagnosis  are  that  reduction  of  the  dislocation 
is  easier  than  usual  and  associated  with  crepitus,  and  that  the 
deformity  is  likely  to  recur.  The  Treatment  consists  in  apposing 
the  bony  surfaces,  if  possible,  by  flexing  the  fore-arm.  Bony  union 
is,  however,  less  important  than  a  freely  moveable  elbow,  and  there- 
fore passive  movement  is  commenced  early. 


Fig.  224. — Fracture  of    Ole- 
cranon BEFORE  Operation. 


FiG.^225. — Fracture  of  Ole- 
cranon Two  Weeks  after 
Operation, 


3.  The  Shaft  of  the  Ulna  is  often  fractured  by  itself  as  a  result  of 
direct  violence,  to  which  its  e.xposed  position  renders  it  peculiarly 
liable.  Fracture  also  occurs  as  a  complication  of  several  of  the 
forms  of  dislocation  of  the  radius  alone.  The  superficial  position 
of  the  posterior  border  renders  examination  of  the  bone  easy;  if 
displacement  or  a  breach  of  substance  occurs,  it  is  readily  detected, 
but  when  merely  a  fissure  exists,  it  is  not  so  easy  to  make  out. 
The  constant  pain  referred  to  one  spot,  the  slight  mobility,  and 
possibly  crepitus,  indicate  the  character  of  the  lesion.  No  longi- 
tudinal displacement  can  occur  if  the  radius  remains  intact,  and 
under  such  circumstances  the  only  deformity  consists  in  a  slight 
drawing  forwards  of  the  upper  fragment  by  the  brachialis  anticus, 


5iS  A   MANUAL  OF  SURGERY 

whilst  the  lower  fraf;ment  is  .'ipproximnt^fl  to  the  radius  liy  the 
pronator  quadratus.  Treatment.  —  The  arm  is  placed  midway 
between  pronation  and  supination,  the  defcjrmit\'  roj-rected,  and  the 
limb  kept  at  rest  between  anterior  and  ])osterior  splints,  or  in  plaster 
of  Paris. 

4.  1  he  Styloid  Process  may  be  detached  by  direct  x'iolence,  or  as 
a  comjilication  of  fracture  of  the  lower  end  of  the  radius.  The  dis- 
placement may  be  considerable  and  very  evident,  being  governed  by 
the  chrection  of  the  violence'.  Treatment  consists  in  replacing  tlie 
fragment  by  manipulation,  and  lixing  it  bv  adhesive  plaster;  an 
anterior  splint  is  applied  with  the  hand  adducted.  Fibrous  union 
usuallv  results. 

Fractures  of  the  Radius. — i.  The  Head  of  the  Radius  may  be 
broken  alone,  but  more  usually  such  an  accident  is  associated  with 
other  injuries  to  the  elbow,  as,  for  instance,  fracture  of  the  outer 
condvle  or  some  form  of  dislocation.  The  line  of  fracture  may  be 
transverse  or  vertical,  and  the  displacement  is  slight  if  the  orbicular 
ligament  remains  intact.  In  complete  separation  the  head  is  im- 
moveable, and  crepitus  is  produced  when  the  arm  is  rotated;  bony 
union  usually  follows,  with  more  or  less  impairment  of  function,  but 
sometimes  the  head,  or  a  portion  of  it,  remains  detached  as  a  loose 
body;  in  the  latter  case  the  small  fragment  may  get  between  the 
articular  ends  from  time  to  time  and  lock  the  joint.  Treatment. — 
Radiography  will  indicate  the  exact  nature  of  the  injury,  and  as  a  rule 
removal  of  the  loose  fragment  and  of  the  remainder  of  the  head,  if 
it  be  small,  is  the  best  plan  to  adopt.  The  incision  is  of  course  a 
posterior  one.  The  limb  is  subsequently  kept  at  rest  for  a  short 
time  midway  between  pronation  and  supination,  and  early  passive 
movement  instituted.  Excision  of  the  head  may  also  be  required 
in  old-standing  cases  for  limitation  of  movement,  due  to  excessive 
formation  of  callus. 

2.  The  Neck,  i.e.,  the  portion  between  the  orbicular  ligament  and 
the  biceps  tuberosity,  is  occasionally  broken.  The  lower  fragment 
is  drawn  upwards  and  forwards  by  the  biceps,  causing  a  bony  pro- 
jection on  the  front  of  the  elbow,  especially  evident  on  attempting 
to  flex  the  joint,  whilst  the  fore-arm  is  pronated  with  loss  of  the 
power  of  rotation,  and  the  head  of  the  bone  does  not  accompany  the 
shaft  on  rotating  it  passively.  Treatment.^ — The  arm  is  flexed  to 
relax  the  biceps  and  supinatcd,  and  the  limb  placed  on  a  posterior 
angular  splint,  with  a  pad  over  the  front  of  the  lower  fragment. 
Passive  movement  should  not  be  commenced  too  early,  as  the  lesion 
is  extra-articular,  and  the  biceps  may  produce  permanent  deformity 
if  allowed  to  act  upon  unconsolidated  callus. 

3.  The  Shaft  of  the  radius  is  not  unfrequently  broken  by  direct 
violence  or  more  rarely  by  falls  on  the  palm;  the  latter  accident, 
however,  rarely  causes  fracture  except  at  the  lower  end.  A 
CJiaiiffeiir' s  fractnre  of  this  bone  has  also  been  described.  It  involves 
the  lower  end  of  the  radius,  and  results  from  a  jerk  backwards  of  the 
starting  handle  of  the  car  due  to  premature  ignition.     The  lesion  is 


INJURIES  OF  BONES— FRACTURES 


519 


IdcaU'd  c>itl!ir  transversely  ilirough  tlie  articular  surface,  or  in  the 
shaft  a  little  above  the  level  of  an  ordinary  CoUes's  fracture,  and 
sometimes  well-marked  displacement  is  present. 

There  is  usually  little  difficulty  in  diagnosing  a  fractured  radius; 
the  chief  signs  are  localized  pain  and  loss  of  power  of  active  rotation, 
whilst  passive  rotary  movements  are  accompanied  by  crepitus,  the 
head  of  the  bone  and  upper  fragment  remaining  immobile  below  the 
outer  condyle,  unless  impaction  is  present.  The  displacement  is 
somewhat  characteristic.     If  the  fracture  is  situated  above  the  inser- 


FiG.    226. — Fracture   of  Shaft    of  Fig.  227. — Fracture  of  Shaft 

Radius.         (Antero  -  Posterior  of  Radius.     (Lateral  View.) 

View.)  From  the  same  patient  as  Fig. 

226,  and  showing  excellently 
the  necessity  for  taking  radio- 
grams from  two  points  of  view. 

tion  of  the  pronator  teres,  the  upper  fragment  is  flexed  and  fully 
supinated  by  the  action  of  the  biceps  and  supinator  brevis,  whilst 
the  lower  fragment  is  drawn  towards  the  ulna  and  fully  pronated  by 
the  unopposed  action  of  the  two  pronator  muscles.  Treatment. — 
Inasmuch  as  it  is  scarcely  possible  to  command  the  small  upper 
fragment,  the  lower  must  be  brought  into  apposition  with  it  by  fully 
supinating  the  fore-arm  and  hand  after  flexing  the  elbow,  and 
apph'ing  a  posterior  splint,  the  patient  being  preferably  kept  in  bed 
for  a  time  and  the  arm  laid  on  pillows.  It  may  afterwards  be  sup- 
ported in  a  hollow  leather  splint  carried  across  the  bod^^  and  with 
the  pahn  directed  upwards. 


520 


A   MANUAL  OF  SURGERY 


When  the  fracture  is  placed  hcloiv  the  insertion  of  the  pronator  teres, 
the  upper  fragment  is  drawn  forwards  by  the  action  of  the  biceps, 
and  inwards  by  the  pronator,  assuming  a  position  midway  between 
pronation  and  supination;  the  lower  fragment  may  be  slightly  ap- 
proximated to  the  ulna  by  the  direct  action  of  the  pronator  quad- 
ratus;  the  hand  is  fully  pronated  looking  downwards.  Union  to  the 
ulna  by  callus  thrcnvn  across  the  interosseous  space  is  not  unlikely 
to  occur.  Treatment. — The  arm  is  placed  midway  between  prona- 
tion and  supination,  and  the  hand  fully  adductcd.  The  frag- 
ments are  manipulated  into  position,  and  splints  applied  back 
and  front.  It  is  wise  to  place  a  good  pad  under  the  palmar  splint 
over  the  site  of  fracture  so  as  to  repress  the  tendency  to  anterior 
displacement  of  the  fragments ;  a  Gordon's  splint  is  useful  in  this 
direction. 

4.  The  Lower  End  of  the  Radius  is  broken  with  extreme  frequency, 
constituting  what  is  known  as  Colles's  Fracture.     This  injury  occurs 


Fig.  228. — Colles's  Fracture: 
Lateral  View. 


Fig.  229. — Colles's  Fracture: 
Palmar  View. 


most  commonly  in  women  of  advanced  years,  although  it  may 
happen  at  any  age  or  to  either  sex.  It  is  almost  invariably  due  to 
falls  upon  the  outstretched  palm,  when  the  hand  is  completely  pro- 
nated and  extended.  The  line  of  fracture  is  placed  about  i  inch 
from  the  wrist,  though  rather  under  than  over  this.  It  is  usually 
transverse  from  side  to  side,  but  is  oblique  in  an  antero-posterior 
direction,  sloping  from  above  downwards  and  forwards,  so  that 
the  fracture  is  nearer  the  wrist-joint  in  front  than  it  is  behind 
(Fig.  231). 

The  displacement  is  somewhat  complicated,  {a)  The  lower  frag- 
ment is  carried  backwards  and  a  little  upwards,  owing  to  the 
direction  of  the  violence,  viz.,  a  fall  on  the  outstretched  hand,  the 
radius  being  compressed  between  the  ground  and  the  weight  of  the 
body,  and  yielding  at  what  is  evidently  a  weak  spot ;  this  deformity 
is  maintained  by  the  radial  extensor  muscles  of  the  wrist,  and  often 
by  impaction  of  the  fragments.  (&)  From  the  fact  that  the  main 
violence  is  received  on  the  thenar  eminence,  the  outer  side  of  the 
lower  fragment  is  displaced  more  than  the  inner,  which  remains  fixed 
to  the  ulna  by  the  strong  inferior  radio-ulnar  ligaments.  This  posi- 
tion is  in  part  kept  up  by  the  extensors  of  the  thumb  and  the 
supinator  longus,  but  mainly  by  impaction  of  the  fragments.     The 


INJUIilBS  OF  BONES—FRACTURES 


521 


hand  and  carpus  al\va\s  follow  the  lower  fragnient.  and  hence  the 
former  is  abducted,  causing  the  st\-loid  process  of  the  ulna  to  become 
prominent  (Fig.  230).  and  lower  than  that  of  the  radms,  whereas  it  is 
normallv  placed  on  a  slightly  higher  level.  In  bad  cases  the  styloid 
process  of  the  ulna  is  actually  torn  off,  or  the  internal  lateral  liga- 
ment ruptured,  allowing  displacement  outwards  of  the  whole  hand, 
(c)  The  lo\\er  fragment  is  also  rotated  around  a  transverse  axis,  so 
that  the  lower  articular  surface  looks  backwards  as  well  as  down- 
wards, a  displacement  due  to  the  fact  that  in  falhng  the  force  is 
directed,  through  the  carpus,  more  to  the  posterior  than  to  the 
anterior  aspect  of  the  bone,  {d)  The  upper  fragment  is  pronated 
and  approximated  to  the  ulna  by  the  pronator  quadratus  muscle. 


Fig.  230. — CoLLEs's  Fracture:  a 
Simple  Case,  without  Much 
Lateral  Displacement  of 
Hand. 


Fig.     231. — Lateral       View       of 

CoLLEs's     Fracture,     showing 

Displacement  Backwards  and 

Upwards  of  the  Lower  Frag- 

ment. 


The  deformity  produced  bv  the  fracture  is  therefore  very  character- 
istic. The  hand  is  in  a  position  of  radial  abduction,  and  usually 
pronated,  with  the  lingers  somewhat  flexed  (dinner-fork  deformity) . 
Three  abnormal  osseous  projections  are  present:  (i.)  The  styloid 
process  or  head  of  the  ulna  is  very  marked,  owing  to  the  radial 
abduction  of  the  hand  (Fig.  229) ;  (ii.)  on  the  back  of  the  wrist  is  a 
prominence  which  terminates  abruptly  above,  caused  by  the  pro- 
jection of  the  lower  fragment  (Fig.  228) ;  and  (iii.)  corresponding  to 
this  dorsal  projection  there  is  a  well-marked  depression  on  the 
palmar  surface,  and  above  it  a  less  sharply  defined  swelling,  which 
gradually  shelves  into  the  fore-arm,  due  to  the  upper  fragment. 
Pronation  and  supination  are  lost,  and,  as  a  rule,  there  is  neither 
crepitus  nor  preternatural  mobility,  owing  to  impaction  of_  the 
fragments.  An  important  diagnostic  point  is  the  relative  position 
of  the  two  styloid^iprocesses;  normally,  that  of  the  radius  is  below 


522  A    MANUAL  OF  SURCIIRY 

that  of  tlu'  ulna,  but  in  cases  of  fractuic  it  is  on  a  k'X'cl  with  or 
above  it. 

As  already  stated,  tlie  fracture  is  commonly  imi)acted,  tlie  upper 
fragment  being  firmly  driven  into  the  cancellous  tissue  of  the  lower 
end;  excess  of  violence  may,  however,  disimpact,  but  often  at  the 
expense  of  comminution  of  the  lower  fragment.  Union  is  effected 
without  difficulty,  but  the  patient  should  always  be  warned  at  an 
early  date  to  expect  some  deformity  about  the  wrist,  as  well  as  con- 
siderable impairment  in  the  subsequent  mobility  of  the  fingers  and 
hand,  owing  partly  to  adhesions  in  the  joint,  partly  to  blood  trickling 
down  the  tendon  sheaths  and  fixing  the  tendons. 

Treatment. — It  is  most  important  completely  to  reduce  the  defor- 
mity, and  to  this  end  extension  and  manipulation  are  both  needed. 
The  patient,  if  not  under  an  anaesthetic,  should  be  seated  on  a  chair, 
and  the  surgeon,  standing  in  front,  should  grasp  the  hand  firmly,  using 
the  right  hand  for  fractures  on  the  right  side,  and  the  left  for 
those  on  that  side.      Counter-extension  is   made  from   the   flexed 


i:::,i;.l,illl:UUUI[L\\illinhHHI,IHIIIIIIIII!linii,'//l/l< 


Fig.  232. — Carr's  Splint  for  Colles's  Fracture  of  Left  Hand. 

elbow,  and  the  hand  is  then  forcibly  extended  and  adducted; 
disimpaction  is  thus  brought  about,  and  a  little  manipulation 
enables  the  fragments  to  be  moulded  into  position.  In  old  people, 
however,  where  impaction  is  present,  it  may  be  wiser  to  leave 
things  alone  and  not  to  attempt  disimpaction  or  correction  of 
the  deformity. 

When  once  the  deformity  has  been  corrected,  there  is  but  little 
tendency  for  it  to  reappear,  and  therefore  the  use  of  elaborate 
retentive  apparatus  or  splints  is  quite  unnecessary  in  the  majority 
of  cases:  (i)  Perhaps  the  simplest  and  most  efficacious  is  a  piece  of 
Gooch  splint,  shaped  so  as  to  cover  the  radius  front  and  back  as  far 
as  the  middle  line  of  the  arm,  and  extending  nearly  from  the  elbow 
to  the  front  and  back  of  the  knuckles  of  the  index  and  middle  fingers: 
its  lower  end  is  hollowed  out  in  a  horseshoe  manner,  so  as  not  to 
reach  beyond  the  end  of  the  metacarpal  bone  of  the  thumb.  This 
is  well  padded  and  firmly  bandaged  on;  it  grasps  the  radius  and 
steadies  the  hand  in  a  position  of  adduction,  without  in  any  way 
interfering  with  the  movements  of  the  fingers.  (2)  Carr's  splint 
(Fig.  232)  may  be  used  in  some  of  the  more  severe  cases,  especially 
when  the  ulnar  styloid  process  has  been  fractured.  It  consists  of 
two  portions  fitting  the  front  and  back  of  the  radial  side  of  the  fore- 
arm, whilst  to  the  palmar  one  is  attached  an  oblique  rod  to  be 


INJURllCS  Oh'  HONES— FRACTURES 


523 


graspod  l\v  tlie  lingers,  and  thus  the  hand  and  wrist  are  maintained 
in  a  position  of  adduction,  whilst  tlie  lingers  can  be  freely  moved. 
(3)  Gordon's  splint  is  another  excellent  contrivance  occasionally 
useful,  which  consists  of  two  pieces.  The  palmar  portion  has  a 
rur\ed  projection  on  its  radial  side,  to  correspond  to  the  site  of  the 
fracture  and  to  the  concavity  of  the  lower  end  of  the  radius ;  on 
the  ulnar  side  it  is  prolonged,  so  as  to  fit  the  ulnar  border  of 
the  hand.  The  dorsal  splint  is  slightly  curved  at  the  lower  end,  so 
as  to  apply  itself  comfortably  to  the  wrist  when  in  a  position  of 
flexion. 

Union  is  usually  firm  enough  in  a  week  to  permit  the  removal 
of  the  splints,  the  arm  being  kept  in  a  leather  or  poroplastic  support 
for  some  time  longer.     Massage   and  passive  movements  should 
be  employed,   and  the  fingers 
left  free  and  exercised  after  the 
first  two  or  three  days. 

A  fracture  of  the  lower  end 
of  the  radius,  known  as  Smith's 
fracture,  is  occasionally  met 
with,  in  which  the  displace- 
ment of  the  fragments  is  exactly 
the  reverse  to  that  seen  in 
Colles's  fracture,  viz.,  the  lower 
end  of  the  radial  shaft  projects 
posteriorly,  whilst  the  lower 
fragment  is  displaced  anterior- 
ly. Treatment  is  conducted  as 
for  a  Colles's  fracture. 

5.  Separation  oJ  the  Lower 
Epiphysis  of  the  radius  occurs 
in  3'oung  people  under  twenty, 
and  when  it  is  displaced  back- 
wards, simulates  somewhat 
closely  a  Colles's  fracture.    The 

lower  end  of  the  diaphysis  projects  anteriorly  to  a  much  greater 
extent,  and,  indeed,  may  protrude  through  the  skin  of  the  wrist. 
The  lower  end  of  the  ulna  may  be  involved  in  the  accident,  either 
the  epiphysis  being  separated,  or  the  shaft  broken  a  little  above. 
This  condition  may  be  mistaken  for  a  backward  dislocation  of  the 
wrist,  but  a  diagnosis  can  be  readily  made  by  observing  the  relative 
position  of  the  styloid  processes  to  the  carpal  bones.  Lateral 
displacement  occurs  in  some  cases  (Fig.  233).  Treatment  is  practi- 
cally the  same  as  for  Colles's  fracture. 

Should  arrest  of  growth  result  from  this  accident,  the  hand  retains 
its  connection  with  the  stunted  radius,  but  the  ulna  continues  to 
grow  downwards,  and  its  lower  end  is  found  on  the  inner  and 
posterior  aspect  of  the  carpus,  which  is  pushed  en  bloc  towards  the 
radial  side,  but  without  any  marked  abduction  (Madelung's 
deformity) . 


Fig.    233. — Radiogram    of   Displace- 
ment OF  Lower  Epiphysis  of  Radius 

AND    OF    THE    HAND    OUTWARDS. 


524 


/}  MANUAL  or  srih'cr.Rv 


Fracture  oJ  both  Bones  oi.  the  Fore-arm  may  result  from  direct 
violence  or  falls  on  the  palm.  Any  part  of  the  bones  may  yield,  but 
the  middle  and  lower  thirds  are  most  frequently  affected  (Fig.  234). 
When  due  to  direct  violence,  both  bones  may  be  broken  at  the  same 
level;  but  if  due  to  a  fall  on  a  palm,  the  ulna  usually  gives  way  at  a 
higher  level  than  the  rachus.  The  line  of  fracture  may  be  transverse 
or  oblique,  and  the  displacement  varies  both  with  this  and  with  the 
force  employed.  The  upper  fragments  are  usually  ch"awn  together 
and  pronated,  whilst  the  lower  end  of  the  radius  is  drawn  up  by  the 
supinator  longus.  In  young  people  a  not  uncommon  result  of  falls 
in  the  football  field  or  at  the  skating-rink  is  a  complete  fracture 

of  the  lower  third  of  the  radius,  and  a 
greenstick  fracture  of  the  ulna.  The 
upper  fragment  of  the  radius  is  dis- 
placed forwards  in  front  of  the  pronator 
quadratus,  which  prevents  its  replace- 
ment even  by  traction  under  an  anes- 
thetic. The  diagnosis  of  these  fractures 
is  very  simple,  since  there  is,  as  a  rule, 
obvious  deformity.  Treatment  consists 
in  reduction  by  extension  conjoined  with 
manipulation,  and  the  application  of 
splints  which  will  prevent  cross-union 
of  the  bones.  If  the  fracture  is  above 
the  insertion  of  the  pronator  teres,  the 
arm  must  be  put  up  in  full  supination,  as 
suggested  for  a  similar  fracture  of  the 
radius  alone  (p.  519),  whilst  below  that 
spot  the  usual  position  midway  be- 
tween pronation  and  supination  may  be 
allowed.  Union  is  generally  complete 
in  five  or  six  weeks.  If  the  fragments 
are  not  readily  manipulated  into  posi- 
tion, as  indicated  by  radiography,  opera- 
tion should  be  undertaken  without  delay, 
as  the  middle  or  lower  end  of  these  bones 
is  a  rather  favourite  site  of  election  for 
non-union  (Fig.  197). 

Fractures  of  the  Carpus.— These  may 
result  from  direct  violence  in  the  nature  of  a  severe  crush,  and  then 
several  of  the  bones  may  be  involved,  and  the  lesion  may  be  com- 
pound. The  ordinary  treatment  of  such  a  condition  must  be 
followed,  and  the  parts  kept  at  rest  on  a  palmar  splint. 

Radiography  has  demonstrated  that  many  '  sprains  of  the  wrist ' 
from  indirect  violence  are  in  reality  associated  with  fracture  of  a 
carpal  bone,  and  of  these  a  transverse  fracture  through  the  waist  of 
the  scaphoid  (Fig.  235)  is  perhaps  the  most  common.  As  a  rule, 
rest  and  subsequent  massage  are  alone  required;  but  occasionally 
movement  is  impaired  by  a  displaced  fragment,  or  painful  weakness 


Fig.  234.  —  Fracture  of 
Both  I3ones  of  the  Fore- 
arm. 


INJUIUJ^S  OF  BONES—FRACTURES 


525 


follows  Iroin  non-union,  and  then    rmiox-al    of    the    fragment    or 
of  {\\c  hone  is  nt'cessarw 

Fractures  of  the  Metacarpal  Bones  and  Phalanges  are  ncjt  un- 
common, particukirly  in  the  third  and  fourth  hngers,  being  due  to 
direct  violence,  and  hence  usually  transverse.  There  is  generally 
but  little  displacement,  though  occasionally  the  fragments  may 
overlap,  whilst  a  certain  amount  of  localized  swelling  and  tender- 
ness is  alwa^^s  noted.     The  treatment  usually  required  is  immo- 


FiG.    235. — Fracture    of    the    Waist 
OF  the   Scaphoid    (X)   in  a  Patient 

SUPPOSED  merely  TO  HAVE  SPRAINED 

HIS  Wrist. 


Fig.  236. — Radiogram  of  a 
'  Stave  of  the  Thumb  ' 
Fracture. 


bilization  for  a  short  time,  and  for  the  phalanges  a  small  zinc 
splint  moulded  along  the  front  of  the  finger  acts  admirably. 
Should  the  fragments  overlap,  operation  may  be  necessary. 

Bennett,  of  Dublin,  has  described  an  interesting  fracture  of  the 
first  metacarpal  [stave  of  the  thumb),  which  is  due  to  indirect  violence, 
and  not  very  rare.  The  line  of  fracture  is  oblique  (Fig.  236), 
separating  the  anterior  portion  of  the  base,  which  remains  in  situ, 
from  the  rest  of  the  shaft,  which  is  drawn  upwards  and  backwards 
by  the  long  extensor  tendons,  so  as  to  lie  behind  the  trapezium. 
Should  the  displacement  be  overlooked,  the  bone  unites  in  this 
position,  and  the  deformity,  which  persists,  determines  weakness 
and  disability  of  the  thumb.  Treatment.— The  fracture  is  reduced 
by  traction.  A  poroplastic  sphnt  is  moulded  to  the  anterior  (palmar) 
aspect  of  the  thumb,  reaching  above  the  wrist ;  it  is  first  fixed  to 
the  distal  end  by  strapping,  and  then  bandaged  above,  so  that 
extension  is  continuously  applied. 


526 


A   MANUAL  OF  SURGERY 


Fractures  of  the  Pelvis. 

Fractures  of  the  pelvic  bones  are  almost  always  the:  result  oi  direct 
injury,  such  as  falls,  blows,  gunshot  wounds,  or  crushes  in  railway, 
carriage  or  cart  accidents.  For  convenience  they  may  be  described 
undci"  the  following  headings: 

I.  Fractures  of  the  False  Pelvis.- — A  portion  of  the  crista  ilii  may  be 
broken  off,  or  the  anterior  superior  spine  separated,  or  merely  a 
fissure  in  the  bone  produced.  The  displacement  is  rarely  great, 
although  a  portion  of  the  crest  may  be  drawn  down  by  the  glutei 
muscles,  or  the  anterior  superior  spine  displaced  by  the  sartorius. 
Considerable  pain  is  always  present,  especially  on  any  vigorous 
respiratory   movements,    but    crepitus   is   rarely   to   be    detected. 

Union  occurs  readily  if  the 
patient  is  kept  quiet  in  bed 
with  the  shoulders  raised, 
and  the  legs  supported  to 
relax  the  muscles.  A  flannel 
bandage  round  the  pelvis  gives 
comfort  and  support. 

2.  Fracture  of  the  True 
Pelvis  is  a  much  more  serious 
accident.  The  line  of  fracture 
in  front  usually  runs  into  the 
obturator  foramen,  and  in- 
volves both  the  horizontal  and 
descending  rami  of  the  pubes 
or  the  ascending  ramus  of  the 
ischium  (Fig.  237).  '1  his  is  fre- 
quently conjoined  behind  with 
a  fracture  in  the  neighbour- 
hood of  the  sacro-iliac  syn- 
chondrosis either  on  the  same  or  opposite  side,  but  more 
frequently  the  latter;  whilst  a  double  fracture,  front  and  back,  may 
also  occur  at  these,  the  weakest,  points.  The  cause  of  the  posterior 
fracture  is  that,  when  the  pelvic  ring  has  yielded  anteriorly  from  the 
violence,  the  continued  strain,  whether  directed  from  the  front  or 
from  the  sides,  must  necessarily  fall  on  the  part  where  the  ilium  is 
most  closely  connected  with  the  sacrum,  and  the  bones  then  give 
way  rather  than  the  unyielding  and  powerful  sacro-iliac  ligaments. 
Probably  the  fracture  involves  the  lateral  mass  of  the  sacrum  rather 
more  frequently  than  the  ilium.  The  Symptoms  are  those  of  severe 
shock  and  pain  in  and  aromid  the  pelvis,  especially  on  movements  of 
the  legs  or  on  coughing.  T  here  may  be  local  ccchymosis  and  tender- 
ness over  the  pubic  ramus,  as  also  deeply  in  the  iliac  fossa,  and  the 
patient  either  cannot  stand,  or  feels  as  if  he  were  falling  to  pieces  on 
attempting  to  do  so.  Usually  there  is  but  little  deformity,  although 
occasionally  displacement  backwards  of   the   innominate   bone  is 


Fig.  237. — Unilateral  Fracture  of 
THE  Pelvis.  (Museum  of  the  Royal 
College  of  Surgeons.) 

The  fracture  runs  through  the  sacrum 
on  the  left  side,  and  through  the 
horizontal  and  descending  rami  of 
the  pubes. 


INJURIES  01-  nONES— FRACTURES  527 

visil)l(.",  and  tk'j)rcssi()n  ol  the  pvibic  sym})hysis  or  of  the  ischial  (jr 
pubic  rami  may  be  palpable.  Crepitus  may  be  elicited  on  grasping 
the  iliac  bones,  and  moving  them  one  on  the  other ;  but  such  a  method 
of  investigation  must  be  very  sparingly  indulged  in. 

The  chief  dangers  from  a  fractured  pelvis  arise  from  the  presence  of 
co-existent  visceral  lesions,  especially  to  the  urethra,  bladder,  or  rec- 
tum. The  membranous  portion  of  the  urethra  is  torn  by  the  dis- 
placement of  the  pubic  symphysis,  and  this  is  indicated  by  escape  of 
blood  from  the  meatus.  Every  effort  must  be  made  to  prevent 
extravasation  of  urine,  and  the  patient  loarned  against  passing  water, 
however  urgent  the  desire.  Rupture  of  the  bladder  results  in  pelvic  or 
intra-peritoneal  extravasation,  according  to  the  site  of  the  lesion. 
The  rectum  may  be  punctured  by  the  displaced  pubic  rami,  and  on 
examination  the  ends  of  the  bones  may  be  felt  in  the  rectum.  The 
vagina  and  the  pelvic  vessels  and  nerves  are  less  frequently  injured. 

Treatment. — The  patient  should  be  moved  with  the  greatest  care, 
both  on  account  of  the  shock,  and  also  for  fear  of  producing  or 
increasing  visceral  complications.  He  is  put  to  bed  on  a  firm  divided 
mattress  with  fracture-boards  beneath  it,  and  kept  quiet  until  the 
shock  has  in  measure  passed  off.  A  more  complete  examination 
is  then  made,  if  need  be  under  an  anfesthetic,  and  complications 
dealt  with.  It  is  rarely  desirable  to  attempt  replacement  of  the 
fragments,  which  gradually  return  to  a  more  or  less  normal  position. 
The  pubes,  however,  may  be  pushed  forwards  by  a  finger  in  the 
rectum  or  vagina.  A  many-tailed  bandage  or  broad  binder  is 
advisable  to  steady  the  parts,  and  the  patient's  knees  must  be  tied 
together ;  he  must  of  course  be  rolled  over  on  the  sound  side  in  order 
to  wash  the  back. 

The  visceral  complications  demand  suitable  treatment,  and 
especially  the  urethra,  which  must  be  examined  in  all  cases  and  the 
water  drawn  off  by  a  sterilized  catheter.  If  the  urethra  is  torn,  it 
may  be  possible  to  pass  a  catheter  and  tie  it  in;  but  failing  this,  a 
perineal  incision  must  be  made  in  order  to  prevent  urinary  infiltra- 
tion. If  the  pubic  rami  are  also  felt  projecting  into  the  rectum,  it 
may  be  advisable  to  prolong  the  permeal  incision  backwards  so  as 
to  lay  open  that  viscus  freely,  thereby  allowing  free  exit  to  faeces 
and  discharge,  and  permitting  of  more  satisfactory  cleansing. 

Apart  from  complications  \inion  may  be  expected  in  about  six 
weeks,  but  the  patient  should  be  kept  in  bed  for  at  least  eight,  and 
even  then  only  allowed  to  get  about  on  crutches,  wearing  a  padded 
belt.  Late  complications  in  the  form  of  abscesses  connected  with 
necrosis  of  the  pubic  rami  or  pelvic  extravasation  may,  of  course, 
arise,  and  prove  fatal  or  delay  convalescence. 

3.  Fracture  of  the  Acetabulum  is  of  two  types:  (i)  The  posterior 
lip  is  broken  off  by  the  head  of  the  femur,  which  is  dislocated  back- 
wards by  the  same  accident.  Reduction  is  effected  easily  and  with 
crepitus,  but  the  displacement  usually  recurs,  and  to  prevent  it  pro- 
longed and  effective  extension  is  required.  (2)  A  heavy  fall  on  the 
trochanter  may  cause  (a)  a  simple  fissure  extending  into  or  across  the 


528  A   MANUAL  OF  SURGERY 

cavity,  or  {b)  a  starred  fracture,  possibly  resolving  tiie  cavity  into  its 
three  constituent  elements,  or  {c)  it  may  even  drive  the  head  of  the 
bone  into  the  pelvis  [central  dislocation  of  the  femur) .  A  mere  fissure 
of  the  acetabulum  produces  but  few  symptoms  beyond  a  little  pain 
and  impairment  of  movement ;  but  if  the  head  of  the  bone  is  driven 
into  the  pelvic  cavity,  the  symptoms  are  much  more  serious,  on 
account  of  the  associated  injuries  to  the  viscera  and  the  greater 
amount  of  violence  employed.  The  case  will  resemble  one  of  frac- 
ture of  the  neck  of  the  femur,  but  there  is  usually  only  very  slight 
mobihty,  and  the  head  may  be  felt  within  the  pelvis  on  rectal 
examination.  An  attempt  should  be  made  to  free  it  by  horizontal 
traction  outwards,  and  manipulation  through  the  rectum;  extension 
is  then  maintained,  and  passive  movement  commenced  early. 

4.  Fracture  of  the  Tuber  Ischii  has  been  known  to  occur  from  falls 
in  the  sitting  position.  The  diagnosis  is  often  obscure,  as  the  dis- 
placement is  slight. 

5.  Fracture  of  the  Sacrum  is  always  due  to  direct  violence  of  con- 
siderable severity,  such  as  kicks,  blows,  or  gunshot  wounds.  It  is 
not  unfrequently  comminuted,  and,  from  the  associated  injury  to  the 
lower  sacral  nerves,  may  result  in  loss  of  power  of  the  bladder  and 
rectum.  In  a  transverse  fracture,  the  lower  fragment  is  usually 
displaced  forwards,  and  may  cause  pressure  upon  the  rectum ;  irregu- 
larity in  the  shape  of  the  bone  may  be  detected  from  within  [per 
rectum)  or  from  without.  Treatment. — The  knver  fragment  should 
be  replaced,  if  possible;  but  considerable  difficulty  may  be  experi- 
enced in  keeping  it  in  position.  A  well-fitting  pelvic  band,  with  rest 
in  bed,  is  probably  all  that  is  necessary. 

6.  Fracture  of  the  Coccyx  occurs  during  parturition  or  results  from 
falls  or  blows,  although  its  mobility  often  protects  it  from  injury. 
Great  pain  is  felt  on  walking,  or  on  any  movement  which  increases 
the  intra-abdominal  pressure,  such  as  straining,  coughing,  defaeca- 
tion,  etc.,  since  the  coccygeus  muscle  forms  part  of  the  pelvic  dia- 
phragm. A  rectal  examination  reveals  preternatural  mobility  of 
the  lower  fragment,  angular  deformity,  and  perhaps  crepitus.  The 
Treatment  consists  in  keeping  the  patient  at  rest  until  union  has 
occurred;  it  is  impossible  to  apply  any  apparatus,  and  hence  the 
bone  may  unite  at  an  angle,  causing  pain,  discomfort,  and  difficulty 
in  parturition.  Excision  of  the  hone  is  then  required.  The  patient 
lies  semi-prone  with  the  legs  slightly  flexed,  or  in  the  lithotomy 
position,  and  a  longitudinal  incision  is  made  in  the  middle  line.  The 
apex  and  lateral  margins  of  the  bone  are  cleared,  and  the  ligamentous 
tissues  uniting  it  to  the  sacrum  divided  by  the  knife ;  the  bone  is  now 
laid  hold  of  by  sequestrum  forceps,  and" its  remaining  attachments 
severed,  due  precautions  being  taken  not  to  encroach  on  the  rectum. 
Two  or  three  stitches  are  inserted,  and  also  a  drainage-tube  for  a 
few  hours;  the  dressing  is  secured  in  position  by  a  T-bandage.  The 
bowels  should  be  confined  for  some  days  after  the  operation. 

Falls  upon  the  coccyx,  unaccompanied  by  fracture,  sometimes  give 
rise  to  a  most  severe  and  intractable  type  of  neuralgia,  known  as 


INJURIES  OF  nONES— FRACTURES 


529 


coccydynia,  which  may  quite  prevent  the  patient  from  following  his 
a\'ocations.  It  is  probably  due  to  adhesions  forming  between  the 
posterior  sacral  nerves  and  the  bruised  periosteum.  If  all  the  usual 
sedatives  fail  in  giving  relief,  the  bone  must  be  excised. 

Fractures  of  the  Upper  End  of  the  Femur. 

I.  Fractures  of  the  Neck  of  the  Femur  may  involve  any  portion  of 
this  region,  but  for  clinical  purposes  are  usually  divided  into  those 
near  the  head  and  those  affecting  the  base  near  the  trochanter. 

Fracture  of  the  Cervix  Femoris  near  the  Head  (the  so-called  intra- 
capsular variety.  Fig.  238,  A)  is  most  frequently  met  with  in  persons  of 
advanced  age,  and  especially  in  females.  This  is  explained  by  the 
atrophic  changes  which  take  place 
in  the  cervix  femoris  of  elderly 
people.  The  spaces  between  the 
bony  cancelli  are  enlarged  and 
loaded  with  soft  fat,  whilst  the 
ensheathing  compact  tissue  is 
thinned,  and  the  '  calcar  femorale  ' 
of  Merkel  {i.e.,  the  process  of 
thick  cortical  substance  running 
from  the  lesser  trochanter  to  the 
under  part  of  the  head)  is  atro- 
phied. As  a  rule  it  requires  but 
little  violence  to  produce  a  frac- 
ture, the  direction  of  which 
varies  according  to  the  force 
applied.  The  accident  is  often 
due  to  some  slight  stumble  or 
fall,  such  as  shpping  off  the  kerb 
or  tripping  upstairs  ;  the  bone 
yields  in  consequence,  and  the 
patient  fahs  to  the  ground.  The  Hne  of  fracture  may  be 
transverse  or  obHque,  and  is  mainly  intracapsular.  Some  of  the 
fibres  reflected  from  the  under  surface  of  the  capsule  to  the 
head  of  the  bone  may  remain  untorn  at  first,  but  later  on  they 
may  give  way  from  inflammatory  softening,  injudicious  manipula- 
tion, or  attempts  to  use  the  limb.  The  fracture  is  not  usually 
impacted;  if,  however,  this  condition  should  occur,  the  upper  end 
of  the  neck  is  driven  into  the  loose  cancellous  tissue  of  the  head. 
The  displacement  is  necessarily  limited  entirely  to  the  lower  frag- 
ment, which  is  drawn  upwards  by  the  glutei,  recti,  and  hamstring 
muscles,  and  rotated  outwards  and  somewhat  backwards,  so  that 
the  fractured  surface  looks  almost  directly  forwards. 

The  course  of  the  case  depends  to  a  large  extent  upon  the  general 
condition  of  the  individual.  If  he  is  healthy  and  free  from  chronic 
pulmonary  affection,  so  that  he  can  be  kept  recumbent  for  six  or 
eight  weeks,  bony  union  may  certainly  occur.     This  takes  place 


Fig.  238. — A,  Fracture    of    the 
Cervix  Femoris  near  the  Head. 

B,  Pertrochanteric  Fracture. 

C,  Subtrochanteric  Fracture. 


530  A   MANUAL  OF  SURGERY 

mainly  from  tlic  lower  end,  as  the  vascular  suj")]:)!}'  of  the  head  is 
only  just  sufficient  to  maintain  its  vitality.  I  f,  however,  the  patient 
is  feeble  and  weakly,  and  especially  if  the  subject  of  chronic  bron- 
chitis and  emphysema,  the  prognosis  is  by  no  means  good,  since 
hypostatic  pneumonia  and  extensive  bedsores  may  carry  him  off 
during  the  short  stay  in  bed  which  is  always  necessary  in  order  to 
relieve  the  more  urgent  symptoms  of  pain.  Bony  union  is  never, 
under  these  circumstances,  to  be  expected,  and  a  loose  fibrous 
union,  or  even  a  false  joint,  is  the  best  that  can  be  looked  for.  Not 
unfrequently  the  joint  undergoes  changes  akin  to  those  of  osteo- 
arthritis, and  the  patient  henceforth  suffers  much  pain  and  dis- 
comfort. Sometimes  the  neck  is  absorbed  and  the  shaft  slips  up 
on  the  dorsum  ilii,  the  weight  of  the  body  being  carried  by  the  outer 
limb  of  the  Y-ligament  of  Bigelow  and  the  obturator  internus 
tendon.  1  he  prognosis  is,  of  course,  much  improved  by  the  pre;ence 
of  impaction,  and  the  fear  of  breaking  this  down  must  ever  be  in  the 
mind  of  the  examining  surgeon;  whilst  the  integrity  of  bridges  of 
periosteum  and  reflected  fibres  from  the  capsule  also  improves  the 
outlook. 

Radiographic  examination  has  shown  that  a  similar  type  of  fracture  occurs 
in  children  and  young  people.  It  is  not  unfrequently  incomplete,  and  may  be 
associated  with  bending  of  the  neck.  The  patient  often  recovers  mobility 
of  the  limb,  and  can  walk  about  after  resting  in  bed  for  a  few  days;  but  the 
deformity  persists,  and,  in  fact,  increases  from  fiu^ther  yielding  of  the  softened 
bone,  so  that  in  time  coxa  vara  results.  A  similar  deformity  follows  a  partial 
or  complete  separation  of  the  upper  epiphysis.  A  mistaken  diagnosis  of 
tubercidous  coxitis  may  be  made,  unless  one  clearly  appreciates  the  rapid 
appearance  of  the  symptoms  after  an  injury,  and  the  facts  that  the  trochanter 
is  raised,  the  limb  shortened,  and  the  movements  limited  only  in  particular 
directions  or  not  at  all.  If  there  is  complete  separation,  treatment  is  best 
carried  out  by  fixation  with  plaster  of  Paris  in  an  abducted  position,  and  by 
prolonged  freedom  from  the  body-weight,  so  as  to  allow  the  callus  to  harden, 
as  by  the  application  of  a  Thomas's  hip-splint. 

Fracture  of  the  Cervix  Femoris  near  the  Trochanter  (the  so-called 
extracapsular  Jract'Hve)  always  involves  the  hip-joint,  since  the  cap- 
sule extends  to  the  shaft  of  the  bone  along  the  anterior  intertro- 
chanteric line,  and  leaves  no  portion  of  the  neck  uncovered  in  this 
situation.  The  line  of  fracture  (Fig.  239)  is  placed  in  front,  either 
along  the  attachment  of  the  capsule  or  well  within  it,  and  is  really 
only  extracapsular  behind;  sometimes,  however,  the  shaft  itself  is 
considerably  encroached  on. 

Mechanism.- — This  fracture  is  usually  the  result  of  violence  acting 
transversely  upon  the  trochanter  major,  as  from  a  heavy  fall  upon 
the  hip.  The  posterior  part  of  the  neck,  being  weaker  than  the 
anterior,  first  gives  way;  the  whole  neck  then  3delds,  and  the  severed 
head  and  neck  are  impacted  into  the  junction  of  the  trochanter  and 
shaft.  The  majority  of  these  cases  are  thus  primarily  impacted, 
continuation  of  the  violence  producing  disimpaction,  coupled  either 
with  detachment  of  one  or  both  trochanters,  or  with  comminution 
of  the  great  trochanter;  at  least  three,  and  perhaps  four,  fragments 


INJURIES  OF  BONES— FRACTURES 


531 


arc  thus  produced  (Fig.  240).  Disimpaction  may  also  follow  at  a 
later  date  from  the  rarefaction  associated  with  the  early  stages_  of 
repair  or  from  injudicious  manipulation;  and  thus  the  shortening 
which  may  at  first  be  slight  often  increases  at  the  end  of  a  few  days. 
The  upper  fragment  remains  in  the  acetabulum,  whilst  the  lower  is 
drawn  up  and  everted. 

Union  of  the  fragments  is  much  more  certain  in  this  variety  than 
in  the  intracapsular,  but  it  is  often  accompanied  by  a  considerable 


Fig.  239. — Fracture  of  Cervix 
Femoris  Near  the  Base. 
(Semi  -  diagrammatic,  from 
THE  Front.) 


Fig.  240. — Fracture  of  Neck  of 
Femur  Near  the  Base,  seen 
from  Behind.  (College  of 
Surgeons'  Museum.) 

The  head  and  neck  are  de- 
pressed, and  the  trochanter 
major  drawn  slightly  upwards. 


development  of  callus,  which  may  subsequently  impair  the  move- 
ments of  the  limb,  whilst  secondary  bending  and  late  increase  of  the 
shortening  may  occur  if  the  patient  walks  too  soon. 

The  Signs  and  Symptoms  of  these  two  fractures  may  well  be  con- 
sidered together,  the  points  of  similarity  and  contrast  being  in  this 
way  more  effectually  emphasized. 

{a)  The  signs  of  local  trmima,  viz.,  pain,  bruising,  and  swelhng, 
may  be  present  in  both;  but  whilst  slight  in  the  intracapsular 
variety,  they  are  often  very  marked  in  the  extracapsular. 

(&)  Crepitus  is  evident  in  the  unimpacted  forms  of  each;  but  it  is 
unnecessary  and,  indeed,  extremely  unwise  to  ehcit  it  by  forcible 
manipulation,  especially  in  the  intracapsular  variety. 

(c)  Loss  of  power  is  perhaps  more  marked  in  the  extracapsular 
form  than  in  the  intracapsular.  Cases  of  the  latter  in  which  the 
patient  was  able  to  walk  into  hospital  some  days  after  the  accident 
are  not  unknown,  and  are  probably  due  to  impaction. 

\d)  Eversion  is  a  most  characteristic  feature  in  both  varieties,  the 
limb  lying  absolutely  helpless  on  its  outer  side.     This  displacement 


532 


A   MANUAL  OF  SURGERY 


is  accredited  to  the  natural  weight  of  tlie  limb,  to  the  greater  fragility 
of  the  back  of  the  cervix,  causing  it  to  be  more  comminuted  than  the 
anterior  surface,  and,  lastly,  to  the  greater  power  of  the  external 
rotator  muscles.  Inversion  has  been  met  with  in  a  few  rare  cases, 
but  is  probably  due  to  the  violence  in  the  particular  instance 
being  directed  from  behind  forwards,  and  to  impaction  of  the 
fragments. 

[e)  Shortening  is  slight  in  the  early  stage  of  intracapsular,  and 
much  greater  in  the  extracapsular,  fractures,  even  reaching  to  2i  or 
3  inches.  It  is  indicated  by  displacement  of  the  trochanter  upwards, 
due  allowance  being  made  for  the  position  of  the  limb  as  regards 
abduction  or  adduction. 

(/)  The  position  of  the  great  trochanter  is  of  the  greatest  importance. 
It  is  raised  above  its  orchnary  level,  and  displaced  backwards  owing 


Sri" 


Fig.  241 . — Nelaton's  Line  and  Bryant's  Measurement  for  ascertaining 
Position  of  Great  Trochanter. 


to  eversion  of  the  limb ;  and  it  is  approximated  to  the  middle  line  of 
the  body.  The  demonstration  of  this  position  is  most  important, 
and,  amongst  others,  the  following  tests  are  employed : 

Nelaton's  line  (Fig.  241)  is  one  drawn  from  the  anterior  superior 
spine  to  the  most  prominent  point  of  the  tuber  ischii  (AB).  The 
centre  of  this  (D)  corresponds  to  the  top  of  the  great  trochanter,  if 
the  limb  is  placed  in  the  axis  of  the  body ;  but  if  either  abduction  or 
adduction  is  present,  the  top  is  situated  slightly  above  or  below  the 
line.     Definite  elevation  of  the  bone  above  the  line  indicates  shorten- 


INJURIES  OF  HONES— FRACTURES  533 

iii!^  ol  till'  liiul)  iluc  to  clisl()Cciti(jn  l);ickwurds,  fracture  of  the  neck, 
or  absori)ti()n  of  the  head  and  neck  from  disease. 

Bryant's  Test  Line  (Fig.  241). — In  this  the  patient  Ues  flat  on  a 
horizontal  couch,  and  a  vertical  line  (AC)  is  drawn  from  the  anterior 
superior  spine;  a  thin  wooden  rod  held  against  the  side  answers  this 
purpose  admirably.  The  perpendicular  distance  of  the  top  of  the 
great  trochanter  from  the  line  (CD)  is  compared  with  a  similar 
measurement  on  the  opposite  side;  definite  shortening  may  thus  be 
discovered.  In  the  normal  adult  this  measurement  is  usually  about 
2  ^  inches. 

Morris's  hitrochantcric  test  indicates  the  amount  of  inward  dis- 
placement. It  is  conducted  by  measuring  the  distance  between  the 
outer  surfaces  of  the  trochanters  and  the  middle  line  of  the  body  by 
means  of  a  rod  graduated  from  the  centre,  along  which  two  pointers 
work  outwards.  Shortening  in  this  direction  will  also  be  observed 
in  most  dislocations  of  the  hip-joint. 

Moreover,  in  the  extracapsular  fracture  a  considerable  amount  of 
thickening  of  the  trochanter  is  always  produced,  owing  to  the  exces- 
sive development  of  callus.  In  the  intracapsular  variety  it  is  rarely 
fissured  or  injured,  and  therefore  no  thickening  occurs. 

(g)  Lastly,  relaxation  of  the  fascia  between  the  crest  of  the  ilium 
and  the  great  trochanter  (that  is,  of  the  upper  part  of  the  iho-tibial 
band)  is  given  as  a  characteristic  feature  of  these  fractures. 

Diagnosis. — A  severe  contusion  of  the  hip,  which  may  be  associated 
with  marked  eversion,  is  known  from  a  fracture  by  the  absence  of 
shortening  and  crepitus ;  there  is  no  displacement  of  the  trochanter, 
which  rotates  in  a  normal  manner.  The  shortening  which  some- 
times follows,  owing  to  subsequent  atrophy  of  the  neck,  may,  how- 
ever, complicate  matters.  In  a  dislocation  the  head  of  the  bone 
can  be  felt  in  an  abnormal  position,  and  hence  no  difficulty  should 
be  experienced  in  its  recognition.  In  chronic  osteo-arthritis  of  the 
hip  a  patient  may  fall  and  present  for  examination  a  limb  with 
definite  shortening  and  marked  bony  crepitus.  It  will  be  found, 
however,  that  there  is  no  acute  eversion,  pain,  or  loss  of  power, 
whilst  the  existence  of  similar  disease  in  other  joints  may  assist  the 
surgeon.  Moreover,  osteo-arthritis  of  the  hip  usually  results  in 
prominence  of  the  trochanter,  and  not  in  flattening,  as  occurs  after 
fracture;  the  fascia,  too,  above  the  trochanter  is  never  relaxed  in 
osteo-arthritis,  always  in  fractures.  It  must  not  be  forgotten  that, 
after  an  intracapsular  fracture,  the  patient  may  fall,  not  on  the 
injured  side,  but  on  the  sound  thigh,  and  cases  have  been  known 
where  the  surgeon's  attention  was  directed  to  the  wrong  limb  owing 
to  the  amount  of  bruising  there  manifested. 

The  Treatment  of  Intracapsular  Fractures  must  depend  in  great 
measure,  as  already  stated,  upon  the  individual.  If  old,  weakly,  and 
with  a  tendency  to  chronic  bronchitis,  long  confinement  to  bed  would 
have  a  most  deleterious,  if  not  fatal,  effect.  In  such  cases  the  limb 
is  put  at  rest  for  a  few  days  between  sandbags,  and  cooling  lotions 
applied.     Some  suitable  appliance,  such  as  a  Thomas's  splint  with 


534  A    MANUAL  OF  SURGERY 

mechanism  for  extension,  or  a  plaster  ofJ^Paris  spica,  shoulcl^be 
fitted  as  early  as  possible,  and  the  patient  encouraged  to  get  about 
on  crutches. 

In  a  healthy  individual  with  good  physique,  a  determined  effort 
must  be  made  to  secure  bony  union,  and  this  will  involve  the 
patient  being  kept  in  bed  for  six  or  eight  weeks.  Reduction  is 
obtained  by  making  manual  extension  on  the  limb,  a  roller-towel 
around  the  perineum  being  employed  for  counter-extension.  This 
is  maintained  until  the  limbs  correspond  in  length,  and  then  the  leg 
is  inverted  so  that  the  foot  is  at  right  angles  to  the  table,  and  the 
whole  hmb  is  slowly  abducted  under  tension  so  as  to  bring  the 
lower  fragment  into  contact  with  the  upper;  only  in  this  position  can 
satisfactory  apposition  of  the  fractured  surfaces  be  obtained.  The 
patient  is  then  placed  in  a  suitable  abduction  frame  (Robert  Jones) 


WW  \    \  \     A _A. 


Fig.  242. — Method  of  Cutting  and  Folding  the  Strapping  in  Applying 

Extension. 


::^^^M3:>~^^3IZZ] 


Fig.  243. — Method  of  Arranging  Strapping  on  Stirrup  or  '  Spreader.' 

The  end  A*  is  attached  by  a  safety-pin  to  A,  the  end  of  the  upper  piece  of 
strapping  in  Fig.  242,  and  a  similar  attachment  is  made  on  the  other  side 
of  the  limb  to  the  other  piece  of  strapping. 

- — a  double  Thomas's  splint  with  the  frame  for  one  limb  abducted — 
and  extension  maintained,  or  in  a  plaster  of  Paris  spica  (Royal 
Whitman).  At  the  end  of  six  weeks  the  leg  is  gently  adducted, 
and  a  Thomas's  knee-splint  with  extension,  or  some  similar  con- 
trivance, is  fitted,  and  massage  and  passive  movements  of  the  limb 
are  undertaken.  It  is  a  mistake  to  commence  walking  too  early, 
and  the  patient  should  always  for  a  time  have  a  support,  such  as 
a  walking  caliper  (R.  Jones),*  which  carries  the  weight  of  the  trunk 
from  the  pelvis  to  the  ground.  Walking  without  support  should 
not  be  permitted  for  at  least  three  months. 

Occasionally  it  may  be  justifiable  to  trust  to  weight-extension  or 
to  the  use  of  a  Liston's  splint,  but  the  results  of  such  treatment  are 
far  inferior  to  those  obtained  by  abduction.  Extension  by  iveighl 
and  pulley  is  required  in  so  many  different  conditions  that  a  de- 

*  Robert  Jones,  Brit.  Med.  Journ.,  December  7,  1912. 


INJURIES  OF  BONES—FRACTURES 


535 


A  stirrup  is  tlien  prqxuod  as  ■»  F'S;^;« .  adh.^'v^^^P^^^^^^       ^  ,,„1^ 

;;;;  -tte  side  of  theCb^nd  secured  to  it  by  a  woollen  or  boraac 
bandage,  which  should  not  extend  m"<:h  >"5lovv  the  knee^  IM 
s;lrn'p^s  then  attached  to  the  stops  by  -fety-P  -  ^A   'o  A'    the 


'^USSaMMMM^ 


■^ 


F,0     ,,,_V0LKMAN>.-S   SLIDING   KEST   FOK   FRACTDKBS   OF   THE   FEMOR. 

A  points  to  the  junction  ol  the  upper  and  lower  pieces  of  strapping,  as  in 
^  Figs.  242  and  243. 

IfpSi-thXtl^S^"^^^^^^^^^^^^^^ 

^t  T,t)'SZiX:ef^^r^^^^^^^      and  secured  to  .t  by  the 

loose  end  of  strapping  and  ^  ba^^age^  comfortable  appli- 

Ltston's  long  'Pj'''{^^'^- r^"^^^^^^^^  the  axilla  to  about 

J^Siris  p-eteilt^S'^^lip^n^^^^^^^^^^^        ei^f  the  splint  nrto  a 


536 


A   MANUAL  OF  SUIiGIiRY 


slot  between  two  '  angle-irons  '  screwed  to  a  substantial  wooden 
base,  which  rests  on  the  bed. 

In  impacted  intracapsular  fractures  no  attempt  should  be  made  to 
separate  the  fragments.  The  patient  is  kept  in  bed  and  a  long  splint 
applied.  A  careful  watch  is  maintained  to  ascertain  if  disimpaction 
has  occurred,  as  tlu'n  the  ordinar\-  treatment  must  be  eniphjyed. 

Treatment  of  Fracture  near  the  Trochanter  is  usually  conducted  on 
similar  lines  to  that  of  the  intracapsular  variety,  but  inasmuch  as 
the  patient  is  usually  healthy  a  determined  effort  to  secure  satis- 
factory union  must  be  made. 

In  the  unimpacled  form  extension  is  the  all-important  element. 
It  is  usually  conducted  by  weight  and  pulley;  the  weights  must  be 


Fig.  245.- — Method  of  Application  of  Liston's  Long  Splint  with 
Weight  Extension. 

The  splint  reaches  from  the  axilla  below  the  side  of  the  foot,  and  is  secured  in 

place  by  sheets. 


heavy,  and  sometimes  as  much  as  14  pounds  are  required;  the 
strapping  must  reach  well  above  the  knee,  or  the  ligaments  of  this 
articulation  may  suffer.  Rotation  may  be  prevented  by  fixing  a 
broad  piece  of  wood  carefully  padded  transversely  bcliind  the  knee 
by  means  of  a  plaster  of  Paris  bandage.  The  addition  of  a  long 
splint  will  keep  the  body  at  rest,  but  inasmuch  as  it  might  interfere 
with  the  extension,  it  may  be  as  well  to  apply  it  to  the  sound  side. 
Treatment  in  the  abduction  frame  will  also  give  good  results.  At 
the  end  of  eight  weeks  the  patient  may  be  allowed  to  get  about 
with  a  Thomas's  splint  and  crutches,  or  a  plaster  spica. 


INJURIES  OF  HONES— FRACTURES  537 

Impacted  fractures  should  rarely  be  broken  up,  except  in  young 
and  active  people.  In  older  patients  the  limb  is  kept  at  rest  for 
six  or  eight  weeks  on  a  long  splint  without  extension. 

Union  occurs  readily  and  by  means  of  bone;  but  there  is  often 
a  good  deal  of  deformity  and  subsequent  disability  from  the  de- 
N'clopment  of  bon\'  outgrowths. 

2.  Fracture  of  the  Great  Trochanter  is  rare,  and  always  due  to 
direct  violence ;  in  the  young  it  occurs  as  an  epiphyseal  lesion.  The 
trochanter,  or  a  portion  of  it,  is  separated  from  the  rest  of  the  bone 
without  any  loss  of  the  continuity  of  the  shaft.  Independent  move- 
ment of  the  fragment  with  crepitus  is  usually  obtainable ;  and  if  the 
displacement  is  at  all  marked,  an  operation  to  fix  it  should  be 
undertaken. 

3.  Fracture  through  the  Great  Trochanter  (the  pertrochanteric 
fracture  of  Kocher)  closely  resembles  the  extracapsular  fracture,  the 
lesion  running  from  the  inner  and  under  part  of  the  neck  obliquely 
upwards  and  forwards  through  the  base  of  the  trochanter  (Fig.  238,  B) . 
The  lower  fragment  is  displaced  upwards  and  everted,  and  its  upper 
edge  can  often  be  felt  distinct  from  the  top  of  the  great  trochanter, 
which  does  not  move  on  rotation  of  the  limb;  there  is  also  much 
thickening  about  the  trochanter  and  pain  on  pressure  over  it. 
This  injury  needs  to  be  carefully  distinguished  from  the  subtrochan- 
teric fracture,  which  encroaches  on  the  upper  end  of  the  shaft.  In 
this  both  trochanters  are  included  in  the  upper  fragment  (Fig.  238,  C), 
which  is  flexed  by  the  ilio-psoas  and  abducted,  whilst  the  lower 
fragment  is  drawn  up  on  its  outer  aspect  and  behind  it  with  con- 
siderable shortening  and  complete  eversion.  Both  types  of  fracture 
require  prolonged  extension  in  the  abduction  frame  or  by  means  of 
Hodgen's  apparatus. 

Hodgen's  splint  (Fig.  246)  consists  of  a  rigid  iron  frame  in  the 
form  of  the  letter  U,  the  outer  and  longer  limb  reaching  from  the 
anterior  superior  spine  to  3  inches  below  the  instep,  and  the  inner 
from  the  adductor  longus  tendon  to  the  same  spot,  where  the  two 
limbs  unite  in  a  crossbar  3  inches  in  width.  The  sides  taper  with 
the  limb,  and  should  be  |  inch  further  apart  than  the  diameter  of 
the  limb  at  any  point.  At  the  upper  end  the  bars  are  united  by  an 
arch  of  the  same  material,  which  should  correspond  to  Poupart's 
ligament ;  one  or  two  similar  arches  are  placed  at  equal  points  lower 
down.     The  splint  is  slightly  bent  at  the  knee. 

Before  applying  the  splint,  an  ordinary  extension  apparatus  is 
attached  to  the  limb.  Strips  of  house-flannel,  about  7  inches  wide, 
are  then  cut  and  arranged  beneath  the  limb  at  right  angles  to  its 
direction,  each  one  overlapping  the  next;  the  length  of  the  strips 
should  be  rather  more  than  the  circumference  of  the  limb  at  the  spot 
to  which  each  is  to  be  applied.  The  splint  is  then  placed  in  position ; 
the  strips  of  flannel  are  raised  in  succession,  and,  being  lapped  over 
the  bar,  are  pinned  or  stitched  there,  so  that  the  limb  lies  in  a  flannel 
trough,  from  which  only  the  upper  surface  projects.  The  cord  of 
the  extension  appliance  is  then  securely  tied  to  the  lower  end  of  the 


538 


A   MANUAL  OF  SURGERY 


splint.  Two  hooks  are  soldered  to  each"side  of  the  frame,  and  to 
them  are  attached  cords,  which  are  brought  together  over  the 
limb;  another  stout  cord  is  tied  to  these,  and  passes  over  a  pulley 
attached  to  a  vertical  post  at  the  end  of  the  bed ;  it  is  weighted  to  a 
sufficient  extent.  The  limb  when  the  weight  is  applied  should  lie 
free  of  the  bed,  even  to  its  extreme  upper  limit.  It  is  advisable  to 
encircle  the  thigh  in  Gooch  splinting,  a  narrow  piece  in  front  between 
the  bars  and  a  broader  piece  behind.  These  are  well  padded  and 
secured  by  bandages  which  extend  over  the  whole  length  of  the 
apparatus;  finally,  starch  is  rubbed  in  so  as  to  fix  it  more  firmly. 
When  correctly  applied,  the  splint  itself  is  pulled  on  by  the  extending 


Fig.  246. — Hodgen's  Splint  and  its  Method  of  Application. 


force  (the  weight),  and  this  is  transmitted  to  the  limb  through  the 
stirrup  end,  which  should  be  taut  '  like  a  harp-string  ' ;  laxity  of  this 
end  indicates  slipping  of  the  splint,  and  necessitates  its  readjust- 
ment. 

Fractures  o£  the  Shaft^of  the  Femur  are  extremely  common 
accidents,  in  spite  of  the  apparent  strength  of  the  bone.  Any  part 
may  be  involved,  particularly  the  centre,  whilst  they  occur  at  the 
lower  end  more  frequently  than  at  the  upper.  In  the  latter  situa- 
tion they  are  usually  due  to  indirect  violence,  whilst  at  the  lower  end 
they  generally  result  from  direct  injury;  either  form  of  violence  may 
lead  to  a  fracture  about  the  middle  of  the  bone,  and  radiography 
has  shown  us  that  spiral  fractures  are  by  no  means  uncommon 
Exact  diagnosis  is  sometimes  difficult,  owing  to  the  amount  of 
swelling  from  hsemorrhage,  and  to  the  muscularity  of  the  part. 

In  almost  every  case  displaceme^it  occurs,  the  direction  and 
amount  of  which  depend  not  only  on  the  line  of  fracture,  but  also 
on  the  situation.     In  the  tipper  third  (Fig.  247),  the  small  upper 


INJURIES  OF  BONES— FRACTURES 


539 


fragment  is  usually  tilted  forwards  by  the  ilio-psoas,  and  abducted 
and  everted  by  the  gluteus  minimus  and  external  rotators;  whilst 
the  lower  fragment  is  drawn  upwards  and  to  the  inner  side  of  the 
upper  by  the  hamstring  and  adductor  muscles,  marked  eversion 
also  resulting,  partly  from  the  weight  of  the  foot,  and  partly  from 
the  action  of  the  adductors;  but  such  a  comphcated  displacement  is 
not  always  present. 

In  the  middle  third,  if  due  to  indirect  violence,  the  hue  of  fracture 
usually  slants  from  above  downwards  and  backwards,  causing  a 
simple  overriding  of  the  fragments  or  an  angular  deformity.     The 


Fig.  247. — Fracture  of  Upper 
Third  of  Femur,  showing  Dis- 
placement OF  Bone.  (After 
Gray's  '  Anatomy.') 

I,  Ilio-psoas  tendon;  2,  rectus;  3, 
adductors;  4,  biceps. 


Fig.  248.— Fracture  of  Lower 
Third  of  Femur,  showing  Dis- 
placement OF  Lower  Fragment 
Backwards.  {After  Gray's 
'  Anatomy.') 

I,  Rectus;  2,  biceps;  3,  semi-mem- 
branosus  and  semi-tendinosus ;  4, 
gastrocnemius. 

lower  fragment  is  drawn  upwards  and  inwards,  either  in  front  of 
or  behind  the  upper  fragment,  and  is  usually  everted.  The  upper 
fragment  is  sometimes  tilted  forwards.  If  due  to  direct  violence, 
the  fracture  is  more  or  less  transverse,  often  comminuted,  and  any 
form  of  displacement  may  then  occur. 

In  the  lower  third  the  fractures  which  arise  from  direct  force  are 
transverse;  the  lower  fragment  may  then  be  tilted  backwards  by 
the  gastrocnemii  muscles  (Fig.  248),  and  compress  or  rupture  the 
popliteal  vessels,  perhaps  causing  gangrene.  Oblique  or  spiral 
fractures  from  indirect  violence,  sloping  from  above  downwards  and 
forwards,  are  also  met  with;  the  upper  fragment  is  driven  into  tne 


540 


A    MANUAL  OF  SURCFAiY 


substance  ut  the  quadricej)S  muscle  and  may  become  fixed  in  it,  pro- 
jecting immediately^  beneath  the  skin,  whilst  the  lower  fragment  is 
drawn  up  behind.  If  such  a  case  is  left  unreduced,  non-union  is 
likely  to  ensue;  the  knee-joint  is  generally  penetrated  by  the  lower 
end  of  the  upper  fragment. 

Treatment. — In  the  uppcy  lliiyd,  where  the  upper  fragment  is  often 
too  short  to  be  controlled  by  any  splint,  reduction  of  the  deformity 
is  accomplished  by  flexing  the  thigh,  and  making  extension  from  the 
knee,  the  lower  fragment  being  thus  lirought  into  the  same  axis  as 
the  upper.     Manipulation  will  usually  correct  any  lateral  displace- 


FiG.  249. 


-Bryant's  Method  of  Extension  for  Treatment  of  Fracturk 
OF  the  Femur  in  Small  Children. 


The  right  leg  is  fractured  and  has  the  weight  attached  to  it;  the  lelt  leg  is 
merely  tied  up  to  keep  it  vertical  and  out  of  the  way. 


ment.  The  limb  must  be  confined  in  this  position  by  some  form  of 
inclined  plane,  such  as  a  Macintyre's  splint,  with  a  long  thigh-piece, 
and  with  small  straight  wooden  splints  or  a  piece  of  Gooch's  splint- 
ing fixed,  if  necessary,  to  the  front  and  outer  sides  of  the  limb,  over 
the  seat  of  fracture.  The  splint  is  slung  at  the  knee,  the  foot-piece 
being  fixed  to  blocks  of  wood,  a  little  lower  than  the  level  of  the 
knee.  If  these  precautions  are  not  taken,  an  ununited  fracture, 
with  the  upper  fragment  in  front  of  the  lower,  is  likely  to  occur. 
Hodgen's  apparatus  also  answers  admirably  in  these  cases,  and 
where  there  is  much  abduction  of  the  upper  fragment  the  abduction 


INJURIES  OF  BONES—FRACTURES  541 

frame  (p.  554)  may  advisably  be  employed;  in  healthy  patients, 
however,  treatment  by  operation  is  often  desirable. 

In  the  middle  Ihird  of  the  thigh,  where  the  upper  fragment  can  be 
controlled  by  splints,  shortening  is  prevented  by  weight  extension 
or  by  the  use  of  a  Thomas's  knee-splint,  the  thigh  being  sur- 
rounded by  pieces  of  Gooch's  splinting,  which  grasp  the  muscles 
and  keep  the  parts  at  rest.  A  half-box  splint  [i.e.,  a  long  splint 
with  a  back-piece)  may  be  successfully  employed  in  many  of  these 
cases,  the  limb  being  firmly  bandaged  to  the  appliance.  Where 
the  fracture  is  oblique  or  spiral,  and  especially  if  there  is  any  ten- 
dency to  overlap,  Hodgen's  apparatus  may  be  utilized,  or  operation 
undertaken. 

In  the  loioer  third,  when  the  lower  fragment  is  tilted  backwards, 
a  Macintyre's  sphnt,  with  a  long  thigh-piece  and  the  knee  well 
flexed,  may  sometimes  be  employed,  together  with  a  short  anterior 
thigh-piece  of  Gooch's  splinting;  but  in  the  oblique  type,  if  the  upper 
fragment  has  penetrated  the  quadriceps,  operation  alone  holds  out 
any  prospect  of  bringing  the  parts  into  apposition,  the  muscular 
fibres  being  divided  to  allow  the  projecting  end  of  the  bone  to  be 
replaced,  and  fixed  by  screws  or  wire.  In  other  cases  the  ordinary 
long  splint  or  Hodgen's  will  be  required. 

In  children,  Bryant's  plan  of  treatment  (Fig.  249)  is  excellent;  it 
consists  in  slinging  the  limb  from  a  crossbar  at  right  angles  to  the 
body,  with  or  without  a  back-splint,  reaching  from  the  heel  to  the 
nates,  and  short  lateral  sphnts,  thus  obtaining  extension  by  utihzing 
the  weight  of  the  body,  whilst  the  bandages,  etc.,  are  kept  from  being 
soiled.  '  If  a  long  spHnt  is  used  for  children,  a  double  one  [e.g., 
Hamilton's  sphnt)  with  a  crossbar  below  is  the  best.  For  the 
obstetric  fracture  which  occurs  in  babies,  the  best  treatment  is  to 
apply  a  small  Thomas's  knee-splint  with  extension.  The  ring 
which  encircles  the  groin  is  well  padded  and  covered  with  impervious 
oilskin,  and  the  extension  is  carefully  maintained. 

A  fractured  femur  usually  unites  well  in  from  six  to  eight  weeks, 
but  the  patient  must  not  bear  his  weight  on  it  for  another  morith 
or  two.  Some  form  of  retentive  mechanism  is  employed,  permitting 
walking,  and  yet  maintaining  sHght  extension — e.g.,  a  Thomas's 
knee-sphnt  with  a  foot-piece.  There  is  certain  to  be  some  amount 
of  stiffness  of  the  knee-joint,  following  effusion,  after  all  fractures 
of  the  femur ;  but  it  generally  passes  away  in  time,  and  that  without 
active  surgical  intervention. 

Fractures  0!  the  Lower  End  of  the  Femur. 

I.  T-  or  Y-shaped  Fracture  of  the  Condyles.— In  this  a  transverse 
fracture  is  compHcated  by  a  fissure,  which  runs  into  the  joint, 
separating  the  two  condyles;  or  a  Y-shaped  fissure  may  start  from 
the  intercondyloid  notch.  The  condition  is  very  painful;  the  joint 
is  distended  with  blood ;  the  bone  may  feel  broader  than  usual,  and 
crepitus  may  be  detected.     Treatment  is  best  effected  by  operation, 


542  A   MANUAL  OF  SURGERY 

in  order  to  empty  the  joint  of  blood,  hrinj^'  tiie  frat^mients  into  apposi- 
tion, and  fix  tlicni  I)y  screws  or  pegs. 

2.  Separation  of  either  Condyle  usually  results  from  direct  violence, 
but  occasionallv  has  followed  such  indirect  injury  as  catching  the  toe 
against  the  kerbstone.  There  is  no  shortening,  but  the  leg  may  be 
deflected  towards  the  side  injured,  and  the  joint  cavity  be  full  of 
blood.  The  fragment,  which  is  tilted  backwards  by  the  gastroc- 
nemius, may^move  separately'  from    the    shaft,  and  give  rise  to 


Fig.  250. — Radiogram  of  Fracture  of  External  Condyle  of  the 
Femur,  with  Fixation  of  Fragments  by  Screws. 

This  fracture  occurred  in  a  healthy  man,  and  was  caused  by  catching  his  toe 
against  'the  kerbstone  whilst  walking.  The  fragment  was  completely 
detached  and  drawn  back  into  the  popliteal  space  by  the  outer  head  of 
the  gastrocnemius.     It  was  treated  by  operation,  with  a  good  result. 

crepitus.  Treatment.- — Reposition  is  effected  by  flexion  of  the  limb, 
which  is  best  put  up  in  this  position ;  but  in  healthy  adults  treatment 
by  operation  is  desirable  (Fig.  250). 

Occasionally  a  small  portion  of  the  condyle  may  be  detached  and 
lie  loose  in  the  knee-joint;  when  the  immediate  symptoms  due  to  the 
injury  have  subsided,  the  signs  of  a  foreign  body  in  the  joint  may 
become  evident,  and  operation  will  be  required  for  its  removal. 

3.  Separation  of  the  Lower  Epiphysis  of  the  Femur  (Fig.  251) 
is  not  a  very  rare  accident,  and  is  frequently  due  to  a  child 
sitting   behind    a  cab    and  getting   a  leg   entangled   between  the 


INJURIES  OF  BONES— FRACTURES 


543 


Spokes  of  the  revolving  wheel.  The  limb  is  tluis  forcibly  hyper- 
extended  at  the  knee,  and  the  epiphysis  yields,  and  is  carried  for- 
wards. The  lower  end  of  the  diaphysis  projects  behind,  and  may 
compress  the  popliteal  vessels;  gangrene  has  been  known  to  result. 
As  in  the  humerus,  the  line  of  separation  does  not  always  correspond 
to  the  epiphyseal  line,  but  sometimes  encroaches  on  the  shaft.  Sup- 
puration occurs  in  a  fair  proportion  of  the  cases.  Treatment.— 
Reduction  is  effected  by  an  assistant  making  traction'on  the  tibia^in 
the  line  of  the  limb  so  as  to  stretch  the  quadriceps  ;[then  the  thigh 
is  gradually  flexed  by  the  surgeon, 
standing  above  and  with  both 
hands  clasped  beneath  it.  The 
epiphysis  is  by  this  means  restored 
to  its  normal  position,  and  the 
limb  is  kept  flexed  by  a  bandage 
at  about  an  angle  of  60°,  and  laid 
on  its  outer  side  with  an  icebag 
applied.  Passive  movement  is  com- 
menced carefully  in  a  fortnight. 

Fractures  of  the  Patella. 

The  patella  is  broken  either  b}- 
muscular  force  or  by  direct  vio- 
lence, and  the  conditions  produced 
are  so  different  that  a  separate 
description  is  necessary. 

1.  Fractures  by  direct  violence 
may  traverse  the  bone  in  an}- 
direction,  but  are  most  often  ver- 
tical or  star-shaped,  and  frequently 
comminuted.  They  are  usually 
mere  fissures  without  displacement, 
owing  to  the  aponeurosis  or  capsule 
of  the  bone  remaining  intact. 
There  is  a  good  deal  of  subcu- 
taneous bruising,  and  perhaps  some 
effusion  into  the  joint,  whilst  on 
careful  palpation   the   fissure  may 

be  felt,  and  crepitus  occasionally  detected.  Treatment  consists  in 
keeping  the  limb  at  rest  on  a  back-splint,  and  perhaps  applying 
evaporating  lotions.  Massage  and  passive  movements  are  com- 
menced early  where  there  has  been  much  haemorrhage  into  the 
joint.     Operative  measures  are  rarely  required. 

2.  Fractures  due  to  muscular  force  are  always  transverse,  usualty 
complete,  and  since  they  involve  the  fibrous  aponeurosis,  consider- 
able displacement  occurs. 

Mechanism. — When  the  knee  is  semi-flexed,  the  patella  is  poised 
upon  the  front  of  the  condyles  of  the  femur,  resting  upon  the  middle 


Fig.  25 1 . — Radiogram  of  Separa- 
tion OF  Lower  Epiphysis  of 
Femur,  with  Displacement 
Forwards. 

The  patella  was  mainly  cartilagin- 
ous, and  is  not  visible. 


544 


A   MANUAL  OF  SURGERY 


of  its  articular  surface:  in  this  position  any  sudden  and  violent  con- 
traction of  the  quadriceps,  as  in  attempting  to  recover  one's  ecjuili- 
brium  after  having  slipped,  takes  the  bone  at  a  disadvantage,  and 
may  succeed  in  snapping  it.  Possibly  in  some  people  there  is  a 
predisposing  weakness,  as  cases  are  not  rare  in  which  the  other 
patella  is  broken  at  a  later  date.  The  fragments  may  be  almost 
equal  in  size  (Fig.  252),  but  the  lower  is  often  the  smaller;  either  of 
them  may  be  again  divided  vertically,  or  comminuted. 

The  Signs  of  this  fracture  consist  of  loss  of  power  in  the  limb,  pain, 
distension  of  the  joint  with  blood,  and  separation  of  the  fragments, 
which  can  be  readily  felt  and  sometimes  seen  (Fig.  253).  This 
displacement  is  due  to  unopposed  muscular  action,  and  is  always 

associated  with  rupture  of  the 
lateral  expansions  of  the  vasti 
muscles.  Union  by  bone  is  rarely 
obtained     apart      from     operation. 


Fig.  252.- — Fracture  of  Patella, 
WITH  Separation  of  Fragments. 
(After  Gray's  '  Anatomy.') 

I,   Rectus;   2,   vastus  externus;   3, 
ligamentum  patellae. 


Fig.  253.  —  Appearance  of 
Knee  after  Fracture  of 
Patella. 


owing  to  the  separation  of  the  fragments,  and  the  carrying  in  of 
loose  tags  of  the  fibrous  aponeurosis  or  capsule,  which  yields  at  a 
different  level  to  the  bone.  Fibrous  union  is  the  usual  result,  and 
when  this  is  short  and  strong,  it  is  quite  satisfactory;  but  more 
commonly  the  bond  of  union  yields  when  the  limb  is  used,  so  that 
the  two  fragments  are  once  again  separated,  merely  a  bridge  of 
fibrous  tissue  intervening,  the  joint  being  left  in  a  weak  state,  and 
the  power  oi  active  extension  of  the  leg  lost. 

The  Treatment  of  these  cases  may  be  grouped  under  three 
headings,  viz.,  by  retentive  apparatus,  by  subcutaneous  ojieration, 
or  by  the  open  method. 

I.  Simple  retentive  apparattis  may  be  employed  in  cases  where  the 
fragments  are  not  widely  separated,  and  can  be  readily  brought  into 
contact,  and  where  the  patient  is  not  a  good  subject  for  operation. 

A  large  piece  of  moleskin  plaster  is  applied  over  the  front  and 


INJiiRIFS  OF  BONES—FRACTURES 


545 


sides  of  the  extensor  surface  of  the  thigh,  reaching  half-way  up  to 
the  groin,  and  terminating  below  in  two  lateral  elongated  ends  or 
tags,  to  which  elastic  traction  is  applied.  The  limb  is  placed  on  a 
back-splint,  with  a  foot-piece,  beneath  which  the  elastic  accumu- 
lator is  firmly  fixed.  Removal  of  the  effusion  in  the  joint  may  be 
hastened  by  the  use  of  the  aspirator.  At  the  end  of  about  three 
weeks  the  patient  is  allowed  to  get  about  on  crutches,  with  his  knee 
in  a  rigid  splint,  which  can  be  easily  removed  for  daily  massage 
and  passive  movements.  At  the  end  of  five  or  six  weeks  active 
movements  are  permitted,  and  a  special 
knee-splint  is  ordered  (Fig.  254),  which 
allows  of  only  a  small  amount  of  mobility 
at  first,  but,  by  filing  away  a  stop,  this 
can  be  gradually  increased,  until  a  full 
range  of  movement  is  permitted.  It  is 
probable  that  only  fibrous  union  is  ob- 
tained by  this  method  of  treatment,  but 
this  is  satisfactory  and  strong  enough 
if  the  patient  can  give  the  time  (6  to  12 
months)  to  ensure  its  solidification.  The 
strength  of  this  fibrous  union  is  best  illus- 
trated by  the  fact  that  if  the  bone  gives 
way  a  second  time,  the  lesion  takes  place 
through  the  bony,  and  not  through  the 
fibrous,  tissue.  When,  however,  the  patient 
has  to  work  for  his  living,  it  is  essential 
that  repair  should  be  established  at  as  early 
a  date  as  possible,  and  this  can  only  be 
secured  by  operative  treatment. 

2.  To  avoid  the  supposed  risks  of 
laying  open  the  joint,  various  subcutaneous 
operations  have  been  adopted.  Of  these 
the  least  objectionable  is  that  recom- 
mended by  Mr.  A.  E.  Barker,  who  ties 
the  fragments  together  by  silver  wire 
(Fig.  255).  An  opening  is  made  with 
a  tenotomy  knife  into  the  joint  just 
below  the  lower  segment,  through  which 

any  effused  blood  or  synovia  can  be  squeezed,  and  along  which 
a  curved  hernia  needle  is  passed,  traversing  the  articulation 
from  below  upwards,  and  emerging  through  the  skin  above 
the  upper  fragment.  A  piece  of  sterilized  silver  wire  is  then 
carried  back  under  the  bone.  The  needle  is  again  inserted  at  the 
same  spot  below,  and  carried  in  front  of  the  bone  under  the  skin, 
emerging  at  the  same  point  above.  The  upper  end  of  the  wire  is 
threaded  through  it,  and  by  this  means  brought  out  at  the  lower 
opening.     The  bone  is  thus  encircled,  and  by  tightening  and  twisting 

*  For  the  loan  of  this  block  we  are  indebted  to  the  late  Mr.  T.  Hawksley, 
357,  Oxford  Street,  W 

35 


Fig.    254. — Splint   for 
Fractured  Patella.* 

The  steel  joints  at  the 
sides  are  made  \vith  an 
adjustable  stop,  which 
prevents  overstretch- 
ing or  rupture  of  the 
newly-formed  bond  of 
union. 


546 


A   MANUAL  OF  SURGERY 


the  wire  the  fragments  are  brcmght  into  apposition.  The  ends  are 
cut  off  and  pushed  back  under  the  skin.  The  linil)  is  placed  on  a 
back-spHnt  for  a  week  or  so,  when  passive  movement  is  com- 
menced, the  patient  being  allowed  to  walk  about  at  the  end  of  the 
second  week,  and  discarding  all  apparatus  at  the  end  of  five  weeks. 

3.  The  open  plan  of  treatment,  advocated  and  perfected  by  Lord 
Lister,  is  undoubtedly  the  best,  in  that  it  permits  of  the  removal  of 
the  tags  of  fascia  and  aponeurosis,  which  always  intervene.  It 
may  be  wise  to  delay  operation  for  a  few  days  in  order  that  the  joint 
may  recover  from  the  immediate  effects  of  the  injury. 

A  horseshoe-shaped  flap  is  usually  dissected  up,  exposing  the 
fractured  ends  of  the  bone,  which  are  cleared  of  all  clot  and  fibrous 
shreds.  Tracks  for  the  wire  sutures  are  now  made  by  a  drill, 
extending  from  the  upper  or  lower  end  through  the  centre  of  the 


Fig.  255. — Barker's 
Method  of  Subcu- 
taneous Suture  for 
Fractured  Patella. 


Fig.  256." — Lister's  Plan 
OF  Suturing  Patella 
BY  Open  Operation. 


Fig.  257. — -G.  G.  Hamil- 
ton's  Method  of 
Introducing  Silver 
Wire  for  Fracture 
OF  Patella. 


bone,  so  as  to  emerge  on  the  fractured  surface  just  in  front  of  the 
articular  cartilage  (Fig.  256) ;  should  the  drill  emerge  at  different 
levels  on  the  faces  of  the  fragments,  cartilage  or  bone  must  be 
chipped  away  to  make  a  channel  in  which  the  wire  may  lie,  so  that 
the  two  fragments  are  exactly  level,  with  no  inequality  of  the 
articular  cartilage.  A  sterilized  silver  wire  of  suitable  thickness  is 
then  passed;  the  bones  are  brought  into  apposition,  and  the  wire 
twisted  into  a  knot  or  loop,  which  is  hammered  or  pressed  down 
into  the  tendinous  or  periosteal  tissue  over  the  upper  fragment,  so 
as  to  keep  it  from  projecting  under  the  skin  and  causing  irritation. 
A  second  wire  is  sometimes  needed  in  order  to  prevent  rotation  of 
the  fragments.     The  wound  is  closed,  and  the  limb  kept  on  a  baok- 


INJUniES  OF  BONES— FRACTURES  547 

splint.  In  healtli}-  adults  passive  movement  may  commence  in 
ten  days,  and  by  the  end  of  a  fortnight  the  patient  is  allowed  to 
walk  in  the  simpler  cases;  but  in  complicated  fractures  and  in 
elderly  people  it  is  better  to  keep  the  limb  immobilized  for  a  longer 
period. 

It  is  sometimes  wise  to  pass  the  wire  transversely  through  the 
fragments  (Fig.  257),  as  suggested  by  Mr.  G.  G.  Hamilton,  of  Liver- 
pool, a  firmer  and  more  secure  hold  being  obtained  in  that  way,  and 
the  wire  being  less  likely  to  cut  out. 

In  old  cases,  where  the  fibrous  union  has  stretched  and  the  utility 
of  the  limb  is  seriously  impaired,  operation  holds  out  the  only  hope  of 
helping  the  patient.  The  fibrous  tissue  must  be  dissected  away,  and 
the  surfaces  of  the  fragments  freshened,  if  need  be,  with  the  saw, 
and  drilled  for  the  passage  of  the  wire.  To  obtain  apposition,  the 
upper  fragment  must  be  detached  from  the  femur,  to  which  it  is 
often  adherent,  and  the  rectus  muscle,  which  is  secondarily  con- 
tracted, may  need  partial  division.  The  limb  should  be  well  raised 
to  relax  the  quadriceps  and  thus  diminish  tension  on  the  bond  of 
union,  and  lowered  inch  by  inch  on  succeeding  days.  The  muscle 
is  thus  stretched  to  accommodate  itself  to  the  altered  conditions. 

If  the  fragments  cannot  be  brought  absolutely  together,  the  same 
treatment  may  be  adopted,  and  the  patient  allowed  to  get  about 
with  a  loop  of  silver  wire  between  the  fragments ;  the  quadriceps  is 
stretched  by  this  means,  and  a  subsequent  operation  may  prove 
successful  in  gaining  bony  union. 

Fractures  of  the  Leg. 

Fractures  of  the  Tibia  alone. — Several  varieties  are  described. 
[a)  The  n.pper  end  is  usually  broken  as  a  result  of  direct  violence,  the 
fracture  being  often  comminuted.  The  characteristic  features  are 
not  always  very  evident  at  first,  since  considerable  swelling  and 
ecchymosis  are  produced.  Occasionally  as  a  result  of  falls  on  the 
heel,  a  T-shaped  fracture  occurs,  the  tuberosities  being  broken  off 
and  the  upper  end  of  the  shaft  impacted  into  one  or  both  of  them. 
A  few  cases  of  vertical  separation  of  one  of  the  tuberosities  alone 
are  also  on  record.  Treatment  consists  in  placing  the  limb  upon  a 
back-splint,  e.g.,  Macintyre's,  with  the  knee  bent,  and,  as  a  rule, 
satisfactory  union  ensues,  though  possibly  with  some  distortion. 
ih)  Fracture  of  the  shaft  of  the  tibia,  apart  from  the  fibula,  is  usually 
caused  by  direct  violence.  It  is  transverse  in  the  upper  part  of 
the  bone,  and  oblique  below.  The  fracture  is  diagnosed  by  feeling 
an  inequality  on  running  the  fingers  along  the  shin,  together  with 
pain  at  this  spot  on  firmly  grasping  the  bones  above  and  below. 
There  is  often  but  little  displacement,  since  the  fibula  acts  as  a 
splint,  but  the  lower  end  of  the  upper  fragment,  which  is  usually 
pointed,  is  tilted  forwards  by  the  action  of  the  quadriceps  and  may 
pierce  the  skin.  The  Treatment  consists  in  the  application  of  back 
or  side  splints  (Cline's)  for  a  few  days  until  the  swelling  has  gone 


548  A   MANUAL  OF  SURGEnV 

down,  and  tlicn  the  limb  may  be  put  up  in  plaster.  If  the  bone  has 
been  comminuted,  treatment  will  be  more  protracted.  In  some 
few  cases  reposition  may  be  difficult  owing  to  the  character  of  the 
lesion,  and  operation  may  then  be  needed.  Thus,  in  the  patient 
whose  fracture  is  represented  in  Fig.  191,  although  the  limb  had  been 
immobilized  in  plaster  of  Paris,  the  fragments  were  not  in  apposi- 
tion, and  operativ'e  treatment  was  required,  (c)  The  iiitenial 
malleolus  is  occasionally  separated  as  the  result  of  direct  injur3^ 
apart  from  any  other  osseous  lesions,  constituting  what  is  known 
as  '  Wagstaffe's  fracture.'  There  is  comparatively  little  displace- 
ment, but  the  malleolus  is  loose,  and  crepitus  can  usually  be  obtained 
on  moving  it  backwards  and  forwards.  Union  by  fibrous  or  osseous 
tissue  ensues,  but  usually  in  a  more  or  less  abnormal  position,  in 
consequence  of  which  the  integrity  of  the  ankle-joint  is  disturbed, 
and  weakness  or  lameness  may  follow.  Treatment  consists  in 
securing  the  fragment  into  position  by  screw  or  nail;  otherwise 
massage  and  the  application  of  lateral  splints  must  be  relied  on. 

Schlatter's  Disease. — This  term  is  applied  to  an  affection  of  the  upper  end 
of  the  tibia  in  young  people,  the  nature  of  which  is  a  little  doubtful.  Probably 
it  is  due  to  a  partial  separation  of  the  lower  tongue-shaped  prolongation  of  the 
upper  epiphysis,  which  forms  the  tubercle  of  the  tibia,  and  this  is  followed  by 
a  subacute  inflammation.  The  child  complains  of  a  tender  swelling  in  this 
region  without  any  affection  of  the  joint,  and  walks  with  a  limp.  The  part 
requires  to  be  kept  at  rest,  and  will  in  time  get  well.  Radiography  suggests 
a  displacement  forwards  of  the  epiphysis,  but  operative  treatment  is  not 
desirable. 

Fractures  of  the  Fibula  alone  are  by  no  means  uncommon,  usually 
occurring  as  a  result  of  direct  violence.  There  is  no  displacement 
or  deformity;  but  the  patient  complains  of  pain  localized  to  some 
particular  spot,  and  this  can  usually  be  elicited  by  grasping  the  bones 
above  and  below,  and  compressing  them  laterally  ('  springing  '  the 
fibula).  Radiography  will  make  the  diagnosis  clear.  Treatment 
consists  in  immobilizing  the  limb  in  a  plaster  case. 

Fracture  of  both  Tibia  and  Fibula  is  a  very  common  accident,  due 
to  both  direct  and  indirect  violence ;  if  to  direct  violence,  any  part 
may  be  injured,  both  bones  yielding  at  the  same  level ;  but  if  in 
consequence  of  an  indirect  injury,  the  tibia  usually  gives  way  at  its 
weakest  part,  viz.,  at  the  junction  of  its  middle  and  lower  thirds,  and 
the  fibula  at  a  slightly  higher  level.  The  fractures  are  often  oblique, 
running  in  any  direction,  although  the  obliquity  is  most  frequently 
directed  downwards,  forwards,  and  inwards.  The  lower  fragment 
is  generally  drawn  upwards  on  account  of  the  contraction  of  the 
powerful  calf  muscles,  and  often  rotated  outwards  from  the  weight 
of  the  foot;  hence  there  is  well-marked  shortening.  The  ordinary 
characteristics  of  a  fracture  are  very  evident,  and  but  little  difficulty 
can  ever  be  experienced  in  making  a  diagnosis.  The  fracture  is 
likely  to  become  compound  when  due  to  indirect  violence,  owing 
to  the  sharp  end  of  the  upper  fragment  of  the  tibia  piercing  the  skin. 
The  fracture  of  the  tibia  has  been  proved  by  radiography  to  be 
frequently  of  a  spiral  character,  and  is  then  probably  always  due  as 


IN  J  UNI  HS  OF  BONES— FRACTURES 


549 


much  to  iurciblc  torsion  of  the  hmb  as  to  vertical  strain.  The 
rotation  is  an  important  element,  and  the  shortening  is  sometimes 
less  marked  than  in  simple  obUque  fractures;  there  is  frequently 
some  diffi,culty  in  getting  satisfactory  approximation  of  the  frag- 
ments, even  on  operation,  owing  to  the  broken  ends  becoming  en- 
gaged in  the  fibro-muscular  tissues  around. 

Treatment. — In  the  simpler  cases  reduction  is  accomplished  by 
flexing  and  fixing  the  knee,  so  as  to  relax  the  muscles  of  the  calf, 
and  then  making  traction  on  the  foot  and  manipulating  the  parts 


Fig.  258. —  Fracture  of  Both 
Bones  of  the  Leg,  seen  from 
IN  Front. 


Fig.  259. — The  Same  Fracture  AS  IN 
Fig.  258,  SEEN  from  the  Inner  Side. 


From  a  study  of  the  two  radiograms  it  will  be  noticed  that  both  lower 
fragments  have  been  displaced  outwards,  with  but  little  alteration  in 
their  antero-posterior  axes. 

into  position.  The  tendo  Achillis  may,  if  necessaiy,  be  di\dded.  It 
will  usually  suffice  to  put  up  the  limb  in  side-splints,  such  as  Cline's, 
the  longer  one  with  the  foot-piece  being  intended  for  the  outer  side. 
In  other  cases  it  may  be  better  to  applj'  a  broad  posterior  splint  with 
a  rectangular  foot-piece,  e.g.,  Macintyre's  or  Neville's,  and  two  lateral 
splints;  or  the  old-fashioned  half-box  splint  may  be  employed. 
\\'hatever  treatment  is  adopted,  it  is  necessary  to  see  that  the  length 
of  the  limb  is  as  far  as  possible  maintained,  and  that  no  rotation  of 
the  lower  fragment  is  present.  To  ensure  absence  of  rotation,  all 
that  is  needed  is  to  note  that  the  inner  aspect  of  the  great  toe,  the 


550  A   MANUAL  OF  SURGERY 

subcutaneous  surface  of  the  internal  malleolus,  and  the  inner  border 
of  the  patella,  are  in  the  same  Hne,  and  correspond  with  the  opposite 
limb.  Union  will  be  sufficiently  advanced  in  two  or  three  weeks  at 
the  latest  to  allow  of  the  limb  being  put  up  in  a  removeable  plaster 
casing,  which  must  be  taken  off  daily  for  purposes  of  massage,  but 
in  spite  of  this  much  subsequent  lameness  is  the  usual  result.  In 
oblique  and  spiral  fractures  there  is  often  very  great  difficulty  in 
getting  the  fragments  together,  and  even  more  in  maintaining  them 
in  good  position.  Taking  into  consideration  the  degree  of  permanent 
depreciation  that  a  man  (especially  if  of  the  labouring  classes) 
suffers  from  vicious  union  of  these  bones,  surgeons  need  now  have 
no  hesitation  in  cutting  down  on  and  fixing  any  fracture  of  the  tibia 
and  fibula  which  is  determined  by  radiography  to  be  obhque  or  spiral 
in  nature  and  with  well-marked  displacement. 

Fractures  in  the  neighbourhood  of  the  Ankle-joint  are  usually  pro- 
duced by  indirect  violence,  the  foot  sUpping,  and  leading  primarily 
to  a  displacement  of  the  ankle,  the  fracture  being  a  secondary  result. 
They  would  therefore  be  better  described  as  Fracture-dislocations  at 
the  Ankle-joint. 

I.  Displacement  of  the  Foot  oiitn^ards  is  by  far  the  most  common 
variety,  resulting  usually  from  the  patient  shpping  on  the  inside  of 
the  foot,  as  from  off  a  kerbstone.  Several  distinct  varieties  of  lesion 
are  now  recognised. 

{a)  In  Pott's  Fracture  (Fig.  260)  sudden  abduction,  usually  com- 
bined with  eversion,  of  the  foot  results  in  severe  strain  upon  the 
internal  lateral  ligament,  which  gives  way,  or  the  base  of  the  internal 
malleolus  is  torn  off.  The  astragalus  is  at  the  same  time  driven 
outwards  against  the  external  malleolus,  and  the  force  is  thence 
transferred  up  the  fibula,  which  bends  and  breaks  at  some  weak 
spot.  Generally  the  line  of  fracture  runs  obliquely  from  above 
downwards  and  forwards  through  the  malleolus;  less  frequently  it 
is  situated  in  the  position  originally  described  by  Pott,  viz.,  about 
three  inches  above  the  tip  of  the  malleolus,  and  is  transverse,  the 
upper  end  of  the  lower  fragment  being  displaced  inwards  towards 
the  tibia.  The  inferior  interosseous  tibio-fibvilar  ligament  remains 
intact,  and  hence  the  foot  itself  is  merely  rotated  outwards  and 
abducted,  and  the  heel  is  drawn  upwards,  whilst  the  toes  point 
downwards.  If  the  internal  lateral  ligament  alone  is  torn,  the 
malleolus  projects  beneath  the  skin,  and  may,  indeed,  protrude;  if 
the  malleolus  is  broken,  a  distinct  sulcus  can  usually  be  felt  between 
it  and  the  lower  end  of  the  tibial  shaft.  In  both  these  types  the 
ankle-joint  is  necessarily  laid  open,  and  there  is  probably  much 
haemorrhage  on  the  inner  side  of  the  ankle  and  into  neighbouring 
tendon  sheaths. 

{h)  In  Dupuytren's  Fracture  (Fig.  261)  a  much  more  serious  lesion 
is  produced.  The  interosseous  tibio-fibular  ligament  yields  more 
or  less  completely,  or  the  flake  of  the  tibia  to  which  it  is  attached  is 
torn  off;  the  foot,  carrying  with  it  the  lower  portion  of  the  fibula 
and  the  superficial  flake  of  the  tibia,  which  has  been  detached,  is 


INJURIES  OF  BONES—FRACTURES 


551 


displaced  firstly  outwards,  and  so  long  as  the  upper  surface  of  the 
astragahis  does  not  clear  the  lower  eirticular  surface  of  the  tibia, 
there  is  merely  lateral  displacement  with  marked  abduction  of  the 
foot  and  increased  breadth  of  the  ankle.  Should  the  force  continue 
to  act,  the  astragalus  may  be  carried  sufficiently  outwards  to  clear 
the  lower  end  of  the  tibia,  and  then  an  upward  and  to  a  less  degree  a 


Fig.  260. — Pott's  Fracture,  show- 
ing Separation  of  Internal 
Malleolus  and  Fracture  of 
Fibula. 

(For  the  loan  of  the  negative  from 
which  this  plate  was  prepared,  we 
are  indebted  to  Mr.  Caldwell,  of 
Mandeville  Place,  W.) 


Fig.  261. — Dupuytren's  Fracture, 
WITH  Well-Marked  Displace- 
ment Outwards  of  the  Foot, 
as  well  as  of  the  Lower  Frag- 
ment OF  THE  Fibula  and  the 
Internal  Malleolus.  (Radio- 
gram TAKEN  from  IN  FrONT.) 


backward  displacement  is  added,  causing  great  eversion  of  the  foot 
and  deformity  of  the  ankle.  On  the  inner  side  either  the  ligament 
or  the  malleolus  may  yield. 

(c)  In  another  variety  the  injury  consists  in  the  usual  type  of 
fracture  of  the  fibula,  associated  with  an  almost  transverse  fracture 
of  the  tibia,  just  above  the  base  of  the  inner  malleolus.  In  this  form 
the  lower  end  of  the  shaft  of  the  tibia  projects  beneath  the  skin,  and 
is  likely  to  be  mistaken  for  the  tip  of  the  malleolus ;  if  this  error  is 
committed,  and  the  fracture  allowed  to  unite  without  proper  rectifi- 
cation, considerable  deformity  results. 

[d)  A  similar  injury  in  children  may-produce  a  separation  of  the 


552  A   MANUAL  OF  SURGERY 

lower  epiphysis  of  the  tibia,  whilst  the  fibula  yields  in  the  usual 
situation.  The  line  of  separation  in  the  tibia  is  uKire  or  less  trans- 
verse, but  may  extend  into  the  diaphysis  on  the  outer  side. 

In  almost  all  of  these  varieties  the  ankle-joint  itself  is  involved,  and 
this,  combined  with  the  amount  of  bleeding  that  occurs  into  tendon 
sheaths  and  muscles  around,  and  the  difficulties  sometimes  experi- 
enced in  complete  reduction  of  the  fracture,  explains  why  the  results 
of  these  cases  are  frequently  so  unsatisfactory.  Sometimes  after 
union  has  occurred,  pain  and  deformity  become  increased,  owing  to 
the  patient  being  allowed  to  walk  too  early,  the  result  being  that 
the  callus  yields  to  the  weight  of  the  body.  Should  union  occur 
with  the  foot  in  a  false  {i.e.,  everted)  position,  a  large  mass  of  callus 
develops  between  the  shaft  of  the  tibia  and  the  malleolus. 

2.  Displacement  of  the  Foot  inwards. — When  the  patient  shps  on 
the  outer  aspect  of  the  foot,  the  astragalus  is  forcibly  driven  against 
the  inner  malleolus,  which  may  be  broken  off  or  impacted  into  it. 
The  outer  malleolus  is  dragged  inwards  with  the  foot,  and  owing  to 
the  integrity  of  the  inferior  tibio-fibular  hgament,  which  acts  as  a 
fulcrum,  the  fibula  }aelds  at  the  same  spot  as  in  Pott's  fracture.  The 
foot  is  displaced  inwards,  and  perhaps  shghtly  backwards. 

3.  Displacement  of  the  Foot  backwards,  by  catching  the  heel  and 
tripping  forwards,  is  usually  associated  with  fractures  of  the  tibia 
and  fibula  in  the  same  position  as  in  Pott's  fracture,  but  eversion  of 
the  foot  is  absent  (see  dislocation  of  the  ankle  backwards,  p.  625). 

Treatment. — In  reducing  these  fractures,  traction  should  be  made 
upon  the  foot  after  the  tension  of  the  calf  muscles  has  been  reUeved 
by  flexing  the  knee  under  an  anaesthetic,  or  by  tenotomy  of  the  tendo 
AchilHs;  the  position  of  the  internal  malleolus  must  be  accurately 
defined.  Before  applying  the  splints,  careful  attention  must  be 
given  to  the  following  points:  {a)  The  foot  must  be  maintained  at 
right  angles  to  the  leg;  [h)  the  heel  must  not  project  unduly  back- 
wards ;  and  (c)  the  foot  must  not  be  rotated  on  the  leg — i.e.,  the  inner 
surfaces  of  the  great  toe,  internal  malleolus,  and  patella  must  be  in 
the  same  line.  A  pair  of  Cline's  spHnts  is  often  sufficient  to  steady 
the  parts  in  simple  cases,  and  must  be  applied  with  sufficient  firm- 
ness to  keep  the  malleoli  together  and  prevent  subsequent  lateral 
play  in  the  ankle-joint.  Some  patients  are  better  treated,  however, 
by  a  Dupuytren's  spHnt  (Fig.  262),  which  is  really  a  Liston's  sphnt 
on  a  small  scale.  It  reaches  from  the  knee  to  below  the  sole  of  the 
foot,  and  is  placed  on  the  inner  side  of  the  limb,  the  patient  lying  on 
the  sound  side  during  its  application.  A  firm  pad  extends  down  as 
far  as  the  base  of  the  internal  malleolus,  and  over  this  as  a  fulcrum 
the  foot  is  drawn  inwards  by  a  handkerchief  applied  around  the 
ankle,  and  tied  to  the  notches  at  the  end  of  the  splint.  The  foot 
being  thus  fixed,  the  upper  end  of  the  splint  is  bandaged  to  the  limb. 
Marked  tendency  to  backward  displacement  of  the  heel  may  be 
counteracted  by  the  application  of  a  Syme's  anterior  horseshoe 
splint,  which  can  be  used  in  combination  with  a  Dupuytren.  It 
consists  of  a  flat  piece  of  wood,  well  padded,  extending  from  the  knee 


INJURIES  OF  BONES— FRACTURES 


553 


to  the  ankle  along  the  crest  of  the  tibia;  the  lower  end  is  shaped 
like  a  horseshoe,  the  two  limbs  passing  one  on  either  side  of  the  loot. 
A  handkerchief  or  piece  of  bandage  is  applied,  with  its  centre  over 
the  point  of  the  heel ;  it  passes  up  on  either  side  between  the  splint 
and  the  foot,  winds  over  the  former  structure,  and  is  tied  behind  the 
heel  which  is  thus  hfted  forwards.  A  similar  end  may  be  obtained 
by  the  use  of  a  Macint^Tc's  back-splint  combined  with  a  pair  of 
Chne's  splints.  . 

At  the  end  of  ten  days  or  a  fortnight,  when  all  tendency  to  dis- 
placement has  ceased,  these  spHnts  mav  be  discontinued  and  lateral 
poroplastic  or  plaster  of  Paris  sphnts  applied,  so  that  they  may  be 
removed  dailv  for  massage  and  suitable  movements.  Even  when 
fit  to  walk,  considerable  after-care  is  needed  to  prevent  harm  ansmg 
from  the  weight  of  the  body.  In  many  cases  it  suffices  to  thicken 
the  sole  of  the  boot  on  the  inner  side  so  as  to  maintain  the  loot  m 


Fig.  262.— Dupuvtren's  Splint  applied  for  Pott's  Fracture.     (Till- 

MANNS.) 

a  position  of  shght  varus;  in  worse  cases  an  outside  iron  should  be 
worn,  passing  down  from  a  circular  band  below  the  knee  to  be  hxed 
in  a  slot  in  the  sole  of  the  boot. 

In  the  simpler  forms,  early  massage  may  be  employed,  and  then 
all  the  retentive  apparatus  necessary  is  a  hght  removeable  plaster 
case  In  the  more  serious  cases,  where  there  is  considerable  dis- 
placement and  much  difficulty  in  keeping  the  fragments  together, 
operation  to  fix  them  is  quite  justifiable. 

In  cases  of  vicious  union  after  Pott's  fracture,  it  is  usually 
necessary  to  re-di\ide  the  fibula,  and  to  excise  a  V-shaped  portion  of 
bone  from  the  tibia,  perhaps  extending  into  the  ankle-joint,  so  as 
to  enable  the  maUeolus  to  be  brought  in  contact  with  the  shaft. 

Fracture  of  the  Os  Calcis  may  result  from  direct  ^^olence,  such  as 
a  blow  or  fall  on  the  heel,  or  possibly  from  muscular  action  the 
epiphysis  being  then  separated,  or  the  sheU  of  bone  into  which  the 
tendo  AcliilUs  is  inserted  being  torn  oft".  The  fragment  thus 
separated  is  displaced  upwards  by  the  contraction  of  the  call 
muscles  and  the  resulting  deformity  is  very  evident.  If  the  hne  of 
fracture  pa^^es  through  the  body  of  the  bone,  there  may  be  no  dis- 
placement owing  to  the  attachment  of  the  interosseous  and  lateral 
ligaments;  but  should  the  sustentaculum  tah  or  greater  process  be 
broken,  the  arch  of  the  foot  may  be  more  or  less  flattened  W  Hen 
due  to  a  fall  from  a  height,  the  bone  is  often  comnunuted  and  the  loot 


554  A   MANUAL  OF  SURGERY 

much  bruised  and  swollen  {compression  fracture).  Treatment  con- 
sists in  immobilizing  the  foot  in  a  plaster  case  if  there  is  no  displace- 
ment ;  but  where  the  posterior  part  of  the  bone  is  drawn  upwards,  it 
must  be  approximated  to  the  rest  of  the  bone  after  flexing  the  leg,  in 
order  to  relax  the  calf  muscles,  or  possibly  after  tenotomy.  A  more 
satisfactory  result  may,  however,  be  obtained  by  cutting  down,  and 
wiring  or  pegging.  In  fractures  which  are  likely  to  be  followed  by 
traumatic  flat  foot,  the  patient  must  not  be  allowed  to  walk  without 
an  effective  support,  and  the  foot  must  be  maintained  in  a  slight 
varus  position. 

Fracture  of  the  Astragalus  is  usually  due  to  falls  on  the  foot  from 
a  height,  or  from  direct  violence  appHed  to  the  foot,  as  by  a  weight 
falling  upon  it.  The  lesion  is  often  a  severe  comminuted  one,  and 
portions  of  the  bone  may  be  displaced  forwards  or  backwards, 
making  a  marked  projection  beneath  the  skin.  Such  accidents  are 
often  associated  with  lesions  of  the  tibia  or  fibula,  and  possibly  even 
of  the  femur.  The  whole  region  of  the  ankle  becomes  infiltrated 
with  blood,  and  an  exact  diagnosis  is  sometimes  difficult.  Treat- 
ment consists  either  in  immobilization,  which  is  likely  to  be  followed 
by  stiffness  of  the  ankle,  or  in  bad  cases  by  excision  of  the  bone  or  of 
projecting  fragments. 

Occasionally  in  less  severe  accidents  the  bone  merely  sphts  across, 
the  lesion  being  usually  situated  about  the  neck.  Such  is  due  eithei 
to  the  weight  of  the  body  flattening  out  the  arch  of  the  bone  beyond 
the  hmits  of  elasticity,  or,  if  the  foot  is  dorsi-flexed,  to  penetration  of 
the  bone  by  the  anterior  edge  of  the  tibia,  impaction  being  sometimes 
produced  in  this  way.  Massage  and  early  mobilization  shoiild  be 
employed  in  such  cases. 

Other  bones  of  the  foot  are  occasionally  fractured,  but  these 
lesions  require  no  detailed  description. 


CHAPTER  XXI. 

DISEASES    OF    BONE. 

Inflammation  of  Bone. 
General  Considerations.— Bones  are  divided  into  the  long,  the  short, 
and  the  flat,  each  of  these  consisting  of  compact  and  cancellous  tissue. 
In  the  short  bones  there  is  but  a  thin  layer  of  compact  tissue  sur^ 
rounding  a  cancellous  central  mass,  the  meshes  of  which  are  filled 
with  medullary  fat  and  connective  tissue.  In  the  flat  bones  the 
compact  tissue  forms  two  hmiting  plates,  separated  by  a  layer  ot 
cancellous  tissue  (known  in  the  skull  as  the  diploe).  In  long  bones 
the  ^haft  consists  of  a  tube  of  compact  structure,  surrounding  a 
space  which  is  normally  filled  with  medulla,  and  known  as  the 
medullary  canal ;  at  each  end  it  gradually  merges  into  a  larger  mass 
of  loose  'cancellous  tissue,  the  interstices  of  which  are  similarly 
packed  with  vascular  fatty  medulla,  which  apparently  performs  the 
function  not  only  of  maintaining  the  nutrition  of  the  bone,  but  also 
of  elaborating  the  blood.  Prolongations  from  the  medulla  extend 
into  the  Haversian  canals,  and  are  thence  continuous  with  the  peri- 
osteum, so  that  the  mineral  skeleton  has  incorporated  withm  it  a 
vascular  fibro-cellular  mass  which  permeates  its  whole  structure. 

The  vascular  supply  of  a  bone  is  derived  [a)  from  the  nutrient  artery 
which  passes  into  the  medullary  space,  and  there  breaks  up  into 
branches  which  ramify  through  the  whole  of  the  medullary  tissue, 
and  thence  extend  into  the  Haversian  canals;  and  (5)  from  the  peri- 
osteum, an  exceedingly  vascular  ensheathing  membrane,  froni  which 
small  vessels  pass  perpendicularly  into  the  Haversian  canals,  and 
estabhsh  a  communication  between  the  two  systems.  These  latter 
vessels  are  especially  numerous  and  large  close  to  the  epiphyses. 
Large  veins  occur  in  the  medullary  and  cancellous  interior,  and  are 
frequently  thrombosed  in  inflammatory  mischief;  if  the  thrombus 
becomes  infected,  and  so  disintegrated,  pysemia  is  very  hkely  to 

ensue. 

The  growth  of  bone  manifests  itself  in  three  different  directions: 
(i.)  It  increases  in  length  from  the  shaft  side  of  the  epiphyseal  carti- 
age,  the  epiphysis  itself  growing  but  little.  In  the  upper  imb  the 
chief  increase  in  length  occurs  at  the  shoulder  and  wnst,  whilst  m  tne 
leg  it  is  mainly  evident  on  either  side  of  the  knee-iomt,  and  this  in 

555 


SSG  A   MANUAL  OF  SURGERY 

spite  of  the  fact  tliat  the  so-called  nutrient  arteries  are  directed  away 
from  these  points,  (ii.)  Increase  in  breadth  is  produced  by  new 
formation  under  the  periosteum.  1'herc  has  been  much  difference 
of  opinion  as  to  whether  this  membrane  has  any  true  bone-forming 
power.  That  bone  is  often  formed  from  it  when  stripped  up  is 
undoubted;  but  it  is  probable  that  the  angular  nucleated  osteoblasts 
found  on  its  under  surface  have  been  derived  from  the  bone  itself 
by  the  process  of  detachment,  which  necessarily  tears  through  or 
drags  out  the  vessels  which  pass  from  the  periosteum  into  the  bone, 
(iii.)  A  bone  increases  in  density  by  a  new  deposit  of  osseous  tissue 
around  the  Haversian  canals  and  cancellous  spaces. 

In  considering  the  inflammatory  affections  of  bones,  it  must  always 
be  kept  in  mind  that  the  essential  pathological  phenomena  (viz., 
hypenemia,  exudation,  and  tissue  changes)  are  similar  to  those 
manifested  in  any  other  vascular  structure,  but  tfiat  the  effects  are 
modified  by  the  Hmited  space  in  which  the  vessels  he,  and  the  resist- 
ing character  of  the  surrounding  osseous  tissue.  Hence  any  actiie 
inflammation,  associated  with  rapid  vasculor  engorgement  and 
considerable  exudation  quickly  poured  out,  leads  to  necrosis  from 
thrombosis,  due  to  increased  pressure  within  the  unyielding  bony 
canals.  If,  however,  the  process  is  subacute,  so  that  the  tissue- 
liquefying  properties  of  the  exudation  and  the  tissue-absorbing 
activity  of  the  leucocytes  can  come  into  play,  then  osteo-porosis  or 
rarefaction  of  the  bone  follows,  a  condition  sometimes  termed  caries. 
On  the  other  hand,  if  the  inflammation  is  chronic,  and  due  to  causes 
other  than  tubercle  or  the  pressure  of  tumours,  then  new  formation 
occurs,  and  osteosclerosis,  or  condensation,  is  most  likely  to  result. 
Tubercle  in  bones,  as  elsewhere,  causes  primary  rarefaction  of  the 
tissue  attacked,  though  sclerosis  may  be  associated  with  or  follow  it, 
and  the  chronic  pressure  of  tumours  or  aneurisms  lea.ds  to  local  rare- 
faction and  atrophy,  although  a  certain  amount  of  sclerosis  may  be 
induced  around. 

Much  needless  confusion  has  arisen  in  connection  with  the  termi- 
nology of  inflammatory  affections  of  bone.  To  all  of  them,  whatever 
their  nature  or  position,  the  term  '  osteitis  '  might  rightl}'  be  applied ; 
but  when  the  medullary  cavity  of  a  long  bone  is  particularly  affected, 
the  term  '  osteo-myelitis  '  is  substituted,  as  also  sometimes  when 
masses  of  cancellous  tissue,  as  in  the  os  calcis,  or  sheets  of  it,  as  in 
the  diploe  of  the  cranial  bones,  become  the  seat  of  an  acute  inflamma- 
tion. The  vascular  continuity  between  the  periosteum  and  medulla 
through  the  Haversian  canals  will  explain  why  periostitis  is  always 
associated  with  osteitis  of  the  underlying  bone,  and  why  osteo- 
myelitis is  never  strictly  limited  to  the  medullary  cavity. 

It  is  also  important  to  realize  that  necrosis,  caries,  and  sclerosis 
are  results  of  inflammation,  and  must  neither  be  confounded  with 
the  pathological  processes  leading  to  them,  nor  described  as  distinct 
diseases. 

Necrosis,  or  death  of  bone,  may  occur  in  a  variety  of  forms,  and 
from  many  different  causes,  e.g. :  {a)  From  acute  localized  suppura- 


DISEASES  OE  BONE  557 

tivc  periostitis,  the  sequestrum  or  dead  mass  being  then  simply  a 
superlicial  plate  or  flake  of  the  compact  exterior  (Fig.  263),  the 
process  by  which  it  is  cast  off  being  then  known  as  '  exfoliation  ' ; 
(/;)  from  acute  infective  osteo-myelitis,  the  sequestrum  then  often 
involving  the  whole  thickness  of  the  bone,  and  invading  more  or  less 
of  the  length  of  the  diaphysis,  if  the  condition  is  not  early  and 
efJiciently  treated  (Figs.  265  and  266) ;  (c)  from  acute  or  subacute 
infective  osteitis  of  cancellous  bone,  the  sequestra  being  small 
spiculated  fragments  of  the  bony  canceUi  which  have  escaped  ab- 
sorption by  the  granulation  tissue  always  forming  in  such  a  process; 
{(i)  from  tuberculous  disease  of  cancellous  tissue,  the  sequestrum 
being  light  and  porous,  often  infiltrated  with  curdy  material,  and 
rarely  separated  completely  from  surrounding  parts  (Fig.  273); 
{c)  from  syphilitic  disease  of  cancellous  or  compact  tissue,  usually 
resulting  from  excessive  sclerosis,  or  gummatous  disease  of  the  peri- 
osteum which  has  become  septic  (Fig.  276);  (/)  from  the  action  of 
local  irritants,  e.g.,  mercury,  or  phosphorus  fumes  gaining  access  to 
the  interior  of  the  teeth;  (g)  occasionally  as  a  simple  senile  loss  of 
nutrition,  as  in  senile  gangrene;  and  [h)  a  variety,  described  by  Sir 
James  Paget  under  the  name  of  '  quiet  necrosis,'  occurs  as  a  result 
of  direct  injury,  the  sequestrum  separating  without  suppuration;  it 
is  one  of  the  causes  of  loose  bodies  in  joints,  and  especially  the  knee, 
following  a  blow  on  one  of  the  condyles. 

The  presence  of  dead  bone  in  a  hmb  may  be  suspected  when  one 
or  more  sinuses  are  present,  discharging  pus  or  serum  according  to 
circumstances,  with  puffy  granulations  pouting  round  the  opening, 
and  the  underlying  bone  thick  and  enlarged.  A  probe  passed  down 
the  sinus  can  usually  be  made  to  strike  against  the  sequestrum, 
perhaps  after  passing  through  a  casing  of  new  bone,  and  its  fixity  or 
freedom  may  be  demonstrated  in  this  manner. 

Caries,  or,  as  it  is  sometimes  called,  osteo-porosis  or  rarefaction  of 
bone,  is  characterized  by  a  soft  and  spongy  state  of  the  bone,  which, 
if  it  can  be  reached,  readily  breaks  down  on  pressure  with  a  probe. 
It  may  result  from  the  following  conditions :  (a)  A  simple  subacute 
inflammatory  process,  e.g.,  during  the  early  stage  of  repair  in  a 
fracture ;  (6)  from  acute  or  subacute  infective  inflammation  of  can- 
cellous tissue;  (c)  from  tuberculous  affections  of  the  cancellous 
tissue  or  periosteum ;  {d)  from  syphihtic  disease  of  the  medulla  or 
of  the  under  surface  of  the  periosteum. 

PathologicaUy,  it  is  characterized  by  the  replacement  of  the 
meduha  by  granulation  tissue,  which  usually  contains  some  large 
multi-nucleated  cehs,  or  osteoclasts,  and  these  seem  to  be  closely  con- 
nected with  the  removal  of  the  bone.  The  cancellous  tissue  be- 
comes hollowed  out  to  accommodate  these  granulatioris,  and  the 
osteoclasts  are  usually  found  occupying  shallow  depressions  known 
as  '  Howship's  lacunae.'  In  tuberculous  and  syphihtic  lesions  the 
bone  corpuscles  often  undergo  fatty  degeneration. 

Caries  may  occur  with  or  without  suppuration  (C.  sicca  or  supp'ura- 
tiva) ;  sometimes  the  development  of  granulation  tissue  is  excessive, 


55S  A    MANUAL  OF  SURGERY 

as  when  it  fungatcs  into  a  joint  (C.  fungosa).  Not  unfrequently  it 
is  associated  with  necrosis,  constituting  a  condition  of  ccirio-necrosis 
(or  C.  necrotica),  as  in  infective  infiammation  of  cancellous  bone, 
minute  spiculated  sequestra  being  found  in  the  discharge,  whilst  in 
tuberculous  osteitis  dead  portions  of  larger  size  often  occur.  In 
fact,  caries  and  necrosis  bear  much  the  same  relation  to  one  another 
as  ulceration  and  gangrene  of  the  soft  tissues. 

If  caries  is  recovered  from,  a  subsequent  condition  of  sclerosis 
usually  follows,  with  loss  of  substance  and  often  deformity. 

Sclerosis  of  bone  (osteo-sclerosis)  is  invariably  the  result  of  some 
chronic  inflammatory  affection,  e.g.,  [a]  chronic  periostitis,  whether 
simple  or  syphilitic;  {b)  chronic  osteo-myelitis,  simple,  tuberculous, 
or  s}'philitic;  or  (c)  chronic  osteitis  of  the  compact  bone,  which  is 
always  secondary  to  one  of  the  former.  In  all  cases  the  condition  is 
due  to  a  slow  formation  of  new  bone  within  the  Haversian  canals  or 
cancellous  spaces,  thus  diminishing  their  lumen;  in  syphilis  this 
may  progress  to  such  an  extent  as  to  lead  to  their  total  occlusion, 
and  even  to  localized  necrosis  from  lack  of  blood-supply,  especially 
when  sepsis  has  occurred.  In  tuberculous  bones  the  sclerosed  tissue 
is  always  at  some  distance  from  the  focus  of  mischief,  and  may  be 
looked  on  as  Nature's  attempt  to  limit  the  spread  of  the  disease;  it 
forms  also  the  final  tissue  or  bone-scar  in  the  process  of  repair  in  those 
cases  where  a  cure  has  been  obtained  by  natural  or  surgical  means. 

Classification  of  Inflammatory  Affections  of  Bone. 

I.  Periostitis  : 

{a)  Acute  localized,  with  or  without  suppuration. 
[h]  Acute  diffuse,  always  associated  with  or  secondary'  to 
acute  infective  osteo-myelitis. 

(c)  Chronic  simple,  or  hyperplastic. 

[d)  Chronic  tuberculous. 
[c)  Chronic  syphilitic. 

II.  Osteitis  of  compact  bone,  which  is  always  associated  with  and 
secondary  to  either  periostitis  or  osteo-myelitis,  and  so 
need  not  be  described  separately.  The  acute  form 
results  in  necrosis,  the  subacute  in  osteo-porosis,  and 
the  chronic  in  sclerosis,  except  in  tuberculous  disease. 

III.  Osteo-myelitis,  or  inflammation  of  the  medulla  of  long  bones: 

(a)  Acute  infective. 

(b)  Subacute  simple  or  infective,  e.g.,  during  the  separation 

of  sequestra,  resulting  primarily  in  rarefaction,  but 
finally  in  sclerosis. 

(c)  Chronic  simple,  tuberculous  or  syphilitic,  usually  caus- 

ing general  enlargement  and  sclerosis  of  the  bone, 
even  if  locally  some  rarefaction  is  present. 

IV.  Osteitis  of  Cancellous  Tissue  may  similarly  be: 

[a)  Acute  infective. 

[b)  Subacute  simple  or  infective. 

[c)  Chronic  simple,  syphilitic,  or  tuberculous. 


DISEASES  OE  BONE  559 

Wlu'ii  liniiteil  to  the  artirular  end  of  a  bone  in  a  young  person, 
this  is  sometimes  termed  Epiphysitis;  this  title  is  also  sometimes 
appHed  erroneously  to  an  acute  osteomyelitis,  which  commences  in 
the  vascular  tissue  on  the  shaft  side  of  the  epiphyseal  line. 

It  is  unnecessary  to  describe  in  detail  all  these  conditions,  since 
many  of  the  divisions  overlap,  and  hence  we  shall  group  together 
the  various  acute  and  chronic  affections. 

Acute  Inflammations  of  Bone. 

I.  Acute  Localized  Periostitis  usually  arises  as  a  result  of  trauma- 
tism applied  directly  to  the  bone,  with  or  without  an  open  wound;  it 
may  also  be  determined  by  rheumatism,  or  by  an  extension  of  in- 
flammatory mischief,  as  in  an  alveolar  abscess. 

Pathologically,  the  process  consists  of  hyperemia  of  and  exudation 
into  the  periosteum,  which  becomes  swollen,  turgid,  and  thickened. 
1  his  may  be  followed  in  due  course  by  resolution,  or  may  leave  the 
bone  thickened  and  in  a  condition  of  chronic  inflammation ;  or  sup- 
puration may  ensue,  and  with  it  usually  a  limited  superficial  necrosis. 
In  the  last  event  pyogenic  organisms  of  no  great  virulence  find  an 
entrance  to  the  area  of  mischief,  and  probably  in  cases  due  to  trauma 
through  the  abraded  or  injured  skin;  in  other  instances  they  may 
come  from  neighbouring  foci  of  inflammation,  or  possibly  from  the 
blood.  The  inflammatory  process  extends  to  the  small  vessels 
entering  the  bone  from  the  under  surface  of  the  periosteum;  these 
become  dilated,  next  thrombosed  and  strangled  by  the  pressure  of 
the  exudation  around  them,  and  finally  pulled  out  from  the  osseous 
canals  by  the  tension  of  the  subperiosteal  effusion.  Consequently, 
the  vitality  of  the  superficial  layer  of  bone  is  destroyed  for  an  area 
corresponding  almost  exactly  to  that  from  which  the  periosteum  has 
been  stripped  (Fig.  263,  A). 

As  soon  as  tension  has  been  relieved  by  the  escape  of  the  pus, 
repair  commences.  Where  the  mischief  is  shght  and  superficial, 
the  involved  bone  may  entirely  recover,  necrotic  portions  being 
absorbed,  if  the  surrounding  parts  are  sufficiently  vascular.  If  the 
dead  portion  of  bone  is  compact  and  more  extensive,  it  will  be 
separated  from  the  subjacent  living  tissues  by  one  of  the  processes 
alread}''  described  (p.  109),  whilst  from  the  under  surface  of  the 
stripped-up  periosteum  a  casing  of  new  bone  is  developed,  constitu- 
ting an  involucrum  or  sheath,  at  first  spongy  and  cancellous  in 
texture,  but  finally  hard  and  sclerosed.  In  the  centre  of  this  new 
formation  are  found  one  or  more  openings  or  cloacce  through  which 
the  discharge  passes,  and  corresponding  in  position  to  the  apertures  in 
the  periosteum  and  skin  made  for  the  escape  of  the  pus  (Fig.  263,  B). 

Clinically,  the  symptoms  of  acute  localized  periostitis  consist  in 
the  ordinary  phenomena  of  acute  inflammation,  the  pain  being  of  an 
intense  aching  character,  worse  at  night,  and  increased  by  lowering 
the  limb  or  by  any  kind  of  pressure.  If  a  subcutaneous  portion  of 
bone  is  involved,  a  painful  swelling  develops,  at  first  brawny  in 
character,  but  when  suppuration  has  occurred  the  centre  softens. 


56o 


A   MANUAL  OF  SURGERY 


whilst  the  skin  over  it  becomes  red  and  (edematous.  When  an 
abscess  has  burst  or  been  opened,  bare  bone  is  felt  beneath  the 
periosteum,  and  the  greater  part  of  this  denuded  structure  usually 
dies,  and  must  then  be  either  absorbed  or  separated;  in  either 
case  a  sinus  remains  for  a  time,  leading  down  thnjugh  a  cloaca  in 
the   involucrum  to   the  sequestral   cavity.     From  this   either  pus 

or  serum  will  be  discharged, 
according  to  whether  the 
wound  has  become  septic  or 
not.  In  about  five  or  six 
weeks'  time  the  sequestrum 
is  loose,  and  this  may  be 
ascertained  by  moving  it  with 
a  probe  within  the  osseous 
cavity,  which  is  now  lined  on 
the  inner  aspect  with  granu- 
hition  tissue. 

Treatment.  —  Rest,    eleva- 
tion of  the  limb,  and  fomen- 
FiG.  363.— Superficial  Necrosis  RESULT-   tations  are  usually  rehed  on 
iNG    FROM    A    Localized     Periostitis   locally  in  the  early  stages,  and 
(Diagrammatic).  favourable  reports  have  been 

A  represents  the  necrosed  tissue  lying  in  given  as  to  the  value  of  Bier's 
continuity  with  the  surrounding  living  induced  hyperemia.  If,  how- 
bone;    the    periosteum   is    stripped    up  ^.v,  rr      ,•  •  j. 

from  it,  and  has  an  opening  through  ^^er,  tUe  attection  IS  not 
which  the  pus  has  been  discharged,  readily  checked,  and  suppura- 
B  shows  a  later  stage,  in  which  the  tion  threatens  or  develops,  a 
sequestrum  is  being  separated  by  a  pro-  fj-ge  aseptic  incision  down  to 
cess  of  rarefying  o.steitis  in  the  immedi-  ,,  hnnp  i<i  thp  bp^f  mpiTr;  nf 
ately  contiguous  living  bone,  whilst  an  ^^^  ^one  IS  tne  Dest  means  01 
involucrum,  or  sheath  of  new  bone,  is  preventmg  or  limitmg  necro- 
formed  from  the  under  surface  of  the  sis.  When  necrosis  has  OC- 
periosteum;  a  cloacal  aperture  remains  cuj-j-ed  the  parts  must  be 
in  the  involucrum  for  the  escape  of  dis-  ^a^pf,,]']^  dressed  and  kent 
charges.  C  shows  the  condition  of  affairs  careiuiiy  ciressea  ana  Kept 
after  the  sequestrum  has  been  removed.     aseptlC,  until  the  sequestrum 

is  absorbed  or  set  loose.  In 
the  latter  case  an  incision  is  made  over  the  involucrum,  the  peri- 
osteum stripped  from  it,  one  of  the  cloacae  enlarged,  and  the  dead 
bone  removed.  The  cavitv  will  then  rapidly  fill  up  and  heal  by 
granulation. 

2.  Acute  Infective  Osteo-Myelitis  [syn.  :  Acute  Necrosis,  Acute 
Diffuse  or  Infective  Periostitis,  Acute  Diaphysitis,  Acute  Panostitis). — - 
This  disease  usually  occurs  in  children,  often  of  a  tuberculous  in- 
heritance, and  not  unfrequently  follows  one  of  the  exanthemata — 
e.g.,  measles  or  scarlet  fever.  It  generally  commences  before  the 
age  of  puberty,  and  is  an  affection  of  the  gravest  import ;  the  multi- 
plicity of  names  attached  to  it  suggests  quite  accurately  that  its 
manifestations  may  be  very  diverse  in  character. 

Pathology. — The  patients  are  always  in  a  state  of  depressed  general 
health,  so  that  their  germicidal  powers  are  considerably  diminished. 


DISEASES  OF  BONE  S6i 

Moreover  spots  of  localized  ulceration  are  often  present  in  the  throat, 
mouth,  (ir  intestines,  which  give  a  ready  entrance  for  micro- 
organisms into  the  system.  Evidently  some  of  these  must  be  circu- 
hiting  within  the  blood,  ready  to  attack  any  area  of  dmimished  tissue 
resistance.  A  slight  injury  in  the  shape  of  a  strain  or  a  wrench, 
which  is  often  entirely  overlooked,  may  sufhce  to  determine  the 
commencement  of  an  inflammatory  process  which  rapidly  spreads, 
until  perhaps  the  whole  bone  is  affected. 

The  majority  of  the  ligaments  and  not  a  few  tendons  are  inserted 
into  the  epiphysis,  and  hence  articular  strain  must  be  mainly  felt  in 
the  iuxta-epiphyseal  region,  i.e.,  immediately  beyond  these  inser- 
tions.    It  has  been  already  mentioned  that  the  traumatic  separation 
of  epiphyses  is  liable  to  be  followed  by  suppuration,  even  m  healthy 
children'  and  it  is  easy  to  understand  that  in  an  unhealthy  child  a  very 
slight  injury  in  the  epiphyseal  region  may  determine  a  similar  process. 
The  disease  almost  always  starts  in  the  soft  vascular  tissue  on  the 
shaft  side  of  the  epiphyseal  cartilage,  but  occasionally  in  the  epi- 
physis itself,  and  in  a  few  instances  (mainly  amongst  young  adults) 
it  may  be  preceded  by  a  patch  of  localized  periostitis,  suggesting 
that  an  acute  infection  has  supervened  upon  a  subacute  periosteal 
focus      The  nature  and  extent  of  the  inflammatory  phenomena 
depend  largely  on  the  exact  situation  of  the  infective  focus,  the 
amount  of  resistance  offered  by  surrounding  tissues,  and  the  viru- 
lence of  the  organisms.     As  in  any  other  part  of  the_  body,  the 
trouble  is  most  likely  to  travel  along  the  line  of  least  resistance. 

(i)  If  the  process  commences  in  the  periphery  of  the  juxta-epiphy- 
seal  region  close  to  the  periosteum,  the  line  of  least  resistance  will 
be  towards  that  structure,  and  hence  a  stib periosteal  abscess  may  form, 
whilst  the  central  portions  of  the  bone  may  escape  almost  entirely. 
The  size  of  this  abscess  varies,  but  considerable  portions  ot  the 
diaphysis  may  be  denuded,  resulting  in  extensive  necrosis.  It  rarely 
spreads  to  the  neighbouring  joint,  owing  to  the  close  bond  ot 
union  which  exists  between  the  diaphyseal  periosteum  and  the 
epiphyseal  cartilage.  In  this  variety  an  early  incision  to  let  out 
the  pus  may  suffice  to  prevent  necrosis,  or,  at  any  rate,  to  limit  it. 
The  constitutional  symptoms  will  be  less  severe  than  in  other  varie- 
ties; there  is  less  likelihood  of  the  development  of  pyaemia,  and  the 
toxic  fever  soon  disappears  after  the  removal  of  the  pus.  bubse- 
quently  the  same  course  of  events  occurs  as  in  the  locahzed  variety 
of  acute  periostitis— viz.,  an  involucrum  forms,  perforated  by  one 
or  more  cloacae,  and  the  sequestrum  in  time  separates. 

A  good  illustration  of  this  type  is  to  be  found  m  the  acute  peri- 
ostitis which  affects  the  lower  end  of  the  femur.  It  almost  always 
starts  posteriorly,  stripping  the  thin  periosteum  off  the  back  ot  the 
bone  as  far  as  the  bifurcation  of  the  hnea  aspera.  Its  preference  tor 
this  situation  is  evidently  due  to  the  fact  that  strains  upon  the  knee- 
joint  are  mainly  experienced  when  the  limb  is  hyper-extended,  and 
that  such  strain  is  directed  to  the  posterior  ligaments  and  hence  tne 
posterior  portion  of  the  epiphyseal  line  is  likely  to  suffer,     buppura- 


562 


A    MANUAL  OF  SURGERY 


tion  follows,  and  if  not  recognised  and  treated  early,  may  burst 
through  tlie  thin  periosteum  and  be  widely  diffused  under  the 
quadriceps.  '1  he  invohicrum  in  this  affection  is  often  defective 
behind. 

(2)  Should  the  process  start  in  the  centre  of  the  juxta-epiphyseal 
region,  it  may  spread  in  several  directions,  and  the  results  vary 
considerably. 

[a]  The  process  may  reach  the  periosteum  first,  and  then  the 
phenomena  of  a  diffuse  subperiosteal  abscess,  as  indicated  above, 
.'-   ---  with  the  addition  of  the  symptoms  due 

*  to  its  deeper  origin,  will  manifest  them- 

selves.    This  is,  perhaps,  the  most  usual 
course  for  the  disease  to  take. 

{h)  If  the  infection  extends  along  the 
medullary  cavity,  the  most  typical  form 
of  osteo-myelitis  ensues  (Fig.  264).     Ihe 
medulla   becomes    intensely   hypenemic; 
the  veins  are  thrombosed;  localized  foci 
of  suppuration  and  gangrene  appear;  and 
in  consequence  of  the  increased  pressure 
infective  emboli  are  likely  to  be  detached 
and  pyaemia  to  follow.     Even  if  the  latter 
does  not  supervene,  the  general  condition 
is  profoundly  affected  by  the  absorption 
of  toxins.     Suppuration  also  occurs   be- 
neath    the     periosteum,     although     the 
amount  of  pus  may  not  be  great  at  first ; 
but  the  membrane  is  stripped  up  from 
the  diaphysis,  perhaps  to  such  an  extent 
as  to  involve  the  whole  length  and  cir- 
cumference of  the  shaft.     Unless  prompt 
Fig.  264.  — xVcuxk    Osteo-  measures  are  taken  to  limit  the  progress 
Myelitis  of  the  Lower  of  the  disease,  necrosis  is  certain  to  follow, 
End  of  the  Femur  in  a  usually  implicating  the  whole  thickness 
?flll.,  T^  ^''""f  Weeks,  ^f  ^j^^  diaphysis,  and  sometimes  its  whole 
length ;  m  fact,  the  diaphysis  is  occasion- 
IC,    Internal    condyle;    K,   j^|j    i^^^^^  lying  loose  in  an  abscess  cavity, 
centre  of  o.ssmcation  in  epi-    , ,  -^  ,  ■    ^   ^        ^        ■        ^  i    .      1    "1 

physis;  A,  abscess  cavity  the  two  epiphyses  having  been  detached, 
in  epiphyseal  line;  S,  se-  A  similar  result  is  sometimes  due  to  the 
questrum;  I,  involucrum.     trouble  starting  at  each  end  of  the  dia- 
physis.    As   a   rule    the    epiphysis,  even 
though   detached,   retains  its   normal  position ;  but   sometimes   it 
becomes  displaced,  and  then  deformity  of  the  limb  results. 

(c)  It  has  been  already  mentioned  that,  owing  to  the  intimate 
connection  between  the  periosteum  of  the  diaphysis  and  the  epi- 
physeal cartilage,  the  neighbouring  joint  usually  escapes  infectitni, 
although  it  is  often  the  site  of  a  sterile  synovial  effusion.  Should, 
however,  the  epiphyseal  line  be  within  the  joint,  as  in  the  hij),  it 
must  perforce  become  the  seat  of  an  acute  infective  arthritis  as  soon 


DISEASllS  OF  BONE  563 

as  the  bacteria  reach  its  periphery.  The  elbow-joint  is  similarly 
liable  to  suffer  when  bacteria  attack  the  upper  end  of  the  ulna, 
since  the  epiphysis  is  a  mere  flake  of  bone,  and  the  greater  part  of 
the  olecranon  is  derived  from  the  shaft.  Sometimes  the  junction 
cartilage  is  softened  and  destroyed  by  the  organisms,  so  that  the 
inflammation  spreads  through  the  epiphysis  to  the  articular  carti- 
lage, which  is  eroded,  and  the  joint  opened.  Occasionally  the  pus 
burrows  along  the  soft  tissues  outside  the  bone,  as  along  the  biceps 
groove  into  the  shoulder-joint. 

In  infants,  where  there  is  little  or  no  bone,  the  cartilage  may  be 
rapidly  destroyed,  and  an  opening  made  through  it  into  the  joint, 
gi\-ing  rise  to  what  was  described  by  the  late  Sir  Thomas  Smith  as 
the  acute  arthritis  of  infants. 

{(i)  When  the  organisms  are  of  a  less  virulent  type,  the  process 
may  be  much  more  localized  and  subacute  in  nature,  resulting  in  a 
limited  central  necrosis,  or  in  a  chronic  abscess  inside  the  bone 
{Brodic's  abscess)  if  the  part  involved  consists  of  a  mass  of  cancellous 
tissue,  as  in  the  head  of  the  tibia.  A  similar  condition  may  affect 
certain  epiphyses  which  occur  away  from  joints,  and  some  chronic 
abscesses  in  such  situations  as  the  great  trochanter  may  be  explained 
on  these  grounds.  A  chronic  abscess  of  this  nature  may  exist  for 
many  years,  and  cause  much  thickening  of  the  surrounding  bone 
from  sclerosis.  Gradually,  but  as  a  rule  very  slowly,  the  cavity 
increases  in  size  and  may  burrow,  finally  opening  into  a  joint  or 
beneath  the  periosteum. 

Another  occasional  result  of  a  subacute  non-suppurative  osteo- 
myelitis is  bending  of  the  affected  bone,  especially  if  the  patient  is 
able  to  put  any  pressure  or  weight  on  it. 

(3)  In  the  flat  bones,  such  as  the  innominate,  scapula,  and  those  of 
the  cranium,  the  cancellous  tissue  becomes  filled  with  pus,  and 
owing  to  the  abundant  supply  of  veins  pyaemia  is  very  likely  to 
develop.  Abscesses  may  form  on  both  sides  of  the  bone,  and  a  larger 
extent  of  necrosis  may  result.  In  the  skull  a  subcranial  abscess 
(p.  764)  may  develop,  and  possibly  be  complicated  by  a  true  abscess 
in  the  brain. 

The  organism  generally  found  in  this  disease  is  the  Staphylococcus 
pyogenes  aureus,  but  occasionally  others  are  responsible  for  it,  and 
the  symptoms  vary  somewhat  with  the  causative  microbe.  Thus, 
if  due  to  the  Staph,  pyog.  alhiis,  the  process  is  less  acute;  a  good 
deal  of  brawny  infiltration  of  the  periosteum  ensues,  and  necrosis 
is  more  easily  prevented  by  early  treatment;  this  variety  is  some- 
times termed  '  periostitis  albuminosa.'  The  Streptococcus  pyogenes, 
if  present  at  all,  is  only  found  in  young  children,  and  the  resulting 
necrosis  is  often  less  extensive.  The  Pneuniococcus  has  also  been 
frequently  discovered  in  this  disease  in  children,  as  well  as  the 
B.  coli,  which  latter  only  occurs  in  association  with  other  organisms; 
the  resulting  pus  is  very  foul. 

Clinical  History. — The  disease  usually  commences  abruptly  with 
a  rigor,  followed  by  high  fever  and  severe  pain  in  the  limb,  which 


564 


A    MANUAL  OF  SURGERY 


soon  becomes  swollen,  brawny,  and  congested.  It  may  be  mistaken 
for  an  acute  attack  of  rheumatism,  although  the  fact  that  the  inter- 
articular  portion  is  affected,  and  not  the  joint,  should  prevent  this 
error.  The  pain  is  of  an  extremely  severe  nature,  so  that  the  child 
screams  whenever  the  limb  or  even  the  bed  is  touched. 

Should  the  trouble  be  mainly  limited  to  the  periosteum,  evidences 
of  its  being  stripped  oft"  the  bone,  and  of  the  accumulation  of  ])us 
beneath  it,  soon  show  themselves.     An  abscess  forms  which  may 


A  B 

Fig.  265. — Diagram  of  Massive  Necrosis  after  Acute  Osteo-IMyelitis 

(Billroth.) 

In  A  (early)  the  necrosed  tissue,  though  continuous  above  and  below  with  the 
healthy  bone,  is  surrounded  by  a  cavity  formed  by  the  stripping  up  of  the 
periosteum,  and  from  it  two  sinuses  pass  to  the  exterior;  in  B  (late)  the 
sequestrum  is  supposed  to  have  been  loosened  and  removed,  and  the 
cavity  remaining  is  lined  by  granulation  tis.sue,  and  surrounded  by  a  thick 
involucrum  of  new  bone,  in  which  the  two  cloacae  still  persist. 


quickly  transgress  its  periosteal  boundary  and  burrow  under  fascial 
or  muscular  planes;  its  limitation  to  the  diaphysis  has  been  already 
explained;  but,  although  the  neighbouring  joints  may  escape  infec- 
tion, they  are  very  likely  to  suffer  from  a  serous  exudation,  and 
subsequently  some  restriction  of  movement  may  be  observed. 
Sooner  or  later  the  abscess  bursts  or  is  opened,  giving  exit  to  a  larger 
or  smaller  quantity  of  pus,  and  the  subjacent  bone  is  found  bare  and 
apparently  dead.  Possibly  the  relief  of  tension  may  suffice  in  such 
cases  to  limit  the  mischief,  the  periosteum  again  becoming  adherent 


DISEASES  OF  BONE 


565 


to  the  bone,  and  a  cure  being  established  without  extensive  necrosis. 
More  frequently  a  considerable  portion  of  the  shaft  loses  its  vitality 
and  has  to  be  separated  in  the  manner  already  described,  whilst  an 
involucrum  forms  around  it  from  the  periosteum  (Figs.  265  and  266). 
If  a  mixed  infection  has  not  occurred,  no 
fever  or  bad  constitutional  symptoms  need  be 
expected  during  this  later  stage.  Sometimes 
the  process  is  so  acute  as  to  cause  actual 
sloughing  or  disintegration  of  the  periosteum, 
so  that  the  involucrum  does  not  develop,  and 
subsequent  repair  becomes  difficult  or  im- 
possible. Pathological  fracture  sometimes 
occurs  as  a  complication  if  any  strain  is 
placed  on  a  limb  which  has  been  weakened 
by  osteo-myelitis. 

When  the  medulla  itself  is  more  especially 
involved,  the  symptoms  of  pysemia  or  of 
severe  toxfemia  become  very  prominent,  and 
the  child  may  die  from  this  cause  before  the 
local  mischief  has  been  able  to  advance  very 
considerablv.  The  pain  will  continue  to  be 
of  a  severe  character,  although  the  patient's 
perceptions  ma3'  be  so  blunted  b}'  the  toxic 
condition  that  he  becomes  more  or  less  un- 
conscious. The  swelling  of  the  limb  is  not  so 
great  as  in  the  former  type,  but  the  mischief 
may  be  very  extensive,  and  although  there  is 
no  great  collection  of  pus  beneath  the  peri- 
osteum, yet  it  may  be  stripped  up  along  the 
whole  length  of  the  shaft,  and  even  detached 
from  the  epiph3''sis  at  each  end.  Should  the 
child  not  die  of  toxfemia,  extensive  destruc- 
tion of  bone  is  certain  to  result. 

In  infants  and  very  young  children,  especi- 
ally^ if  the  subjects  of  inherited  syphilis, 
the  disease  early  spreads  through  the  epi- 
physis to  the  neighbouring  joint,  and  the 
symptoms  of  acute  suppurative  arthritis 
supervene.  The  head  of  the  humerus  and 
the  upper  and  lower  ends  of  the  femur  are 
the  parts  most  commonly  involved  in  this 
way.  In  some  of  these  cases  the  liga- 
ments are  so  seriously  weakened  and  relaxed 
that  a  loose  flail-joint  results,  and  patho- 
logical dislocation  may  result. 

In  the  milder  type's  of  osteo-myehtis,  the  patients  complain  of 
severe  pain  in  one  of  the  bones  (one  type  of  '  growing  paiii '),  and 
this  may  be  attended  by  some  degree  of  fever  and  of  local  disability. 
The  syrnptoms  may  quiet  down  after  a  time  and  no  harm  result,  but 


Fig.  266.  —  Necrosis 
FOLLOWING  Acute  Os- 
teo-Myelitis.  (From 
Specimen  in  Col- 
lege OF  Surgeons' 
Museum.) 

The  irregular  new  bone 
of  the  involucrum  is 
well  seen,  and  within 
it  portions  of  the  se- 
questrum. 


566  A   MANUAL  OF  SURGERY 

in  some  cases  the  growth  of  the  bone  will  be  checked  or  entirely 
stopped.  In  other  patients  a  subacute  or  chronic  abscess  may  form 
and  perhaps  come  to  the  surface  at  a  later  date,  and  on  opening  it 
a  sinus  is  found  leading  to  the  interior  of  the  bone,  in  which  a 
sequestrum  of  cancellous  tissue  is  found.  In  such  a  case  the  sur- 
rounding bone  may  at  first  be  rarefied  to  such  an  extent  as  to  bend 
under  the  weight  of  the  body,  but  in  the  later  stages  is  certain  to  be 
much  thickened  and  very  sclerosed.  The  patient  will  have  suffered 
from  repeated  attacks  of  pain  in  the  bone,  which  may  be  felt  to  be 
thickened,  and  in  the  case  of  an  encysted  abscess  a  spot  of  localized 
tenderness  can  usually  be  detected. 

The  Prognosis  of  the  acute  form  is  always  grave.  Life  may  be 
threatened  by  py?emia  or  toxsemia  in  the  early  stages,  whilst  later 
on  hectic  fever,  amyloid  disease,  and  exhaustion,  may  terminate  the 
case  if  a  mixed  infection  has  occurred. 

The  utility  of  the  limb  may  be  unimpaired  if  the  disease  has  not 
been  too  extensive,  and  if  prompt  treatment  has  been  adopted;  but 
if  life  is  threatened  by  toxa;mia,  or  if  neighbouring  joints  suppurate, 
or  if  the  osteogenetic  powers  of  the  periosteum  have  been  destroyed 
by  the  acuteness  of  the  process,  amputation  may  be  required.  In 
cases  which  have  recovered,  excessive  growth  of  the  bones  some- 
times follows,  owing  to  the  long-standing  hyperemia  of  the  part; 
but  if  the  epiphyseal  cartilage  has  been  much  affected,  the  limb  may 
be  stunted  in  its  subsequent  development. 

Treatment. — Prompt  surgical  interference  must  be  adopted  in  or- 
der, if  possible,  to  cut  short  the  malady.  As  soon  as  the  local  pain  and 
high  fever  give  evidence  that  this  affection  is  present,  a  free  incision 
should  be  made  in  the  long  axis  of  the  limb  through  the  periosteum, 
whether  pus  can  be  detected  or  not.  The  surgeon  will  then  proceed 
to  investigate  carefully  the  condition  of  the  bones  by  inspection  and 
the  use  of  the  finger  and  probe.  As  a  rule,  he  will  fincl  himself  in 
the  neighbourhood  of  the  epiphyseal  cartilage,  and  if  the  case  has 
been  taken  in  hand  early,  it  is  possible  that  the  mischief  will  be  quite 
limited;  all  that  is  then  required  is  to  scrape  or  gouge  awav  the  soft- 
ened and  hyperaemic  bone  at  the  end  of  the  diaphysis,  together  with 
any  necrotic  tissue  which  may  be  present,  taking  the  greatest  care 
not  to  perforate  the  epiphyseal  cartilage.  The  cavity  thus  formed 
is  douched  with  an  antiseptic ;  a  drainage-tube  or  gauze  packing  is 
inserted,  and  in  all  probability  recovery  will  rapidly  ensue. 

If  the  case  has  gone  further,  the  periosteum  will  be  found  stripped 
from  the  bone  for  a  varying  distance,  although  but  little  pus  may 
be  present  beneath  it.  Under  these  circumstances  it  is  always 
necessary  to  open  up  by  gouge,  drill,  or  cutting-pliers  the  medullary 
canal,  so  as  to  allow  pus  to  escape  and  the  hyperaemic  and  gan- 
grenous fatty  tissue  contained  therein  to  be  scraped  out.  If  this 
proceeding  involves  a  considerable  portion  of  the  shaft,  it  may  be 
possible  to  leave  bridges  of  compact  tissue  here  and  there,  scraping 
out  the  medullary  cavity  beneath  them.  When  grave  constitutional 
phenomena  are  present,  associated  with  loosening  of  the  epiphysis, 


DISEASES  OF  HONE  56? 


it  will  often  bo  found  expedient  to  amputate  in  order  to  prevent 
death  from  toxaemia.  ,      ,       i  t- 

If  the  periosteum  has  been  extensively  involved,  a  large  amount 
of  bone,  possibly  the  whole  diaphysis,  is  denuded,  and  perhaps 
both  epiphyses  are  loosened.  The  dead  diaphysis  should  be  re- 
moved at  once  if  the  leg  or  fore-arm  is  involved,  as  there  is  always 
a  second  bone  to  maintain  the  length  of  the  limb ;  but  for  the  femur 
and  humerus  its  removal  should  be  delayed— inimediate  removal 
would  lead  to  hopeless  shortening  and  cripphng  of  the  Imib. 

When  it  is  probable  that  the  medulla  is  not  much  involved,  the 
PUS  is  given  a  free  exit  through  an  incision,  the  cavity  is  irrigatea, 
and  the  stripped-up  periosteum  allowed  to  fall  back  upon  the  bone, 
and  regain  adhesions  to  it,  if  possible.     Drainage  is  provided  lor 
strict  asepsis  maintained,  and  the  discharge  soon  becomes  merely 
serous      A  portion  of  the  bone  dies,  and  during  its  separation  from 
neighbouring  parts  becomes  encased  in  a  newly-formed  involucrum. 
When  the  sequestrum  is  free-that  is,  in  about  five  or  six  weeks- 
seqmstrectomy  will  be  required;  it  consists  in  reflecting  the  peri- 
osteum from  the  new  casing,  and  in  enlarging  or  uniting  one  or  more 
of  the  cloaca,  so  as  to  allow  the  sequestrum  to  be  withdrawn      in 
some  cases  it  is  desirable  to  approach  the  sequestral  cavity  by  some 
safer  route  than  that  suggested  by  the  sinus,  ^.g.,  when  the  necrosis 
involves  the  lower  end  of  the  femur,  it  is  often  wise  to  cut  down  on 
it  from  the  side,  although  the  sinuses  are  central.     It  is  not  always 
easy  to  remove  the  sequestrum  en  bloc,  and  it  may  be  necessary  to 
divide  it;  the  greatest  care  must  be  taken  not  to  leave  any  portion 
behind,  as  the  wound  cannot  heal  in  this  case.  Jbe  empty  cavity 
should  be  irrigated  and  disinfected,  and  may  be  left  to  close  by 
granulation,  or  be  packed  with  gauze;  sometimes  it  is  possible  t.o 
detach  or  fracture  one  side  of  the  involucrum,  and  by  pressing  it 
down  to  obUterate  the  space  partially  and  thereby  hasten  healing 
which  is  often  a  somewhat  slow  process.     Occasionally  removal  ot 
the  sequestrum  is  almost  impracticable,  and  under  such  circum- 
stances amputation  may  be  preferable.     This  summary  proceeding 
may  also  be  needed  in  the  course  of  this  disease  on  account  ot 
pyaemia,  defective  repair,  exhaustion  from  chrome  toxsemia.  or  sup- 
puration in  a  neighbouring  joint. 

Osteo-myelitis  of  the  flat  bones  involves  opening  freely  into 
the  cancellous  tissue  by  gouge  or  trephine,  and  scrapmg  away  all  the 
bone  which  is  diseased  or  infiltrated  with  pus  In  the  cranium 
the  inner  table  should  not  be  perforated  unless  the  surgeon  suspects 
the  existence  of  subcranial  suppuration.  _ 

S  The  Acute  Traumatic  Osteo-myelitis  which  arises  as  a  result  ot 
infection  from  without,  e.g.,  in  cases  of  compound  .^actures  and 
after  amputation,  excision,  or  even  osteotomy,  requires  a  separate 
description.  The  clinical  history  of  a  case  involving  the  shaft  ot  a 
long  bone  is  as  follows:  The  patient  during  an  attack  of  septic 
traSmatic  fever  due  to  an  injury  or  operation  has  one  or  more  rigors 
which    suggest  the  existence  of  pyaemia,   and  is  suddenly  seized 


568 


A    MAXUAL  OF  SURGERY 


h 


with  severe  pain  in  the  limb,  which  becomes  intensely  sensitive. 
On  examining  the  wound,  the  soft  parts  are  found  to  be  unhealthy 
and  infiltrated,  the  lower  end  of  the  bone  is  bare  and  yellow,  and 
from  the  interior  a  stinking  mass  of  gangrenous  medullary  tissue 
sometimes  protrudes.  Should  early  and  efficient  treatment  not 
be  undertaken,  the  patient  runs  a  considerable  risk  of  succumbing 
to  acute  pysemia  or  toxsemia,  whilst  a  varying  amount  of  the 
interior  of  the  bone  dies  {central  or  tubular  necrosis),  and  a  small 
segment  of  its  whole  thickness  below,  so  that 
the  sequestrum  which  ultimately  separates  is 
annular  and  conical  (Fig.  267).  Should  the 
patient  survive,  the  necrotic  tissue  gradually 
separates,  and  during  this  process  a  mass  of 
new  bone  is  formed  from  the  under  surface  of 
the  periosteum,  so  that  the  shaft  becomes 
much  thickened  externally.  In  the  slighter 
cases  a  mass  of  granulations  projects  from 
the  medullary  cavity  of  the  divided  end  of 
the  bone,  and  in  this  there  may  be  a  newly- 
formed  bony  substratum. 

Treatment.  —  The  wound  is  thoroughly 
opened  up  as  early  as  possible,  flushed  out, 
and  the  sloughing  medullary  tissue  scraped 
from  the  interior  of  the  bone,  which  is  subse- 
quently disinfected  with  pure  carbolic  acii,  a 
drainage-tube  or  gauze  wick  being  placed  in 
it  for  a  few  days.  A  certain  amount  of 
necrosis  follows,  but  without  high  fever  or 
toxaemia.  Should  this  treatment  fail,  ampu- 
tation will  be  required. 

A  similar  process  may  also  invade  the 
short  bones,  and  the  cancellous  extremities 
of  long  bones,  being  often  secondary  to  acute 
infective  arthritis,  or  to  a  compound  fracture 
involving  such  parts.  The  local  and  general 
phenomena  are  very  similar  to  those  detailed 
above,  except  that  no  large  sequestra  are 
formed,  the  dead  bone  coming  away  in  small  spicules  (one  form  of 
caries  necrotica),  whilst  the  pain  and  fever  are  less  severe,  and  there 
is  less  likelihood  of  the  development  of  pyaemia.  Treatment  consists 
in  free  drainage,  removal  of  the  infected  tissue,  and  efficient 
purification  of  the  w^ound. 


h 


il 


J 


Fig.  267. — Tubular  OR 
Conical  Sequestrum 
FROM  Acute  Osteo- 
myelitis OF  Femur 
AFTER  Amputation. 


Typhoid  Osteitis. 

Affections  of  the  osseous  system  are  not  uncommon  in  typhoid  fever,  and 
usually  come  on  about  the  third  week  or  during  the  early  stages  of  convales- 
cence. The  tibia  and  ribs  are  most  often  affected,  and  in  a  large  percentage 
of  cases  typhoid  bacilli,  with  or  without  pyogenic  cocci,  will  be  found.  It  is 
curious  to  note  how  long  the  organisms  may  lie  latent  in  the  tissues  before 


DISEASES  OF  BONE 


569 


causing  an  abscess — in  one  case  (Sultan's)  for  six  years.  The  trouble  com- 
mences either  as  a  periostitis  or  osteo-myelitis,  subacute  in  character,  often 
improving  for  a  time,  and  then  relapsing.'  It  usually  develops  an  abscess,  and 
tlien  some  amount  of  necrosis  or  caries  may  follow; 
thus  in  a  case  operated  on  by  one  of  us  a  considerable 
sequestrum  was  removed  from  the  upper  third  of  the 
femur,  whilst  in  the  opposite  leg  there  had  been  an 
abscess  in  a  similar  position,  but  without  death  of 
bone.  The  abscess  isgenerallysubacuteor  chronic,  and 
the  affected  bone  may  be  carious  rather  than  necrotic. 
On  its  first  appearance  the  affected  limb  should  be 
elevated  and  fomented,  and  frequently  the  more 
acute  symptoms  will  yield ;  but  the  part  often  re 
mains  enlarged,  swollen,  and  tender,  and  exacerba- 
tions of  pain  are  not  unlikely  to  develop  from  time 
to  time,  sooner  or  later  leading  up  to  the  formation 
of  an  abscess.  When  suppuration  has  occurred,  the 
parts  must  be  freely  incised,  diseased  bone  removed, 
granulation  tissue  scraped  away,  and  the  parts  dis 
infected  with  liquefied  carbolic  acid.  The  wounds 
are  usually  found  to  be  extremely  chronic  and  in- 
dolent, and  may  require  scraping  several  times. 

Chronic  Inflammation  of  Bone. 

Chronic  Osteo-periostitis  is  a  chronic  infiam- 
matorv  condition  of  the  bone,  which  results 
in  overgrowth,  thickening,  and  condensation. 

Varieties. — {a)  It  may  arise  as  a  localized 
chronic  periostitis,  traumatic,  toxic,  rheu- 
matic, or  svphihtic  in  origin,  or  due  to  the 
close  proximity  of  a  chronic  ulcer.  It  is 
characterized  by  a  formation  of  new  bone 
beneath  the  periosteum,  the  so-called  node 
(Fig.  268),  the  cancelli  of  which  are  arranged 
at  right  angles  to  the  surface.  At  first  this 
new  material  is  soft  and  spongy,  but  it  rapidly 
becomes  hard  and  sclerosed,  and  a  similar 
condition  affects  the  subjacent  compact  struc- 
ture, which  is  thickened  and  indurated  by  a 
new  formation  around  the  Haversian  canals. 
If  the  irritation  persists,  as  in  the  case  of  a 
chronic  ulcer,  this  condition  may  run  on  into 
the  following  variety. 

(b)  The  diffuse  form  of  chronic  osteo-peri- 
ostitis usually  originates  in  some  deep-seated 
or  central  affection,  tuberculous  or  syphilitic 
in  nature,  and  often  involves  the  whole  bone, 
although  sometimes  limited  to  one  or  other 
end.  If  tuberculous,  there  may  be  a  small 
chronic  abscess  or  some  central  necrosis,  and 
around  this  the  bone  becomes  thick  and  indurated.  In  the  later 
stages  a  considerable  new  formation  may  occur  beneath  the  peri- 
osteum, and  the  medullary  canal  become  encroached  on  or  obliterated 


Fig.  268.  —  Chronic 
OsTEG  -  Periostitis 
OF  Tibia,  showing 
Fusiform  Swell- 
ing ON  the  Front 
OF  THE  Bone,  con- 
sisting OF  Dense 
Osseous  Tissue, 
AND  the  Medul- 
lary Cavity  en- 
croached UPON. 
(]\Iuseum  of  Royal 
College  of  Sur- 
geons.) 


57°  A   MANUAL  OF  SURGERY 

(Fig.  272).  If  sypliilitic  in  origin,  it  may  be  due  to  a  central 
gumma,  or  to  a  general  condition  of  sclerosis,  developing  without 
any  localized  focus. 

The  Symptoms  consist  of  deep  aching  pain  in  the  limb,  worse  in 
bed,  with  perhaps  tenderness  over  some  particular  spot,  especially 
in  cases  where  an  encysted  abscess  exists  in  the  head  of  a  bone,  such 
as  the  tibia.  On  examination  the  bone  is  felt  to  be  thickened,  and 
its  surface  more  or  less  nodulated.  If  the  disease  is  limited  and 
superficial,  a  distinct  node  may  be  felt,  consisting  of  a  hard,  fusiform, 
and  tender  swelling.  Where  the  enlargement  is  more  general,  there 
is  less  tenderness,  though  the  pain  is  constant. 

The  Diagnosis  of  such  cases  is  not  always  easy,  the  enlargement 
of  the  bone  being  sometimes  mistaken  for  the  early  stage  of  a  malig- 
nant tumour.  The  rate  of  growth  will  be  of  little  assistance,  since  it 
is  very  variable;  but  a  tumour  may  have  more  defined  limits,  and  its 
tension  is  often  not  the  same  throughout.  Radiography  is  valuable 
in  this  direction,  since  in  simple  chronic  periostitis  the  bone  is 
solid  and  throws  a  continuous  and  well-defined  shadow,  while  in 
malignant  disease  a  certain  amount  of  soft  tissue  is  alwa3^s  present, 
either  centrally  or  peripherally,  easily  penetrated  by  the  rays,  and 
hence  leaving  gaps  in  the  shadow.  If,  in  spite  of  such  assistance, 
the  case  is  still  doubtful,  an  exploratory  incision  will  be  required. 

The  Treatment  consists  in  resting  the  limb,  applying  counter- 
irritation  {e.g.,  iodine  paint  or  the  actual  cautery),  and  giving  iodide 
of  potassium  internally.  If  relief  is  not  thereby  obtained,  it  will 
be  necessar}'  to  cut  down  over  the  whole  length  of  the  thickened 
bone  through  the  periosteum,  which  is  stripped  aside,  and  if  merely 
a  nodular  enlargement  is  present,  to  chisel  away  the  new  formation. 
When  the  whole  thickness  of  the  bone  is  involved,  a  gutter  or 
trench  must  be  made  by  gouge  and  mallet,  extending  into  the  me- 
dullary cavity,  and  its  length  corresponding  to  the  enlargement. 
The  soft  parts  are  loosely  drawn  together;  the  hollow  will  fill  with 
blood-clot,  which  is  allowed  to  organize.  If  enough  bone  has  been 
removed,  most  satisfactory  results  follow;  but  in  some  aggravated 
conditions  which  have  lasted  for  many  years  amputation  is 
required. 

Tuberculous  Diseases  of  Bone. 

Bone  may  be  affected  in  many  ways  by  tubercle,  the  process 
starting  either  beneath  the  periosteum  or  more  commonly  in  the 
cancellous  tissue  of  the  interior.  The  infection  is  obviously  second- 
ary to  disease  elsewhere,  and  the  bronchial  or  mesenteric  glands 
are  the  commonest  source  of  its  origin.  The  osseous  affection  is 
often  insidious  in  its  onset,  and  chronic  in  its  course;  it  has  a  con- 
siderable tendency  to  involve  neighbouring  joints  and  to  give  rise 
to  suppuration. 

I.  In  Tuberculous  Periostitis  a  specific  infiltration  of  the  perios- 
teum is  met  with,  consisting  of  a  deposit,  partly  in  that  membrane 


DISEASES  OF  HONE  571 

and  partly  under  it,  of  pulpy  granulation  tissue  containing  the 
characteristic  miliary  tubercles,  which  are  chiefly  developed  around 
the  \'cssels  passing  from  the  periosteum  into  the  bone.  As  in  tuber- 
culous disease  elsewhere,  caseation  and  suppuration  are  likely  to 
follow,  leading  to  the  formation  of  abscesses,  which  arc  primarily 
subperiosteal  and  filled  with  curdy  pus ;  these  in  time  find  their  way 
to  the  surface,  either  directly  or  by  more  or  less  tortuous  channels, 
and  leave  sinuses,  extending  down  to  the  diseased  area.  The  effect 
on  the  bone  may  be  insignificant  if  the  part  affected  is  dense,  con- 
sisting merely  in  some  slight  superficial  erosion  ;  occasionally, 
however,  the  disease  may  spread  along  the  periosteum,  and  involve 
a  neighbouring  epiphysis  or  joint.  If  the  compact  layer  is  thin, 
as  in  the  sternum,  ribs,  or  bodies  of  the  vertebrfe,  the  underlying 
cancellous  tissue  is  almost  certain  to  be  secondarily  affected,  and 
caries  will  result . 

Clinical  History. — In  a  superficial  bone  a  doughy  or  pulpy  swelling 
forms,  which  is  slightly  tender  on  pressure.  It  takes  weeks  or 
months  to  develop,  and  on  radiography  the  underlying  osseous  tissue 
may  appear  quite  normal  in  texture.  In  the  later  stages,  when 
caseation  or  suppuration  is  present,  the  swelling  often  becomes 
more  defined  and  somewhat  resembles  an  ordinary  node,  but  is 
more  irregular  in  shape,  of  somewhat  unequal  consistency,  and  on 
firm  pressure  small  portions  may  be  felt  to  give  way.  If  an  abscess 
forms,  the  skin  becomes  reddened,  the  swelling  is  elastic  to  the  touch, 
and  the  pain  greater,  but  it  diminishes  as  soon  as  tension  is  relieved 
by  discharge  of  the  pus.  A  sinus,  however,  forms,  and  a  probe 
passed  down  impinges  on  soft  carious  bone.  The  admission  of 
pyogenic  infection  increases  the  trouble. 

Treatment. — In  the  early  stages,  constitutional  treatment  ma}/ 
suffice,  together  with  rest  and  carefully-adjusted  pressure,  as  by 
strapping  with  Scott's  dressing,  or  Bier's  induced  hyperaemia,  where 
applicable.  The  condition,  however,  demands  incision  if  a  neigh- 
bouring joint  is  threatened,  or  when  suppuration  has  occurred. 
Free  removal  of  all  the  granulation  tissue  and  softened  bone  with  a 
Volkmann's  spoon  is  required,  disinfection  of  the  cavity  with  undi- 
luted carbolic  acid,  and  packing  it  with  gauze  soaked  in  a  sterilized 
emulsion  of  glycerine  and  iodoform  (10  per  cent.),  the  wound  being 
aUowed  to  granulate  from  the  bottom.  If  a  rib  is  involved,  it  is 
wiser  to  remove  entirely  the  affected  portion  of  bone. 

2.  Tuberculous  Osteitis  arises  in  cancellous  tissue,  and  usually  in 
the  epiphyses,  or  under  the  articular  cartilage;  occasionally  it 
develops  in  the  medullary  cavity  as  a  chronic  osteo-myelitis. 

Pathology. — The  tubercle  bacilli  are  deposited  in  the  interior  of 
the  bone,  which  may  have  previously  sustained  some  mild  injury. 
The  outcome  of  this  is  the  transformation  of  the  normal  medulla 
into  pulp}/  granulation  tissue  containing  tubercles,  the  bony  cancelli 
becoming  meanwhile  eroded  and  rarefied,  and  the  bone  corpuscles 
undergoing  fatty  degeneration  {vide  Caries,  p.  557).  Sequestra 
occasionally  form,  but  more  often  in  adults  than  in  children,  owing 


572 


A   MANUAL  OF  SUHGERY 


to  the  greater  density  of  the  bone  in  the  former.  They  are  due  to 
a  cutting-off  of  the  blood-supply  of  a  definite  portion  of  the  bony 
tissue,  either  as  a  result  of  tuberculous  endarteritis,  or  from  early 
caseation  within  the  cancclJi  of  the  whole  of  the  granulation 
tissue.  The  sequestra  are  soft  and  friable,  usually  yellowish-white 
in  colour  from  the  presence  of  the  caseating  tissue  in  their  substance, 
and  are  seldom  completely  separated  from  the  surrounding  bone. 
When  the  tuberculous  disease  does  not  involve  the  whole  bone,  the 

nearest  healthy  tissue  may 
become  sclerosed,  and  thus 
one  not  unfrequently  finds 
a  central  sequestrum  sur- 
rounded by  rarefied  bone, 
which  in  turn  is  enclosed  by 
a  zone  of  sclerosed  tissue. 
V^ery  frequently  the  disease 
extends  from  the  interior  of 
the  bone  either  to  a  neigh- 
bouring joint  or  to  the  peri- 
osteum, or  possibly  to  ad- 
jacent tendon  sheaths,  and 
external  abscesses  are  then 
likely  to  develop.  The  ad- 
mission of  pyococci  leads  to 
increasing  rapidity  of  the 
destructive  process,  and 
minute  spiculated  sequestra 
often  come  away  in  the  dis- 
charge. Radiography  is  a 
useful  adjunct  in  estimating 
the  amount  of  disease  pre- 
sent, since  the  affected  bone 
offers  little  or  no  resistance 
to  the  passage  of  X  rays 
(Fig.  269). 

{a)  The  short  hones  of  Ihc 
hands  and  feet  are  very  liable 
to  this  condition  in  weakly 
children  whose  general 
health  has  been  depressed 
by  one  of  the  exanthemata. 
Some  slight  injury  may  determine  the  onset  of  the  attack,  which 
frequently  involves  several  bones  simultaneously.  When  the 
phalanges  are  involved,  the  chsease  is  known  as  Tuberculous 
Dactylitis. 

Clinical  History. — The  affected  segment  of  the  finger  becomes 
slowly  enlarged,  bulbous,  and  painful,  the  pain  being,  however, 
slight  in  amount,  though  sometimes  worse  at  night.  At  lirst  the 
finger  looks  white,  and  the  skin  is  smooth  and  shiny;  but  after  a 


Fig.  269.- 


-tuberculous  disease  of 
Radius. 


The  patient  was  a  lady  over  fifty  years  of 
age,  who  had  suffered  for  some  months 
from  pain  and  swelling  of  this  bone. 
The  site  and  extent  of  the  disease  is 
indicated  by  the  light  area  in  the  shadow 
of  the  bone.  Eventually  amputation 
was  required. 


DISEASES  OF  BONE 


573 


time  one  spot  rapidly  increases  in  size,  becoming  red  and  tender,  and 
finally  an  abscess  forms,  which  bursts  or  is  opened,  leaving  a  sinus, 
down  which  a  probe  can  be  passed  into  the  carious  interior  of  the 
bone.  Occasionally  contiguous  joints  are  involved  in  this  process, 
whilst  the  tendon  sheaths  are  also  liable  to  be  affected;  a  large 
portion  of  the  swelling  is  often  due  to  periosteal  infiltration  (Fig.  270) . 
In  some  cases  the  bone  appears  to  be  expanded,  but  the  term 
expansion  is  scarcely  correct,  inasmuch  as  the  enlargement  is  due 
to  absorption  on  the  inner  aspect, 
whilst  there  is  a  new  formation  of 
bone  under  the  periosteum.  Natural 
cure  without  suppuration  is  known  to 
occur,  but  even  then  the  growth  of 
the  phalanx  may  be  hindered,  and  the 
finger  remains  shortened. 

The  Treatment  of  tuberculous  dac- 
tylitis in  the  early  stages  consists  in 
attention  to  the  general  health,  to- 
gether with  local  rest,  induced 
hyperaemia,  and  perhaps  strapping 
the  part  with  Scott's  dressing.  Should 
the  disease  progress  or  suppuration 
occur,  operation  must  not  be  unduly 
delayed,  since  neighbouring  joints 
and  tendon  sheaths  are  likely  to  be 
attacked.  An  incision  is  made  down 
to  the  bone  at  some  suitable  spot 
where  tendons  or  other  important 
structures  will  not  be  injured;  the 
periosteum  is  divided,  and  the  outer 
layer  of  compact  bone  removed  by 
gouge,  so  as  to  allow  the  diseased 
medulla  to  be  scraped  away  with  a 
Volkmann's  spoon.  The  cavity  is 
swabbed  out  with  liquefied  carbolic 
acid,  any  excess  being  washed  away 
with  absolute  alcohol,  and  the  wound 
packed  with  gauze  soaked  in  iodoform 
emulsion,  in  order  to  ensure  healing 
by  granulation.  In  this  operation  the 
integrity  of  epiphyses  and  of  articular  cartilages  must  be  carefully 
respected.  Not  unfrequently  the  growth  of  the  bone  is  consider- 
ably hindered,  either  by  the  disease  or  by  the  treatment  requisite 
in  order  to  eradicate  it,  the  part  becoming  stunted  or  deformed  in 
consequence.     In  the  worst  cases  amputation  is  required. 

(&)  Any  of  thehones  of  the  tarsus  maybe  involved  in  exactly  the  same 
manner,  the  clinical  history  and  treatment  being  identical,  although 
articular  lesions  are  more  common  than  when  the  disease  is  limited 
to  the  phalanges.     The  affected  portion  of  the  foot  becomes  swollen 


Fig.  270. — •  Tuberculous  Dac- 
tylitis. (Royal  College  of 
Surgeons'  Museum.) 

The  disease  stai'ted  in  the  proxi- 
mal phalanx,  and  has  spread 
to  the  periosteum  and  flexor 
tendon  sheath,  whilst  the  first 
interphalangeal  joint  is  be- 
coming invaded. 


574 


A   MANUAL  OF  SURGERY 


and  shiny,  since  the  overlving  jieriosteum  is  often  involved  in  the 
process;  and  it  is  sometimes  difficult  to  determine  whether  the 
lesion  is  limited  to  the  bones  or  also  involves  the  jcnnts.  In  the 
early  stages  one  part  of  the  foot  may  be  more  swollen  than  an(jther, 
according  to  the  location  of  the  trouble.  The  os  calcis  is  most  otten 
affected,  and  afterwards,  in  order  of  frequency,  come  the  first  meta- 
tarsal, astragalus  (the  head),  and  scaphoid.  When  it  starts  in  the 
astragalus,  the  swelling  occurs  below  the  level  of  the  ankle-joint 
in  front  of  or  behind  the  malleoli,  whilst  pressure  over  the  head  of 
the  bone  gives  rise  to  pain.  The  foot  is  usually  in  a  position  of 
equinus,  but  not  to  such  a  marked  degree  as  when  the  ankle-joint 
itself  is  affected;  the  subastragaloid  movements  (inversion  and 
eversion,  abduction  and  adduction)  are  also  considerably  limited. 


Vsr-* 


li^-m 


Fig.  271. — Arrangement  of  Synovial  Membranes  of  Foot. 

I,  Posterior  calcaneo-astragaloid,  behind  the  interosseous  ligament;  2,  anterior 
calcaneo-astragaloid  and  astragalo-scaphoid ;  3,  calcaneo-cuboid;  4,  cubo- 
metatarsal;  5,  the  large  common  sac  between  scaphoid  and  cuneiform, 
between  the  three  cuneiform  bones,  and  between  the  cuneiform  and  second 
and  third  metatarsals;  6,  between  the  internal  cuneiform  and  first  meta- 
tarsal. 


or  may  be  absent.  An  examination  of  the  accompanying  illustra- 
tion (Fig.  271)  will  explain  the  fact  that  tuberculous  disease  starting 
in  the  astragalus  is  very  likely  to  involve  the  ankle-joint,  or  to 
spread  to  the  os  calcis  or  scaphoid.  Disease  of  the  os  calcis  leads 
to  more  limited  swelling  of  the  back  of  the  foot  on  one  or  both 
sides  of  the  heel ;  the  movements  of  the  ankle  will  not  be  impaired, 
although  walking  is  painful,  and  hence  the  patient  limps,  treading 
only  on  the  toes.  Further  forwards,  tuberculous  disease  is  most 
likely  to  start  in  or  around  the  scaphoid,  the  bulbous  swelling  of 
the  foot  being  then  shifted  anteriorly,  and  the  movements  of  the 
ankle  remaining  unimpaired.  Owing  to  the  arrangement  of  the 
synovial  membranes,  the  prognosis  is  much  worse  when  the  disease 
attacks  the  inner  half  of  the  foot,  comprising  the  astragalus,  sca- 
phoid, cuneiform,  and  three  inner  metatarsal  bones,  than  when  it 


DISEASES  OF  BONE 


575 


affects  the  outer  segment,  consisting  of  the  cuboid  and  two  outer 
nietatarsals,  which  are  exckided  from  the  general  synovial  mem- 
brane, and  are  thus  more  amenable  to  treatment. 

Sooner  or  later  suppuration  occurs,  with  increased  pain,  and, 
should  the  sinus  which  results  from  opening  the  abscess  become 
septic,  the  trouble  is  sure  to  spread  much  more  rapidly,  and  the 
prognosis  becomes  increasingly  grave. 

Ihe  Treatment  consists  in  the  usual  local  and  constitutional 
measures  adopted  in  tuberculous  disease  (p.  184).  In  the  early 
stages  the  foot  and  ankle  are  immobilized,  and  preferably  in  plaster 
of  Paris  or  water-glass,  and  the  foot  is  not  allowed  to  be  used  until 
all  pain  has  ceased.  Older  patients 
are  fitted  with  a  Thomas's  knee- 
splint  and  a  patten,  and  allowed  to 
get  about  on  crutches. 

Should  the  disease  persist,  or 
should  suppuration  occur,  operation 
will  be  required.  If  the  os  calcis 
alone  is  involved,  it  will  usually 
suffice  to  open  it  from  one  or  both 
sides,  to  scrape  out  and  disinfect  its 
interior,  and  then  pack  it  with  iodo- 
form and  gauze.  The  cavity  fills 
with  granulation  tissue,  and  subse- 
quently with  fibrous  tissue,  with 
perhaps  a  few  bony  spicules,  and  a 
marked  permanent  depression  always 
remains  at  the  site  of  operation.  If 
the  disease  mainly  affects  the  astrag- 
alus, it  may  suffice  to  remove  it 
entirely,  neighbouring  articulations 
being  curetted;  but  probably  the 
disease  will  have  spread  so  far  that 
amputation  will  be  required,  and 
then  Syme's  operation  is  better  than 
methods,  such  as  Pirogoff's,  which 

retain  any  portion  of  the  tarsus.  Disease  of  the  cuboid  and  outer 
half  of  the  foot  in  front  of  the  os  calcis  can  often  be  dealt  with 
efficiently  by  scraping,  but  when  the  common  synovial  membrane 
on  the  inner  side  is  involved,  amputation  will  probably  be  needed. 

(c)  If  the  tuberculous  disease  affects  the  ends  of  long  hones,  it  most 
commonly  starts  in  the  epiphysis,  or  under  the  articular  cartilage, 
though  sometimes  on  the  shaft  side  of  the  epiphyseal  cartilage. 
1  he  changes  already  described  take  place,  and  lead  to  early  destruc- 
tion of  the  latter  cartilage,  so  that  the  adjacent  parts  of  both  epi- 
physis and  diaphysis  become  involved  (tuberculous  epiphysitis). 
ihe  general  signs  are  similar  to  those  present  when  the  smaller 
bones  are  affected,  but  the  results  produced  may  vary  considerably, 
(i.)  In  the  earlier  cases  where  efficient  treatment  is  adopted,  the 


Fig.  272. — Chronic  Abscess  in 
THE  Lower  End  of  the  Tibia. 
(King's  College  Hospital  Mu- 
seum.) 


576 


A   MANUAL  OF    SURGERY 


tuberculous  tissue  may  be  totally  absorbed,  and  the  })rocess  thus 
comes  to  an  end,  though  the  aflection  of  the  epiphyseal  cartilage 
may  lead  to  subseciuent  impairment  of  growth,  (ii.)  In  others  it 
may  be  circumscribed  by  the  bone  becoming  sclerosed  around  a 
caseating  focus,  and  then,  if  suppuration  ensues,  a  deep  abscess  in 
the  end  of  the  bone  may  be  produced  (Fig.  273).  Such  is  rarely  of 
large  size,  containing  at  most  i  or  2  drachms  of  curdy  pus,  and  is 
lined  by  a  definite  pyogenic  membrane  of  the  usual  tuberculous 
type.     The  effects  produced  by  this  condition  are  similar  to  those 


B- 


/    .^, 


;-^3 


'i^iM^> 


Fig. 


273- 


-Lower  End  of  Tibia  affected  with  Tuberculous  Disease. 
(King's  College  Hospital  Museum.) 

In  A,  a  subperiosteal  deposit  of  new  bone  is  seen  surrounding  an  opening  (cl), 
which  leads  into  the  interior  of  the  bone;  in  B,  the  interior  of  the  same 
bone  is  seen,  and  shows  a  sequestrum  (S)  just  above  the  epiphyseal  line. 
The  ankle-joint  is  healthy. 

of  any  chronic  inflammation  of  bone,  viz.,  a  deep  aching  or  boring 
pain,  worse  at  night,  together  with  enlargement  of  the  affected 
bone,  whilst  one  spot  is  often  very  tender  on  palpation.  If  it  has 
existed  for  any  length  of  time,  the  whole  shaft  may  become  en- 
larged as  a  result  of  chronic  osteo-periostitis.  (iii.)  The  disease  may 
burrow  along  the  epiphyseal  line,  and  find  its  way  into  the  neigh- 
bouring joint,  if  the  epiphysis  is  intra-articular,  as  in  the  hip;  but 
if  the  epiphyseal  cartilage  is  placed  beyond  the  limits  of  the  caj^sule, 
a  subperiosteal  extra-articular  abscess  will  develop  (Fig.  273). 
Should  the  disease  spread  equally  in  all  directions,  the  epiphysis 
may  actually  be  separated,     (iv.)  A  more  common  result  is  for  the 


DISEASES  OF  BONE 


577 


whole  or  part  of  the  CLincellous  tissue  of  the  epiphysis  to  become  in- 
volved, and  the  joint  to  be  secondarily  affected  with  tuberculous 
arthritis,  either  by  perforation,  erosion,  or  necrosis  of  the  articular 
cartilage,  or  by  extension  to  the  synovial  membrane  around  its 
margins.'    (v.)  The  process  may  sometimes  extend  upwards  along 
the    medulla    into    the     shaft, 
causing    a     diffuse     osteo-peri- 
ostitis,  with  or  without  a  medul- 
lary abscess  (Fig.  274). 

The  Treatment  of  tuberculous 
epiphysitis  is  conducted  in  the 
first  place  by  absolute  immobili- 
zation  and  hygienic   measures; 
but    the    surgeon  must   not   be 
tempted  to  trust   too    long    to 
such   a  regime,  for  fear  of  the 
joint  becoming  also  affected.     If 
considered  necessary,  an  opening 
is  made  into  the  interior  of  the 
epiphysis,   and   all  the 
pulpy   granulation   tis- 
sue, caseous  debris,  or 
diseased  bone  removed  ,  - 

with  a  sharp  spoon,  the 
cavity  being  subse- 
quently disinfected,  and 
packed  with  gauze  in- 
filtrated with  iodoform. 
Of  course,  the  utmost 
care  must  be  taken  not 
to  open  the  joint  by 
scraping  through  the 
articular  cartilage. 
Where  a  chronic  ab- 
scess exists  in  the  end 
of   a  bone,   a  trephine 

should  be  applied  over  „ 

the  tender  spot,  and,  if  the  cavity  is  not  at  first  opened,  the 
bone  may  be  drilled  in  different  directions  to  ascertain  whether  or 
not  pus  exists. 

{d)  The  medullary  canal  of  the  shaft  of  a  long  bone  sometimes 
becomes  the  seat  of  tuberculous  disease;  this,  as  also  the  abscess  of 
bone  described  above,  is  more  common  in  adults  than  in  children. 
The  part  thus  affected  becomes  carious,  with  or  v,^ithout  the  forma- 
tion of  sequestra  or  pus;  but  the  most  marked  feature  of  this  deep- 
seated  central  trouble  is  that  the  whole  bone  passes  into  a  state  of 
chronic  inflammation,  which  we  have  described,  as  well  as  the 
treatment  necessary  for  it,  under  the  title  of  chronic  diffuse  osteo- 
periostitis (p.  569). 


Pjg  274.— Localized  Abscess  in  the  Lower 
End  of  the  Femur,  extending  from  the 
Epiphyseal  Line  Upwards  into  the  Me- 
dulla. (From  Specimen  in  the  College  of 
Surgeons'  Museum.) 


578  A   MANUAL  Of  SURGERY 


Syphilitic  Diseases  of  Bone. 

In  the  Secondary  Stage  ll>ing  pains  about  the  bones  (sometimes 
termed  vstcocopic)  arc  otten  c()nii)lained  of;  they  are,  however,  of  but 
Httle  importanee,  and  cUsappear  rapidly  as  the  patient  gets  under 
the  influence  of  mercury.  In  the  late  secondary  or  early  tertiary 
periods,  a  periosteal  node  is  often  met  with,  as  a  result  of  chronic 
periostitis.  It  usually  affects  only  one  bone,  and  most  commonly 
the  tibia,  and  consists  of  an  infiltration  and  thickening  of  the  peri- 
osteum, which  may  entirely  disappear,  but  later  on  is  accompanied 
by  a  formation  of  new  bone.  This  is  at  first  spongy  and  soft  in 
character,  but  after  a  while  becomes  hard  and  sclerosed.  When 
such  has  once  occurred,  absorption  of  the  newly-formed  bone  does 
not  readily  follow,  even  under  treatment,  the  part  perhaps  remaining 
permanently  thickened.  It  is  recognised  clinically  as  a  fusiform 
swelling,  a  little  tender  on  pressure,  and  the  seat  of  deep  aching 
pain,  usually  worse  at  night.  It  must  be  understood  that  the  pain 
is  not  so  much  associated  with  the  onset  of  night  as  with  the  in- 
creased warmth  of  the  limbs  when  in  bed;  indeed,  patients  with 
syphilitic  tibiai  frequently  sleep  with  their  legs  exposecl  Night- 
watchmen  and  others,  on  the  contrary,  complain  of  pain  during 
the  day,  when  they  take  their  rest.  Suppuration  does  not 
often  occur,  and  constitutional  rather  than  local  treatment  is 
required. 

In  the  Tertiary  Period  the  bones  may  participate  in  the  changes 
which  involve  any  and  every  tissue  of  the  body.  The  following 
lesions  are  described: 

{a)  The  formation  of  subperiosteal  gummata,  either  localized  or 
diffuse,  probably  resulting  in  caries  of  the  subjacent  bone;  if  the 
afiection  is  limited,  only  a  small  portion  may  be  thus  involved ;  but 
where  it  is  widely  diffused,  an  extensive  surface  of  the  bone  may 
become  eroded  and  irregular.  This  process  is  sometimes  accorn- 
panied  by  a  development  of  new  bone  under  the  adjacent  peri- 
osteum, and  is  very  often  complicated  by  sclerosis  and  necrosis. 
Xhe  calvarium  is  the  part  most  frequently  involved,  and  as  but 
little  new  bone  forms  in  this  situation  the  skull  often  presents  a 
curiously  pitted  or  worm-eaten  appearance  (Fig.  275).  Frequently 
the  overlying  scalp  is  invaded  and  destroyed  by  the  gummatous 
process,  permitting  the  entrance  of  pyogenic  organisms,  and  giving 
rise  to  deep  and  sometimes  extensive  wounds,  discharging  an  abun- 
dance of  foul  pus,  at  the  bottom  of  which  bare  and  even  dead  bone 
may  be  felt. 

(&)  At  the  same  time  a  condition  of  sclerosis  may  he  produced  in 
the  underlying  or  surrounding  parts,  and  this  may  progress  to  such 
a  degree  as  seriously  to  compress  and  constrict  the  vessels  in  the 
Haversian  canals.  Moreover,  an  obliterative  endarteritis  is  almost 
ahvays  present,  and  these  factors,  combined  with  the  separation  of 
the  periosteum  by  the  above-mentioned  gummatous  changes,  so 


DISEASES  Of  BONE  579 

interfere  with  the  vitaHty  of  the  bone  that,  should  pyococci  be 
atlniitted,  necrosis  is  ahnost  certain  to  ensue. 

Tlie  effects  produced  vary  considerably  in  different  cases,  and 
esi)ecially  with  the  situation.  When  the  calvanum  is  attacked, 
pyogenic  infection  often  supervenes,  owing  to  the  thinness  of  the 
scalp  and  the  depth  to  which  the  hair  follicles  penetrate,  and 
consequently  necrosis  is  common.  The  process  in  such  a  case,  as 
is  represented  in  Fig.  276,  is  probably  as  follows :  The  pericranium 
corresponchng  to  the  necrotic  area  becomes  gummatous,  and  at 
the  same  time  the  subjacent  bone  undergoes  sclerosis.  Sooner  or 
later  the  gummata  burst  or  are  opened;  pyogenic  infection  occurs, 
and  the  scalp  tissues  are  stripped  off  the  calvarium  to  the  limits 
of  the  disease,  necrosis  resulting  in  the  sclerosed  area  of  bone.  A 
line  of  rarefaction  subsequently  forms  around  the  sequestrum  in 
consequence  of  Nature's  attempts  to  separate  it.  The  later  stages 
of  the  disease  are  marked  by  extreme  chronicity,  the  sequestrum 


Fig.  275. — Syphilitic  Caries  of  Skull  from  Diffuse  Gummatous  Disease. 
(From  King's  College  Hospital  Museum.) 

1  ying  bare  in  the  wound  perhaps  for  years  without  being  separated, 
owing  to  the  slight  degree  of  vascularity  and  the  extreme  conden- 
sation of  the  surrounding  parts.  Moreover,  as  explained  above, 
there  is  an  entire  absence  of  an  involucrum.  In  the  shafts  of  long 
bones,  where  the  compact  tissue  is  thick  and  resistant,  there  may  be 
extensive  periosteal  disease,  with  but  little  affection  of  the  under- 
lying parts;  but  if  this  compact  layer  is  thin,  and  especially  when 
the  cancellous  ends  are  involved,  a  considerable  amount  of  destruc- 
tion from  caries  may  result,  though  if  pyococci  are  not  admitted 
there  will  be  an  entire  absence  of  necrosis. 

The  sternum  is  not  uncommonly  affected  by  syphilitic  disease, 
which  manifests  itself  as  a  gumma,  which  breaks  down  and  sup- 
purates, but  does  not  often  cause  much  bone  destruction.  The 
nasal  bones  and  hard  palate  are  frequently  the  site  of  subperiosteal 
gummatous  formation,  resulting  in  suppuration  and  necrosis;  a 
foul  discharge  from  the  nose  results  in  the  former  case,  which  may 
be  followed  by  destruction  of  the  septum  nasi  and  permanent 
deformity.     The  palatal  trouble  often  results  in  perforation. 


58o 


A   MANUAL  OF  SURGERY 


In  the  Treatment  constitutional  remedies  must  be  emi)Ioyed,  and 
will  be  valuable  if  su])puration  and  necrosis  have  not  occurred. 
They  may  have  but  little  effect,  however,  if  i)yogenic  infection  has 
supervened  apart  from  measures  directed  t(j  providing  effective  drain- 
age and  removal  of  the  dead  bone.  In  the  calvarium,  however,  no 
attempt  should  be  made  to  take  away  the  dead  bone  unless  it  is  loose, 
(c)  Occasionally  a  gummatous  osteo-myelitis  is  met  with,  in  which 
a  gumma  forms  in  the  interior  of  a  bone.  It  results  in  the  so-called 
expansion  of  bone  and  secondary  thickening  and  enlargement  of 

its  whole  structure — i.e.,  a 
diffuse  chronic  osteo  -  peri- 
ostitis. Ihe  symptoms  are 
the  same  as  those  described 
for  the  latter  affection,  and 
if  it  resists  the  administration 
of  anti-syphilitic  remedies,  it 
must  be  treated  in  the  same 
way,  viz.,  by  separation  of 
the  periosteum,  freely  open- 
ing the  medullary  cavity, 
and  removing  all  diseased 
tissue.  'Ihese  cases  when 
affecting  the  long  bones  have 
often  been  mistaken  for  malig- 
nant growths;  necessarily,  it 
is  a  matter  of  the  greatest 
importance  to  come  to  a  right 
conclusion  as  to  their  nature. 
Ihe  greater  rapidity  of 
growth  in  the  syphilitic  cases, 
and  the  evidences  of  tertiary 
lesions  elsewhere,  or  of  a 
syphilitic  history,  and  the 
existence  of  a  positive  Was- 
sermann  reaction,  will  often  guide  the  surgeon  to  a  right  conclusion, 
whilst  radiography  is  also  helpful;  but  if  there  is  any  doubt  an 
exploratory  incision  and  a  microscopic  examination  of  the  diseased 
tissues  should  always  be  made  before  amputation  is  undertaken. 

In  Inherited  Syphilis  any  of  the  above  manifestations  may  be  seen, 
but  with  more  or  less  special  features  added,  and,  in  addition  to 
these,  certain  forms  which  do  not  occur  in  the  acquired  type  of  the 
disease  have  been  described. 

I.  A  new  formation  of  bone  beneath  the  periosteum  is  perhaps  the 
most  frequent  result,  and  this  occurs  with  but  little  pain.  Perhaps 
the  most  common  situation  of  this  lesion  in  infants  is  the  calvarium, 
where  bony  masses  known  as  Parrot's  nodes  form  around  the 
anterior  fontanelle,  causing  the  top  of  the  skull  to  resemble  a  '  hot 
cross  bun  '  in  shape.  In  the  early  stages  the  bone  is  soft  and 
spongy,  and  on  post-mortem  examination  is  dark  red  or  maroon  in 


Fig.  276. — Syphilitic  Necrosis  of  the 
Skull.  (King's  College  Hospital 
Museum.) 

The  sequestrum  is  becoming  separated, 
and  a  ring  of  caries  is  forming  around  it. 


DISriASES  OF  BONE  581 

colour.  If  the  process  is  not  checked  by  suitable  antisypliilitic 
treatment,  the  newly-formed  osseous  tissue  becomes  dense  and 
sclerosed,  and  the  deformity  may  then  persist  through  life  (Fig.  39, 
p.  173).  Any  part  of  the  calvarium  may,  however,  be  affected,  and 
the  change  is  not  necessarily  limited  to  the  first  years  of  life. 

2.  A  somewhat  similar  condition  is  met  with  in  the  shafts  of  long 
bones,  due  to  the  deposition  of  alternating  lamella  of  soft  and  hard 
bone  outside  the  ordinary  compact  tissue  and  beneath  the  peri- 
osteum. 

3.  Syphilitic  epiphysitis  (or,  as  it  is  termed,  syphilitic  osteo-chon- 
liritis)  is  a  lesion  characterized  by  enlargement  of  the  ends  of  the 
bones,  as  in  rickets,  but  coming  on  within  the  first  year  after  birth. 
The  enlargement  is  mainly  situated  in  the  epiphysis,  but  also 
extends  some  way  along  the  shaft,  thus  contrasting  forcibly  with 
rickets.  Occasionally  only  one  side  of  the  epiphysis  is  affected. 
The  change  commences  in  the  zone  of  calcified  cartilage  nearest  the 
diaplwsis,  which  becomes  friable,  opaque,  and  irregular,  and  as  the 
condition  progresses  it  may  be  transformed  into  granulation  tissue, 
so  that  separation  of  the  epiphysis  follows.  Pyogenic  infection 
may  follow,  resulting  in  suppuration  and  necrosis  of  the  epiphysis 
or  acute  arthritis,  or  the  limb  hangs  powerless  in  a  condition  known 
as  syphilitic  pseudo-paralysis.  The  disease  is  usually  symmetrical, 
and  often  multiple,  and  situated  in  much  the  same  positions  as 
rachitic  affections,  the  knees,  elbows,  and  wrists  being  perhaps  most 
often  affected.  It  may  terminate  in  the  early  stages,  and  be 
followed  by  organization  of  the  granulation  tissue,  the  ultimate 
result  being  cessation  of  growth  in  the  bone. 

4 .  A  symmetrical  overgrowth  of  the  tibia,  perhaps  combined  with 
an  anterior  curvature,  also  occurs  in  syphilitic  children,  resulting  in 
permanent  elongation  of  the  legs  (p.  457)- 

5.  Craniotahes  consists  of  a  locahzed  absorption  of  the  osseous 
tissue  of  the  cranium,  leaving  small  areas  where  the  bone  is  thinned 
or  absent,  so  that  on  pressure  a  sensation  of  crackling,  like  that  of 
parchment,  is  imparted  to  the  finger.  It  occurs  most  frequently  in 
the  parietal  bone  (in  60  per  cent,  alone;  in  95  per  cent,  with  other 
bones — Carpenter*),  and  in  the  majority  of  cases  within  the  first 
six  months  of  life,  a  fact  that  throws  considerable  doubt  on  the  idea 
that  it  is  due  to  rickets. 

The  Treatment  of  syphilitic  lesions  in  children  must  be  carried  out 
in  accordance  with  general  principles,  and  mainly  by  the  administra- 
tion of  suitable  drugs. 

Rickets. 

Rickets  is  a  general  disease  of  malnutrition,  occurring  in  children 
and  manifesting  itself  mainly  in  lesions  connected  with  the  bones 
It  usually  commences  within  the  first  three  years  of  life,  but  some- 
times appears  later. 

♦Carpenter,  'Syphilis  of  Children  in  Everyday  Practice.'  Biilliore 
Tindall  and  Cox.     1901. 


582  A   MANUAL  OF  SURGERY 

Causes. — Rickets  is  induced  chiefly  by  giving  to  the  child  in- 
sufficient or  improper  food,  especially  by  the  too  early  administration 
of  starchy  materials  and  the  want  of  suitable  fats,  whilst  uncleanli- 
ness  and  want  of  air  and  light  also  predispose  to  it.  Prolonged 
lactation  is  not  necessarily  a  cause,  if  the  mother  is  healthy  and 
capable  of  feeding  the  child;  but  amongst  poor  patients  this  habit 
is  frequently  responsible  for  its  appearance,  although  in  Japan, 
where  the  children  are  suckled  for  two  or  three  years,  the  disease  is 
unknown.  Syphilis  has  no  causative  connection  with  rickets,  except 
by  inducing  marasmus  and  digestive  and  assimilative  chsorders. 

The  Symptoms  may  be  divided  into  the  early  or  general,  and  the 
later  or  osseous.  The  general  symptoms  are  mainly  referable  to  a 
state  of  irritability  of  the  gastro-intestinal  mucous  membrane.  The 
child  may  be  fat  and  flabby,  or  thin  and  ennciated;  the  mucous 
membranes  are  pale,  and  vomiting  and  diarrhrea  are  constantly 
present,  the  motions  being  often  green,  slimy,  and  very  offensive. 
The  spleen  is  enlarged,  the  abdomen  tumid,  and  profuse  sweating 
of  the  head  is  very  characteristic. 


Fig.  277. — Section  of  Costal  Cartilage  and  of  End  of  Rib  in  Rickets, 
SHOWING  Depression  at  the  Junction  on  Anterior  Surface  and 
Projection  on  Inner  Surface. 

The  commencement  of  the  osseoiis  changes  is  usually  indicated  bv 
increasing  irritability  and  restlessness,  the  child  tossing  off  his  bed- 
clothes at  night,  and  crying  out  when  handled  or  touched.  The 
articular  ends  of  the  long  bones  become  enlarged,  as  also  the  junction 
of  the  costal  cartilages  with  the  ribs.  Sooner  or  later  the  shafts  of 
the  long  bones  soften,  and  may  bend  in  various  directions,  and  thus 
many  deformities  may  be  produced. 

The  head  usually  becomes  flattened  antero-posteriorly,  so  that 
the  forehead  appears  square  in  shape  and  enlarged,  whilst  frontal 
bosses  may  develop  on  either  side,  due  to  new  formation  of  bone 
under  the  periosteum;  it  is  a  question,  however,  whether  these  are 
not  syphilitic  rather  than  rachitic  in  origin.  The  fontanelles  remain 
open  much  longer  than  usual,  and  craniotabes  is  said  to  occur.  The 
teeth  do  not  erupt  till  late,  and  are  stunted,  defective  in  enamel,  and 
easily  eroded,  so  that  the  ends  of  the  incisors  are  often  concave;  they 
must  not  be  mistaken  for  syphilitic  teeth,  since  the  concavity  is  a 
small  arc  of  a  large  circle,  whilst  the  typical  notch  of  syphilis  is  a 
large  segment  of  a  small  circle. 

The  spine  may  be  affected  by  kyphosis  (p.  440),  or  less  frequently 
by  scoliosis  (p.  435) ;  the  kyphotic  curve  results  when  the  patient 


DISEASES  OF  HONE  583 

is  allowed  to  lie  too  much  in  bed  with  the  head  on  a  high  pillow, 
or  if  the  child  is  carried  about  with  a  curved  back;  scoliosis  more 
often  occurs  when  the  patient  is  able  to  walk.  Occasionally  a 
kypho-scoliosis  is  produced  as  a  result  of  the  child  being  carried 
about  sitting  on  a  nurse's  arm  with  the  j^elvis  tilted. 

('.hanges  in  the  thorax  are  produced  by  enlargement  of  the  costo- 
chondral  junctions  [beaded  ribs),  which,  when  present  on  either  side 


Fig.  278. — Pelvis  and  Leg-Bones  in  Rickets.     (From  College  of 
Surgeons'  Museum.) 

The  photograph  on  the  left  is  taken  from  the  side,  in  order  to  show  the  extent 
of  the  antero-posterior  curvature  of  the  bones. 

of  the  sternum,  produce  what  is  known  as  the  rickety  rosary.  The 
swelling  is  more  marked  on  the  pleural  aspect  than  on  the  outer  side 
of  the  bone  (Fig.  277).  If  there  is  any  obstruction  to  the  entrance 
of  air  into  the  lungs,  as  from  tracheitis  or  bronchitis,  the  atmospheric 
pressure  may  cause  the  softened  bone  and  cartilage  to  sink  inwards, 
and  as  a  result  of  this  the  sternum  may  be  pushed  forwards  [pigeon 


584 


A   MANUAL  OF  SURGERY 


breast),  wliilst  the  curvature  of  the  ribs  nt  the  anpjle  is  increased.  A 
very  characteristic  feature,  of  the  rickety  change  consists  in  the 
lateral  groove  thus  produced  on  each  side  of  the  sternum,  which  may 
meet  with  a  transverse  depression  below,  caused  by  the  projection 
of  the  lower  floating  ribs  by  the  tumid  abdomen. 

The  pelvis  is  flattened  antero-posteriorly,  or  more  rarely  tri- 
radiate,  tlie  former  condition  being  produced  when  the  patient  lies 
hal  itually  on  his  back,  the  latter  only  occurring  when  walking  is 

permitted,  the  acetabula  being  then 
pressed  inwards  and  backwards  by  the 
heads  of  the  femora. 

The  deformity  of  the  long  hones 
(Fig.  278)  usually  consists  in  an  in- 
crease in  their  natural  curves,  especially 
at  points  where  powerful  muscles  are 
attached.  The  femora  are  curved 
antero-posteriorly,  and  the  tibiae  in  a 
similar  direction,  although  there  is 
often  some  lateral  displacement  super- 
added. Most  commonly  the  lower  end 
of  the  tibia  is  bent  inwards — i.e.,  in  a 
direction  opposite  to  that  represented 
in  Fig.  278.  Genu  valgum  or  varum 
may  also  result  from  these  changes 
(pp.  452,  455,  and  456). 

When  the  acute  stage  of  rickets  has 
passed  away,  any  deformities  present 
become  fixed  by  the  complete  ossifica- 
tion of  the  softened  bony  tissues.  As 
a  rule  the  density  of  such  deformed 
bones  is  increased,  whilst  their  natural 
shape  is  altered  by  deposits  of  new 
subperiosteal  bone  or  struts  in  the 
concavities,  so  that  on  section  they 
are  usually  more  or  less  flattened  from 
side  to  side,  and  the  medullary  canal 
appears  to  be  displaced  towards  the 
convexity.  Growth  is  often  checked  by  this  disease,  and  thus 
the  individual  becomes  stunted  and  dwarf-like. 

Pathologically,  the  chief  changes  in  rickets  are  found  in  the 
neighbourliood  of  the  epiphyses.  Ordinarily,  the  epiphyseal  car- 
tilage is  a  lamella  about  a  line  in  thickness,  bounded  on  either  side 
by  a  zone  of  calcified  tissue,  containing  regular  alveolar  spaces 
filled  with  vascular  medulla,  and  lined  by  osteoblasts,  passing 
gradually  into  normal  cancellous  bone.  Tn  rickets  the  epiphyseal 
cartilage  is  not  only  circumferentially  enlarged,  but  also  thickened 
and  irregular  (Fig.  279),  outgrowths  of  cartilage  projecting  on  either 
side  into  the  calcified  tissue,  which  is  more  abundant  and  more 
open  in  texture  than  usual,   whilst  it  passes  irregularly  into  the 


Fig.  279. — Section  through 
Lower  End  of  Rickety 
Radius,  showing  Exagger- 
ated Depth  and  Irregular 
Borders  of  the  Prolifer- 
ating Epiphyseal  Carti- 
lage. 

(From  Ashby  and  Wright's 
'  Diseases  of  Children.') 


DISEASES  OF  BONE  5S5 

cancellous  bone.  Thus,  there  is  an  increased  preparation  f(jr  the 
formation  of  bone,  but  the  ossifying  process  is  inefficiently  carried 
out.  In  addition  to  this,  the  Haversian  canal  systems  and  the 
nirtlullary  spaces  in  the  diaphyses  are  enlarged,  so  that  the  bones 
become  weaker  and  less  rigid  from  the  insufficient  amount  of  lime 
salts  present,  and  thus  readily  bend  under  the  weight  of  the  body 
or  from  muscular  action.  Less  frequently  the  subperiosteal  com- 
pact bone  becomes  similarly  rarefied.  When  the  disease  comes  to 
an  end,  the  deformities  may  persist,  but  the  bone,  now  effectively 
ossified,  becomes  harder  and  stronger  than  usual. 

In  the  Treatment  of  rickets  the  most  essential  feature  in  the  early 
stages  is  the  correction  of  all  errors  in  the  personal  hygiene.  The 
diet  should  consist  of  good  cow's  milk,  diluted  if  need  be,  and  with 
lime-water  added;  whilst  the  juice  expressed  from  raw  beef,  or  one 
of  the  many  meat  juices  now  sold,  may  also  be  administered.  The 
condition  of  the  bowels  must  be  attended  to,  and  the  child  placed 
in  as  good  surroundings  as  possible.  Cod-liver  oil  must  be  adminis- 
tered, together  with  Parrish's  food  (syr.  ferri  phos.  co.) .  Deformities 
must,  if  possible,  be  prevented  by  keeping  the  child  in  the  recumbent 
posture  and  not  allowing  it  to  crawl  or  run  about.  The  early  stages 
of  deformity  in  young  children  can  often  be  corrected  by  daily 
manipulation  of  the  affected  bones;  for  the  legs,  it  may  suffice  to 
keep  them  off  their  feet,  as  by  a  splint  which  extends  from  the 
thighs  6  inches  below  the  soles;  a  certain  amount  of  pressure  can 
also  be  exercised  by  this  appliance.  Osteotomy,  or  even  resection 
of  portions  of  bone,  is  required  in  the  severer  cases  where  the 
deformity  persists,  and  the  bony  changes  have  become  consolidated 
(seep.  457). 

Adolescent  Rickets  comes  on  about  puberty,  and  is  usually  independent  of 
an  early  rachitic  history,  although  in  a  few  cases  it  may  be  looked  on  as  a 
recrudescence  of  the  infantile  ailment.  Imperfect  nutrition  is  probably  a  less 
important  aetiological  factor  than  in  infancy;  but  strain,  mental  or  ph^'sical, 
combined  with  defective  hygiene,  has  been  present  in  most  instances.  Ihe 
chief  changes  are  to  be  found  in  the  shafts  of  the  long  bones  of  the  legs,  which 
become  bent  from  the  superjacent  weight  of  the  body.  Deformities  in  the 
upper  extremities  are  less  frequent.  Enlargement  of  the  epiphyses  is  also 
observed.  There  is  usually  no  sweating  of  the  head,  but  the  patient  is  pale, 
and  complains  of  fatigue  and  languor,  but  not  of  pain.  The  softened  bones 
bend,  and  no  buttresses  or  struts  are  formed  in  the  concavities;  hence  the 
deformities  produced  are  often  serious,  and  the  course  of  the  case  is  slow. 
(See  Fig.  170,  which  occurred  in  a  girl  of  thirteen  years,  the  subject  of  this 
affection.)  Treatment  must  be  directed  towards  an  improvement  of  the  general 
health  and  of  the  conditions  of  life;  undue  mechanical  strain  must  be  avoided, 
and,  if  need  be,  the  patient  kept  at  rest.  Deformities  are  dealt  with  by  the 
use  of  orthopaedic  appliances  or  by  osteotomy. 

Infantile  Scurvy  [syn.  :  Barlow's  Disease^  Scurvy  Rickets,  Hsemorrhagic 
Rickets). — This  condition,  first  accurately  described  by  Sir  Thomas  Barlow, 
presents  the  symptoms  of  scurvy  in  a  rachitic  child,  and  in  its  manifestations 
either  one  or  the  other  set  of  phenomena  may  predominate.  It  is  usually 
seen  in  the  children  of  well-to-do  people  from  four  to  eighteen  months  old, 
and  apparentlv  arises  from  defective  nutrition,  especially  from  the  prolonged 
administration  of  peptonized  or  prepared  foods,  or  even  possibly  of  sterilized 
milk.     In  the  slighter  cases  there  may  be  but  little  evidence  of  the  scorbutic 


586  A   MANUAL  OF  SURGERY 

condition,  beyond  the  fact  that  in  a  rickety  child  there  is  some  tendency 
for  the  glims  to  bleed,  or  a  little  hematuria;  but  in  those  that  are  more  marked 
the  rickety  signs  are  of  little  importance  compared  with  those  due  to  haemor- 
rhagic  extravasations.  The  disease  often  comes  on  suddenly  with  some 
amount  of  pyrexia,  rarely  exceeding  102°  F.,  but  the  child  is  evidently  ill, 
and  perhaps  complains  of  tenderness  of  the  limbs,  which  mav  l)e  kejit  so  (juiet 
as  to  suggest  that  they  are  paralyzed.  This  is  followed  by  the  appearance  of 
swellings  of  some  size,  due  to  sub-periosteal  extravasations,  the  skin  over  the 
affected  parts  being  at  first  shiny  and  (Edematous,  but  subsequently 
becoming  stained  by  the  blood-pigment.  The  femur  and  tibia  are  most  often 
affected  in  this  way,  and  the  epiphyses  may  occasionally  become  detached, 
or  evxn  spontaneous  fractures  occur.  Bleeding  may  also  take  place  beneath 
the  conjunctiva  or  in  the  orbit,  leading  to  protrusion  of  the  eyeball,  whilst 
there  may  be  blood-stained  diarrhoea,  haematuria,  or  epistaxis. 

The  disease,  when  recognised,  is  readily  amenable  to  treatment,  but  should 
its  nature  be  overlooked,  the  child  is  likely  to  become  emaciated  and  die. 
Attention  to  the  diet  is  the  main  point  to  be  attended  to,  for  when  fresh  milk, 
lime-juice,  or  vegetables  are  given,  the  symptoms  soon  disappear.  The 
affected  limbs  must  be  kept  at  rest,  and  cooling  lotions  applied,  whilst  splints^ 
aie  required  when  epiphyses  are  separated  or  fractuies  have  occurred. 

Achondroplasia  (Chondrodystrophia  foetalis)  is  a  curious  congenital  con- 
dition, somewhat  rescmV)ling  rickets,  in  which  the  growth  of  osseous  tissue 
on  the  shaft  side  of  the  epiphyses  of  the  long  bones  of  both  arms  and  legs 
is  defective,  so  that  the  limbs  are  short  and  stunted,  and  the  stature  corre- 
spondingly diminished,  although  the  epiphyses  are  normal.  The  bones 
generally  are  not  bent  or  curved  abnormally,  though  there  is  probably  some 
change  of  the  neck  or  shaft  of  the  femur,  resulting  in  lordosis,  which  is  very 
marked  when  the  patient  stands.  The  fingers  taper  to  their  tips,  and  are 
separated  one  from  another  in  '  spoke-like  '  fashion.  The  bones  at  the  base 
of  the  skull,  being  of  cartilaginous  origin,  undergo  premature  synostosis, 
whilst  the  upper  half  of  the  skull,  being  derived  from  membrane,  and  therefore 
developing  naturally,  looks  unusually  large;  the  face  is  small,  and  the  bridge 
of  the  nose  depressed  as  in  congenital  syphilis.  The  children,  if  they  live, 
are  usually  efficient  in  their  mental  development,  and  the  thyroid  body 
normal.     Xo  known  treatment  is  of  anv  value. 

Osteo-genesis  imperfecta  (or  idiopathic  psathyrosis)  is  a  rare  congenital  con- 
dition, characterized  by  a  defective  development  of  osseous  tissue  from 
cartilage,  so  that  the  bones  are  brittle  or  soft,  and  thus  are  easily  bent  or 
broken,  constituting  a  condition  of  fragilitas  ossium.  Nothing  is  known  as 
to  aetiology,  except  that  there  is  a  strong  hereditary  tendency.  Not  a  few 
of  the  subjects  are  stillborn,  with  broken  or  deformed  limbs,  whilst  many  die 
within  the  first  year  of  life.  Cases  in  which  fractures  occur  more  or  less 
spontaneously  and  frequently  in  older  life  are  probably  due  to  some  other 
condition,  such  as  osteo-malacia.  If  the  child  lives,  one  fracture  occurs 
after  another,  and  the  limbs  may  become  terriblv  deformed,  although  with 
care  they  sometimes  unite  very  well.  In  addition  to  the  deformities  due  to 
the  malunion  of  fractures,  the  JDones  are  usually  bent  and  distorted,  and  thus 
the  case  may  be  confused  with  rickets  or  osteo-malacia.  The  cranial  bones 
sometimes  participate  in  the  process,  and  the  basi-occiput  may  be  driven 
upwards  into  the  cranial  cavity  by  the  thrust  of  the  spine;  this  condition  is 
demonstrable  by  radiography.  The  actual  anatomical  changes  in  the  bones 
consist  in  the  persistence  of  cartilage  cells  in  their  capsules  and  calcification 
of  the  trabeculae  between,  very  little  f)one  being  formed  and  that  of  a  defective 
type.  No  known  remedies  are  of  any  avail,  and  all  that  can  l)c  done  is  to 
protect  the  patient  from  mechanical  injuries  and  treat  the  fractures  as  they 
occur. 

Mollities  Ossium  (m  ».  .•  Osteo-malacia)  is  an  acquired  disease  of  somewhat 

unusual  occurrence,  characterized  by  the  absorption  of  the  osseous  substance 

of  the  bones,  as  a  result  of  which  softening  and  rarefaction  are  produced, 

followed  by  bending  or  spontaneous  fracture. 

The  complaint  is  almost  limited  to  the  female  sex  (only  <S  per  cent,  of  the 


DISEASES  OF  BONE  587 

cases  reported  arc  in  males),  and  often  commences  during  pregnancy;  it  is 
said  to  be  sometimes  connected  with  a  rheumatic  tendency.  Any  part  of 
the  skeleton  may  be  affected;  in  females  the  change  usually  attacks  the  pelvis, 
si)inal  column  and  ribs  first,  and  the  limbs  later;  in  men  the  process  starts 
ia  the  long  liones. 

Pathologically,  the  change  consists  in  a  replacement  of  the  medullary  sub- 
stance by  a  soft  fibro-cellular  tissue,  which  is  exceedingly  vascular,  and  into 
which  haemorrhage  often  occurs;  the  resulting  material  looks  in  the  fresh  state 
somewhat  like  splenic  pulp.  The  bony  cancelli  are  absorbed,  as  also  the 
greater  part  of  the  compact  tissue,  with  the  exception  of  a  thin  layer  situated 
beneath  the  periosteum;  in  a  well-marked  case  the  mineral  salts  may  be 
diminished  to  about  one-sixth  of  their  normal  amount,  but  the  relative  pro- 
portion of  phosphate  of  lime  to  the  carbonate  is  not  changed.  Part  of  the 
bone  substance  remains  for  a  time  in  a  decalcified  state,  with  the  corpuscles 
evident,  but  in  a  condition  of  fatty  degeneration.  Possibly  some  acid^ 
e.g.,  lactic  acid — is  the  active  agent  in  dissolving  the  earthy  salts,  which 
escape  partly  in  the  urine,  partly  in  the  faeces.  The  process  is  probably  con- 
nected with  the  absorption  of  some  internal  secretion,  normal  or  vitiated, 
particularly  that  from  the  ovary,  since  the  removal  of  the  uterine  appendages 
has  in  a  few  cases  stayed  the  disease. 

Clinically,  the  onset  is  somewhat  indefinite,  the  only  complaint  being  of 
pain  in  various  parts  of  the  body,  whilst  the  patient  becomes  emaciated  and 
exhausted.  Sooner  or  later  skeletal  changes  ensue  and  demonstrate  the 
character  of  the  disease.  In  women  the  mischief  usually  commences  m  the 
pelvis,  which  becomes  flattened  at  first,  and  subsequently  triradiate,  owing 
to  the  acetabula  being  pressed  inwards  and  backwards  by  the  weight  of  the 
body,  and  in  pregnant  women  this  may  cause  so  much  deformity  as  to  necessi- 
tate' C^sarian  section.  The  spine  becomes  curved,  whilst  the  limbs  bend 
and  break;  in  the  latter  case  sometimes  no  attempt  at  repair  is  made,  or  healing 
may  occur  with  deformity.  Death  may  result  from  exhaustion,  or  from 
obstruction  to  parturition,  or  the  patient  may  live  more  or  less  bedridden  for 
years,  the  limbs  becoming  useless,  shortened,  and  perhaps  contorted  in  a 
strange  and  abnormal  fashion.  In  women  the  disease  may  cease  to  progress, 
or  even  recovery  may  occur  at  the  menopause. 

Treatment  is  unsatisfactory.  Opiates  may  be  administered  to  relieve  pam, 
which  is  often  very  severe,  and  various  drugs,  such  as  alum,  and  phosphate  or 
hypophosphite  of  lime,  have  been  recommended.  In  cases  not  associated 
with  parturition  or  pregnancy,  oophorectomy  is  said  to  have  been  employed 
with  benefit.  The  induction  of  premature  labour  is  considered  by  some  to 
be  beneficial,  not  only  for  the  sake  of  obviating  the  necessity  for  such  opera- 
tions as  Caesarian  section,  but  also  on  the  chance  of  checking  the  disease. 

Osteitis  Deformans. 

Osteitis  deformans  is  an  inflammatory  disease  of  the  osseous  skeleton,  first 
described  by  Sir  James  Paget  in  1876.  The  onset  is  insidious,  and  the  progress 
very  slow.  It  is  characterized  by' a  painful  overgrowth  of  the  long  bones, 
spine,  cranium,  and  pelvis,  which  are  also  softened,  so  that  those  which  bear 
the  weight  of  the  body  become  curved.  It  may  commence  in  one  bone  alone, 
and  then  usually  the  tibia  or  femur,  but  more  often  many  bones  are  affected 
at  the  same  time.  Attention  may  be  drawn  to  the  condition,  either  by  the 
pain,  which  the  patient  at  first  considers  to  be  rheumatic,  or  by  the  general 
enlargement  and  bending  of  the  bones,  or  by  the  increased  size  of  the  head, 
necessitating  the  use  of  larger  hats.  The  cranial  overgrowth  is  eccentric  m 
character,  and  the  calvarium  may  become  very  thick;  the  facial  skeleton, 
however,  is  not  much  affected.  The  spine  becomes  markedly  k>^hotic 
(Fig.  280),  the  dorsal  curve  being  increased,  and  the  lumbar  concavity  ob- 
literated ;  it  is  nearly  rigid  from  ankylosis  of  the  vertebrae,  and  may  be  very 
painful.  In  the  later  stages  the  head  is  carried  forwards  by  the  bent  spine,  the 
height  is  diminished,  the  shoulders  are  round,  and  the  chest  sunken  towards 


588 


A   MANUAL  OF  SURGERY 


the  pelvis;  the  gait  is  slow  and  awkward.  The  disease  usually  attacks  middle- 
aged  men;  its  progress  is  exceedingly  slow,  the  patient  often  living  to  an 
advanced  age,  or  dying  from  some  intercurrent  malady.  Some  cases  have 
terminated  in  multiple  sarcomata  of  the  bones.  The  structure  of  the  os.seous 
tissue  is  suggestive  of  intlammatory  rather  than  degenerative  changes.  It 
is  softer  and  more  uniform  in  structure  than  usual,  the  difference  between  the 
cancellous  and  compact  tissue  being  less  defined;  the  Haversian  canals  are 
large    and  arranged  irregularlv,  whilst  the  bonv  substance  looks  chalky. 


Fig.  280. — Early  Stage  of  Osteitis  Deformans.     (From  Photographs 


Differential  Diagnosis. — From  arthritis  deformans,  which  it  resembles  by 
the  attitude  and  gait  of  the  patient,  it  is  known  by  the  absence  of  articular 
lesions,  especially  in  the  fingers,  and  the  enlargement  of  the  bones,  notably 
of  the  cranium.  From  acromegaly  it  is  distinguished  by  the  absence  of  enlarge- 
ment of  the  hands,  feet,  and  lower  jaw. 

Treatment  is  most  unsatisfactory,  no  remedy  at  present  known  having  any 
control  over  the  disease. 

Acromegaly. 

Acromegaly  is  a  rare  condition,  the  characteristics  of  which  were  first  de- 
scribed by  Dr.  Pierre  Marie  in  1885.  It  is  a  general  affection  involving  mainly 
the  osseous  system,  commencing  usually  in  young  adults,  and,  after  lasting 
for  a  long  time,  killing  the  patient  by  syncope  or  cerebral  compression,  if  some 
intercurrent  malady  does  not  destroy  him. 

It  is  characterized  by  a  very  definite  enlargement  of  the  hands  and  feet, 
which  are,  however,  not  lengthened,  so  that  the  hands  have  been  compared 
to  battledores,  and  the  fingers  to  .sausages.  The  bones  themselves  are  enlarged, 
and  the  soft  structures  on  the  palmar  aspects  project  as  pads.     The  nails  and 


DISEASES  OF  BONE 


589 


skin  arc  unchanged,  whilst  the  other  segments,  both  of  the  upper  and  lower 
limbs,  arc  usually  unaffected,  though  sometimes  considerable  overgrowth  in 
length  occurs;  in  fact,  many  of  the  so-called  giants  who  have  been  exhibited 
are  typical  illustrations  of  acromegaly.  Both  the  upper  and  lower  jaws  are 
thickened  and  prominent,  whilst  the  lower  lip  is  enlarged  and  overhanging. 
The  orbital  ridges  project,  and  the  forehead  is  usually  low;  the  nose  and  tip 
of  the  tongue  are  also  more  or  less  enlarged.  The  spine  is  kyphotic  in  the 
dorsal  region,  with  a  slight  lumbar  lordosis.  The  ribs  and  sternum  project 
anteriorly. 

The  patient  usually  suffers  from  headache,  lassitude,  and  great  fatigue, 
wandering  pains  about  the  body,  and  excessive  appetite  and  thirst;  amenor- 
rhcva  is  a  marked  symptom  in  women,  whilst  men  suffer  from  a  loss  of  virile 
power.  The  urine  is  abundant,  but  of  a  low  specific  gravity.  Vision  is 
usuallv  diminished,  and  optic  neuritis  has  been  observed  in  some  cases. 


Fig.  281.- 


-Head  of  Woman  with  Acromegaly. 

AND    FROM    THE    SiDE.* 


Seen  from  the  Front 


Morbid  Anatomy. — The  cause  of  acromegaly  appears  to  be  overgrowth  of 
the  anterior  half  of  the  pituitary  body,  and  excessive  absorption  of  its  secre- 
tion (hvperpituitarism) .  The  sella  turcica  is  expanded,  and  this  can  be 
recognised  by  X  rays.  The  changes  in  the  bones  are  merely  those  of  over- 
growth. 

Diagnosis. — The  disease  has  been  mistaken  for  myxcedema,  but  there  is  not 
much  difficulty  in  distinguishing  the  two  if  it  be  remembered  that,  in  the  latter 
condition,  the  skin  is  not  mobile  over  the  thickened  subcutaneous  tissue,  that 
the  face  is  broad,  pasty,  and  puffy,  and  that  masses  of  gelatinous  tissue  are 
found  above  the  clavicle,  whilst  in  acromegaly  the  face  is  elongated  and  the 
skin  and  subcutaneous  tissues  normal.  The  mental  condition  and  speech 
of  a  patient  suffering  from  myxoedema  are  widely  different  from  those  in 
acromegaly;  whilst  in  the  former  the  thyroid  body  is  either  absent  or  diseased, 
and  in  the  latter  skeletal  changes  are  present.  From  chronic  osteo-arthritis 
affecting  the  hands,  the  diagnosis  is  easy,  in  that  there  are  usually  no  signs 
of  articular  disease,  and  much  less  pain.  From  osteitis  defoymans,  the  dis- 
tinguishing features  have  already  been  indicated. 

Medical  Treatment  is  merely  symptomatic,  antipyrine  being  useful  in  re- 
lieving the  headache,  as  also  valerianate  of  caffeine.     Possibly  thyroid  extract 


*  Reproduced  from  the  Edinburgh  Medical  Journal,  by  kind  permission  of 
the  late  Dr.  G.  A.  Gibson. 


590 


A   MANUAL  OF  SURGERY 


may  be  of  some  use  in  combating  tlie  functional  phenomena,  though  it  will 
not  influence  the  skeletal  changes.  Attempts  have  lieen  made  to  remove  the 
growth  by  operation  tlnough  the  nose  anil  base  of  the  skull,  and  with  some 
degree  of  success,  though  naturally  the  mortality  is  high  (p.  77'^). 

Hypertrophic  Osteo- Arthropathy.* 

It  has  long  been  known  that  clubbing  of  the  ternnnal  jihalanges  is  associated 
with  chronic  j)ulmonary  and  cardiac  disease;  and  it  is  probal)le  that  such  is 
the  earliest  stage  of  this  more  generalized  affection,  liist  described  by  Pierre 
Marie.  In  it  the  ends  of  the  lingers  and  toes  are  enlarged  and  bulbous,  with 
the  nails  curved  over  towards  the  jialm  or  sole;  in  tlie  early  stages  the  change 
may  be  limited  to  the  soft  tissues,  but  radiography  has  demonstrated  that 
in  the  later  there  is  a  well-marked  new  formation  of  bone  along  the  shafts  of 
the  phalanges  and  also  of  the  metatarsal  and  metacarpal  bones.  There  is  a 
considerable  swelling  of  the  bones  just  above  the  wrists  and  ankles,  extending 
some  way  along  the  shafts,  and  similar  bony  enlargements  sometimes  occur 
elsewhere;  they  aic  due  to  a  diffuse  osteo-pcriostitis.  The  spine  is  kyphotic 
in  the  upper  dorsal  region,  but  with  well-marked  lordosis  below.  It  is  thus 
seen  that  the  changes  are  somewhat  like  those  of  acromegaly,  from  which 
they  are  distinguished  by  (a)  the  implication  chiefly  of  the  lingers  and  toes, 
and  particularly  of  the  terminal  phalanges,  whilst  in  acromegaly  the  enlarge- 
ment of  the  different  portions  of  the  hands  and  feet  is  general;  {b)  the  nails 
are  not  affected  in  acromegaly;  [c]  the  joints  are  but  little  involved  in  acro- 
megaly; and  [d)  the  enlargements  of  face,  tongue,  jaw,  etc.,  so  marked  in  acro- 
megaly, are  absent  in  osteoarthropathy.  These  phenomena  probably  result  from 
chronic  toxic  absorption,  since  the  condition  arises  in  such  diseases  as  chronic 
bronchitis,  bronchiectasis,  and  chronic  empyema,  where  suppuration  has 
existed  for  some  time.  It  is,  however,  sometimes  associated  with  lesions  other 
than  pulmonary — e.g.,  chronic  jaundice,  syphilis,  and  even  influenza,  and  has 
even  been  found  in  otherwise  apparently  healthy  individuals.  Little  can  be 
done  in  the  way  of  treatment,  except  to  deal  with  the  cause,  if  obvious. 

Tumours  oJ  Bone. 

The  characters  of  the  osteomata,  chonckomata,  and  fibromata  of 
bone  have  been  described  in  Chapter  IX.,  and  various  stjlid  and 
cystic  tumours  connected  with  the  teeth  are  dealt  with  elsewhere. 
"  Myeloma  (Fig.  283)  is  practically  a  benign  tumour,  rarely  giving 
rise  to  secondary  deposits  either  in  lymphatic  glands  or  viscera,  and 
its  growth  within  the  bone  is  strictly  limited,  with  no  tendency  to 
diffusion  along  the  medulla;  occasionally  a  layer  of  condensed  bone 
demonstrable  by  radiography  forms  an  effective  barrier  in  this 
direction.  For  its  pathological  features,  see  p.  211.  The  sites  of 
election  for  myeloid  tumours  are  the  growing  ends  of  the  long  bones, 
especially  the  lower  ends  of  the  femur  and  radius,  and  the  upper 
ends  of  the  humerus,  tibia  and  fibula,  whilst  they  also  occur  in  the 
diploe  and  lower  jaw,  and  constitute  one  form  of  epulis.  The 
development  of  the  tumour  leads  to  the  so-called  expansion  of  the 
bone,  in  which  the  osseous  tis.sue  is  absorbed  from  the  inner  aspect, 
and  new  bone  is  laid  down  externally;  the  outer  layers,  however, 
gradually  become  thinned,  so  that  after  a  time  the  osseous  lamina 
can  be  pressed  inwards,  giving  rise  to  a  feeling  known  as  '  egg-shell 

*   See  Janeway,  Amer.  Jonrn.  of  Med.  Sci.,  October,  1903. 


DISEASES  OE  BONE 


591 


crackling  ';  and  Unally  tlic  tumour  projects  through  the  bony  wall, 
i  his  expansion  may  be  central,  and  the  bone  end  thus  becomes 
more  or  less  globular,  or  it  may  be  eccentric,  and  then  the  growth 
projects  merely  on  one  side.  vSooner  or  later  spontaneous  fracture 
is  likely  to  occur.  Neighbouring  joints  usually  escape,  but  in  old- 
standing  cases  the  growth  may  project  arcjund  the  articular  cartilage 
and  somewhat  impair  the  movements;  there  may,  however,  be 
some  serous  effusion  in  the  cavity.  The  Symptoms  may  be  so  slight 
at  the  commencement  that  nothing  is  noted  until  fracture  has 
taken  place;  but  sometimes  pain  similar  to  that  of  a  chronic  osteo- 
periostitis draws  attention  to  the  enlargement  of  the  bone.  Radio- 
graphic examination  reveals  a  well-defined  area  of  bone  which  is 
unduly  translucent,  but  with  a  characteristic  '  stippling,'  due  to 
the  presence  of  calcareous  foci  scattered  through  the  growth 
(Fig.  282).  The  accurate  limita- 
tion of  the  growth,  and  its  de- 
marcation from  the  medullary 
cavity,  are  important  diagnostic 
signs. 

Treatment  is  governed  by  the 
assurance  that  a  myeloma  is  non- 
malignant,  and  hence  may  be 
dealt  with  in  a  conservative 
manner  by  a  localized  removal 
of  the  growth,  amputation  being 
reserved  for  the  more  advanced 
cases  and  for  those  where  a  local 
removal  would  leave  a  more  or 
less  useless  limb.  In  quite  the 
early  stages  it  suffices  to  incise 
the  growth  and  scrape  it  away 
with  a  sharp  spoon,  disinfecting 
the  cavity  with  liquefied  carbolic 
acid,  and  packing  it  with  gauze 
to  ensure  healing  by  granulation. 

or  X  rays  is  desirable  in  order  to  ensure  total  destruction  of  any 
remaining  portions  of  the  growth.  In  a  later  stage  the  affected 
portion  of  the  bone  must  be  completely  removed,  and  if  necessary 
the  gap  thus  produced  bridged  by  bone  grafting.  Thus  a  myeloid 
tumour  of  the  upper  end  of  the  fibula  can  be  treated  by  excision, 
care  being  taken  of  the  external  popliteal  nerve  and  its  branches; 
but  if  the  upper  end  of  the  tibia  or  lower  end  of  the  femur  is  involved, 
amputation  will  usualh'  be  required,  although  bone  grafting  may  be 
sufficient  to  make  good  the  defect.  When  affecting  the  lower  end 
of  the  radius  or  upper  end  of  the  humerus,  and  not  in  too  advanced 
a  stage,  an  attempt  may  be  made  to  save  the  limb  by  excising  the 
diseased  portion  of  bone.  In  the  wrist  the  lower  part  of  the  ulna 
is  taken  away,  as  well  as  the  growth  in  the  radius;  by  this  plan  there 
is  less  chance  of  the  hand  being  drawn  up  and  abducted,  and  hence 


r 

1 

1 

*; 

1 

^ 

j 

n 

■ 

1 

\_- 

i^H^H 

Bi 

Fig.  282. — Radiograph  of  Mye- 
loma OF  Outer  End  of  Clavi- 
cle. (By  Favour  of  Dr. 
Salmond.) 

Exposure  of  the  part  to  radium 


592 


A   MANUAL  OP  SUliGERY 


it  is  Diurc  likely  to  be  of  use  subsequently,  especi;illy  it'  ;i  leather 
yauntlet  is  worn. 

Sarcoma  is  the  most  important  primary  tumour  of  bones,  and 
eilmo'^t  any  variety  may  occur.  The  microscopical  characters  have 
been  detailed  in  the  chapter  on  tumours,  and  we  shall  here  chiefly 
refer  to  their  clinical  characteristics.  They  may  be  divided  into  two 
main  groups — the  endosteal  or  central,  and  the  periosteal. 

Central  Round-  or  Spindle-celled  Sarcoma  is  of  an  extremely 
malignant  nature.  There  is  usually  more  pain  in  its  development, 
which  is  much  more  rapid  than  with  a  myeloid  growth,  but  the 


Fig.  283. — Myeloma  of  Head  of  Tibia. 
(King's  College  Hospital  Museum.) 


Fig.  284. — Round-celled  Endos- 
teal Sarcoma,  disseminating 
Itself  in  the  Medullary 
Cavity.  (King's  College 
Hospital  Museum.) 

bone  may  be  but  little  expanded  (Fig.  284),  since  the  growth  tends 
rather  to  diffuse  itself  along  the  medullary  cavity,  and  encroaches 
more  closely  upon  the  neighbouring  joint.  The  outer  wall  is  likely 
to  be  absorbed  earlier  than  in  a  myeloid,  and  invasion  of  the  sur- 
rounding tissues  or  spontaneous  fracture  results.  Lymjihatic  glands 
and  viscera  are  soon  involved  by  dissemination  of  the  disease.  The 
tumour  substance  itself  is  usually  of  a  soft  nature,  not  containing 
much  newly-formed  bone;  cartilaginous  and  myxomatous  foci  are 
often  associated  with  it.  The  growth  is  highly  vascular,  and  cysts 
may  form  therein,  but  not  so  frequently  as  in  the  myeloid  tumours 


J)lSJ;ASIiS  OJ:   BONE 


593 


l\;uli()grai)hy  shows  an  irregular  removal  of  bony  tissue,  and  there  is 
no  sharj)ly  defined  limiting  zone  of  thickened  bone  (Fig.  287).  The 
rapidit\'  of  growth  and  the  radiographic  characters  are  the  features 
on  \\  hich  a  diagnosis  of  a  malignant  endosteal  sarcoma  must  be  based. 
Periosteal  Sarcomata  are  round-  or  spindle-celled  in  nature,  and 
occur  less  frequently  than  the  endosteal  variety.  They  often 
develop  rapidly  without  giving  rise  to  much  pain,  unless  causing 
erosion  of  the  bone.  They  usually  start  on  one  side,  but  may 
surround  the  whole  circumference  later  on,  and  spread  for  some 
distance  along  the  shaft.     A  high  degree  of  malignancy  is  attained 


4f^  t' 


Fig.  285. — Soft  Periosteal  Sarcoma 
OF  Lower  End  of  Femur,  eroding 
Bone  and  leading  to  Spontaneous 
Fracture.  (King's  College 
Hospital  Museum.) 


Fig.  286. — Ossifying  Periosteal 
Sarcoma  of  Fibula.  (King's 
College  Hospital  Museum.) 


by  them,  secondary  growths  forming  in  lymphatic  glands  or  the 
viscera.  Ossification  often  occurs  in  their  substance  with  or  with- 
out the  previous  development  of  cartilage,  and  in  such  cases  the 
subjacent  bone  may  become  sclerosed  and  thickened,  so  that  spon- 
taneous fracture  is  not  common  in  this  variety.  The  bony  skeleton 
of  such  a  growth  is  very  characteristic,  consisting  of  fine  spiculated 
trabecule ,  radiating  more  or  less  regularly  from  the  surface,  and 
looking  in  the  dried  state  somewhat  hke  asbestos  (Fig.  286) .  These 
ossifying  sarcomata  have  a  very  characteristic  appearance  on  radio- 
graphy (Fig.  288).     When  a  periosteal  sarcoma  does  not  become 

38 


594 


A   MANUAL  OF  SURGERY 


ossified,  the  growth  often  erodes  the  underlying  bone  (Fig.  285), 
and  ma}'  lead  to  spontaneous  fracture;  the  tumour  in  such  cases 
is  softer  and  more  elastic  than  in  the  fomier  variety,  and  usually 
attacks  the  bone  from  one  side  and  not  equally  all  round.  Osseous 
sarcomata  are  always  exceedingl}'  vascular,  and  may  even  pulsate, 
whilst  the  superficial  veins  are  obviously  chlated  beneath  the 
stretched  integument,  giving  rise  to  a  blue  network. 

The  Diagnosis  of  osteo-sarcoma  in  the  early  stages  is  often  a 
matter  of  the  greatest  difficulty.     The  endosteal  form  may  easily 


Fig.  2S7. — Radio(.,kam  of  En- 
dosteal Sarcoma  of  Upper 
End  of  Humerus,  burrow- 
ing   ALONG    THE    ShAFT    AND 

CAUSING  Spontaneous  Frac- 
ture. 


Fig.    2S8. — Radiogram    of   Periosteal 
Sarcoma  of  Lower  End  of  the  Femur. 

The  irregular  outgrowths  of  ossific 
material  arc  very  characteristic,  as 
also  the  limitation  of  the  growth  to 
the  diaphysis. 


be  mistaken  for  chronic  osteo-periostitis,  medullar}^  gumma,  or  a 
deep  abscess  of  the  bone,  and  can  sometimes  only  be  distinguished 
from  them  by  an  exploratory  incision  and  microscopic  examination 
of  a  portion  of  the  growth;  this  should  always  be  undertaken  in 
doubtful  cases  prior  to  radical  operations,  such  as  amputation.  In 
the  later  stages,  the  presence  of '  egg-shell  crackling  '  or  cystic  changes 
\\\\\  help  to  make  evident  the  nature  of  the  disease.  The  periosteal 
form  may  at  first  be  looked  upon  as  a  periosteal  node,  or  a  deeply- 
placed  abscess.     The  rounded  and  definite  edge  of  the  growth,  its 


DISEASES  OF  BONE  595 

iricgular  consistency,  and  the  history  of  the  case,  will  assist  in  the 
determination  of  its  nature;  but  in  the  early  stages  an  exploratory 
operation  is  not  unfrequently  necessary.  For  the  diagnosis  of  a 
pulsating  sarcoma  from  an  aneurism,  see  p.  312.  When  either  form 
involves  the  articular  end  of  a  bone,  especially  the  lower  end  of  the 
femur,  it  may  simulate  tuberculous  disease  of  the  adjacent  bone.  It 
will,  however,  be  noted  that  the  centre  of  the  swelling  corresponds 
to  a  point  well  above  or  below  the  joint,  that  a  certain  amount  of 
movement  is  possible  and  even  painless,  whilst  the  starting  pains  at 
night  characteristic  of  joint  mischief  are  absent.  The  age  of  the 
patient,  and  the  presence  or  not  of  cachexia,  are  also  important 
features  which  have  to  be  taken  into  consideration.  Radiographic 
examination  serves  in  most  cases  as  an  important  diagnostic 
adjuvant. 

It  is  of  the  greatest  importance  that  a  clear  opinion  as  to  the 
diagnosis  be  made  at  the  earliest  possible  moment,  as  thereby  both 
prognosis  and  treatment  are  immensely  influenced.  Periosteal  sar- 
comata have  a  bad  prognosis,  as  general  dissemination  occurs  early; 
the  small  spindle-celled  are  the  worst.  Secondary  deposits  often 
contain  ossific  material — e.g.,  in  the  lungs.  Central  sarcomata  are 
not  quite  so  malignant,  althougli  the  round-celled  variet}'  is  decidedly 
unfavoural:)le. 

The  Treatment  of  osteo-sarcoma  is  eminentl}'  unsatisfactory,  as., 
even  though  the  most  radical  measures  are  taken,  recurrence  is  only 
too  frequently  observed,  or  death  from  secondary  deposits  occurs 
in  spite  of  a  successful  issue  locally;  hence  the  importance  of  a 
thorough  investigation,  and,  if  need  be,  of  an  early  exploratory 
incision  in  doubtful  cases,  cannot  be  over-estimated.  Formerly,  the 
rule  that  governed  surgical  practice  was  to  amputate  the  limb 
well  above  the  growth  in  all  cases,  and  to  ascertain  by  microscopic 
examination  of  the  medulla  at  the  time  that  it  was  free  from  disease. 
Ihus,  for  a  tumour  of  the  lower  end  of  the  tibia,  amputation  through 
the  knee  would  be  practised;  if  the  upper  end  of  the  tibia  is  in- 
volved, amputation  through  the  middle  of  the  thigh;  and  for  a 
growth  of  the  lower  end  of  the  femur,  disarticulation  at  the  hip-joint 
would  be  required  for  a  periosteal  growth,  though  for  an  endosteal 
one  just  below  the  trochanters  might  suffice.  For  a  sarcoma  of  the 
upper  end  of  the  humerus,  disarticulation  of  the  shoulder  was  thought 
to  be  scarcely  sufficient ;  it  was  usually  considered  wiser  to  remove 
the  scapula  in  addition  (interscapulo-thoracic  amputation). 

The  results  of  such  treatment  have  been  so  bad,  and  dissemination 
of  the  growth  to  the  lungs  so  constant,  that  surgeons  are  now 
doubting  the  desirability  of  such  mutilating  procedures,  and  trusting 
rather  to  the  effects  of  local  excision,  where  feasible,  followed  by 
treatment  with  radium,  X  rays,  or  Coley's  fluid.  In  some  cases 
disappearance  or  diminution  of  the  primar\^  growth  have  been  re- 
ported after  burying  radium  in  its  substance  for  twenty-four  or 
fortj'-eight  hours,  but,  of  course,  this  does  not  in  any  way  touch  the 
question  of  secondary  deposits.     From  an  early  diagnosis,  and  that 


596 


A   MANUAL  OF  SURGERY 


alone,  can  any  improvement  be  expected  in  the  terrible  statistics 
of  the  results  of  treatment  of  this  dreadful  disease. 

Secondary  Sarcoma  of  bone  is  by  no  means  imcommon.  It  is 
almost  always  endosteal  in  character,  and,  except  in  the  most  un- 
usual circumstances,  will  not  demand  treatment,  owing  to  the 
general  infection  of  the  system.  Possibly  where  it  has  led  to 
spontaneous  fracture,  and  there  is  much  pain  owing  to  the  dilftculty 
of  fixation,  it  would  be  justifiable  to  remove  the  limb. 

Carcinoma  of  bone  is  always  secondary  in  nature,  although  it  may 
be  inN"o]\'ed  by  direct  extension  in  a  primary  growth.     Secondary 

growths  are  endosteal  in  char- 
acter, and  often  extremely 
painful;  they  may  occasion- 
rdly  lead  to  spontaneous 
fracture  (Fig.  289),  but  the 
bone  may  consolidate  again 
satisfactorily.  After  scirrhus 
mammpe,  the  upper  end  of 
the  femur  and  vertebra  are 
the  bones  most  often  affected, 
apart  from  those  of  the  chest 
wall. 

For  the  so-called  Thyroid 
Cancer  of  bone,  see  ]).  894. 

Pulsating  Tumours  of  Bone, 
or  Osteo-Aneurism.  —  Apart 
from  pulsating  sarcoma,  two 
other  conditions  are  met  with, 
in  which  distinct  pulsation  is 
also  noticeable.  In  the  first 
of  these  the  medullary  cavity 
is  occupied  by  a  non-malig- 
nant vascular  tissue,  prac- 
tically identical  with  what 
has  been  already  described 
as  an  aneurism  by  aiiasfoiiiosis 
(P-  353)-  Such  tumours  are 
situated  most  frequently  in 
the  cranial  bones,  and  may 
be  multiple,  the  medullary  tissue  being  in  consequence  atrophied, 
and  the  compact  tissue  thinned,  so  that  '  egg-shell  crackling ' 
may  be  obtained.  The  second  form  is  found  most  commonly 
in  the  upper  end  of  the  tibia,  or  some  such  cancellous  mass. 
It  consists  of  a  hollow  cavity,  filled  with  blood.  Several  distinct 
arterial  twigs  may  open  into  it,  and  the  overlying  bone  is  thinned 
and  absorbed.  It  is  probable  that  the  majority  of  such  cases  are 
in  reality  due  to  the  breaking  down  of  a  sarcoma  of  extreme 
teniiity,  or  possiblv  of  a  myeloma. 

Treatment." — If  it  seems  probable  that  the  condition  is  not  asso- 


FiG.  289.  —  Radiogram  of  Secondary 
Carcinoma  of  Upper  End  of  Femur, 
resulting  in  spontaneous  fracture. 

The  primary  disease  was  in  the  breast. 


DISEASES  OF  BONE  597 

ciatcd  with  nuilignant  disease,  the  cavity  slu)uld  be  incised,  scraped, 
swabbed  out  with  pure  carbolic  acid,  and  then  hrmly  packed  with 
gauze,  so  as  to  obtain  healing  by  granuhition  from  the  bottom. 
If  the  bleeding  persists,  amputation  is  the  only  treatment,  as  also 
in  the  malignant  cases. 

Hydatid  Disease  of  Bone.— The  cancellous  tissue  of  bones  occa- 
sionally becomes  the  site  of  hydatid  development,  any  part  either 
of  the  medullary  cavity  or  of  the  ends  being  involved.  The  bone 
becomes  expanded,  with  all  the  symptoms  of  an  endosteal  growth. 
Considerable  deformity  may  occur,  and  when  the  compact  layer  lias 
been  sufticiently  absorbed,  spontaneous  fracture  may  follow.  In 
this  affection  there  is  no  limiting  wall,  the  small  daughter  cysts  being 
diffused  through  the  affected  area.  A  diagnosis  is  little  likely  to  be 
made  (at  any  rate  in  countries  where  hydatid  disease  is  rare)  prior 
to  an  exploratory  incision.  Treatment.— If  all  the  cysts  can  be 
removed  without  interfering  with  the  integrity  of  the  shaft,  a 
recovery,  with  good  subsequent  utility  of  the  limb,  should  follow. 
Where,  however,  the  disease  has  encroached  widely  on  the  bony 
tissue  whether  spontaneous  fracture  has  occurred  or  not,  amputa- 
tion holds  out  the  only  prospect  of  cure,  unless  bone-grafting  is 
feasible.  .  .   . 

Simple  Cysts  o!  Bone  are  observed  most  frequently  m  the  tibia  or 
upper  end  of  the  humerus.  The  condition  develops  insidiously, 
probably  without  pain,  and  may  be  mistaken  for  a  sarcoma,  the 
true  state  of  affairs  not  being  recognised  until  after  amputation  ot 
the  limb  •  or  attention  may  be  drawn  to  the  part  by  the  occurrence 
of  a  spontaneous  fracture.  The  cyst  is  found  to  be  lined  with  a  thin 
layer  of  fibrous  tissue,  with  no  endothelial  covering.  The  actual 
pathology  is  not  clear,  but  it  is  thought  possible  that  it  is  akin  to 
osteitis  deformans  or  osteo-malacia,  since  in  all  three  conditions  the 
true  bony  tissue  disappears  and  the  medullary  tissue  increases,  in 
■  osteo-malacia  it  remains  fatty;  in  osteitis  deformans  new  irregular 
bone  is  deposited  in  its  place;  and,  in  this  condition  there  is  a  new 
formation  of  fibrous  tissue,  which,  however,  subsequently  becomes 
cystic.  This  osteitis  fibrosa,  as  it  has  been  termed,  may  be  more  or 
less  generalized  through  a  bone,  or  may  be  locahzed,  and  then  a 
simple  cyst  may  develop.  The  only  available  means  of  diagnosis, 
apart  from  incision,  is  radiography.  The  thinning  of  the  bone  is 
more  regular  than  in  any  sarcomatous  condition,  and  there  is  a  com- 
plete absence  of  motthng  or  detail  such  as  is  usually  seen  in  cases  ot 
myeloid  disease.  Treatment  consists  in  laying  open  the  cavity, 
scraping  it  out,  and  packing,  so  as  to  determine  healing  by  granula- 
tion; or  by  excising  the  affected  portion  of  bone,  and  replacing  it 
by  a  bone  graft. 

Bone-grafting  is  sometimes  required  to  replace  the  normal  bone 
in  cases  of  comminuted  fractures  where  much  destruction  of  tissue 
has  occurred,  or  after  resection  of  portions  of  the  shaft  of  a  bone  tor 
tumours,  cysts,  or  caries. 

Formerly  fragments  of  dead  bone,  or  rods  of  ivory  or  bone,  were 


598  A   MANUAL  OF  SURGERY 

used  for  the  purpose,  but  it  has  been  abundantly  proved  that  they 
are  merely  passive  actors  in  the  process  of  regeneration,  being 
absorbed  or  replaced.  Living  bone,  on  the  contrary,  is  capable  of 
retaining  its  vitality  and  uniting  with  the  surn^unding  parts,  even 
if  totally  separated  from  its  former  osseous  connections. 

Much  discussion  has  arisen  as  to  whether  the  bone  graft  sliould  be 
covered  by  periosteum  or  not.  Some  claim  that  a  graft  with  its 
periosteum  intact  lias  a  greater  chance  of  living  and  uniting  with  the 
adjoining  bones  than  one  devoid  of  periosteal  covering,  because, 
although  it  is  believed  that  the  periosteum  itself  takes  no  active 
share  in  new  bone  formation,  it  conveys  nutrition  to  the  graft 
and  obtains  a  fresh  blood-supply  from  its  new  surroundings  more 
rapidly  than  does  uncovered  bone,  and  thus  secures  the  vitality  of 
the  graft.  This  idea,  however,  is  quite  open  to  question,  since  it  is 
possible  that  naked  bone  is  more  porous  and  permeable  to  newly- 
formed  vessels  than  periosteum.  As  a  matter  of  fact,  excellent 
results  have  been  gained  in  both  ways. 

The  graft  may  be  obtained  from  the  patient  himself  [anlogcnous) , 
or  from  another  patient  {Iioiiwgeneous),  or  from  a  freshly  killed 
animal  {heierogeneous).  Of  these,  the  first  method  is  usually  adopted, 
and  at  present  it  gives  the  best  results.  The  bone  is  usually  taken 
from  the  surface  of  the  tibia,  or  a  portion  of  the  whole  thickness 
of  the  fibula.  It  is  generally  employed  in  a  long  strip,  and  the  prac- 
tice of  breaking  it  up  into  small  fragments  has  no  obvious  advan- 
tages except  in  special  circumstances,  as  after  trephining.  The 
graft  is,  if  possible,  fixed  firmly  to  the  two  bony  ends,  between 
which  a  bond  of  union  is  required,  either  by  implantation  into  the 
suitably  prepared  medullary  cavities,  or  by  means  of  catgut  or  silk 
sutures.  Metal  plates,  wires,  or  screws  are  undesirable  means  of 
fixation.  New  bone  can  also  live  when  implanted  in  the  midst  of 
soft  tissues,  as  is  evident  from  grafts  surviving  which  have  been 
utilized  in  the  re-formation  of  a  nose.  Of  course,  in  all  cases  abso- 
lute asepsis,  both  of  the  graft  and  oi  the  cavit}^  in  which  it  is  placed, 
must  be  present,  and  therefore  it  is  useless  at  once  to  attemi)t  bone- 
grafting  in  the  cavity  left  by  the  removal  of  the  diaphysis  after  an 
attack  of  acute  osteomyelitis  which  has  caused  necrosis  of  the  whole 
shaft.  When  once  the  cavity  is  free  from  infection,  a  bone  graft 
may  be  introduced  with  some  prospect  of  its  survival. 


CHAPTER  XXII. 

INJURIES  OF  JOINTS- DISLOCATIONS. 

Sprains  and  Strains  result  from  sudden  violence  applied  to  a  joint 
either  directly  or  indirectly,  as  in  the  football  field  or  in  many 
laborious  occupations.  They  consist  in  a  tearing  or  stretching  of 
the  synovial  membrane,  partially  detached  portions  of  which  may 
be  tucked  inwards,  or  of  ligaments,  which  in  bad  cases  may  be 
torn  from  their  attachments  to  the  bones.  The  accident  itself  is 
associated  with  severe  pain,  and  is  immediately  followed  by  more  or 
less  haemorrhage  into  the  surrounding  tissues,  or  into  the  articular 
cavity.  Inflammatory  effusion  follows,  and  unless  suitably  treated, 
persistent  weakness  and  pain  may  result,  either  from  the  formation 
of  adhesions,  or  from  imperfect  repair.  A  neglected  sprain  may 
originate  tuberculous  disease  in  those  who  are  so  predisposed,  whilst 
osteo-arthritis  is  by  no  means  an  uncommon  sequela.  If  the  patient 
is  in  a  bad  state  of  health  at  the  time  of  the  injury,  an  attack  of 
acute  infective  arthritis  may  be  determined.  Treatment. — The 
joint  should  be  firmly  supported  by  a  wet  bandage  as  soon  after  the 
accident  as  possible,  in  order  to  limit  the  amount  of  effusion.  The 
part  is  raised  and  kept  quiet,  and  the  bandage  dabbed  over  with 
evaporating  lotion  from  time  to  time.  In  the  slighter  cases  the 
patient  may  be  allowed  to  use  the  limb  in  a  few  days,  the  part  being 
supported  by  strapping  or  an  elastic  bandage;  but  in  severe  sprains 
it  may  be  necessary  to  keep  the  part  absolutely  at  rest  for  a  much 
longer  period,  before  the  pain  and  tenderness  disappear.  Friction 
with  stimulating  liniments,  douching  the  joint  alternately  with  hot 
and  cold  water,  massage,  passive  and  active  movements,  and  finally 
exercises  against  resistance,  are  useful  in  restoring  the  limb  to  full 
functional  activity. 

Penetrating  Wounds  of  Joints  are  often  accompanied  by  an  escape 
of  synovia,  which  is  recognised  as  a  glairy,  oily  fluid,  floating 
perhaps  on  the  surface  of  the  blood;  if,  however,  the  aperture  is 
small,  this  may  not  occur.  It  is  always  followed  by  a  certain 
amount  of  reaction,  the  character  of  which  depends  on  whether  or 
not  the  joint  is  infected.  If  no  infection  has  taken  place,  a  simple 
synovitis  ensues,  but  soon  passes;  if,  however,  infection  has  occurred, 

599 


6oo  A   MANUAL  OF  SURGERY 

acute  arthritis  proljably  supervenes,  leading  to  disorganizati(jn  of 
the  joint.  (For  symptoms  and  treatment,  see  p.  634.)  A  pene- 
trating wound,  even  if  untreated,  does  not  necessarily  become 
infected;  thus,  if  the  lesion  is  produced  by  a  small,  clean  instrument, 
and  especially  if  this  is  inserted  in  a  slanting  direction,  so  that 
the  wound  is  valvular,  or  if  the  incision  is  a  large  one,  allowing  free 
vent  t(j  all  discharges,  recovery  without  infection  is  possible. 

Treatment. — If  the  wound  is  small,  and  there  is  reason  to  believe 
that  the  instrument  inflicting  it  was  aseptic,  the  external  skin 
should  be  thoroughly  purified,  and  an  antiseptic  dressing  applied. 
A  careful  watch  must  be  kept  upon  the  condition  of  the  joint  and 
upon  the  temperature  of  the  patient;  as  soon  as  any  signs  of  acute 
arthritis  manifest  themselves,  free  incisions  are  made  into  the  joint, 
so  as  to  relieve  tension,  and  allow  the  cavity  to  be  irrigated.  If, 
however,  the  wound  is  dirty,  and  probably  involves  the  joint,  it 
should  be  enlarged  so  that  its  depths  may  be  purified,  and  then 
carefully  examined.  If  it  is  found  that  the  cavity  has  been  opened, 
the  aperture  should  be  increased  in  size  so  as  to  allow  it  to  be  washed 
out  and  a  drainage-tube  inserted.  Bier's  treatment  may  assist  in 
preventing  infection,  but  if  it  supervenes,  the  condition  must  be 
treated  in  the  usual  way. 

Dislocations. 

Congenital  Dislocation. — This  term  is  applied  generally  to  any 
irregularity  of  location  of  the  bony  constituents  of  a  joint  present 
at  birth,  but  is  rather  due  to  an  error  of  development  than  to  any 
forcible  displacement.  The  hip-joint  is  most  frequently  affected; 
but  similar  malformations  have  occurred  in  the  shoulder,  wrist,  and 
jaw,  whilst  the  patella  may  be  congenitally  absent  or  displaced. 
For  congenital  dislocation  of  the  hip,  see  p.  447. 

Pathological  Dislocations  are  produced  as  the  result  of  some  intra- 
articular affection,  e.g.,  tuberculous  disease,  osteo-arthritis,  Charcot's 
disease,  etc.     It  is  unnecessary  to  describe  them  here. 

Traumatic  Dislocations. — The  Causes  are  divided  into  predisposing 
and  exciting.  Under  the  former  head  may  be  included  anatomical 
peculiarities,  such  as  the  shallow  socket  of  the  glenoid  cavity,  or 
some  muscular  or  ligamentous  weakness.  Dislocations  are  rare  in 
children,  since  any  violence  directed  to  a  joint  or  its  neighbourhood 
is  more  likely  to  lead  to  an  epiphyseal  separation.  Moreover,  in  old 
people  the  bones  become  brittle,  and  thus  fractures,  rather  than 
dislocations,  are  produced;  hence  the  latter  lesions  are  almost 
limited  to  adults,  and,  owing  to  their  greater  exposure  to  injury, 
occur  in  men  rather  than  in  women. 

The  Exciting  Causes  are  the  application  of  external  violence  and 
muscular  force,  acting  alone  or  in  combination.  The  former  may 
be  direct,  but  is  more  commonly  indirect,  the  force  being  applied  at 
a  distance  from  the  joint.  Muscular  action  by  itself  can  only  pro- 
duce dislocation  in  certain  joints;  the  head  of  the  humerus,  the 
patella  and  condyle  of  the  jaw,  are  the  bones  most  often  affected  in 


INJURIES  OF  JOINTS— DISLOCATIONS  6oi 

this  way.  If,  however,  the  Hgaments  of  a  joint  have  been  stretched 
by  previous  disease  or  disphicement,  recurrent  dislocations  from 
muscular  action  are  not  unusual. 

The  term  complete  dislocation,  or  luxation,  is  applied  to  that  con- 
dition in  wliich  the  articular  surfaces  of  the  bones  are  completely 
sej^arated  from  one  another.  An  incomplete  dislocation,  or  sitbliixa- 
tion,  is  one  in  which  the  surfaces  are  only  partially  separated. 

A  compound  dislocation  is  one  in  which  the  skin  has  been  ruptured 
and  a  communication  established  with  the  external  air.  A  com- 
f^licated  dislocation  is  one  in  which  there  has  been  some  associated 
injury  of  vessels,  nerves,  or  viscera.  The  term  fracttive-dislocation 
is  one  applied  to  a  condition  in  which  a  dislocation  is  complicated  by 
fracture  of  one  or  both  bones  involved. 

The  Signs  of  a  dislocation  are  as  follows:  (i)  The  evidences  of  a 
local  trauma,  e.g.,  pain,  bruising,  and  swelhng  of  the  soft  tissues, 
due  to  their  laceration  and  the  effusion  of  blood  into  them:  the 
amount  of  this  varies  in  different  cases;  (2)  deformity  of  the  limb, 
due  to  the  articular  end  of  the  displaced  bone  being  in  some  ab- 
normal position,  where  it  can  often  be  felt  and  sometimes  seen;  and 
(3)  restricted  mobility  of  the  affected  joint,  and  hence  impairment  of 
function  of  the  limb.  The  degree  to  which  this  latter  phenomenon 
obtains  is  necessarily  variable,  but  as  a  rule  it  is  very  marked;  if, 
however,  fracture  is  also  present,  passive  movements  may  be 
possible,  though  associated  with  pain  and  crepitus. 

The  Effects  produced  by  a  dislocation  extend  to  all  the  structures 
entering  into  and  surrounding  the  site  of  injury.  The  ligaments  are 
partially  or  completely  torn ;  the  bony  surfaces  are  not  unfrequently 
fractured,  especially  in  closely-fitting  hinge  joints,  such  as  the  elbow 
and  ankle;  the  cartilages  may  be  bruised,  or  portions  of  them 
detached,  and  neighbouring  muscles  and  tendons  lacerated  and  dis- 
placed; adjacent  vessels  and  nerves  are  often  contused  or  com- 
pressed. Considerable  effusion  of  blood  is  always  present,  infiltrating 
the  whole  area  involved. 

The  character  of  the  injury  explains  the  difficulties  that  are  met 
with  in  its  reduction.  These  arise  from  two  main  causes:  {a)  The 
anatomical  arrangement  of  the  joint  and  its  ligaments,  resulting  in 
the  hitching  of  bony  prominences  against  one  another,  whilst  the 
head  of  the  bone  does  not  always  lie  opposite  the  hole  in  the  capsule 
through  which  it  originally  passed.  In  a  few  cases  the  end  of  the 
bone  may  be  grasped  by  neighbouring  ligaments  and  tendons  in  such 
a  way  as  to  render  its  replacement  a  matter  of  the  greatest  diffi- 
culty, {b)  Muscular  contraction  also  constitutes  an  obstacle,  which, 
though  it  can  be  counteracted  by  suitable  traction,  is  more  effectively 
overcome  by  the  use  of  an  aucesthetic.  Not  only  does  the  patient 
maintain  the  limb  in  a  condition  of  rest  by  a  voluntary  tonic  con- 
traction, but  it  becomes  fixed  by  the  involuntary  passive  tension  of 
the  displaced  muscles. 

When  once  reduced,  there  is  usually  but  little  tendency  for  a  dis- 
location  to   recur.     Reparative   changes   quickly  manifest   them- 


6o2 


A   MANUAL  OF  SURGERY 


selves;  hlood-rlot  is  absorlK'd,  the  rent  in  the  capsule  closes  by 
cicatrization,  and  in  many  cases  no  permanent  lesion  remains;  in 
some,  however,  the  joint  is  left  in  a  weak  and  relaxed  state,  and 
liable  to  a  recurrence  of  the  displacement,  while  intra-articular 
adhesions,  or  the  cicatricial  contraction  of  the  injured  ligaments 
and  muscles,  may  cause  some  loss  of  mobility. 

If  a  dislocation  is  allowed  to  remain  unreduced,  the  true  articular 
cavity  becomes  shallow  and  partly  filled  up  by  a  transformation  of 
its  cartilage  into  fibrous  tissue,  whilst  the  displaced  head  of  the  bone 
becomes  adiierent  to  the  structures  amongst  which  it  lies;  as  the 
result  of  a  })lastic  inflammation,  eitlier  dense  fibrous  adhesions  are 


V 


A 


Fig.  290. — Old-Standing  Subcoracoid  Dislocation  of  the  Shoulder, 
SHOWING  Atrophy  of  True  Glenoid  Cavity,  together  with  Forma- 
tion OF  New  Joint  and  Alteration  in  Shape  of  Head  of  Bone. 
(From  College  of  Surgeons'  Museum.) 


formed,  or  a  new  false  joint  {pseudarihroi^is).  The  articular  cartilage 
is  eroded,  and  the  exposed  bone  eburnated  and  sclerosed,  whilst, 
owing  to  chronic  periostitis,  the  end  of  the  shaft  may  be  considerably 
deformed.  The  portion  of  bone  upon  which  the  disi)laced  head 
rests  undergoes  changes,  partly  atrophic  (from  pressure),  partly 
hypertrophic  (as  a  result  of  chronic  periostitis),  whereby  a  new 
socket  is  produced  (Fig.  290).  Neighbouring  muscles  are  second- 
arily shortened,  and  accommodate  themselves  to  the  abnormal 
position  of  the  limb,  and  tendons  which  have  been  torn  gain  fresh 
attachments.  These  changes  necessarily  interfere  more  or  less 
seriously  with  the  power  of  the  limb  and  the  movements  of  the 
joint.  Serious  pain  is  not  unfrequently  caused  by  pressure  on 
neighbouring  nerves. 


INJURIES  OF  JOINTS— DISLOCATIONS  603 

Treatment. — ^The  treatment  of  dislocations  consists  in  tlie  reduc- 
tion of  the  displaced  bone  with  as  little  delay  as  possible.  There  are 
two  chief  methods  of  gaining  this  end,  viz.,  manipulation  and 
extension. 

iMdnipiUation  is  always  the  best  means  to  employ  where 
practicable,  less  injury  being  sustained  by  the  surrounding  tissues. 
It  consists  in  moving  the  limb  in  such  directions  as  shall  cause  the 
displaced  end  to  retrace  the  course  that  it  has  already  taken, 
through  the  rent  in  the  capsule  to  its  normal  position.  The  shoulder 
and  hip  joints  are  more  amenable  to  this  method  of  treatment  than 
hinge  joints.  Anaesthesia  will  be  required  in  chfficult  cases,  and 
especially  in  dislocations  of  the  shoulder  and  hip  joints.  Chloro- 
form is  generally  preferred,  as  inducing  deeper  muscular  relaxation 
but  where  the  patient  is  in  a  bad  state  for  the  administration — i.e., 
with  his  stomach  full  of  food — ether  may  be  preferable.  It  is  only 
right  to  draw  attention  to  the  fact  that  a  large  number  of  fatal  cases 
of  chloroform  administration  have  been  reported  as  occurring  in 
the  treatment  of  shoulder  dislocations ;  this  is  due  mainly  to  two 
causes,  viz.,  the  deep  anaesthesia  required,  and  the  want  of  prepara- 
tion of  the  patient.  The  greatest  care  must  therefore  be  exercised 
in  giving  the  anaesthetic,  and  for  the  hip-joint  spinal  analgesia  might 
be  preferable. 

Extension  is  employed  to  overcome  muscular  and  other  forms  of 
resistance,  so  as  to  allow  the  bone  to  slip  back  or  be  manipulated 
into  its  original  position.  In  order  to  make  this  effectual,  the  parts 
above  the  dislocation  are  steadied  by  some  counter-extending  force 
apphed  either  by  the  hands  of  an  assistant,  or  by  a  belt  or  towel,  or 
by  the  knee  or  foot  of  the  surgeon.  Extension  may  be  made  by  the 
hands,  or  a  firmer  grip  may  be  maintained,  and  greater  force  used, 
by  applying  a  bandage  or  towel  to  the  limb.  In  a  few  cases,  the 
force  may  be  exerted  through  some  form  of  multiplying  pulley,  fixed 
at  one  end  to  a  hook  or  staple,  and  at  the  other  end  attached  to  the 
limb.  When  any  such  contrivance  is  employed,  precautions  must 
be  taken  to  prevent  the  soft  tissues  from  being  injured.  A  useful 
plan  consists  in  applying  a  damp  bandage  at  the  point  from  which 
traction  is  to  be  made,  and  over  this  a  thick  skein  of  worsted  in  the 
form  of  a  clove-hitch,  the  loop  being  attached  to  the  hook  of  the 
pulley.  The  extension  must  be  made  continuously;  no  jolting  or 
jerking  action  is  allowable,  or  considerable  mischief  may  ensue. 
Since  the  introduction  of  anaesthetics,  however,  pulleys  have  been 
very  rarely  required. 

Reduction,  however  produced,  is  usually  accompanied  by  a  sudden 
and  distinct  snap  or  suction  sound,  due  to  the  contraction  of  muscles, 
unless  the  patient  is  deeply  under  an  anaesthetic,  and  the  muscles 
are  absolutely  relaxed.  The  limb  is  subsequently  kept  at  rest  for 
some  days,  to  allow  the  rent  in  the  capsule  to  heal,  but  massage  may 
be  started  in  a  day  or  two,  and  passive  movements  after  a  week. 

The  treatment  of  an  unreduced  dislocation  is  often  a  matter  of  con- 
siderable difficulty.     Attempts  at  reduction  may  be  undertaken  up 


6o4  A   MANUAL  OF  SURGERY 

tu  two  or  three  months,  but  the  greatest  caution  must  be  employed 
for  fear  of  rupturing  adhesions  and  endangering  the  main  v(!ssels  or 
nerves.  Extension  by  pulleys  has  given  rise  to  so  many  accidents, 
varying  in  severity  from  laceration  of  the  skin  to  actual  avulsion 
of  the  limb,  that  it  is  wise  to  discontinue  such  treatment  if  it  has 
failed  on  its  first  application. 

The  amount  of  mobility  possible  in  an  unreduced  dislocation  varies 
a  good  deal  in  different  cases,  and  the  character  of  the  treatment  is 
mainly  governed  by  this.  If  movement  is  tolerably  free,  and  not 
particularly  painful,  massage  and  manipulation  may  be  undertaken, 
and  a  very  useful  limb  result.  Where,  however,  movement  is  both 
])ainful  and  limited,  one  or  other  of  the  following  plans  of  operative 
treatment  should  be  undertaken:  (i.)  Reduction  by  an  open  operation. 
The  head  of  the  bone  is  cut  down  on,  and  freed  from  its  adhesions 
to  surrounding  structures,  the  capsule  of  the  joint  being  also  opened 
and  the  cavity  cleared;  reduction  may  then  be  possible  by  means  of 
maniimlation  or  extension.  A  few  cases  of  successful  treatment  of 
old-standing  dislocations  of  the  shoulder  by  this  means  have  been 
recorded;  but  as  a  rule  the  gain  derived  thereby  is  scarcely  com- 
mensurate with  the  risks  and  difficulties  of  the  operation,  especially 
if  a  considerable  interval  has  elapsed  since  the  accident,  (ii.)  Ex- 
cision of  the  displaced  head  of  the  bone  will  give  the  best  results  in 
most  cases.  In  the  elbow-joint  it  is  often  the  only  practicable  treat- 
ment, and  in  the  shoulder  and  hip  it  is  usually  better  than  attempt- 
ing open  reduction. 

Compound  dislocations  are  always  serious  lesions,  for  not  only  are 
adjacent  vessels  and  nerves  liable  to  injury,  but  unless  efficient 
treatment  is  adopted,  suppurative  arthritis  ensues,  leading  to  dis- 
organization of  the  articulation,  with  subsequent  ankylosis,  or,  in  the 
case  of  larger  joints,  possibly  to  death  from  pyaemia  and  toxic 
poisoning.  The  treatment  consists  in  rigid  antisejisis  to  the  wound, 
together  with  reduction  of  the  dislocation  and  temporary  drainage. 
If  necessary,  the  opening  in  the  skin  must  be  enlarged,  in  order  to 
allow  of  the  replacement  of  the  bone,  and  should  the  latter  structure 
be  much  bruised  or  injured,  it  may  be  advisable  to  resect  it  at  once. 
If,  however,  vessels  and  nerves  are  also  injured,  or  if  the  patient  is 
old  or  debilitated,  amputation  may  be  required. 

Special  Dislocations. 

Dislocation  of  the  Lower  Jaw  forwards  is  not  a  very  common 
accident,  and  usually  results  either  from  muscular  action,  or  from  a 
blow  on  the  chin  when  the  mouth  is  widely  open,  as  in  gaping,  laugh- 
ing, or  attempting  to  take  a  large  bite.  It  has  also  been  produced  in 
dentistry  by  a  violent  strain  during  tooth-drawing,  or  from  digging 
out  nwts  with  an  elevator.  In  some  persons  the  accident  ha])pens 
with  the  greatest  ease,  and  constantly  recurs,  owing  probably  to  laxity 
of  the  capsule  or  insufficient  development  of  the  eminentia  articularis. 

The  mechanism  of  the  dislocation  is  as  follows:  When  the  mouth 


INJURIES  OF  JOINTS— DISLOCATIONS 


605 


Fig.  291. — Dislocation  of  Jaw. 


is  opened,  the  condyle  of  the  jaw  slips  forwards  on  to  the  eminentia 
articularis,  and  it  requires  very  little  force  to  displace  it  still  further 
into  the  zygomatic  fossa  (Fig.  291).  The  inter-articular  cartilage 
follows  the  condyle,  and  the  attachment  of  the  external  pterj-goid 
muscle  to  that  structure  and  to  the  bone  explains  the  (occurrence 
of  dislocation  from  muscular  action. 

The  displacement  may  be  unilateral  or  bilateral,  more  frequently 
the  latter.  The  mouth  remains 
widely  open,  the  teeth  and  the 
jaws  being  separated  by  an  in- 
terval of  about  an  inch.  The 
lower  jaw  projects  unduly,  and 
is  fixed,  saliva  dribbling  over  the 
lip;  speech  and  deglutition  are 
impaired,  the  pronunciation  of 
the  labial  consonants  being 
especially  difficult.  A  hollow 
can  be  detected  immediately  in 
front  of  the  tragus,  where  the 
condyle  is  normally  lodged, 
and  in  front  of  this  hollow  the 
condyle  can  be  felt,  being 
recognised  by  the  slight  amount 
of  passive  movement  still 
possible.  A  finger  in  the  mouth  may  define  the  coi  onoid  process  in 
an  abnormal  position  beneath  the  zygoma. 

When  the  dislocation  is  unilateral,  the  symptoms  are  much  less 
marked.  Some  amount  of  movement  of  the  jaw  still  remains,  whilst 
the  chin  is  displaced  towards  the  sound  side. 

Treatment. — Reduction  is  usually  easy.  All  that  is  needed  is  to 
depress  the  condyle  below  the  level  of  the  eminentia  articularis,  when 
the  masseter,  temporal,  and  internal  pterygoid  muscles  speedily  draw 
it  back  into  the  glenoid  cavity.  The  patient  is  seated  in  a  chair; 
the  surgeon  standing  in  front  protects  his  thumbs  with  thick  napkins, 
and  introduces  them  into  the  mouth,  pressing  upon  the  lower  molar 
teeth.  Pressure  is  continued  in  a  downward  and  backward  direction 
until  the  condyle  is  free,  and  then  the  chin  is  raised  by  the  fingers  on 
either  side.  The  jaw  is  kept  at  rest  for  a  week  or  ten  days  by  means 
of  a  four-tailed  bandage.     Anaesthesia  is  occasionally  necessary. 

A  few  cases  are  on  record  of  displacement  of  the  cond\de  oi  the 
jaw  hackitmrds,  associated  with  fracture  of  the  tympanic  plate  and 
tearing  or  separation  of  the  cartilage  of  the  auricle,  leading  to  bleed- 
ing from  the  ear.  Displacement  upwards  into  the  cranial  cavity 
through  the  roof  of  the  glenoid  fossa  has  also  been  described. 

Subluxation  of  the  Temporo-maxillary  Joint  is  due  to  displacement 
of  a  relaxed  interarticular  cartilage,  which  becomes  folded  or  nipped 
on  opening  the  mouth,  the  result  being  a  painful  temporary  fixation 
of  the  jaw  with  a  snap  or  crack  on  freeing  it.  The  condition  is 
associated  with  a  passive  synovial  effusion  into  the  joint,  and  may 


Go6  A   MANUAL  OF  SURGERY 

be  dealt  with  by  the  external  application  of  blisters;  should  this 
fail,  it  is  justihable  to  open  the  joint  and  fix  the  cartilage  by  sutures 
or  rcmox'c  it  i]).  81JK 

Dislocation  of  the  Sternal  End  of  the  Clavicle.  In  spite  of  the 
apparent  weakness  of  this  joint  and  the  great  strains  to  which  it  is 
subjected,  dislocation  is  uncommon,  owing  to  the  strength  of  the 
ligaments  surrounding  it,  particularly  of  the  rhomboid,  the  clavicle 
being  more  easily  broken  than  displaced.  The  cause  of  these  dis- 
locations is  always  violence  directed  to  the  outer  end  of  the  bone, 
and  since  that  usually  acts  from  in  front,  the  inner  end  of  the  bone 
is  generally  thrown  forwards.  Two  other  varieties  are  described, 
however,  in  which  the  displacement  is  backwards  or  upwards. 

In  the  forward  dislocation  the  end  of  the  bone  lies  on  the  anterior 
surface  of  the  manubrium,  where  it  can  be  easily  detected;  all  the 
ligaments  of  the  joint  are  torn,  except,  perhaps,  the  interclavicular. 
The  point  of  the  shoulder  is  approximated  to  the  middle  line.  Treat- 
menf.^  Reduction  is  effected  by  placing  the  knee  against  the  spine 
between  the  scapula,  and  drawing  the  shoulders  backwards,  the 
elbow  on  the  affected  side  being  kept  in  front  of  the  mid-axillary 
line.  To  prevent  recurrence,  the  shoulders  are  kept  back  by  hand- 
kerchiefs passed  round  the  axilla  and  knotted  together  in  the  middle 
line  behind,  as  for  a  fractured  clavicle  (p.  501).  The  elbow  is  then 
drawn  forwards  in  front  of  the  mid-axillary  line,  and  supported  by  a 
sling  or  bandage.  It  is  advisable  to  keep  the  patient  in  bed  for  a 
few  days,  so  as  to  give  the  ligaments  a  better  chance  of  re-uniting, 
but  some  amount  of  forward  displacement  is  very  likely  to  persist. 
No  bad  result  follows,  even  should  the  dislocation  remain  unreduced. 

The  backward  dislocation  is  not  often  seen.  The  end  of  the  bone 
lies  behind  the  upper  part  of  the  sternum,  and  pressure  upon  the 
trachea,  oesophagus,  and  vessels  of  the  neck,  result,  giving  rise  to 
difficulty  in  breathing  and  swallowing,  and  to  congestion  of  the 
head.  Reduction  and  after-treatment  are  similar  to  that  suggested 
for  the  former  variety.  If  the  condition  cannot  be  reduced,  and 
serious  symptoms  of  pressure  are  present,  the  end  of  the  bone  should 
be  excised. 

The  upward  dislocation  is  one  of  extreme  rarity,  the  end  of  the 
bone  lying  in  the  episternal  notch  behind  the  sterno-mastoid,  and 
compressing  both  trachea  and  oesophagus.  To  effect  reduction,  the 
shoulders  are  drawn  forcibly  backward^,  and  direct  pressure  applied 
to  the  end  of  the  bone. 

Dislocation  of  the  Acromio-clavicular  Joint  consists  in  the  acromion 
being  forced  either  above  or  below  the  outer  end  of  the  clavicle,  more 
commonly  the  latter.  Ihe  displacement  is  easily  recognised  by  the 
abnormal  prominence  of  one  or  other  of  the  bones.  It  usually 
results  from  violence  directed  to  the  scapula.  No  difficulty  is 
experienced  in  reduction,  but  the  displacement  is  ver\-  liable  to 
recur,  especially  in  the  more  common  form.  Ihe  elbow  is  then 
flexed  to  a  right  angle,  and  pads  of  lint  or  small  towels  placed  over 
the  acromion  and  beneath  the  elbow;  a  bandage  or  strap,  applied 


INJURIES  OF  JOINTS— DISLOCATIONS 


607 


over  the  slinuldor  and  under  the  elbow,  suffices  to  maintain  the  bone 
in  position.  The  strap  is  kept  from  shpping  by  passing  a  bandage 
under  it  round  the  opposite  side  of  the  chest.  Should  the  displace- 
ment persist,  the  bones  may  be  wired  together  after  bringing  the 
cartilaginous  surfaces  into  contact.  Care  must  be  taken  to  prevent 
subsequent  ankylosis  by  passing  the  wires  in  such  a  way  as  not  to 
encroach  on  the  joint  surfaces.  Either  they  may  be  passed  through 
the  bones  vertically,  or  as  a  mattress  suture  from  before  backwards. 
Dislocation  of  the  Shoulder  occurs  almost  as  frequently  as  all  the 
other  dislncations  of  the  body  put  together.  The  shallowness  of 
the  glenoid  cavity,  the  size  of  the  head  of  the  humerus,  the  laxity 
of  the  capsule,  the  extent  and  force  of  the  movements  possible,  and 
the  exposed  position  of  the  shoulder,  explain  the  great  frequency  of 
the  accident.  It  usually  results  from  falls  upon  the  hand  or  elbow, 
the  arm  at  the  time  oi  the  accident  being  widely  outstretched. 
The  weak  lower  and  inner  part  of  the  capsule  first  yields,  the  head  of 


Fig.  292. — Subglenoid  Dislocation 
OF  Shoulder.     (Tillmanns.) 


Fig.  293. — SuBcoRACoiD  Disloca 
TioN  OF  Shoulder.  (Tillmanns.) 


the  bone  being  primarily  displaced  downwards  into  the  axilla 
(subglenoid  variety),  and  then,  according  to  the  direction  of  the 
force,  or  the  character  of  the  subsequent  manipulations,  the  head 
travels  either  forwards  (subcoracoid  or  subclavicular  dislocation) 
or  backwards  (subspinous).  Falls  on  the  elbow  or  shoulder  may, 
however,  cause  a  direct  forward  or  backward  displacement. 

The  Signs  of  a  dislocation  of  the  shoulder  are  sufficiently  ob\'ious, 
and  certain  characteristic  features  are  present  in  almost  all  varieties, 
(i)  The  shoulder  looks  flattened,  owing  to  displacement  of  the  head 
inwards  (Figs.  212,  B,  and  294),  and  as  a  result  of  this  the  acromion 
process  is  unduly  prominent,  and  a  hollow  is  felt  below  it,  occupied  by 
the  tense  deltoid.  (2)  The  head  of  the  bone  lies  in  some  abnormal 
position,  and  the  glenoid  cavity  is  empty.  (3)  The  elbow  is  displaced 
awa\-  from  the  side,  and  it  is  impossible  to  make  it  touch  the  chest 
wall  at  the  same  time  that  the  hand  is  placed  on  the  opposite  shoulder 
(Dugas'  test) ;  this  does  not  always  obtain  in  the  subcoracoid  tj'pe. 


6o8 


A   MANUAL  OF  SURGERY 


(4)  The  vertical  measurement  round  the  axilla  is  increased  in  all  the 
varieties  (Callaway's  test) ;  whilst  inspection  reveals  a  lowering  of 
the  anterior  or  posterior  axillary  fold  (Bryant's  test).  (5)  A  ruler 
or  straight-edge  can  be  made  to  touch  both  the  acromif)n  process  and 
the  outer  condyle  of  the  elbow  in  most  cases  of  dislocation  (Hamil- 
ton's ruler  test) ;  this  is  impossible  when  the  head  of  the  bone  is  in  its 
normal  position,  but  can  also  occur  in  fractures  of  the  anatomical 
neck.  At  the  same  time,  the  usual  signs  of  a  dislocation,  viz., 
rigidity  and  local  bruising,  are  also  present.  Stereoscopic  radio- 
graphy is,  of  course,  invaluable  for  diagnostic  purposes. 

Subglenoid  Dislocation  (Fig.  292)  is  always  the  primary  condition 
when  due  to  a  fall  upon  tlie  outstretched  arm,  but  is  not  often  seen, 

since  further  dis- 
placement usually 
occurs  before  the 
case  comes  under 
observation.  The 
head  of  the  bone 
passes  down  into 
the  axilla,  resting 
against  the  outer 
border  of  the 
scapula  below  the 
glenoid  cavity,  be- 
tween thesubscapu- 
laris  above  and  the 
teres  minor  below, 
with  the  long  head 
of  the  triceps  be- 
liind.  The  capsu- 
V  "     lar     ligament     and 

^^^^  -  muscles  passing  to 

the  tuberosities  are 
torn,  whilst  the  ax- 
illary vessels  and 
nerves  may  be  seriously  compressed,  leading  to  numbness  of  the 
fingers.  The  head  of  the  bone  is  felt  in  the  axilla,  and  the  anterior 
axillary  fold  is  much  lowered;  the  elbow  is  directed  away  from  the 
side  and  slightly  backwards;  the  arm  is  lengthened,  perhaps  to  the 
extent  of  i  inch,  whilst  the  fore-arm  is  usually  flexed. 

A  few  cases  have  been  recorded  in  which  the  arm  was  alxlucted 
and  displaced  vertically  upwards,  although  the  head  of  the  bone  was 
in  the  usual  position  of  a  subglenoid  dislocation.  This  variety  is 
known  as  the  luxatio  erecta. 

Subcoracoid  Dislocation  (Figs.  293  and  294)  is,  without  doubt,  the 
most  common  form.  The  head  of  the  bone  lies  under  the  coracoid 
process  on  the  anterior  part  of  the  neck  of  the  scapula,  immediately 
in  front  of  the  glenoid  cavity,  the  anatomical  neck  impinging  on  its 
anterior  border.     In  this  position  it  is  above  the  tendon  of  the  sub- 


FiG.  294. — Subcoracoid  Dislocation  of  the  Right 
Shoulder. 


INJURIES  OF  JOINTS— DISLOCATIONS  609 

scapularis,  which  is  cither  torn  or  stretched  over  the  neck  as  a  tense 
band,  and  may  considerably  impede  reduction.  The  muscles 
attached  to  the  great  tuberosity  may  be  stretched,  resulting  in 
marked  external  rotation  of  the  limb  (subcoracoid  variety),  or  they 
are  torn,  or  even  the  great  tuberosity  itself  pulled  off,  the  humerus 
being  then  rotated  inwards  (intracoracoid  variety).  The  elbow  is 
displaced  backwards  and  outwards,  and  the  head  of  the  bone  can 
be  usually  felt  on  rotation  of  the  arm  under  the  outer  third  of  the 
clavicle.  Comparatively  little  alteration  is  produced  in  the  length 
of  the  arm. 

The  Subclavicular  variety  is  uncommon,  and  merely  an  exaggera- 
tion of  the  subcoracoid.  The  head  of  the  humerus  passes  further 
inwards,  and  lies  deeply  under  the  pectoralis  minor,  on  the  second 
and  third  ribs.  The  elbow  is  markedly 
separated  from  the  side  and  directed  a 
little  backwards,  whilst  distinct  shorten- 
ing is  present. 

The  Subspinous  Dislocation   (Fig.  295) 
is  unusual.      The  head  of  the  bone  hes 
in    the    infraspinous    fossa,    immediately 
behind  the  glenoid  cavity,  between  the 
infraspinatus    and    teres    minor  muscles, 
the   subscapularis   being    generally   torn. 
The  elbow  is  displaced  considerably  for- 
wards,  biat   can   be  made   to   touch   the 
chest  wall ;   the  arm  is  rotated  inwards, 
so    that   the  hand  is  thrown   across  the    fig.  295  .^Subspinous  Dis- 
front   of   the   body.      There  is  usually  a        location  of  Shoulder. 
marked  hollow  in  front  of  the  shoulder,        (Tillmanns.) 
whilst    a   prominence    is    caused   behind 

by  the  head  of  the  bone  in  its  false  position.  The  length  of  the 
Hmb  is  frequently  unaffected,  or  if  any  change  is  present,  the  arm  is 
slightly  lengthened. 

A  few  cases  have  been  described  of  what  is  known  as  a  Supra- 
coracoid  Dislocation.  The  head  of  the  bone  is  displaced  upwards, 
and  either  the  coracoid  or  acromion  process  is  broken,  more  com- 
monly the  former.  Replacement  with  crepitus  is  easily  obtained, 
but  the  dislocation  is  Hable  to  recur. 

The  Treatment  of  Dislocation  o£  the  Shoulder  consists  in  reduction 
by  manipulation  or  extension. 

I.  For  reduction  by  manipulation  an  angesthetic  is  always  ad- 
visable, but  must  be  given  with  caution.  Many  different  niethods 
of  manipulation  have  been  suggested,  of  which  the  following  are 
the  more  important.  Not  unfrequently,  however,  when  the  muscles 
are  relaxed,  any  slight  rotary  movement  suffices  to  "'  put  the 
bone  in.' 

Kocher's  Method  for  Subcoracoid  Dislocations. — The  surgeon  stand- 
ing in  front  of  his  patient,  who  is  seated  or  recHning,  and  supported 
by  an  assistant,  grasps  the  elbow  after  flexion  of  the  fore-arm,  and 

39 


Cio 


.1    MANUAL  OF  SURGERY 


Figs.  296,  297,  29S.  — Kocher's  Method 
OF  Reduction  of  a  Subcokacoid 
Dislocation  of  the  Shoulder. 


l)resses  it  to  tlie  side  and  slightly 
backwards.  With  one  hand  hold- 
ing the  wrist  and  the  other  the 
elbow,  the  arm  is  now  rotated 
iirmly  and  steadily  outwards 
as  far  as  it  will  go,  the  elbow 
still  being  pressed  to  the  side 
(Fig.  296) .  Distinct  resistance 
will  be  felt  during  this  move- 
ment, which  causes  the  head 
of  the  humerus  to  roll  out 
beneath  the  acromion,  and 
may  suffice  to  effect  reduction. 
If  the  limb  is  still  displaced, 
the  elbow  should  be  drawn 
forwards  and  upwards  as  far 
as  it  will  go,  with  the  hu- 
merus still  fully  everted 
(Fig.  297),  whilst  "finally  the 
arm  is  rotated  inwards  so  as 
to  carry  the  hand  towards 
the  opposite  shoulder,  and  the 
elbow  drawn  across  the  chest 
and  lowered  (Fig.  298).  All 
these  movements  should  be 
carried  out  steadily  and  evenly, 
and  without  undue  force  for 
fear  of  fracturing  the  surgical 
neck  of  the  bone.  The  value 
of  this  plan,  according  to 
Kocher,  turns  on  the  fact 
that  '  .  .  .  the  posterior  part 
of  the  capsule  and  the  scapular 
tendons  inserted  therein  are 
usually  untorn  and  stretched 
tightly  across  the  glenoid 
fossa.  Rotation  outwards  re- 
laxes these  structures  and 
removes  them  from  the  fossa, 
whilst  the  rent  in  the  capsule 
gapes;  but  owing  to  the  fact 
that  the  upper  and  lower 
luargins  of  the  opening  are 
stiir  tight,  the'  head  of  the 
humerus  remains  fixed  against 
the  neck  of  the  scapula  until 
the  elbow  is  carried  forwards 
and  raised.  The  upper  part 
of   the    capsule    then    relaxes. 


INJURIES  OF  JOINTS— DISLOCATIONS  6ii 

and  the  lower  part,  which  remains  tense,  guides  the  head  of  the 
bone  into  the  joint.' 

Siiii/h's  Method  varies  somewhat  in  its  appHcation,  according  to 
whether  the  head  of  the  bone  is  displaced  anteriorly  or  posteriorly. 
For  anterior  displacements  the  surgeon  stands  in  front  of  the  patient, 
and  grasps  the  shoulder,  using  the  right  hand  for  the  right  shoulder 
and  the  left  for  the  left,  so  that  the  thumb  rests  on  the  head  of  the 
bone,  and  the  fingers  grasp  and  steady  the  scapula.  With  the  other 
hand  he  seizes  the  arm  near  the  elbow  which  has  been  flexed,  and 
raises  it  from  the  side,  extending  and  everting  it.  Having  thus 
raised  it  to  a  right  angle,  the  limb  is  steadily  and  continuously  cir- 
cumducted inwards,  the  thumb  following  the  head  of  the  bone  and 
assisting  it  to  reach  the  lower  and  under  side  of  the  capsule,  and 
thus  enter  the  socket  through  the  rent.  For  the  subspinous  disloca- 
tion, the  surgeon  stands  behind  the  patient  and  grasps  the  shoulder 
with  one  hand,  raising  the  arm  with  the  other,  and  making  extension 
backwards  combined  with  external  rotation;  i.e.,  the  limb  is  circum- 
ducted outwards,  and  finally  brought  to  the  side. 

2.  Extension  may  be  applied  in  different  ways,  the  object  being  to 
overcome  the  tension  of  surrounding  ligaments  and  muscles.  It 
may  be  applied  directly  downwards  by  the  surgeon  grasping  and 
pulling  on  the  arm,  whilst  his  unbooted  foot  is  used  as  a  counter- 
extending  force  in  the  axilla,  the  patient  lying  flat  on  a  mattress 
placed  on  the  ground,  and  the  surgeon  sitting  by  the  side.  Another 
plan  consists  in  using  the  knee  as  a  fulcrum  instead  of  the  heel,  the 
patient  sitting  in  a  chair.  Occasionally  the  foot  has  been  placed 
against  the  thoracic  wall,  and  extension  made  directly  outwards  at 
right  angles  to  the  body,  as  recommended  by  Sir  Astley  Cooper. 
\Vhite  of  Manchester  suggested  vertical  traction,  the  arm  being 
pulled  directty  upwards,  the  surgeon's  foot  having  been  placed  over 
the  acromion,  the  patient  being  in  the  recumbent  posture.  The 
only  objection  to  this  last  method,  which  may  succeed  when  other 
plans  fail,  is  that  the  axillar\^  vessels  are  somewhat  exposed  to 
injury. 

Dislocations  of  the  Elbow- Joint  are  not  very  uncommon,  occur- 
ring particularly  in  young  people,  and  are  due  to  either  direct  or 
indirect  violence.  The  diagnosis  is  often  difficult  from  the  amount 
of  swelling  that  quickly  follows.  A  careful  investigation  of  the 
relative  position  of  the  bony  points  (p.  510),  and  of  the  degree  of 
mobility  of  the  difterent  parts  on  each  other,  is  essential  in  order 
to  arrive  at  a  definite  conclusion  as  to  the  exact  nature  of  the  lesion. 
In  cases  of  doubt,  a  radiogram  should  be  taken. 

I.  Dislocation  of  Both  Bones  may  occur  either  hacki&afds,  for- 
wards, or  laterally. 

The  backward  variet}'  (Fig.  216,  A)  is  that  most  often  met  with; 
it  usually  occurs  without  either  the  coronoid  process  or  the  olecranon 
being  fractured,  although  occasionally  the  former  is  detached.  If 
the  coronoid  remains  intact,  it  sometimes  becomes  locked  in  the 
olecranon  fossa,  and  renders  the  arm  immobile;  if,  however,  it  is 


6l2 


A    MANUAL  OF  SURGERY 


brokt-n,  considerable  mobility  of  both  bones  occurs,  with  crepitus. 
The  fore-arm  is  semi-flexed,  the  hand  held  midway  between  prona- 
tion and  supination,  and  the  displaced  bones  form  a  considerable 
swelling  at  the  back  ot  the  joint,  above  which  is  a  marked  hollow, 
crossed  by  the  triceps.  The  lower  end  of  the  humerus  projects  in 
front,  and  the  artery  and  the  soft  parts  are  displaced  forwards.  The 
measurement  from  the  acromion  process  to  the  external  condyle 
remains  unaltered,  but  that  from  the  condyle  to  the  styloid  process 
of  the  radius  is  distinctly  shortened,  and  the  distance  between  the 
condyles  and  the  olecranon  process  is  increased. 

Dislocation  forwards  of  both  bones  rarely  occurs  without  frac- 
ture of  the  olecranon  process,  although  a  few  cases  of  this  unusual 

accident  are  on  record.  The  dis- 
placement is  readily  detected, 
the  fore-arm  being  lengthened 
perhaps  to  the  extent  of  an  inch. 
The  arm  is  in  a  condition  of 
flexion,  and,  indeed,  the  accident 
can  only  take  place  from  falling 
backwards  on  the  point  of  the 
elbow  when  in  this  position. 
The  triceps  muscle  may  be  con- 
siderably torn. 

Lateral  dislocations  of  the 
fore-arm  are  almost  always  in- 
complete, and  are  not  very 
frequent ;  the  bones  may  be  dis- 
placed either  inwards  or  out- 
wards, the  latter  being  the  more 
common.  They  are  recognised 
by  a  careful  examination  of  the 
relative  position  of  the  bony 
prominences  and  by  stereoscopic 
radiography. 

2.  Dislocation  of  the  Ulna 
alone  occurs  only  in  a  backicard 
direction.  It  is  very  rare  owing 
to  the  position  and  strength  of  the  orbicular  and  oblique  ligaments 
and  of  the  interosseous  membrane.  If,  however,  the  bones  of  the 
fore-arm  are  rotated  backwards  upon  the  head  of  the  radius  as  a 
fulcrum,  and  then  the  fore-arm  adducted,  this  displacement  can 
occur  without  extensive  ligamentous  lacerations,  which,  indeed, 
have  not  been  noted  in  any  of  the  cases  observed. 

In  the  Treatment  of  the  above  dislocations,  all  that  is  necessary  is 
to  unhitch  the  interlocking  bony  prominences,  so  as  to  allow  the 
bones  to  return  to  their  normal  positions  by  muscular  contraction. 
This  is  usually  accom])lish(?d  by  the  method  described  by  Sir  Astley 
Cooper.  The  patient  being  in  a  sitting  position,  the  surgeon  presses 
backwards,  with  his  knee  in  the  bend  of  the  elbow,  against  the 


Fig.  299. — Reduction  of  Backward 
Dislocation  at  the  Elbow. 


INJURIES  OF  JOINTS—DISLOCATIONS  316 

lower  cMid  of  tlu>  humerus;  at  tlie  same  time  he  grasps  the  patient's 
wrist,  and  slowly  and  forcibly  bends  the  fore-arm  (Fig.  299). 

3.  Dislocation  of  the  Radius  alone  may  occur  either  forwards, 
hackwards,  or  outwai'ds. 

The  forward  dislocation  (Fig.  300)  is  that  usually  seen,  and  results 
from  falls  on  the  hand  when  the  fore-arm  is  in  a  state  of  extreme 
pronation,  or  from  forcible  traction  upon  the  hand,  or  from  chrect 
injurv  applied  to  the  back  and  outer  side  of  the  elbov/.  The  head  of 
the  radius  rests  against  the  lower  end  of  the  humerus  in  the  hoHow 
above  the  capitellum,  and  the  most  characteristic  feature  consists 
in  the  inability  of  the  patient  to  flex  his  fore-arm,  owing  to  the  bone 
impinging  against  the  lower  end  of  the  humerus.  Tt  can  be  readily 
detected  in  this  situation,  rotating  with  the  movements  of  the  fore- 
arm, whilst  a  deep  hollow  is  felt  behind,  immediately  below  the 
external  condjde.  The  fore-arm  is  somewhat  flexed,  and  midway 
between  pronation  and  supination ; 
the  former  act  can  be  satisfac- 
torily accomplished,  but  supina- 
tion cannot  be  carried  further  than 
half-way.  A  marked  fulness  exists 
on  the  anterior  aspect  of  the 
limb  when  the  arm  is  extended. 
Fracture  of  the  upper  third  of  the 
ulna  sometimes  accompanies  this 
accident,  especially  when  pro- 
duced by  direct  violence.  If  this 
luxation  is  not  reduced,  great  Fig.  300. — Dislocation  of  the 
impairment  of  the  mobility  of  the  Radius  Forwards.     (Pick.) 

limb    results,    flexion    beyond    an 

obtuse  angle  becoming  impossible.  Treatment. — Reduction  is 
accomplished  by  traction  from  the  wrist,  with  the  fore-arm  flexed 
to  a  right  angle,  combined  with  pressure  over  the  head  of  the  bone. 
Owing  to  the  fact  that  the  orbicular  ligament  is  ruptured,  the  de- 
formity is  likely  to  recur,  unless  the  limb  is  kept  completely  flexed 
in  order  to  relax  the  biceps.  Active  movements  of  the  limb  must 
be  interdicted  for  three  or  four  weeks.  In  old-standing  cases 
excision  of  the  head  of  the  bone  is  desirable. 

Dislocation  backwards  is  less  common.  The  head  lies  behind  the 
external  condyle  on  the  outer  side  of  the  olecranon,  where  it  can  be 
detected  on  rotating  the  limb.  The  fore-arm  is  flexed,  and  the  limb 
pronated.   Even  if  left  unreduced,  it  leads  to  but  little  inconvenience . 

Dislocation  outwards  is  also  rare,  the  head  of  the  bone  being  dis- 
placed to  the  outer  side  of  the  external  condyle,  where  it  can  be 
felt,  causing  considerable  impairment  of  movement.  Reduction  is 
accomplished  without  difficulty,  or,  if  necessary,  the  head  may  be 
excised. 

Occasionally  a  rare  form  of  dislocation  is  met  with  in  which  the 
ulna  passes  backwards  and  the  radius  forwards,  resulting  in  great 
deformity. 


6i4  A    MANUAL  OF  SURGERY 

A  very  common  arrident  in  children  under  four  years  of  aj^c 
consists  of  a  subluxation  of  the  head  of  the  radius  downwards 
within  tlie  orhiruhir  Hganient,  so  that  a  f(jld  (jf  syn(jvial  incmbrane 
shps  up  and  becomes  nipped  between  the  head  and  capitellum. 
It  results  from  forcible  traction  of  the  hand,  as  from  pulling  up  a 
child  roughly  after  it  has  fallen,  and  is  a  common  nursery  accident, 
popularly  known  as  pulled  elbow.  The  limb  becomes  fixed  in  a 
position  of  slight  flexion,  and  witli  the  hand  pronated.  and  the  child 
cries  out  with  the  pain;  it  is  readily  treated  by  completely  flexing  the 
limb,  and  subsequently  extending  and  fully  supinating  it,  and  leaves 
no  bad  results. 

It  must  not  be  forgotten  that  here  merely  the  pure  dislocations 
have  been  described.  In  actual  practice  complications  of  a  serious 
nature  are  frequently  present  in  the  shape  of  fracture  (jf  one  or  both 
condyles,  which  add  to  the  difficulty  of  diagnosis,  apart  from 
radiography,  and  even  then  the  results  of  treatment  may  be  un- 
satisfactory. Abundant  callus  is  formed,  and  fibrous  adhesions  of 
such  strength  are  developed,  that  considerable  impairment  of  func- 
tion is  liable  to  ensue. 

Dislocation  of  the  Wrist  is  a  very  uncommon  accident,  and  may 
occur  fontHirds  or  backwards.  The  lower  ends  of  the  radius  and 
ulna  project  under  the  skin,  and  the  styloid  processes  retain  their 
relative  positions;  it  is  thereby  easily  distinguished  from  a  Colles's 
fracture. 

Occasionally  the  radius,  carrying  with  it  the  hand,  is  dislocated 
from  the  lower  end  of  the  ulna,  as  a  result  of  forcible  pronation, 
which  results  in  laceration  of  the  inferior  radio-ulnar  ligaments,  and 
probably  of  the  lowest  portion  of  the  interosseous  membrane.  The 
triangular  fibro-cartilage  is  in  some  of  these  cases  loosened,  and  its 
mobility  may  subsequently  give  rise  to  a  painful  weakness  of  the 
wrist.  The  ulna  projects  backwards,  and  its  reduction' is  eas}^;  but 
some  laxity  of  the  inferior  radio-ulnar  joint  may  persist,  unless  the 
bones  are  kept  firmly  together  by  suitable  bandaging. 

Dislocations  of  Various  Carpal  Bones  have  been  described,  and 
radiography  has  demonstrated  that  they  are  by  no  means  uncommon. 
That  which  is  best  known  is  a  displacement  of  the  os  magnum  back- 
wards. It  forms  a  rounded  prominence  under  the  skin  in  the  usual 
situation  of  the  bone,  which  becomes  more  prominent  on  flexion, 
and  may  disappear  on  extension.  As  a  rule,  it  is  readily  reduced, 
but  is  very  likely  to  recur.  If  troublesome,  the  bone  may  be 
excised. 

Dislocations  of  the  Metacarpal  Bones  and  Phalanges  are  not  un- 
frequent,  but  need  no  special  mention,  except  in  the  case  of  Disloca- 
tion Backwards  of  the  First  Phalanx  of  the  Thumb.  The  chief 
interest  here  lies  in  the  difficulty  experienced  in  reduction,  which  was 
formerly  attributed  to  the  head  slipping  between  the  two  portions  of 
the  flexor  brevis  pollicis  and  being  grasped  by  them,  as  a  button  in  a 
button-hole.  It  has  now  been  shown  that  there  are  two  much  more 
important  factors,  viz.,  the  tension  of  the  long  flexor  tendon,  which 


INJURIES^OF  JOINTS— DISLOCA  TIONS 


615 


hitches  round  the  neck  (Fig.  301),  and  the  arrangement  of  the  glenoid 
hgament.  This  libro-cartilaginous  structure  passes  between  the 
two  heads  of  insertion  of  the  short  flexor,  and  is  thus  incorporated 
between  the  two  sesamoid  bones ;  whilst  tirmlv  attached  to  the  base 
of  the  phalanx,  it  is  but  loosely  connected  with  the  head  of  the 
metacarpal  bone,  so  that  it  accompanies  the  phalanx  in  its  disloca- 
tion, and  will  then  be  situated 
immediateh'  behind  the  head 
of  the  metacarpal,  so  as  to 
prevent  any  attempts  at 
reduction.  Treatment. — Trac- 
tion and  manipulation  are 
alwa\-s  attempted  in  the  first 
instance.  The  thumb  is 
grasped  by  a  suitable  ap- 
paratus and  M'per-extended 
to  a  right  angle,  thus  making 
the  head  of  the  metacarpal 
project  still  further  through 
the  muscular  interspace,  and, 
as  it  w^ere,  enlarging  the 
buttonhole.  Still  maintaining 
the  traction,  the  thumb  is 
rapidly  flexed  into  the  palm, 
the  metacarpal  bone  being 
at  the  same  time  pressed 
inwards.  Should  this  fail,  as 
it  often  \vi\\,  a  sterilized  teno- 
tome should  be  inserted  in 
the  middle  line  of  the  thumb 
behind,  immediately  above 
the  base  of  the  phalanx,  and  should  be  pushed  on  till  it  reaches 
and  divides  the  glenoid  fibro-cartilage  between  the  sesamoid  bones ; 
this  little  manoeu\T"e  will  at  once  render  replacement  simple. 

Dislocation  of  the  Hip,  though  not  ver}-  common,  is  a  condition  of 
extreme  gravity.  The  depth  of  the  socket  in  which  the  femur  rests, 
and  the  strength  of  the  muscles  and  ligaments  surrounding  the 
articulation,  explain  the  comparative  unfrequency  of  the  accident. 
It  always  results  from  violence  applied  to  the  feet  or  knees,  or,  if  the 
legs  be  fixed,  to  the  back.  It  is  rarel}'  met  ^^dth  except  in  young 
people  or  adults,  since  after  the  age  of  forty-five  fractures  of  the 
neck  of  the  bone  are  much  more  likely  to  occur. 

Four  chief  varieties  of  dislocation  are  described,  in  two  of  which 
the  head  of  the  bone  is  displaced  posteriorh^  and  in  two  anteriorly. 
The  two  former  are  known  as  the  Dorsal  and  the  Sciatic  varieties, 
in  which  the  head  of  the  bone  occupies  some  situation  on  the  dorsum 
ilii,  determined  by  the  integrity  or  not  of  the  obturator  internus 
tendon.  The  two  anterior  dislocations  are  known  as  the  Ohtiirator  or 
Thyroid,  and  the  Pubic;  in  the  former  the  head  of  the  bone  is  located 


Fig.  301. — -Dislocation  of  Thumb, 
SHOWING  Head  of  the  Metacarpal 
Bone  protruding  Forwards  between 
the  Heads  of  the  Short  Flexor 
Muscle.     (Pick.) 


6i6  A   MANUAL  OF  SURGERY 

in  the  obturator  notch,  and  in  the  latter  upon  the  i)ul)ii;  ramus.  The 
relative  frequency  of  these  dislocations  is  as  follows:  About  50  to 
55  per  cent,  of  the  cases  are  of  the  dorsal  type,  20  to  23  per  cent, 
sciatic,  10  to  15  per  cent,  obturator,  and  5  to  10  per  cent,  pubic.  In 
addition  to  these  four  varieties,  many  other  slight  modifications 
Tiave  been  described,  which  it  will  be  unnecessary^  further  to 
particularize. 

Mechanism. — In  considering  these  dislocations,  the  relative 
strength  or  weakness  of  the  different  parts  of  the  capsule  and  its 
surrounding  structures  must  be  remembered.  The  weakest  part  of 
the  capsule  is  placed  below  and  behind,  and  it  is  through  a  rent  in 
this  position  that  the  head  of  the  bone  most  frequentl}'  escapes.  In 
front,  the  ilio-femoral  or  Y-shaped  ligament  of  Bigelow  is  a  structure 
of  much  strength,  on  the  integrity  of  which  depends  the  fact  whether 
the  displaced  head  of  the  bone  shall  occup}-  some  definite  position  or 
be  freely  moveable.  Bigelow,  to  whom  we  owe  so  much  in  the 
elucidation  of  the  mechanism  of  these  dislocations  has  divided  them 
into  two  classes — the  regular  and  the  irregular — according  to  whether 
this  ligament  is  intact  or  completely  lacerated.  Posteriorly,  the 
plicated  tendon  of  the  obturator  internus  is  the  most  important 
structure,  and  the  position  and  level  of  the  bone  on  the  dorsum  ilii 
depend  in  some  measure  on  whether  it  remains  intact  or  is  ruptiired. 
It  must  also  be  remembered  that  the  ligamentum  teres  is  relaxed 
when  the  thigh  is  forcibly  abducted,  and  is  made  tense  by 
adduction. 

The  limb  is  usually  in  a  position  of  abduction  at  the  moment  of 
dislocation,  the  head  of  the  bone  escaping  through  a  rent  in  the 
lower  and  back  part  of  the  capsule.  The  type  of  accident  responsible 
for  this  is  a  fall  with  the  legs  widely  separated,  or  when  the  limbs  are 
drawn  forcibly  apart,  as,  for  instance,  when  one  leg  is  placed  on  a 
boat  just  moving  away  from  a  pier  on  which  the  other  is  fixed.  The 
direction  of  the  violence,  or  the  subsequent  manipulations  performed 
by  willing  but  ignorant  friends,  or  the  voluntary  movements  of  the 
individual,  determine  what  form  of  dislocation  will  be  subsequently 
produced.  If  the  limb  is  externally  rotated  and  extended,  or  the 
trunk  is  hyper-extended  and  the  limb  remains  fixed,  the  head  travels 
forwards,  and  either  the  pubic  or  obturator  variety  results.  If, 
however,  the  leg  is  inverted  and  flexed,  the  head  of  the  bone  passes 
backwards,  and  either  the  dorsal  or  sciatic  form  is  produced.  Again, 
in  the  posterior  dislocations,  if  the  obturator  internus  tendon  remains 
intact,  it  may  hitch  across  the  front  of  the  neck,  and  prevent  any 
further  upward  displacement  of  the  bone,  thus  giving  rise  to  the 
so-called  sciatic  variety,  or  as  Sir  Astley  Cooper  called  it,  the  dorsal 
below  the  tendon :  but  if  the  tendon  is  ruptured,  or  if  the  head  of  the 
bone  slips  in  front  of  it,  there  is  no  obstacle  to  its  upward  displace- 
ment on  the  dorsum  ilii. 

Dislocation  may  also  result  when  the  limb  is  in  a  position  of 
adduction,  a  direct  dorsal  dislocation  being  thus  produced,  the  head 
of  the  bone  escaping  from  the  capsule  above  the  tendon  of  the 


INJURIES  OF  JOINTS—DISLOCATIONS 


617 


obturator  internus;  such  an  accident  is  sometimes  associated  with 
fracture  of  the  posterior  Hp  of  the  acetabuhun.  The  type  of  violence 
leading  to  this  occurrence  is  when  a  heavy  weight  falls  on  the  back  of 
a  person  whilst  kneeling,  or  when,  the  knee  being  flexed,  the^body  is 
thrust  forwards,  so  that  the  limb  is  forcibly  inverted.  If,  however, 
the  thigh  is  in  a  position  of  extreme  flexion,  the  head  may  be  dis- 
placed below  the  tendon  of  the  obturator 
internus,  and  the  sciatic  variety  will  then 
result. 

1 .  Dorsal  Dislocation  (Fig.  302)  .—The  head 
of  the  bone  lies  on  the  dorsum  ilii,  a  variable 
distance  above  and  behind  the  acetabulum, 
and  always  above  the  obturator  internus 
tendon.  It  may  be  detected  on  manipula- 
tion of  the  hmb,  although  in  muscular  sub- 
jects this  is  difficult.  The  ligamentum  teres 
is  necessarily  ruptured,  as  also  the  capsule, 
the  rent  being  situated  either  below  or  above 
the  obturator  tendon,  according  to  whether 
the  dislocation  is  due  to  forcible  abduction 
or  adduction.  The  small  external  rotator 
muscles  are  often  lacerated,  and  perhaps  even 
the  glutei  and  the  pectineus.  The  ilio- 
femoral ligament  usually  remains  intact. 
The  great  sciatic  nerve  is  sometimes  com- 
pressed or  contused.  The  trochanter  is  raised 
above  Nelaton's  line  (p.  532)  and  approxi- 
mated to  the  anterior  superior  spine;  the  ilio- 
tibial  band  of  fascia  is  therefore  relaxed,  and 
there  is  considerable  shortening  of  the  limb, 
amounting  sometimes  to  2  or  3  inches.  The 
leg  is  in  a  position  of  flexion,  adduction,  and 
inversion,  so  that  the  axis  of  the  femur 
crosses  the  lower  third  of  the  sound  thigh. 
The  knee  is  semi-flexed,  and  the  ball  of  the 
great  toe  rests  against  the  opposite  instep ; 
the  heel  is  somewhat  raised.  A  marked 
hollow  is  felt  in  the  upper  part  of  Scarpa's  triangle,  and  the  main 
vessels  of  the  limb  appear  to  be  unsupported. 

The  Diagnosis  should  be  easy,  the  only  difficulty  being  experienced 
in  distinguishing  it  from  an  impacted  extra-capsular  fracture.  The 
character  of  the  accident,  the  presence  of  adduction  and  inversion, 
the  increased  breadth  of  the  trochanter  in  the  case  of  fracture,  and 
the  abnormally  placed  head  of  the  bone  in  dislocation,  are  the  points 
to  which  attention  must  be  directed. 

2.  Sciatic  Dislocation,  or  dorsal  below  the  tendon,  is  one  in  which 
the  head  of  the  bone  is  prevented  from  travelling  upwards  to  the 
dorsum  ilii  by  the  integrity  of  the  obturator  internus  tendon.  It 
may  occur  either  from  forced  abduction  of  the  limb,  or  from  extreme 


Fig.  302. — Dorsal  Dis- 
location OF  THE  Hip. 

(TiLLMANNS.) 


6i8 


A   MANUAL  OF  SURGERY 


flexion  in  the  addueted  position.  Tlie  lesions  of  muscles  and  liga- 
ments are  practieally  the  same  as  for  the  dorsal  variety.  The  ilio- 
femoral ligament  is  uninjured. 

The  Signs  resemble  those  of  a  dorsal  dislocation,  but  are  less 
marked.  There  is  less  shortening,  often  not  more  than  |  to  i  inch; 
the  limb  is  fiexed,  addueted,  and  inverted,  but  the  axis  of  the  femur 
is  directed  across  the  opposite  knee,  and  the  great  toe  rests  against 
the  ball  of  the  great  toe  of  the  opposite  side.  The  head  of  the  bone 
is  often  much  less  distinct,  owing  to  the  greater  thickness  of  the 
glutei  muscles  at  the  lower  level. 

Treatment  of  the  Two  Backward  Dislocations  is  effected  in  much 
the  same  way,  whether  the  dorsal  or  sciatic  variety  is  present.  The 
most  usual  method  is  that  of  manipulation  and  rotation,  so  accurately 
worked  out  by  Bigelow.  The  patient  is 
anaesthetized,  preferably  on  a  mattress 
placed  on  the  floor.  The  leg  is  first  flexed 
on  the  thigh,  and  the  thigh  on  the  abdo- 
men, the  position  of  adduction  being  still 
maintained,  so  that  the  knee  extends 
beyond  the  middle  line  of  the  body 
(Fig.  303).  This  position  is  maintained 
for  some  moments,  and  then  the  limb  is 
freely  circumducted  outwards,  and  brought 
rapidly  down  into  a  position  of  extension 
parallel  with  the  othei.  By  this  man- 
oeuvre the  tense  structures  in  front 
of  the  joint  are  relaxed,  and  then  the 
head  of  the  bone  is  made  to  retrace  its 
course  towards  the  rent  in  the  capsule, 
and  finally  directed  upwards  into  the 
acetabular  cavity.  These  movements  are  tersely  summarized  in 
Bigelow's  words — '  Lift  up,  bend  out,  roll  out.' 

If  this  plan  does  not  succeed,  the  following  method  of  traction  may 
be  employed.  The  patient,  lying  on  his  back,  is  firmly  fixed  by  a 
bandage  or  towel  passed  over  the  pelvis  and  secured  to  two  or  three 
hooks  or  staples  driven  into  the  floor.  The  surgeon  stands  over  the 
patient,  whose  thigh  is  flexed  to  a  right  angle  on  the  abdomen,  as 
also  the  knee  upon  the  thigh.  The  surgeon's  arms  are  passed  under 
the  knee  sufficiently  far  to  enable  him  to  grasp  his  own  elbows,  and 
the  front  of  the  leg  is  steadied  against  the  operator's  perineum. 
Direct  and  forcible  traction  upwards  can  now  be  made,  and  this  is 
often  sufficient  in  itself  to  lift  the  head  of  the  bone  into  the  acetabu- 
lum. If  this  is  unsuccessful,  the  movements  described  above  can  be 
energetically  repeated  in  this  position.  The  above  plans,  combined 
with  the  use  of  an  anaesthetic,  rarely  fail  in  reducing  a  backward 
dislocation  of  the  hip,  and  hence  extension  by  means  of  pulleys  is  rarely 
required.  If,  however,  it  is  needed,  traction  should  always  be  made 
in  the  direction  of  the  displaced  limb,  i.e.,  across  the  other  thigh, 
counter-extension  being  obtained   by  a  towel  passed  between  the 


Fig.  303. — Reduction  of 
Dorsal  Dislocation  of 
Hip.      (Bryant.) 


INJURIES  OF  JOINTS— DISLOCATIONS 


619 


injured  tliii;li  and  the  perineum.  When  suiiieient  force  has  been 
a})pHed,  the  surgeon  rotates  the  Hmb  outwards  so  as  to  allow  th  e 
head  of  the  bone  once  more  to  slip  into  its  socket. 

3.  Thyroid  or  Obturator  Dislocation  fFig.  304). — ^The  head  of  the 
bone  in  this  case  passes  downwards  through  a  rent  in  the  lower  part 
of  the  capsule,  and  its  position  is  subsequently  but  little  altered,  a 
slight  forward  and  upward  movement  being  alone  superadded.  The 
ilio-femoral  ligament  is  untorn,  but  the  pectineus  and  adductors  are 
very  tense,   or  may  even  be  lacerated;  the  ligamentum  teres  is, 


Fig.  304. — Dislocation  of  the 
Hip  :     Obturator     Variety. 

(TiLLMANNS.) 


Fig.  305. — Dislocation  of  the 
Hip  Forwards:  Pubic 
Variety.     (Tillmanns.) 


of  course,  ruptured.  The  head  Hes  on  the  obturator  externus 
muscle,  and  can  be  detected  in  the  perineum.  The  trochanter  is 
less  prominent  than  usual,  and,  indeed,  its  normal  position  may  be 
represented  bj^  a  depression.  The  limb  is  slighth^  abducted  and 
everted,  as  well  as  lengthened,  perhaps  to  the  extent  of  2  inches, 
though  this  is  more  apparent  than  real.  It  is  also  flexed,  owing  to 
the  tension  of  the  ilio-psoas  muscle,  and  advanced  before  the  other, 
with  the  toes  pointing  outwards.  The  adductor  longus  tendon 
stands  out  prominently,  and  much  pain  may  be  experienced  from 
pressure  on  the  obturator  nerve.  If  the  patient  stands,  the  body 
is  bent  forwards,  whilst  it  is  interesting  to  note  that  if  the  disloca- 
tion remains  unreduced  the  patient  may  be  able  to  walk  without 


620  A   MANUAL  OF  SURGERY 

miuii  pain  or  inconvenience,  though  in  a  more  or  less  stooping 
position. 

4.  Pubic  Dislocation  (Fig.  305).—  In  this  variety  the  head  of  the 
bone  either  escapes  from  the  joint  below,  or  may  be  forced  out  in 
front  and  to  the  inner  side  of  the  ilio-femoral  ligament  as  a  result  of 
hyper-extension  of  the  trunk.  The  head  lies  on  the  horizontal  ramus 
of  the  pubes,  just  internal  to  the  anterior  inferior  spinous  process  of 
the  ilium,  where  it  can  be  felt  rolling  under  the  finger  on  any  move- 
ment of  the  limb.  The  vessels  are  pushed  inwards,  and  considerable 
pain  may  be  felt  down  the  limb  from  pressure  on  the  anterior  crural 
nerve.  The  ilio-fcmoral  ligament  is  untorn,  whilst  the  ligamentum 
teres  and  capsular  ligament  are  ruptured;  the  small  external  rotator 
muscles,  with  the  exception  of  the  obturator  internus,  are  usually 
torn.  There  is  marked  flattening  of  the  hip,  the  trochanter  being 
approximated  to  the  middle  line  and  raised.  Tfie  limb  is  shortened 
to  the  extent  of  i  inch,  and  there  is  considerable  abduction  and 
eversion,  so  that  the  inner  aspect  of  the  limb  looks  forwards.  The 
thigh  is  slightly  flexed  to  relax  the  ilio-psoas  muscle. 

Treatment  of  the  thyroid  and  pubic  dislocations  is  undertaken 
along  similar  lines  as  for  the  posterior  dislocations.     The  patient  is 

anesthetized;  the  knee  is  flexed,  as  also 
the  thigh  upon  the  abdomen,  but  in  a 
position  of  abduction;  circumduction 
inwards  follows  (Fig.  306),  and  on  ex- 
tension of  the  limb  the  head  again  enters 
the  acetabulum.  The  thyroid  variety 
may  sometimes  be  reduced  by  upward 
and  outward  traction  when  the  limb  has 
been  flexed  to  a  right  angle  in  the  ab- 
ducted position,  the  unbooted  foot  being 
placed  against  the  pelvis  to  steadv  it. 

If  extension  by  pulleys  is  required  in 

the  thyroid  dislocation,  it  is  made  trans- 

FiG.  306.  — Reduction    of    versely  outwards  across  the  upper  part 

Anterior  Dislocation  OF    of    the    thigh,    counter-extension   being 

THE  Hip.     (Bryant.)  obtained    by  means    of  a  band   passed 

round  the  abdomen.     The  limb,  at  first 

in  a  position  of  abduction,  is  subsequently  adducted  forcibly  by 

drawing  the  ankle  inwards,  the  band  b}^  means  of  which  extension 

is  being  made  acting  as  a  fulcrum  to  lever  the  head  of  the  bone  into 

the  acetabulum.     In  the  pubic  variety  traction  is  made  downwards, 

outwards,  and  backwards,  and  the  head  of  the  bone  drawn  into  its 

socket  by  a  towel  passed  transversely  across  the  limb. 

After  reduction  of  any  form  of  dislocation  of  the  hip,  the  patient 
should  be  kept  in  bed  with  the  legs  tied  together  for  about  a  fort- 
night, and  then  passive  movement  may  be  commenced,  but  with 
considerable  caution;  voluntary  movements  should  not  be  under- 
taken for  another  week  or  two. 

Should  the  dislocation  recur,  it  may  be  due  to  fracture  of  the 


INJURIES  OF  JOINTS—DISLOCATIONS  621 

posterior  lip  of  the  acetabulum,  or  to  some  involuntary  movements 
of  the  patient,  or  perhaps  to  the  fact  that  the  displacement  has  not 
been  fully  reduced.  Under  such  circumstances  further  attempts  at 
replacement  should  be  undertaken,  and  the  limb  subsequently  kept 
immobilized  for  a  longer  period  than  usual  with  a  weight-extension 
and  a  Liston's  splint. 

Dislocation  of  the  Patella  may  occur  onhvanis,  im&ards,  or  edgeways. 
A  dislocation  upwards  resulting  from  rupture  of  the  ligamentum 
patellae  is  sometimes  described,  but  it  is  scarcely  to  be  included  in 
the  same  category  as  the  others.  The  displacement  may  be  com- 
plete or  incomplete;  in  the  former  the  capsule  is  always  lacerated;  in 
the  latter,  not  necessarily  so. 

The  outward  variety  is  much  the  commonest  on  account  of  the 
obliquity  of  the  limb,  and  may  result  from  muscular  action,  especially 
in  people  suffering  from  genu  valgum;  it  also  arises  from  direct 
violence.  In  either  case  it  occurs  most  frequently  when  the  limb  is 
extended,  since  during  flexion  the  bone  is  firmly  lodged  in  the  inter- 
condyloid  notch.  When  completely  displaced,  it  lies  upon  the  outer 
surface  of  the  condyle,  with  its  inner  margin  projecting  forwards. 
In  this  situation  it  Is  easily  felt,  whilst  the  knee  appears  flattened 
and  broader  than  usual,  the  intercondyloid  notch  being  plainly  dis- 
tinguishable in  the  position  usually  occupied  by  the  patella.  It  is 
not  unfrequently,  however,  incomplete,  and  then  the  inner  half  of  the 
articular  surface  of  the  patella  lies  in  contact  with  the  cartilaginous 
surface  of  the  outer  condyle,  with  its  outer  border  projecting  for- 
wards. Reduction  may  take  place  spontaneously,  but  is  usually 
effected  by  manipulation.  The  thigh  is  flexed  on  the  abdomen,  and 
the  knee  extended,  so  as  to  relax  the  quadriceps,  and  then  a  little 
pressure  on  its  outer  margin  causes  the  bone  to  slip  back  into  place. 
In  the  incomplete  form,  where  one  of  the  borders  of  the  bone  is 
odged  in  the  intercondyloid  notch,  reduction  is  sometimes  very 
difficult,  and  to  effect  it  an  open  operation  may  be  required. 

The  inward  dislocation  is  rare,  being  always  due  to  direct  violence. 
In  characters  and  treatment  it  is  the  exact  converse  of  those  met  with 
when  the  bone  is  displaced  outwards. 

A  dislocation  edgeways,  or  Vertical  Rotation  of  the  patella,  is  an 
interesting  condition  in  which  the  bone  is  said  to  be  twisted  vertically 
upon  its  own  axis,  and  even  to  have  been  turned  completely  round. 
Incomplete  rotation  is  practically  identical  with  that  just  described 
as  an  incomplete  lateral  dislocation,  whilst  the  complete  rotation  of 
the  patella  must  indeed  be  a  rare  accident. 

Recurrent  dislocation  of  the  patella  may  be  associated  with  genu 
valgum,  or  with  laxity  of  the  extensor  muscles  from  paralysis.  In 
the  former  case  it  may  be  cured  by  correcting  the  deformity  by 
means  of  osteotomy  of  the  femur ;  but  sometimes  the  synovial  mem- 
brane of  the  knee-joint  on  the  inner  side  will  require  to  be  braced  up 
by  excision  of  a  portion  and  suture  of  the  margins  of  the  defect. 
In  the  paralytic  variety,  when  the  extensor  muscle  is  slack,  it  may 
suffice  to  pleat  up  the  rectus  or  to  shorten  it  by  a  plastic  operation. 


622  A   MANUAL  OF  SURG  11 RY 

Dislocations  of  the  Knee  may  occur  laterally,  as  also  fonoanls  or 
hackivards.  When  due  to  disease  of  the  joint,  the  backward  disloca- 
tion is  commonest;  but  when  arising  from  traumatic  causes,  the 
lateral  is  the  most  frequent. 

The  lateral  displacements  arc  rarely  complete,  and  are  usually 
associated  with  a  certain  amount  of  rotation;  the  leg  is  partially 
flexed.     Reduction  is  effected  without  difficult}^ 

Dislocation  of  the  tibia  forwards  is  more  common  than  displace- 
ment backwards.  It  is  generally  complete,  the  lower  end  of  the 
femur  projecting  into  the  popliteal  space,  and  compressing  the 
vessels,  so  that  gangrene  not  unfrequently  follows.  The  upper  end 
of  the  tibia,  carrying  with  it  the  patella,  lies  in  front,  forming  a  well- 
marked  swelling  with  a  hollow  above  it.  There  is  usually  consider- 
able shortening  of  the  limb  if  the  articular  surfaces  overlap. 

Dislocation  of  the  tibia  backwards  is  a  much  rarer  accident,  and  is 
also  as  a  rule  complete  (forty  out  of  fifty-five  cases  were  complete).* 
The  signs  are  exceedingly  characteristic,  the  pressure  effects  upon 
the  popliteal  vessels  and  nerves  often  resulting  in  gangrene  (ten  cases 
out  of  fifty-five). 

Reduction  of  either  of  these  conditions  is  easily  accomplished  by 
traction  on  the  limb,  whilst  the  thigh  is  flexed,  combined  with 
manipulation  in  order  to  guide  the  head  of  the  tibia  into  its  normal 
position.  The  limb  must  subsequently  be  kept  at  rest  on  a  splint  for 
two  or  three  weeks. 

Displacement  or  Rupture  of  a  Semilunar  Cartilage  [svn.  :  Subluxa- 
tion of  the  Knee,  Internal  Derangement  of  the  Knee-Joint)  is  a  condi- 
tion frequently  met  with,  resulting  from  sprains  and  strains 
associated  with  torsion.  In  an}'  rotary  movement  of  the  knee, 
which  is  only  possible  when  the  limb  is  flexed,  the  pressure  of  the 
condyles  always  tends  to  modify  the  position  of  the  cartilages, 
which,  moreover,  are  relaxed  and  more  freely  moveable  on  the  upper 
surface  of  the  tibia  in  flexion  than  in  extension.  Displacement  of  a 
cartilage  is  almost  always  due  to  a  sudden  strain  or  wrench  of  a 
rotary  type,  e.g.,  turning  quickly  round  in  such  games  as  tennis  or 
football,  or  slipping  off  the  kerb  with  the  knee  bent.  The  inner 
cartilage  is  much  more  frequently  affected  than  the  outer,  and  the 
character  and  extent  of  the  lesion  varies  much  in  difterent  cases. 
Sometimes  its  anterior  or  posterior  tibial  attachment  is  torn  through, 
thereby  permitting  considerable  lateral  mobility  (Fig.  307) ;  but 
more  frequently  the  cartilage  is  broken  across  the  middle  (Fig.  30S) 
or  split  longitudinally  (Fig.  309),  thereby  detaching  a  hinged  portion 
from  its  free  border,  which  slips  in  or  out  of  position,  and  not  un- 
commonl}'  gets  nipped  between  the  bones,  or  may  even  be  doubled 
over.  It  subsequently  becomes  inflamed  and  swollen,  and  unless 
properly  treated  the  displacement  is  likely  to  be  repeated. 

Ihe  Symptoms  produced  by  this  accident  are  a  sudden  sickening 
pain  of  much  severity,  located  in  the  knee,  which  becomes  partially 
locked  in  a  position  of  flexion,  with  inability  to  extend  it.  The  patient 
*  Sheldon,  Annals  of  Surgery,  January,  1903. 


INJURIES  OF  JOINTS— DISLOCATIONS 


623 


Fig.  .307. 


Fio.  308. 


inuy  be  able  to  '  wriggle  '  his  joint  free,  or  the  limb  nuiy  remain  stiff 
for  some  hours,  or  even  a  day  or  two,  wlien  movement  suddenly  re- 
turns more  or  less  spontaneously, 
a  snap  being  at  the  same  time 
felt  within  the  joint.  An  attack 
of  subacute  synovitis  usually  fol- 
lows. In  other  cases  tfie  cartilage 
remains  out  of  place,  until  reduced 
by  the  surgeon,  with  or  without 
an  anesthetic.  If  the  case  is  not 
correctly  treated,  the  displacement 
is  liable  to  recur,  the  cartilage 
constantly  slipping  in  and  out,  and 
getting  nipped  between  the  bones; 
as  times  goes  on,  this  becomes 
more  and  more  easy,  owing  to  the 
ligaments  of  the  joint  being  re- 
laxed from  the  recurrent  attacks  of 
synovitis.  In  fact,  the  limb  may 
pass  into  such  a  state  of  chronic 
weakness  as  to  interfere  seriously 
with  the  patient's  comfort.  Ihere 
is  usually  a  spot  of  localized  pain 
in  the  front  of  the  joint,  corre- 
sponding to  the  upper  surface  of 
the  tibia;  possibly  there  may  be 
some  amount  of  lateral  mobility 
of  the  leg,  and  movement  of  the 
cartilage  ma,y  be  detected  on  flexing 
and  extending  the  knee. 

The  Diagnosis  is  not  always 
easy,  as  the  symptoms  may  be 
simulated  by  other  conditions,  such 
as  a  loose  foreign  body  in  the 
joint  (p.  664),  or  a  fringe  of  syn- 
ovial membrane  thickened  and 
swollen  protruding  backwards  and 
getting  caught  between  the  bones, 
or  perhaps  pushed  backwards  by 
enlargement  of  the  bursa  beneath 
the  ligamentum  patellae.  The 
definite  history  of  a  traumatic  onset 
is  an  important  element  in  the  diag- 
nosis of  a  torn  or  loose  meniscus. 
Inflammation  of  a  semilunar  carti- 
lage [meniscitis)  also  needs  to  be 
considered;  it  usually  results  from  a  heavy  fall  on  the  foot  or  heel, 
whereby  the  cartilage  is  bruised;  painful  limitation  of  movement 
results,  and  especially  pain  on  standing,  or  straightening  the  knee. 


Fig  309. 


Figs.  307,  308,  309. — Diagrams  of 
Various  Types  of  Injury  sus- 
tained BY  THE  Internal  Semi- 
lunar Cartilage. 

In  Fig.  307  the  anterior  attach- 
ment has  been  stretched  and 
torn,  and  the  cartilage  is  conse- 
quently loose.  In  Fig.  308  the 
cartilage  has  been  torn  trans- 
versely across,  and  a  weak  cica- 
trix has  formed.  In  Fig.  309 
the  cartilage  is  split  longitudin- 
ally, and  it  has  a  loose  tag,  which 
causes  trouble. 


624 


A   MANUAL  OF  SURGERY 


which  is  kept  semiflexed;  there  are  usually  no  sudden  attacks  of 
painful  locking  of  the  joint,  but  the  cartilage  is  tender,  and  can 
perhaps  be  f<]t,  though  it  is  not  moveable. 

The  Treatment  in  the  early  stages  consists  in  replacement  of  the 
cartilage  by  manipulation.  The  limb  is  fully  flexed  and  then 
suddenly  extended,  pressure  being  applied  at  the  same  time  in  the 
neighbourhood  of  the  displaced  cartilage,  which  often  returns  into 
position  with  a  distinct  snap.  The  limb  is  subsequently  kept  at  rest 
on  a  back-splint,  and  cooling  lotions  are  applied  until  the  inflamma- 
tion has  subsided;  it  is  then  further  immobilized  for  s(jme  weeks  in 
removeable  plaster  of  Paris  or  w^ater-glass,  so  as  to  allow  the 
lacerated  ligaments  to  reunite  and  consolidate.  During  this  period 
massage  is  employed,  passive  movements 
are  permitted,  followed  by  active  move- 
ments, and  movements  against  resistance, 
and  finally  the  patient  is  again  allowed  to 
walk. 

When  the  cartilage  has  become  loose 
and  is  constantly  slipping  out  of  place,  im- 
mobilization of  the  limb,  with  pressure  by 
an  elastic  knee-clip,  or  by  a  knee-truss 
(Fig.  310),  may  be  useful.  Should  this  not 
prove  satisfactory,  operative  proceedings 
must  be  undertaken. 

The  knee-joint  is  opened  by  a  curved 
incision    on   the    appropriate    side   of    the 

j7j(..,jQ  Knee-Truss   patella,  and  the  condition  of  the  cartilage 

FOR  Dislocated  In-  ascertained.  If  of  normal  shape  and  merely 
loose  and  moveable,  it  may  perhaps  be 
stitched  to  the  periosteum  over  the  head  of 
the  tibia,  so  as  to  keep  it  from  again  slipping 
between  the  bones;  this  is  sometimes  best 
accomplished  by  splitting  the  cartilage 
diagonally  into  two  portions,  and  securing  each  of  these  by  two  or 
three  stitches.  If,  however,  the  cartilage  is  very  loose  or  much 
torn,  it  is  better  to  remove  it.  The  joint  is  carefully  closed,  and 
kept  quiet  for  ten  days,  when  massage  and  suitable  exercises  are 
commenced,  so  as  to  consolidate  and  strengthen  the  divided  tissues. 
For  general  considerations  concerning  intra-articular  operations, 
see  p.  629. 

Rupture  of  the  Crucial  Ligaments  is  another  form  of  internal 
derangement,  resulting  from  great  violence.  The  integrity  and 
strength  of  the  joint  are  much  impaired,  and  abnormal  lateral  and 
antero-posterior  movements  are  possible.  The  only  Treatment  is 
to  open  the  joint  and  suture  the  ligaments.* 

Dislocations  of  the  Ankle-joint  may  occur  in  the  following  direc- 
tions:  onhvards,  inwards,  hackicards,  fonvards,  and   upwards,   this 
being  the  order  of  their  frequency.     Owing  to  the  fact  that  the 
*  Mayo  Robson,  Annals  of  Surgery,  May,  1903. 


ternal  or  external 
Semilunar  Cartil- 
ages, OR  FOR  Chronic 
Dislocations  of  the 
Patella. 


INJURIES  OF  JOINTS— DISLOCATIONS  625 

astragalus  is  wedged  like  a  l)lock  into  the  mortice  formed  by  the 
lower  ends  of  the  tibia  and  fibula,  it  is  obvious  that  fractures  of  these 
bones  are  frequently  met  with  as  complications. 

The  lateral  dislocations  are  in  reality  fracture-dislocations,  and 
have  been  already  described  in  the  chapter  on  fractures  (p.  550). 

Although  the  upper  articular  surface  of  the  astragalus  is  broader  in 
front  than  behind,  dislocation  of  the  foot  backwards  is  a  more  com- 
mon accident  than  displacement  forwards.  It  results  from  falls  on 
the  feet  while  running  or  jumping,  or  by  sudden  violence  applied  to 
the  limb  when  the  foot  is  fixed.  Usually  both  malleoli  are  fractured, 
and  the  articular  surface  of  the  astragalus  is  thrown  behind  the  lower 
end  of  the  tibia.  The  heel  projects  unduly  backwards,  and  the 
articular  surface  of  the  tibia  usually  rests  upon  the  neck  of  the  astra- 
galus, the  scaphoid,  or  even  the  cuneiform  bones. 

Dislocation  forwards  is  ver}'  uncommon,  and  may  occur  without 
any  associated  fracture  of  the  bones  of  the  leg.  The  foot  is  appar- 
ently lengthened,  and  the  tibia  rests  upon  the  posterior  part  of  the 
upper  surface  of  the  os  calcis,  behind  the  astragalus,  the  prominence 
of  the  heel  and  of  the  tendo  Achillis  being  lost. 

The  treatment  of  antero-posterior  dislocations  consists  in  reduction 
by  traction.  The  leg  is  flexed  upon  the  thigh,  so  as  to  relax  the 
tendo  Achillis,  or,  if  necessary,  this  structure  is  divided.  The  ankle 
is  subsequently  commanded  by  a  pair  of  Cline's  side-splints,  care 
being  taken  to  keep  the  foot  at  right  angles  to  the  leg,  and  the 
articular  surfaces  of  the  astragalus  and  tibia  exactly  in  apposition. 

A  dislocation  upwards  has  been  described  in  which  the  astragalus, 
together  with  the  foot,  is  carried  up  between  the  tibia  and  fibula,- 
owing  to  a  rupture  of  the  inferior  tibio-fibular  ligament  and  the 
lower  end  of  the  interosseous  membrane.  The  displacement  is  very 
marked. 

Dislocation  of  the  Astragalus  alone  is  by  no  means  common. 
It  consists  in  a  partial  or  complete  detachment  of  the  bone  from  all 
its  normal  connections,  both  to  the  bones  of  the  leg  and  of  the  foot, 
and  its  displacement  from  under  the  tibio-fibular  arch.  It  may 
travel  backwards  or  forwards  with  or  without  lateral  rotation,  and 
be  complete  or  incomplete.     It  is  frequently  more  or  less  compound. 

Dislocation  forwards  is  much  the  more  common  variety,  and  is 
usually  associated  with  partial  rotation,  the  displacement  occurring 
more  frequently  outw^ards  than  inwards.  When  complete,  the  bone 
is  entirely  detached  from  its  connections,  and  lies  upon  the  upper 
surface  of  the  external  cuneiform  and  cuboid  bones,  the  skin  of  the 
dorsum  being  tightly  stretched  over  it,  or  even  torn. 

In  the  incomplete  variety,  the  head  of  the  astragalus  impinges 
either  upon  the  scaphoid  on  the  inner  side,  or  the  cuboid  on  the 
outer,  whilst  the  lower  end  of  the  tibia  rests  on  the  posterior  half  of 
the  articular  surface  of  the  astragalus. 

Dislocation  backwards  is  almost  always  complete,  and  may  or  may 

not  be  associated  with  rotation  of  the  bone,  which  can  easily  be  felt 

between  the  tendo  Achillis  and  the  malleoh. 

40 


626  A   MANUAL  OF  SURGERY 

Treatment. — Reduction  is  only  possible  in  the  incomplete  forms  of 
dislocation.  The  patient  is  anaistlietized,  the  knee  flexed  to  relax 
the  muscles  or  the  tendo  Achillis  divided,  and  traction  upon  the  foot 
established,  so  as  to  enable  the  surgeon  to  apply  pressure  upon  the 
displaced  bone  in  a  suitable  direction.  In  the  complete  variety  re- 
duction is  impracticable,  owing  to  the  fact  that  the  os  calcis  is  drawn 
up  into  contact  with  the  malleolar  arch.  In  such  cases  manipulation 
is  useless,  and  excision  of  the  bone  is  necessary.  Comparatively  little 
impairment  in  the  function  of  the  foot  results  from  this  operation. 

Subastragaloid  Dislocation. — By  this  term  is  meant  a  displacement 
of  all  the  bones  of  the  foot  from  below  the  astragalus,  which  retains 
its  normal  position  between  the  malleoli.  It  is  due  to  some  violent 
strain  or  wrench  of  the  foot.  Displacement  may  occur  either  for- 
wards or  backwards,  but  in  the  great  majority  of  cases  it  is  either 
backwards  and  inwards  or  backwards  and  outwards.  The  luxation  is 
rarely  complete  as  regards  the  calcaneo-astragaloid  joint,  but  the 
articular  surfaces  of  the  head  of  the  astragalus  and  scaphoid  are 
completely  separated,  the  former  structure  lying  on  the  dorsal  surface 
of  the  latter  bone.  The  foot  is  greatly  deformed,  the  anterior  portion 
being  shortened,  the  heel  projecting,  and  the  toes  pointing  down- 
wards. The  head  of  the  astragalus  forms  a  rounded  globular 
swelling  under  the  tense  skin.  In  a  compound  dislocation  of  this 
nature  examined  post-mortem,  the  inner  edge  of  the  under  surface  of 
the  astragalus  had  burst  through  the  skin;  the  vessels  and  nerves 
were  torn  or  stretched,  and  even  when  the  wound  in  the  skin  had 
been  enlarged,  reduction  was  impossible  owing  to  the  tendons  which 
were  caught  around  the  neck  of  the  astragalus.  In  such  a  case 
removal  of  the  astragalus  would  have  been  the  only  practicable 
treatment. 

In  the  inward  displacements,  the  foot  is  somewhat  inverted,  so 
that  the  outer  malleolus  is  unduly  prominent,  and  the  inner  malleolus 
is  lost  in  a  deep  depression  caused  by  the  lateral  displacement  of  the 
OS  calcis;  the  foot  is  thus  in  a  position  somewhat  simulating  talipes 
equino-varus.  In  the  outward  dislocations  the  foot  is  everted,  the 
inner  malleolus  prominent,  and  tlie  outer  buried,  a  position  of  talipes 
equino-valgus  being  thus  assumed.  In  both  forms  the  tendo  Achillis 
is  curved,  with  its  concavity  towards  the  displacement.  Treatment 
consists  in  reduction  by  manipulation,  which  is  sometimes  readily 
accomplished,  but  may  be  a  matter  of  the  greatest  difficulty,  pro- 
bably from  the  tibial  tendons  becoming  hitched  aroimd  the  neck  of 
the  astragalus.  Section  of  the  tendo  Achillis  is  occasionally  needed. 
In  difficult  cases  excision  of  the  astragalus  may  be  required,  and 
when  there  is  much  associated  injury  to  the  soft  parts  amputation. 


CHAPTER  XXIII. 
DISEASES  OF  JOINTS. 

General  Considerations— A  careful  study  of  the  anatomy  and  physiology  of 
ioints  IS  requh-ed  in  order  to  appreciate  the  many  problems,  mechanical  and 
pathological,  which  confront  the  surgeon  in  the  treatment  of  their  diseases 
Limitations  of  space  prevent  us  from  discussing  these,  but  we  would  remind 
students  that  the  exposed  ends  of  the  bones  entering  into  a  joint  are  covered 
with  articular  cartilage,  and  in  young  people  are  separated  Irom  the  shafts 
bv  the  intervention  of  epiphvses,  which  protect  the  joint  m  many  cases  froni 
the  spread  of  disease  from  the  diaphyses,  but  in  some  cases  are  a  source  of 
danger  in  that  the  junction  cartilages  are  mtra-articular.  Holding  the  bones 
together  is  a  complicated  series  of  ligaments,  of  varying  strength  and  density, 
usually  inserted  into  the  epiphyses  in  young  people,  and  arranged  so  as  to 
resist  the  various  forms  of  strain  to  which  the  particular  joint  is  exposed. 
Lining  the  under  side  of  the  ligaments,  and  more  or  less  closely  attached  to 
them  is  the  synovial  membrane,  a  thick,  smooth  structure  which  secretes  a 
glairy  fluid  for  lubricating  purposes;  it  extends  as  far  as  the  margins  of  the 
articular  cartilages.  \\Tiere  it  is  not  in  close  proximity  to  the  ligaments, 
as  in  the  knee-joint,  the  interspaces  are  padded  with  fat,  which  niay  occa- 
sionally prove  a  source  of  trouble.  On  the  inner  aspect  of  the  niembrane  are 
a  number  of  small  villi,  which  sometimes  develop  to  a  considerable  size. 

Inflammatory  affections  of  joints  are  of  the  most  diverse  character,  and  are 
brought  about  bv  injury,  infection,  or  general  constitutional  conditions,  such 
as  gout  The  trouble  may  be  limited  mainly  to  the  s^movial  membrane,  con- 
stituting merely  a  synovitis,  or  may  spread  to  or  involve  the  other  articular 
structures,  such  as  ligaments,  cartilages,  ends  of  the  bones,  etc.,  thereby  con- 
stituting an  arthritis. 

Effusion  into  a  joint  occurs  in  most  of  the  various  manifestations, 
the  exudate  varying  with  the  cause.  The  phenomena,  however,  are 
similar  in  all  the  diverse  conditions,  and  it  would  be  ^^•ell  to  note 
them  here.  Shoulder  :  The  curvature  of  the  shoulder  is  mcreased, 
and  the  deltoid  expanded  by  a  fluid  swelling  beneath  it,  which  is 
especially  noticeable  at  its  anterior  border  along  the  bicipital  groove, 
and  sometimes  posteriorly ;  in  the  axilla  a  painful  intumescence  may 
also  be  felt.  These  s>miptoms  may  be  somewhat  simulated  by 
inflammation  of  the  multilocular  subdeltoid  bursa,  but  the  latter 
condition  is  recognised  by  the  absence  of  any  axillary  swelling,  by 
its  not  encroaching  on  the  anterior  and  posterior  borders  of  the 
deltoid,  and  bv  the'fact  that,  although  when  the  patient  voluntarily 
moves  his  arm  pain  is  produced,  yet  when  the  surgeon  gently  mani- 

627 


628  A  MANUAL  OF  SURGERY 

pulates  it,  so  as  to  press  the  head  of  the  bone  against  the  glenoid 
cavity,  there  may  be  none.     Elboip  :  The  hollows  on  either  side  of 
the  olecranon  and  tendon  of  the  triceps  are  replaced  by  soft  fluid 
swellings,  the  outer  of  which  also  extends  down  to,  and  masks,  the 
head  of  the  radius;  there  is  usually  a  little  general  pufftness  in  front 
of  the  joint.     It  is  readily  distinguished  from  inflammation  of  the 
olecranon  bursa  by  the  fact  that  in  the  latter  condition  there  is  a 
central  fluid  prominence  over  the  bone,  whilst  in  the  former  the 
swellings  are  placed  on  either  side  of  and  above  the  bony  projection. 
Uyisi  :  There  is  a  general  fulness  around  the  joint,  most  marked  (jn 
the  anterior  and  posterior  aspects,  but  also  noticeable  behnv  the 
styloid  processes.     The  tendons  in  their  sheaths  are  lifted  up  back 
and  front,  and  deep  fluctuation  ma}^  be  detected  beneath  them.     It 
is  distinguished  from  a  teno-synovitis  by  the  facts  that  the  swelling 
is  limited  more  or  less  to  the  joint  line,  and  does  not  extend  up  and 
down  in  the  direction  of  the  tendons;  there  is  also  no  limitation  of 
movement  of  the  fingers,  and  the  characteristic  crepitus  of  teno- 
synovitis is  absent.     Effusion  into  the  Hip-joint  cannot  be  easily 
detected  b}'  digital  examination.     There  may  be  a  little  fulness  and 
tenderness  in  the  gluteal  region,  or  in  the  upper  and  outer  part  of 
Scarpa's  triangle.     The  most  characteristic  feature,  however,  is  the 
position  of  flexion,  abduction,  and  eversion  taken  by  the  hmb,  whilst 
limitation  of  movement  is  equally  marked.    The  Knee,  when  dis- 
tended with  fluid,  presents  a  rounded  outline,  in  which  all  the  normal 
hollows,  especially  those  on  either  side  of  the  patella  and  ligamentum 
patellcC,  have  disappeared.     There  is  also  a  swelling  corresponding  to 
the  subcrural  pouch,  more  marked  on  the  inner  than  the  outer  side, 
and  extending  for  3  or  4  inches  above  the  patella.     Fluctuation  can 
be  readily  detected  when  one  hand  is  placed  above  the  patella,  and 
the  fingers  of  the  other  hand  compress  the  tissues  on  either  side  of  the 
ligamentum  patellae  below,  or  by  alternate  pressure  on  either  side  of 
the  rectus  tendon.     When  the  eft'usion  is  considerable,  the  patella  is 
felt  to  float,  and  on  pressing  it  sharply  backwards  can  be  made  to  tap 
against  the  intercondyloid  notch  of  the  femur   {patellar  tap).     A 
smaller  effusion  is  recognised  by  pressing  the  fluid  downwards  from 
the  subcrural  pouch  with  the  knee  fully  extended,  when  the  patellar 
tap  can  usually  be  demonstrated.     Enlargement  of  the  bursa  patelke 
is  recognised  by  the  swelling  being  central  and  in  front  of  the  patella, 
so  that  its  outline  is  obscured.     Ankle:  The  hollows  between  the 
tendo  AchiUis  and  the  malleoli  are  replaced  by  fluctuating  swellings, 
whilst  the  dorsal  tendons  are  displaced  forwards,  and  a  fluid  swelling 
appears  in  front  of  eacn  malleolus.      Enlargement   of  the  bursa 
beneath  the  tendo  Achillis  is  so  obviously  confined  to  the  back  of  the 
joint  that  it  should  never  be  mistaken  for  true  synovitis  of  the  ankle. 
Finally,  it  must  be  noted  that  joints  are  peculiarly  liable  to  bac- 
terial  invasion,    especially   from   without.     Any   breach   of   strict 
aseptic  precautions  is  only  too  likely  to  be  followed  by  an  infection 
which  will  have  disastrous  results,  endangering  both  the  utility  of 
the  limb  and  also  the  life  of  the  patient.     Hence  the  most  minute 


DISEASES  OF  JOINTS  629 

cair  must  be  taken  in  all  operations  which  involve  the  opening  of 
joints.  Prolonged  sterilization  of  the  skin  must  be  insisted  on  when 
possible,  and  all  needless  introduction  of  fingers  into  the  wound 
should  be  avoided.  No  antiseptics  are  allowed  to  enter  the  joint,  as 
they  are  always  somewhat  irritating,  and  may  cause  a  considerable 
synovial  effusion  which  becomes  a  suitable  nidus  for  the  develop- 
ment of  bacteria,  if  such  happen  to  be  present.  At  the  conclusion  of 
the  intra-articular  manipulation,  the  joint  must  be  carefully  closed 
by  buried  sutures,  which  involve  seriatim  the  synovial  membrane, 
the  ligaments,  the  overl^'ing  muscular  or  aponeurotic  structures,  and 
finallv  the  superficial  parts;  exact  co-aptation  of  each  of  these  struc- 
tures" is  necessary  if  good  functional  repair  is  to  be  obtained,  free 
from  weakness.  Drainage  is  not  as  a  rule  necessary ;  but  if  there  has 
been  much  bleeding  the  patient's  comfort  is  increased  by  introducing 
a  drainage-tube  for  twenty-four  hours.  The  joint  is  usually  kept  at 
rest  for  a  week  or  ten  days,  perhaps  on  a  splint,  and  then  movements 
are  cautiously  permitted,  at  first  passive,  then  active,  and  finally 
active  against  resistance,  and  all  these  advisably  before  the  patient 
strains  the  joint  (if  a  knee)  by  bearing  upon  it  the  weight  of  the  body. 
Massage  to  the  surrounding  muscles  will  of  course  be  employed  as 
soon  as  the  wound  is  securely  healed. 

Acute  Synovitis. 

In  this  affection  the  inflammation  is  limited  almost  entirely  to  the 
synovial  membrane,  the  ligaments  and  other  structures  of  the  joint 
being  but  little  affected. 

The  Causes  are  local  and  general.  Local  conditions  include  cold 
and  injury;  general  or  constitutional  comprise  rheumatism,  gout, 
syphilis,  and  gonorrhcea.  It  is  probable  that  in  all  cases  apart  from 
trauma  there  is  some  mild  infection,  but  it  is  limited  in  its  action  and 
results. 

Pathological  Anatomy.—  Acute  synovitis  is  characterized  by  hyper- 
emia, of  the  synovial  membrane,  and  exudation  of  plasma  and 
leucocytes,  firstly  into  the  substance  of  the  membrane,  causing  it  to 
be  thickened  and  spongy,  and  subsequently  into  the  joint;  the 
endothelium  also  proliferates,  and  is  shed.  In  the  early  stages  the 
effusion  consists  of  synovia,  diluted  with  blood  plasma,  and  often 
discoloured  with  blood  in  traumatic  cases,  and  hence  on  removal  is 
sometimes  spontaneously  coagulable;  after  a  time  the  plasma  may 
coagulate,  depositing  hmiph  upon  the  articular  surface,  whilst  serum 
remains.  This  hmiph  may  either  be  removed  by  a  natural  process 
of  absorption  when  the  inflammation  comes  to  an  end,  or  it  may 
organize,  so  as  to  form  adhesions.  In  some  varieties,  especially  if 
repair  is  not  quickly  established,  a  certain  amount  of  peri-synovial 
inflammation  follows,  resulting  in  the  ligaments  becoming  corgesti^d, 
infiltrated,  and  perhaps  somewhat  relaxed. 

The  Clinical  Signs  of  acute  synovitis  consist  in  the  joint  becoming 
painful  and  distended,  whilst  if  the  articulation  is  superfixial,  as  m 


630  A   MANUAL  OF  SURGERY 

the  knee,  a  sense  of  heat  may  be  imjxirted  to  the  hand,  and  the 
surface  may  even  be  red  and  liypenennc  The  hmb  is  maintained 
by  muscular  spasm  in  that  position  whicli  gives  the  most  ease- — viz., 
that  in  wliich  its  capacity  is  the  greatest,  and  this  is  usually  one  of 
slight  flexion.  If  the  condition  is  neglected,  the  flexion  may  increase 
considerably,  and  the  limb  become  more  or  less  fixed  in  an  undesir- 
able position,  whilst  the  muscles  governing  the  movements  of  the 
joint  undergo  rapid  atrophy.  The  phenomena  resulting  from 
effusion  into  various  joints  have  been  already  noted  (p.  627). 

When  the  acute  stage  has  passed,  the  joint  is  usually  left  in  a 
somewhat  weak  and  relaxed  condition,  with  a  little  passive  effusion, 
or  perhaps  some  adhesions.  The  adhesions  which  follow  acute  syno- 
vitis are  usually  slight  in  character,  if  the  case  has  been  properly 
treated;  they  result  from  the  union  of  patches  of  lymph  on  opposing 
surfaces  of  synovial  membrane  or  bone,  which  become  organized  into 
loose  libro-cicatricial  tissue,  containing  a  few  delicate  bloodvessels, 
and  covered  by  endothelium  extending  over  them  from  the  adjacent 
serous  membrane.  The  characteristic  signs  of  such  a  condition  are 
painful  limitation  of  movement  in  some  particular  direction,  and 
possibly  a  little  soft  crepitus. 

The  Treatment  of  acute  synovitis  consists  in  so  immobilizing  the 
joint  as  to  give  the  patient  the  greatest  amount  of  ease,  whilst,  should 
ankylosis  result,  the  limb  is  left  in  as  favourable  a  position  as  possible 
for  subsequent  utilitv.  Thus,  the  shoiihier  should  be  bandaged  to  the 
side,  and  the  hand  kept  in  a  sling;  the  elhoiv  is  placed  on  an  internal 
angular  splint,  and  flexed  to  a  little  more  than  a  right  angle,  whilst 
the  hand  is  midway  between  pronation  and  supination;  for  the  icri^.t 
all  that  is  needed  is  to  apply  a  palmar  splint  to  the  fore-arm;  the 
hip  is  immobilized  by  the  application  either  of  a  Thomas's  splint 
or  of  a  Liston's  long  splint,  or  by  placing  the  limb  between  sand- 
bags and  adjusting  an  extension  apparatus;  the  knee  is  put  on  a 
back-splint,  perhaps  slightly  flexed;  whilst  the  ankle  is  best  kept  at 
rest  by  applying  what  is  known  as  a  Roughton's  splint,  i.e.,  an  ex- 
ternal splint  with  a  foot-piece.  Necessarily,  in  all  severe  cases  of 
acute  synovitis  the  patient  should  be  confined  to  bed  and  the  limb 
elevated.  In  the  early  stages  cold  should  be  applied  to  the  joint  by 
means  of  evaporating  lotion,  an  icebag  or  Leiter's  tubes,  but  this  is 
not  advisable  in  old  people.  In  the  later  stages  fomentations  give 
greater  relief,  whilst  the  application  of  a  few  leeches  may  also  be 
beneficial.  When  the  distension  is  considerable,  removal  of  some  of 
the  fluid  by  a  carefully  ptirified  aspirator,  or  trocar  and  cannula,  may 
diminish  pain  and  hasten  recovery.  Such  fluid  should  always  be 
examined  bacteriologically,  and  if  organisms  are  found  a  vaccine 
should  be  prepared.  In  not  a  few  cases  of  acute  synovitis  the 
induction  of  passive  hyperemia  by  the  application  of  an  elastic 
bandage  will  give  relief  and  hasten  repair. 

In  the  subacute  stage,  when  the  joint  is  weak  and  relaxed,  massage 
or  friction  with  stimulating  liniments  should  be  employed,  whilst  in 
the  later  stages  elastic  pressure  is  often  of  the  greatest  value.     If  the 


DfSEASES  OF  JOINTS 


631 


case  has  been  neglected  and  tlie  limb  has  assumed  a  vicious  position, 
the  patient  should  be  amesthetizcd  and  the  deformity  forcibly  cor- 
rected ;  or  gradual  extension  is  made  by  means  of  a  weight  and  pulley 
until  the  correct  position  is  attained. 

If  adhesions  are  present,  they  should  be  carefully  broken  down 
under  chloroform ;  the  limb  is  subsequently  kept  at  rest  for  a  few 
da>-s  upon  a  splint,  whilst  passive  movements  and  massage  are  after- 
wards adopted.  In  bad  cases  it  mav  be  desirable  not  to  do  too  much 
at  a  time,  as  a  good  deal  of  inflammatory  reaction  is  thereby  lighted 
up;  the  manipulation  may  be 
repeated  more  than  once  with 
a  few  days'  interval. 

Chronic  Synovitis. 

This  affection  follows  an  acute 
attack,  or  may  be  lighted  up 
by  some  injury  or  condition  in- 
sufficient to  determine  a  more 
violent  form  of  inflammation. 
The  synovial  membrane  becomes 
thick  and  infiltrated,  whilst  the 
effusion  is  sometimes  relatively 
less  than  in  the  acute  form, 
sometimes  excessive. 

Three  varieties  have  been  de- 
scribed :     (a)     Chronic     Serous 
Synovitis  (Fig.   311)   is   a   con- 
dition in  which  effusion  is   the 
most      prominent      factor.       It 
results  from  many  causes,  which 
throw  strain  upon  the  joint,   or 
is    sometimes    inexphcable»      It     ^^^  3ii.__Chronic  Serous  Synovitis 
is    not  unfrequently   associated        ^^  Knee,  with  Distension  of  the 
with    some    condition    such    as        Subcrural    Pouch.     (From    Col- 
a  loose  cartilage,  osteo-arthritis,        lege  of  Surgeons'  Museum.) 
etc.,  and  in  its  most  aggravated  j    j     .     ,      ^,.\ 

form  constitutes  a  condition  of  hydrarthrosis  or  hydrop^_  (p.  b3o)- 
It  is  not  unfrequently  seen  affecting  the  knees  after  rising  from 
a  prolonged  stay  in  bed.  The  fluid  is  often  clear  and  limpid, 
and  the  changes  in  the  structure  of  the  membrane  are  but  slight. 
The  pain  is  usually  not  severe,  being  replaced  by  a  sense  ot 
uselessness  and  weakness.  It  is  interesting  to  note  that,  m  cases 
where  the  effusion  is  well  marked,  the  burs^e  commumcatmg  with  the 
joint  frequently  become  distended;  they  are  prevented  from  partici- 
pating in  the  acute  forms  of  inflammation  by  the  fact  that  the 
apertures  of  communication  with  the  interior  of  the  joint  are  narrow 
and  slit-like,  and  thus  readily  become  occluded  by  the  swelling  of  the 
membrane. 


632 


A   MANUAL  OF  SURGERY 


(b)  Chronic  Synovitis  with  Thickening  of  the  Synovial  Membrane  is 

always  a  suspicious  condition,  as  it  may  be  a  precursor  ol  tuberculous 
disease,  if  it  lasts,  or  an  outcome  of  a  syphilitic  infection.  There  is 
but  little  effusion,  and  the  membrane  may  even  be  pal])able.  Crepitus 
is  sometimes  met  with  in  this  condition,  possibly  from  a  roughening 
of  the  articular  surfaces  on  which  lymph  has  been  deposited,  or 
between  which  fibrous  adhesions  have  formed. 

(c)  Chronic  Papillary  Synovitis. — Occasionally  the  synovial  fringes 
and  the  villi  of  the  sjnovial  membrane  become  hypertrophied, 
giving  rise  to  a  conchtion  somewhat  similar  to  that  described  under 
osteo-arthritis  (p.  654).  The  overgrown  villi  usually  spring  from  the 
reflections  of  the  synovial  membrane  close  to  the  bone,  and  may  be 
loaded  with  fat,  constituting  a  condition  known  as  '  Lipoma  arbo- 

rescens.'  In  the  knee- 
joint  the  fringes  may  be 
felt  rolling  under  the 
fingers,  and  painful  symp- 
toms may  be  caused  by 
the  loose  ends  being 
caught  and  nipped  be- 
tween the  bones. 

Treatment  varies  some- 
what in  the  different 
varieties,  but  in  all  com- 
mences by  keeping  the 
joint  at  rest  in  a  suitable 
position,  and  applying 
counter  -  irritation  and 
pressure;  Scott's  dressing 
and  blisters  are  especially 
useful  in  this  affection. 
At  a  somewhat  later  stage 
Bier's  hyperemia  may  be 
helpful,  or  elastic  pressure 
by  a  Martin's  bandage 
over  the  affected  joint  may  be  employed,  together  with  friction 
with  stimulating  liniments,  or  even  hot-air  baths.  When  effusion 
is  marked  and  resists  these  methods  of  treatment,  removal  of  some 
of  the  fluid  b}-  aspiration  and  subsequent  compression  may  do 
good ;  but  if  the  effusion  re-appears,  the  best  procedure  consists  in 
opening  the  joint,  washing  it  out  with  sterile  saline  solution,  and 
draining  it  for  a  few  days. 

In  the  chronic  fibroid  form  iodide  of  potassium,  or  iodolysin*  may 
be  useful  in  addition  to  the  above-mentioned  nu'thods,  but  as  a  rule 
one  has  to  rely  on  prolonged  massage,  radiant-heat  baths,  the  intro- 
duction of  iodine  by  ionic  medication,  or  spa  treatment. 

Should  enlarged  villi  be  present  and  give  rise  to  trouble,  the  joint 

*  Iodolysin  is  a  5  per  cent,  solution  of  the  ethyl-iodide  of  thiosinamin  (p.  263) ; 
20  to  60  minims  may  be  given  by  the  mouth  three  times  a  day. 


Fig.  312. — Baker's  Cysts  from  Back  of 
Knee.     (Howard  Marsh.) 


DISEASES  OF  JOINTS  633 

Should  be  opened,  and  if  they  arc  limited  in  their  distribution  they 
mav  be  clipped  away,  or  the  synovial  membrane  from  which  they 
^row  dissected  out.  When  very  extensive,  so  that  removal  would 
involve  total  excision  of  the  synovial  membrane  and  consequent 
stiffness  it  may  be  wise  to  wash  out  and  dram,  in  the  hope  that  tliey 
may  become  fixed,  before  undertaking  complete  extirpation  of  the 
membrane. 

Hydrarthrosis  (Hydrops  Articuli)  is  the  term  appHed  to  any  '^°f^*['^\°|^^ 
chrome  nature  in  which  the  joint  is  much  distended  with  fluid  It  ^ay  anse 
from  at  least  five  different  affections:  («)  Chronic  serous  synovitis  (^)mosteo-- 
artliritis,  a  very  common  cause;  (c)  in  Charcots  disease;  (d)  ^^  secondary 
syphilitic  synovitis;  and  {e)  occasionally  in  tuberculous  disease.  I*  must  be 
remembered  that  it  is  but  a  symptom,  and  not  a  disease  sui  generis,  aad  tieat- 
mcnt  necessarily  varies  with  the  cause.  .,_,,,..,   +^  ivr^    Mr,rrant 

Baker's  Cysts.-This  condition,  first  described  by  ^he Jate  Mr.  Morrant 
Baker,  consists  in  a  hernial  protrusion  o  the  synovial  membrane  of  ajomt 
through  an  aperture  in  its  fibrous  capsule  (Fig.  3 1 2)  ■  It  is  usually  due  to 
some  chronic  affection  of  the  articulation,  especially  osteo-arthi itis  or  tuber 
culous  disease,  whereby  the  intra-articular  pressure  is  i^^^^^^f^^'  ^"\J°^ 
uncommonly  several  such  sacs  are  connected  ^^i^hthe  same  joint^l hey 
vary  much  in  size,  contain  synovial  fluid,  and,  though  at  ^.^-^^  ':ommim^catm 
with  the  joint  cavity,  have  a  tendency  to  travel  away  from  it  burr°wing  alon 
muscular  and  fascial  planes,  and  coming,  perhaps,  to  the  surface  at  a  distance 
from  their  origin,  the  aperture  of  communication  with  the  lo^nt  Imping  m 
some  instances  been  shut  off.  If  causing  no  troublesome  ^yniptoms^  there 
is  no  necessity  to  interfere;  but  if  they  become  mconyenient  or  pamtui  _it 
IS  best  to  dissect  them  out,  closing  where  necessary  by  If^^f  ^,°fJ^J,^'™ 
narrow  neck  which  leads  into  the  joint.  Of  course,  the  strictest  asepss  must 
be  maintained  in  all  such  proceedings,  and  the  causative  affection  must  not 
be  forgotten. 

Acute  Arthritis. 
Causation.-  Acute  arthritis  is  nearly  always  due  to  infection  of  the 
joint  cavity  with  pyogenic  bacteria,  which  reach  it  either  from  withm 
or  without  the  bSdy.  (i.)  It  may  be  due  to  the  entrance  of  cocci 
through  a  punctured  or  valvular  wound  of  the  joint,  or  during  opera- 
tions The  micro-organisms  most  commonly  present  are  the  Fneto- 
mococcus  and  the  Streptococcus  pyogenes,  but  staphylococci  and  other 
pathogenic  organisms  have  also  been  found,  (u.)  It  rnay  arise  in  a 
manner  exactly  analogous  to  that  in  which  acute  infective  osteo- 
myelitis is  produced,  viz.,  by  auto-infection.  A  slight  injury  (g.g.,  a 
sprain  or  strain  occurring  in  a  weakly  child,  convalescent  from 
rneasles  or  scarlet  fever)  may  result  in  this  affection  which  is  then 
commonly  due  to  the  pneumococcus.  (iii.)  It  may  be  produced  by 
the  lodgment  of  a  pyemic  emhohts,  and  in  a  similar  way  it  not  un- 
frequently  follows  as  a  sequela  of  fevers,  such  as  enteric  or  pneu- 
monia by  direct  transmission  of  some  infective  material,  (iv.)  it  is 
sometimes  met  with  as  a  result  of  gonorrhoea,  and  may  then  run  its 
course  with  or  without  suppuration,  (v.)  It  may  be  hghted  up  a.s  a 
result  of  the  extension  of  inflammation  from  the  end  of  a  neighbouring 
bone,  or  from  the  bursting  of  a  subcutaneous  or  bursal  abscess  into 
the  joint.  Acute  arthritis  of  the  hip-joint  is  sometimes  due  to  the 
former  of  these  conditions,  being  consecutive  to  an  acute  mtective 


634  A   MANUAL  OF  SURGERY 

ostco-myc'litis  of  tlic  upper  end  of  the  femur,  (vi.)  It  is  occasionally 
observed  as  a  result  of  vhcmnaiisin,  the  inllanunation  running  a  very 
acute  course,  and  leading  to  disorganization  of  the  joint,  though 
without  suppuration.  Such  attacks  are  undoubtedly  bacterial  in 
origin. 

Course  of  the  Case. — In  the  early  stages  acute  arthritis  manifests 
itself  as  a  hyperacute  synovitis,  combined  with  severe  pain  and  fever. 
The  pain  is  often  so  intense  that  the  patient  cannot  bear  the  part  to 
be  touched  or  the  bed  shaken,  and  indeed  the  slightest  jar  of  the 
limb  is  so  exquisitely  painful  that  the  patient  may  scream  with 
agony.  The  joint  itself  is  distended  with  a  turbid  effusion,  which 
rapidly  bcconles  purulent,  and  the  tissues  around  are  hypertemic  and 
oedematous.  The  patient  naturally  places  himself  in  that  position 
in  which  the  limb  obtains  the  greatest  ease,  and  therefore  usually 
semiflexes  the  joint  and  fixes  it  by  muscular  contraction. 

As  the  disease  progresses,  pus  is  formed  within  the  capsule,  but 
in  time  bursts  through  it,  and  either  travels  directly  to  the  surface, 
or  burrows  deeply  into  the  substance  of  the  limb,  and  spreads  along 
the  muscular  planes;  thus,  in  the  knee  an  enormous  abscess  may 
collect  beneath  the  vasti  muscles,  stripping  them  from  the  bone  for 
a  considerable  distance.  The  pain  increases  whilst  the  abscesses  are 
forming,  and  becomes  especially  distressing  at  night,  the  patient 
being  often  waked  by  a  painful  start  just  as  he  has  fallen  asleep. 
This  condition  usually  indicates  that  the  articular  cartilages  are 
becoming  affected,  and  is  explained  by  the  fact  that  just  as  the 
patient  loses  consciousness,  the  muscles  which  fix  the  joint  are  re- 
laxed, and  allow  the  inflamed  surfaces  to  shift  their  position  slightly, 
exciting  severe  pain  and  a  sudden  spasmodic  contraction  of  the 
muscles.  Gradually  the  deformity  becomes  more  and  more  obvious, 
whilst  the  infiltration  and  relaxation  of  the  ligaments  sometimes 
allow  of  abnormal  movements — e.u,.,  of  lateral  mobility  in  the  knee- 
joint  ;  the  ends  of  the  bones  become  carious,  and  absolute  displace- 
ment or  dislocation  may  follow.  Sinuses  may  open  in  all  directions, 
and  the  patient  suffer  from  recurrent  rigors,  caused  by  toxaemia  or 
the  onset  of  pyeemia.  The  constitutional  effects  are  always  severe, 
consisting  of  high  fever,  and  rapid  exhaustion  from  the  pain,  sleep- 
lessness, and  absorption  of  toxins. 

The  terminations  of  this  affection  are  as  follow:  [a)  Recovery,  rarely 
with  a  moveable  joint,  and  then  only  after  active  interference;  in 
most  cases  ankylosis  in  a  good  or  bad  position,  according  to  the 
treatment,  is  the  best  result  that  can  be  expected,  [h]  During  the 
acute  stage  the  patient  may  die  of  pysemia,  or  acute  toxaemia  and 
exhaustion,  (c)  If  he  survive  the  acute  stage,  chronic  suppuration 
may  ensue,  and  symptoms  of  hectic  and  amyloid  degeneration  of  the 
viscera  may  supervene.  In  such  cases  sinuses  leading  down  to 
carious  bones  exist,  and,  unless  efficient  measures  are  taken  to 
obtain  asepsis,  or  to  remove  the  diseased  structures,  perhaps  bv 
amputation,  the  patient  is  likely  to  die  from  exhaustion  or  chronic 
toxaemia. 


DISEASES  OF  JOINTS 


635 


Pathological  Anatomy. — The  synovial  inoiibrane,  at  first  merely 
infiltrated  and  hypenemic,  soon  becomes  converted  into  granulation 
tissue,  exuding  an  abundance  of  pus.  The  ligaments  in  turn  are 
sodden  and  relaxed  by  the  presence  of  a  plastic  exudation  between 
the  fibres,  rendering  them  soft  and  edematous,  so  that  the  tonic 
contraction  of  the  muscles  easily  stretches  them  and  brings  about 
displacement.  The  articular  cartilages  are 
disintegrated  and  destroyed  in  various  ways 
according  to  the  acuteness  of  the  inflamma- 
tion and  the  amount  of  pressure  to  which  they 
are  exposed.  In  acute  cases  the}^  early  lose 
their  normal  l)luish-white  appearance,  and 
become  opaque  and  slightly  yellow.  The 
central  parts,  which  are  exposed  to  pressure 
between  the  ends  of  the  bones,  soon  disappear, 
whilst  the  peripheral  portions  are  eroded  by 
the  overgrown  granulation  tissue  developing 
from  the  synovial  membrane.  When  once  the 
cartilage  has  been  perforated  at  any  one  spot, 
the  suppurative  inflammation  spreads  along 
its  under  surface,  stripping  it  from  the  bone, 
and  thus  inducing  necrosis,  as  a  result  of 
which  isolated  portions  of  dead  cartilage  may 
be  found  lying  in  the  joint.  The  inter -articular 
cartilages  are  affected  in  a  very  similar  manner, 
and  quickly  disappear.  The  ends  of  the  bone 
pass  into  a  condition  of  acute  osteitis,  re- 
sulting in  the  transformation  of  the  medulla 
into  granulation  tissue,  absorption  of  the  bony 
cancelli  with  or  without  suppuration,  and 
sometimes  necrosis  of  small  portions  of  the 
cancellous  tissue  [caries  necrotica) .  The  veins 
within  the  cancelli  become  thrombosed,  and 
hence  p^^aemia  may  result.  The  periosteum 
covering  the  ends  of  the  bones  is  also  inflamed 
and  hypergemic,  in  consequence  of  which  spicii- 
lated  or  stalactitiform  osteophytes  are  pro- 
duced (Fig.  313).  The  muscles  in  the  neigh- 
bourhood of  the  joint  undergo  rapid  atrophy 
and  fatty  degeneration. 

Treatment. — In  the  early  stages  the  limb  must 
be  elevated,  absolute^  immobilized,  and  put  into  such  a  position 
that,  if  ankylosis  subsequently  obtains,  it  may  be  of  some  use  to  the 
patient.  \Veight  extension  is  usually  desirable  in  order  to  keep  the 
inflamed  articular  ends  from  rubbing ;  but  as  light  a  weight  as  possible 
must  be  used,  or  the  inflamed  and  softened  ligaments  may  be  stretched. 
Bier's  treatment  by  induced  hyperemia  is  sometimes  of  the  greatest 
value  in  checking  the  inflammation  and  relieving  pain,  which  may  also 
be  helped  by  applying  fomentations  or  an  icebag.   Increasing  effusion. 


Fig.  313. — Ends  of 
THE  Bones  after 
Acute  Arthritis 
OF  Elbow,  show- 
ing THE  Carious 
Surfaces  Devoid 
OF  Cartilage, 
and  the  Devel- 
opment OF  Stal- 
actitiform Os- 
teophytes. (From 
King's  Col- 
lege Hospital 
Museum.) 


636  A   MANUAL  OF  SURGERY 

espeiially  if  supi)ur;iti<)n  is  })r()l)al)lc,  necessitates  an  incision  into  the 
joint,  and  the  demonstration  of  the  existence  of  pus  indicates  the 
free  opening  of  the  joint  in  as  many  situations  as  may  be  necessary 
to  ensure  perfect  drainage.  The  cavity  is  frequently  washed  out 
with  some  sterile  or  mild  antiseptic  solution,  and  to  assist  this  the 
openings  are  made  for  choice  on  opposite  sides  of  the  joint.  A 
vaccine  is,  of  course,  grown  from  the  pus  as  quickly  as  possible  and 
administered.  It  may  be  wise  to  discontinue  the  use  of  the  elastic 
bandage  during  the  stage  of  free  suppuration,  but  as  soon  as  it  is 
checked  the  hypenemic  treatment  may  be  continued.  The  fixation 
of  the  limb  is  carefully  maintained,  and  the  general  health  attended 
to.  Irrigation  should  be  continued  until  all  signs  of  inflammation, 
pain,  heat,  and  startings  of  the  limb  have  passed  away.  Should  this 
not  occur,  it  may  be  desirable  to  lay  the  joint  even  more  freely  open, 
and  to  maintain  continuous  irrigation  with  salt  solution,  to  which 
peroxide  of  hydrogen  has  been  added.  Under  such  a  r'^ime  it  is 
sometimes  possible  to  obtain  a  moveable  joint,  but  more  frequently 
ankylosis  must  be  expected.  Excision  may  be  required  in  order  to 
secure  effective  drainage  in  some  joints,  such  as  the  shoulder;  to 
prevent  or  remedy  faulty  ankylosis,  or  to  place  the  limb  in  a  good 
position:  it  is  also  undertaken  in  some  cases  of  chronic  suppuration, 
with  caries  of  the  ends  of  the  bones  or  displacement,  but,  as  a  rule, 
not  until  all  acute  symptoms  have  passed  away.  If  the  patient  is 
suffering  from  severe  toxsemic  or  pysemic  symptoms  threatening  life, 
amputation  may  be  required,  as  also  for  exhaustion  from  long-stand- 
ing suppuration  and  hectic  fever. 

Acute  Arthritis  of  Special  Joints. 

In  the  Shoulder,  infection  sometimes  occurs  through  the  axilla 
where  the  capsule  is  weak  and  easily  invaded  by  organisms,  as  after 
an  axillary  cellulitis;  more  frequently  it  follows  a  penetrating  injury. 
Severe  pain  is  caused  by  any  movement  of  the  arm  affecting  the 
joint,  and  if  abscesses  form,  they  will  come  to  the  surface  in  front 
of  or  behind  the  deltoid,  or  in  the  axilla.  It  may  suffice  to  open  the 
articulation  anteriorly,  and  flush  it  out,  but,  if  possible,  a  counter- 
opening  should  be  made  behind  by  cutting  down  on  a  pair  of  dressing- 
forceps  pushed  backwards  through  the  capsule.  In  many  instances 
the  patient's  condition  will  not  improve  until  the  head  of  the  bone 
has  been  excised.  The  subsequent  results  as  regards  movement  and 
power  of  the  arm  are,  on  the  whole,  very  satisfactory. 

In  the  Elbow,  there  are  no  points  requiring  special  mention  as  to 
clinical  history  or  results,  although  it  must  be  remembered  that  the 
superior  radio-ulnar  articulation  is  necessarily  involved,  and  hence 
the  power  of  pronation  and  supination  of  the  hand  is  threatened.  As 
to  treatment,  incisions  should  be  made  on  either  side  of  the  olecranon, 
the  ulnar  nerve  being  avoided.  The  limb  is  then  placed  on  a  rect- 
angular splint,  and  with  the  hand  midway  between  pronation  and 
supination;  of  course,  the  patient  is  kept  in  bed,  with  the  arm  raised 
on  a  pillow.     In  an  adult  excision  may  be  undertaken  as  soon  as  the 


DISEASES  OF  JOINTS  637 

acute  stage  has  passed,  in  order  to  obtain  a  moveable  elbow;  but 
hi  .iuldren.  where  the  growth  is  incomplete,  it  is  better  to  allow 
ankxiosis  to  occur,  and  excise,  if  need  be,  at  a  later  date. 

The  Wrist  may  be  inlected  secondaril\-  to  septic  conditions  follow- 
ing operations  on  ganglia  in  the  neighbourhood  or  through  direct 
injury.  The  essential  treatment  consists  in  free  incisions  parallel 
with 'the  tendons,  and  avoiding  the  sheaths.  Ankylosis  usually 
results,  and  excision  is  not  resorted  to  except  when  the  disease  has 
become  very  chronic,  with  extensive  caries  of  the  carpus. 

Acute  arthritis  of  the  Hip-joint  is  usually  a  sequela  of  acute  infec- 
tive osteo-myelitis  attacking  the  upper  end  of  the  shaft  of  the  femur, 
and  involving  the  joint,  owing  to  the  epiphyseal  cartilage  being  intra- 
capsular ;  it  also  results  from  pyaemia,  and  rarely  from  penetrating 
injuries.  The  symptoms  are  similar  to  those  of  the  first  stage  of 
ordinary  tuberculous  disease  (p.  670),  but  much  more  acute.  Ihere 
is  high  fever,  together  with  intense  pain,  marked  flexion  and  e version 
of  the  limb,  early  suppuration,  and  rapid  disorganization  if  not 
properly  treated;  indeed,  where  nothing  is  done,  and  the  patient  lives 
long  enough,  the  head  of  the  bone  may  be  entirely  absorbed,  or  is 
detached,  and  remains  as  a  sequestrum  in  the  disorganized  articular 
cavity.  As  soon  as  the  capsule  gives  way,  the  pus  may  come  to  the 
surface  in  any  of  the  usual  locahties  for  hip-jomt  ab_scesses._  In 
treating  these  cases,  the  joint  should  be  freely  laid  open  in  the  situa- 
tion which  appears  most  favourable.  The  anterior  incision  is  more 
suitable  for  the  early,  and  the  posterior  for  the  later,  stages,  when 
the  head  of  the  bone  is  either  dislocated,  or  remains  m  sifu  and 
separated  from  the  shaft.  A  double  opening  may  sometimes  be 
utilized  with  advantage.  . 

The  Knee-joint  is  more  frequently  involved  by  this  disease  than 
any  other,  and  is  usually  infected  from  mthout.  The  symptoms  are 
exceedingly  tj-pical:  the  pain  is  very  acute,  and  the  joint  hot  and 
distended  to  its  utmost  capacity,  the  limb  lying  semiflexed  and  on  its 
outer  side.  Left  to  itself,  the  capsule  gives  way,  and  suppuration 
rapidly  extends  upwards  beneath  the  vasti,  giving  rise  to  large 
abscesses,  which  ultimately  find  their  way  to  the  surface.  The  de- 
formity gradually  increases,  until  in  the  worst  forms  the  tibia  shps 
behind  the  cond\-les  of  the  femur,  the  leg  is  flexed  to  a  right  angle 
and  rotated  outwards,  and  if  the  limb  has  long  rested  on  its  outer 
side,  considerable  lateral  displacement  may  also  occur.  Early  and 
efficient  treatment  will  usually  prevent  such  a  disaster.  The  joint 
should  be  freely  incised  on  each  side  of  the  patella,  so  as  to  open  up 
the  subcrural  pouch,  and  the  whole  articular  cavity  well  washed  out. 
In  some  cases  a  counter-opening  may  be  made  with  advantage  and  a 
drainage-tube  inserted,  by  passing  a  pair  of  sinus  forceps  through  the 
outer  portion  of  the  posterior  ligament  of  Winslow,  and  cutting 
down  on  it  to  the  inner  side  of  the  biceps  tendon  and  clear  of  the 
external  popliteal  nerve.  By  this  means  more  efflcient  drainage  of 
the  articular  cavity  is  obtained.  r        ^.     -u 

When  the  Ankle-joint  is  involved,  amputation  has  often  to  be 


638  A   MANUAL  OF  SURGERY 

resorted  to,  in  consequence  of  the  difficulty  of  securing  good  drain- 
age, although  excision  of  the  astragalus  will  sometinK^s  cut  short  the 
disease  and  lead  to  a  good  result. 

Special  Forms  of  Synwitis  and  Arthritis. 

Rheumatic  Synovitis  is  met  with  in  the  course  of  acute  rheuma- 
tism, or  as  a  chronic  affection  from  the  commencement.  In  the 
former  one  joint  after  another  is  involved;  complete  resolution  usu- 
ally follows,  but  there  may  be  some  thickening  of  ligaments  and  con- 
sequent impairment  of  mobility.  If  the  disease  is  limited  to  one 
joint,  absolute  disorganization,  though  without  suppuration,  may 
ensue  (acute  rheumatic  arthritis).  There  can  now  be  little  question 
that  this  disease  is  of  bacterial  origin  and  due  to  a  diplococcus 
(Poynton,  Paine). 

The  chronic  variety  is  characterized  by  swelling  of  the  joints,  due 
partly  to  effusion,  partly  to  thickening  of  the  synovial  membrane, 
and  of  the  capsular  and  other  ligaments.  If  neglected,  it  may  pro- 
duce fixity  of  the  joint,  due  mainly  to  ligamentous  changes,  but  also 
resulting  from  the  development  of  intra-articular  adhesions;  but 
there  is  never  any  lipping  of  the  cartilages  or  new  formation  of  bone, 
as  in  osteo-arthritis.  Not  unfrequently  other  evidences  of  rheuma- 
tism may  be  present,  such  as  chorea,  erythema,  etc.,  whilst  rheu- 
matic nodules*  [i.e.,  new  growths  of  fibrous  tissue  beneath  the  skin, 
perhaps  attaining  the  size  of  a  walnut,  but  more  often  much  smaller) 
may  also  develop. 

The  Treatment  of  the  acute  form  is  medical  rathei  than  surgical, 
and  general  rather  than  local.  The  affected  joints  must  be  kept  at 
rest  in  good  position,  and  wrapped  in  warm  cotton-wool,  or,  perhaps 
better,  soda  fomentations  may  be  applied.  Should  the  inflammation 
resist  such  measures,  it  is  quite  justifiable  to  open  and  wash  out  the 
joint,  which  is  found  to  be  occupied  by  a  greenish,  semi-puriform 
effusion. 

In  the  more  chronic  forms  anti-rheumatic  drugs  have  less  power., 
and  more  attention  must  be  paid  to  diet.  Butcher's  meat,  sweets, 
and  rich  dishes  should  be  avoided,  and  as  far  as  possible  a  '  white 
diet  '  obtained.  Alkaline  mineral  waters  are  valuable,  and  a  visit 
to  a  suitable  home  or  Continental  spa  may  be  desirable.  Locally, 
massage  and  stimulating  embrocations  do  good,  but  in  bad  cases 
counter-irritation  by  repeated  blisters,  or  even  bv  applying  the  actual 
cautery,  may  be  required.  Malposition  should  be  corrected  under 
an  anaesthetic  or  by  weight  extension.  Localized  or  general  hot-air 
baths  do  good  in  most  cases,  as  also  diathermy  (p.  49)  and  ionic 
medication  (p.  54)  with  iodine. 

*  Dr.  Bannatyne's  opinion  as  to  the  diagnostic  value  of  fibrous  or  bonj' 
subcutaneous  nodules  connected  with  articular  lesions  is  as  follows:  '  Muscular 
swellings  are  most  often  due  to  rheiimatism,  small  subcutaneous  nodules  also 
to  rheumatism,  larger  ones  to  rheumatoid  arthritis,  bursal  enlargements  to 
chronic  gout,  rheumatoid  arthritis,  or  rheumatism,  and  bony  nodes  (of  the 
Heberden  type)  to  chronic  gout  or  chronic  rheumatoid  arthritis.' 


DISEASES  OF  JOINTS  G39 

Gouty  Arthritis  is  characterized  by  certain  well-marked  features. 
It  often  attacks  the  metatarso-phalangeal  articulation  of  the  great 
toe  (podagra) ,  or  the  metacarpo-phalangeal  joint  of  the  thumb  (cheir- 
agra).  Its  onset  is  usually  sudden,  and  it  frequently  commences 
in  the  middle  of  the  night.  The  tissues  around  the  joint  become 
swollen,  red,  shiny,  and  oedematous,  whilst  the  superficial  veins  are 
prominent.  The  attack  is  exceedingly  painful,  and  the  skin  ex- 
quisitely tender.  These  symptoms  pass  off  in  the  course  of  a  few 
days,  leaving  the  articulation  swollen  and  sensitive. 

Even  a  single  attack  results  in  a  slight  deposit  of  bi-urate  of  soda 
in  acicular  crystals  in  the  matrix  of  the  articular  cartilage  close  to 
the  surface;  but  when  the  joint  has  been  several  times  inflamed,  the 
whole  thickness  of  the  cartilage  may  be  invaded  by  this  chalky  de- 
posit, whilst  the  hgaments  and  ends  of  the  bones  are  also  infiltrated. 
In  the  smaller  joints  it  may  increase  to  such  an  extent  as  to  form 
well-marked  swellings,  or  '  tophi,'  similar  in  character  to  those  so 
commonly  seen  in  the  external  ear;  the  skin  sometimes  gives  way 
over  them,  and  a  chalky  discharge  results.  In  some  cases  the  carti- 
lages are  eroded,  and  eburnation  of  the  exposed  bone  may  follow,  as 
in  osteo-arthritis.  The  treatment  of  acute  gout  consists  in  foment- 
ing the  parts  or  applying  glycerine  of  belladonna,  whilst  colchicum, 
citrate  of  lithia,  and  alkaline  purgatives  are  administered.  In  the 
more  chronic  forms  iodides  may  be  given,  and  the  diet  and  drink 
are  carefully  regulated.  Probably  some  form  of  hydro-therapeutic 
treatment  will  be  required,  and  if  the  patient  cannot  go  to  a  suitable 
spa  much  may  be  done  at  home  by  getting  him  to  drink  a  large  cup 
of  hot  water  an  hour  before  each  meal. 

Pysemic  Synovitis  is  due  to  embolic  infection  from  some  suppurat- 
ing focus.  The  joint  becomes  rapidly  distended  with  pus,  and  often 
without  pain.  If  the  joint  is  promptly  opened,  washed  out  and 
drained,  its  disorganization  may  be  in  many  cases  prevented  (vide 
Pyaemia,  p.  97) ;  otherwise  destructive  changes  ^vill  quickty  follow. 

Typhoid  Disease  of  Joints. — i.  A  simple  synovitis  occurs  in  one  or 
more  joints,  with  but  slight  effusion  and  little  inflammatory  disturb- 
ance. It  is  somewhat  resistant  to  treatment,  and  hence  may  cause 
limitation  of  movement.  Possibly  it  is  due  to  the  action  of  toxins 
rather  than  of  the  living  organism.  2.  The  true  typhoid  avthritis,  due 
to  the  B.  typhosus,  is  characterized  by  a  marked  inflammatory  effu- 
sion into  one  or  more  joints,  and  is  liable  to  end  in  spontaneous  dis- 
location, especially  in  the  hip-joint.  Suppuration,  however,  is  rare, 
and  the  prognosis  favourable,  provided  the  limb  is  kept  in  a  good 
position.  The  presence  of  a  large  effusion  indicates  aspiration, 
3.  A  mixed  pyogenic  and  typhoid  infection  results  in  active  suppura- 
tion within  the  joints,  the  B.  typhosus  playing  quite  a  subsidiary 
part.  4.  A  ptire  pyogenic  infection.  In  these  latter  two  varieties 
the  ordinar}'-  symptoms  of  acute  suppurative  arthritis  occur,  and 
the  treatment  for  that  aft'ection  must  be  instituted. 
^  Pneumococcal  Arthritis. — In  the  course  of  an  acute  pneumonia  the 
pneumococcus  is  occasionally  disseminated  through  the  body,  and  is 


640  A   MANUAL  OF  SURGERY 

then  ver}'  likely  to  attack  a  joint  which  has  been  already  damaged, 
giving  rise  to  a  suppurativ^e  arthritis  with  an  effusion  of  thick  creamy 
pus,  or  sometimes  to  a  milder  form  of  syno\itis.  Males  are  more 
often  affected  than  females,  and  the  upper  rather  than  the  lower 
extremity.  Occasionally  more  than  one  joint  is  involved,  and,  with 
the  exception  of  the  hip,  the  larger  joints  are  attacked  rather  than 
the  smaller.  1  here  are  no  special  peculiarities  in  the  disease,  but 
since  it  is  merely  part  of  a  general  infection,  a  high  mortality  is  asso- 
ciated with  it.  Suppuration  usually  occurs,  and  its  onset  is  always 
an  indication  for  incising,  washing  out,  and  draining  the  joint. 

It  may  also  occur  primarily  and  apart  from  any  other  obvious 
pneumococcal  lesion.  The  symptoms  are  then  those  of  a  subacute 
arthritis  with  effusion,  which  may  be  so  resistant  to  treatment  as  to 
require  arthrotomy.  Some  limitation  of  movement  is  likely  to 
follow. 

Gonorrhceal  Disease  oi  Joints  is  always  due  to  infection  with  the 
gonococcus,  transmitted  by  the  blood  from  the  primary  focus  of 
mischief.  It  is  sometimes  associated  with  pyogenic  organisms,  and 
then  the  prognosis  is  decidedly  worse.  In  the  later  stages  the  pus  or 
serum  from  the  joint  is  sometimes  found  to  be  sterile,  the  gonococci 
having  died  after  causing  the  inflammation.  Such  an  occurrence  is 
always  suggestive,  as  sterile  pus  is  rarely  found  in  an  acute  abscess 
due  to  ordinary  pyococci.  Whilst  usually  seen  in  connection  with 
gonorrhceal  urethritis  in  males,  it  has  been  known  to  follow  ophthal- 
mia neonatorum,  and  has  been  lighted  up  by  passing  a  full-sized 
bougie  on  a  patient  with  gleet.  It  generally  commences  after  the 
third  week  of  the  gonorrhfeal  attack,  when  the  discharge  is  becoming 
subacute,  but  may  sometimes  appear  at  a  much  later  period.  It  may 
involve  one  or  many  joints,  the  knee,  ankle,  and  wrist  being  most 
frequently  affected,  and  perhaps  on  both  sides  of  the  body.  Many 
distinct  types  of  trouble  manifest  themselves,  and  they  are  not 
unfrequently  combined.  In  one,  the  synovial  membrane  is  mainly 
affected,  and  the  effusion  is  chiefly  intra-articular,  so  that  the  con- 
dition closely  resembles  an  ordinary  attack  of  acute  traumatic  syno- 
vitis, except  that  it  is  more  severe,  more  painful,  and  more  persistent. 

Occasionally  a  synovial  effusion  occurs  with  but  little  reaction, 
and  then  the  gonorrhceal  origin  is  likely  to  be  overlooked.  A  more 
frequent  form  is  that  in  which  the  peri-articular  structures  bear  the 
brunt  of  the  mischief ;  and  there  is  at  first  but  little  effusion  in  the 
joint,  but  much  around  it,  the  parts  even  becoming  (edematous  and 
reddened;  the  ligaments  are  infiltrated  and  softened,  so  that  dis- 
placement readily  occurs;  surrounding  muscles  atrophy  rapidly;  the 
patient  suffers  from  severe  pain  and  fever,  so  that  he  becomes  thin 
and  worn.  In  the  worst  cases  the  intra-articular  effusion  increases, 
and  is  sero-purulent,  yellfjwish-green  in  colour,  and  contains  flakes  of 
lymph;  sometimes  it  becomes  frankly  purulent.  All  the  forms  are 
very  chronic  and  resistant  to  treatment,  and  hence  ankylosis,  with  or 
without  disorganization,  is  very  liable  to  follow.  Treatment  is  not 
very  satisfactory.     The  urethral  discharge  must  be  arrested  as  soon 


DISEASES  OF  JOINTS  641 

as  possible,  whilst  the  affected  joints  are  kept  at  rest;  moderate 
pressure  and  counter-irritation,  as  by  Scott's  dressing,  are  useful 
appliances,  but  Bier's  treatment  is  perhaps  of  more  value,  or  in  the 
more  chronic  stages  ionic  medication  with  iodine  preparations  or 
hot-air  baths.  Iodide  of  potassium,  mercury,  and  quinine  may  be 
administered  internally.  Should  the  local  phenomena  be  at  all 
severe,  the  joint  must'be  opened  and  irrigated,  and  if  undertaken 
sufficiently  early,  ankylosis  may  be  prevented.  Anti-streptococcic, 
and  even  anti-diphtheritic,  serum,  given  per  rectum,  has  proved  of 
value  in  some  of  these  cases,  probably  by  increasing  the  general 
resisting  power  of  the  body.  In  most  cases  a  gonococcal  vaccine 
(p.  146)  may  be  employed  with  advantage,  even  as  an  intra-articular 
injection. 

Tuberculous  Disease  o£  Joints. 

Tuberculous  Arthritis  [Syn.  :  Pulpy  Degeneration  of  the  Synovial 
Membrane,  White  Swelling,  etc.)  may  commence  either  in  the  syno- 
vial membrane  or  in  the  articular  end  of  the  adjacent  bone  (tuber- 
culous epiphysitis,  p.  575) ;  or  it  may  spread  to  the  synovial  mem- 
brane from  the  periosteum,  as  a  result  of  a  tuberculous  periostitis,  or 
from  a  neighbouring  bursa.  In  children  the  disease  commences 
most  frequently  in  the  epiphyses,  whilst  in  adults  it  may  start  either 
in  membrane  or  bone  with  about  equal  frequency,  but  considerable 
variation  occurs  according  to  the  particular  joint  affected. 

The  Causes  may  be  summed  up  as  follows:  The  individual  is  pre- 
disposed to  the  development  of  tuberculous  disease,  often  as  the 
result  of  an  inherited  tendency;  the  general  health  of  the  patient 
may  also  be  at  fault.  Some  slight  injury,  of  which  but  little  notice 
is  taken,  may  lead  to  the  actual  deposit  of  the  B.  tuberculosis,  which 
has  probably  been  lying  latent  in  the  bronchial  or  mesenteric  glands, 
or  is  present  in  an  active  state  in  the  lungs.  Severe  articular  lesions, 
such  as  dislocations,  are  less  likely  to  induce  tuberculous  disease, 
partly  because  their  gravity  demands  efficient  treatment,  partly 
because  the  activity  of  the  reparative  process  is  capable  of  dealing 
with  the  organisms,  even  if  they  are  brought  to  the  spot. 

Pathological  Anatomy.- — The  synovial  membrane  becomes 
thickened,  pulpy,  and  oedematous,  and  in  the  early  stages  is  found 
to  be  studded  with  small  gelatinous  nodules,  about  the  size  of  a 
pin's  head,  situated  immediately  beneath  the  serous  lining;  later  on, 
these  may  amalgamate  into  caseous  masses,  which  burst  and  dis- 
charge into  the  joint,  leaving  ulcerated  surfaces.  Occasionally 
these  masses  are  of  considerable  size;  more  often  they  are  only  small. 
Finally,  the  synovial  membrane  is  changed  into  a  so-called  pyogenic 
membrane,  consisting  of  granulation  tissue  similar  to  that  lining  the 
cavity  of  a  chronic  abscess,  and  more  or  less  closely  attached  to  the 
surrounding  structures,  which  are  transformed  into  oedematous 
fibro-cicatricial  tissue,  whilst  the  superficial  parts  undergo  fatty  or 
necrotic  changes.  Fringes  of  the  sjmovial  membrane,  swollen  and 
succulent,  spread  over  the  margins  of  the  articular  cartilage,  and  as 

41 


642 


A   MANUAL  OF  SURGERY 


they  increase  in  size  become  adlierent  to  it,  just  as,  according  to 
Rillroth's  classical  description,  ivy  creeps  along  a  wall.  C)n  lifting 
the  edges  of  these  fringes,  the  underlying  cartilage  is  found  hollowed 
out  and  eroded.  As  soon  as  the  whole  thickness  is  destroyed  at  any 
one  spot,  the  cancellous  tissue  at  the  end  of  the  hone  becomes  invaded 
by  the  tuberculous  disease,  and  the  granulations  spread  along  under 
the  cartilage,  cutting  it  off  from  its  nutritive  supply,  and  thus  large 
flakes  of  necrosed  cartilage  may  be  shelled  oft  (Fig-  314)-  As  a 
result  of  the  hypersemic  condition  of  the  end  of  the  bone,  especially 

when  pyogenic  infection  is  super- 
added, a  new  formation  of  subperi- 
osteal osteophytes,  stalactitiform  in 
character,  sometimes  takes  place, 
but  not  to  such  an  extent  as  in 
a  true  pyococcal  arthritis.  Occa- 
sionally the  periosteum  itself  is  in- 
volved in  the  tuberculous  process, 
and  the  disease  may  then  extend 
some  distance  from  the  joint.  The 
joint  itself  usually  contains  but 
little  fluid,  being  fully  occupied  by 
the  swollen  synovial  membrane  ; 
but  occasionally  in  the  early  stages 
there  is  much  effusion,  constituting 
a  condition  known  as  tuberculous 
hydrops,  and  in  it  there  may  be  a 
considerable  amount  of  fibrin,  which 
is  moulded  by  the  movements  of 
the  joint  into  the  so-called  melon- 
seed  bodies.  The  chief  cytological 
element  in  the  effusion  is  the  lym- 
phocyte. 

The  peri-synovial  tissues  are  fre- 
quently   affected    in    these    cases, 
especially  where  there  is  much  loose 
fatty  tissue,   as    around   the  knee. 
The  parts  are  infiltrated  and  gela- 
tinous,   and   muscles   and   tendons 
are  incorporated  in  the  swelling  and  modified  similarly  in  texture. 
This  change  constitutes  a  large  element  in  what  is  known  as  the 
white  SKeiling  of  a  joint. 

When  the  disease  originates  in  the  bone  in  adults,  the  tissue 
directly  contiguous  to  the  articular  cartilage  is  often  that  primarily 
attacked;  but  in  children  it  more  frequently  starts  in  connection 
with  the  epiphyseal  cartilage.  The  joint  is  usually  infected  by 
extension  of  the  disease  through  the  articular  cartilage;  but  when 
the  synovial  membrane  extends  along  the  bone  beyond  the  cartilage, 
as  in  the  hip-joint,  it  may  become  involved  without  any  cartilaginous 
lesion.     In  the  early  stages  a  simple  synovial  effusion  may  occur, 


Fig.    314.  —  Tuberculous    Dis- 
ease OF  Head  and  Neck  of 
,   THE  Femur. 

The  disease  evidently  started  on 
the  under  side  of  the  nerk, 
which  has  been  eroded,  and 
spread  into  the  head;  the 
articular  cartilage  is  loose,  and 
necrotic  fragments  of  it  have 
been  stripped  up  off  the  bone. 


DISEASES  OF  JOINTS 


643 


and  should  the  osseous  trouble  quiet  down  and  be  cured,  this  may  be 
absorbed,  and  merely  a  few  adhesions  be  left.  More  frequently, 
however,  infection  follows,  and  the  type  of  trouble  varies.  Some- 
times a  tuberculous  abscess  of  the  bone  or  surrounding  parts  bursts 
into  a  joint;  acute  symptoms 
supervene,  but  gradually  quiet 
down,  and  the  usual  chronic  phe- 
nomena subsequently  develop. 
More  commonly  the  infection  is 
due  to  the  gradual  erosion  of 
the  cartilage  towards  its  peri- 
phery, and  the  onset  of  the  ar- 
ticular symptoms  is  then  of  a 
chronic  type. 

At  any  period  of  the  disease 
a  natural  cure  may  supervene, 
and  is  characterized  by  the  ab- 
sorption of  the  tuberculous  tissue 
and  its  replacement  by  healthy 
cicatricial  tissue.  The  result  of 
this  is  the  production  of  adhe- 
sions, slight  or  dense,  as  the  case 
may  be,  and  which  may  remain 
fibrous  or  osseous;  ankylosis  is 
naturally  a  common  termination. 
If,  however,  the  condition  does 
not  improve,  abscesses  develop, 
and  when  opened  are  liable  to 
pyococcal  infection  ;  the  liga- 
ments soften  and  yield;  deformity 
is  produced,  and  even  if  at 
length  a  cure  is  established,  it 
is  at  the  expense  of  usefulness 
and  perhaps  growth,  and  may  be 
associated  with  deformity. 

Clinical  History. — The  disease 
usually  commences  in  a  most  in- 
sidious manner.  It  may  be  dated 
back  to  some  injury,  but  as  often 
as  not  no  such  occurrence  has 
been  noted.  Slight  impairment  of 
movement,  together  with  some 
pain,  especially  when  the  limb  is 
jarred  or  twisted,  is  perhaps  the 
first  sign,  causing  the  patient  to 
limp  if  one  of  the  lower  extremities  is  involved.  This  limitation  of 
movement  is  usualh^  manifested  in  all  directions,  and  this  will  often 
assist  in  diagnosing  it  from  the  fixity  due  to  the  presence  of  adhe- 
sions in  a  simple  chronic  synovitis.     The  amount  of  rigidity  varies 


Fig.  315. — Bones  entering  into 
Formation  of  Knee- Joint,  which 
HAS  BEEN  Disorganized  by  Tu- 
berculous Disease.  (From  Col- 
lege of  Surgeons'  Museum.) 

The  cartilage  is  almost  entirely  de- 
stroyed, and  the  exposed  bone  is 
carious  and  eroded. 


644  A   MANUAL  OF  SURGERY 

much;  in  a  purely  synovial  lesion  the  movements  may  at  first  be 
painless  and  but  little  impaired,  although  the  whole  region  of  the 
joint  may  be  puffy  and  swollen ;  when,  however,  the  bone  is  affected, 
either  primarily  or  secondarily,  the  limitation  of  movement  is  con- 
siderably increased.  The  position  of  the  limb  is  that  which  will  give 
the  greatest  amount  of  comfort,  and  varies  in  different  joints  {<i.v.) 
and  at  different  stages  of  the  disease.  On  inspection  a  superficial 
joint,  like  the  knee,  looks  white,  smooth,  and  rounded  (constituting 
the  '  white  swelling,'  or  tumor  albus  of  the  older  textbooks),  the 
swelling  being  more  apparent  on  account  of  the  wasting  of  adjacent 
muscles.  On  palpation,  the  part  is  found  to  be  slightly  hotter  than 
that  on  the  opposite  side  of  the  body,  whilst  fluctuation  is  not  readily 
detected,  there  being  but  little  fluid  in  the  joint,  though  the  affected 
tissues  are  elastic  and  puffy.  In  a  few  cases,  where  the  synovial 
membrane  is  widely  involved,  the  affection  commences  with  con- 
siderable serous  exudation,  giving  rise  to  the  condition  known  as 
tuberculous  hydrops  ;  after  persisting  for  a  while,  the  usual  mani- 
festations of  the  disease  show  themselves.  If  fibrinous  melon- 
seeds  are  present,  a  soft  crepitus  may  be  felt  on  moving  the  joint. 

From  time  to  time  exacerbations  of  pain  and  increase  of  swelling 
occur,  which  subside  after  resting  for  a  few  days,  but  leave  the  joint 
more  and  more  crippled.  Starting  pains  at  night  develop  when  the 
cartilages  are  becoming  eroded,  together  with  slight  fever  and 
malaise.  Sooner  or  later  an  abscess  forms,  with  increased  local  and 
general  disturbance.  When  it  bursts  or  is  opened,  temporary  relief 
is  experienced ;  but  fresh  abscesses  are  liable  to  form.  If  pyogenic 
infection  supervenes,  the  patient  develops  a  hectic  temperature; 
am3'loid  degeneration  of  the  viscera  may  follow;  the  limb  becomes 
more  and  more  deformed;  and  finally  the  patient,  exhausted  partly 
by  the  discharge,  partly  by  the  pain,  and  partly  by  want  of  sleep, 
becomes  emaciated,  and  may  even  die,  unless  prompt  measures  are 
taken  for  his  relief. 

Results. — {(i)  If  seen  in  the  early  stages,  and  suitably  treated, 
the  disease  may  be  entirely  cured,  and  a  moveable  joint  retained. 
{h)  More  frequently  the  articular  structures  are  so  severely  damaged, 
that  a  cure  can  only  be  established  by  means  of  ankylosis.  Unless 
measures  have  been  adopted  to  maintain  the  limb  in  a  satisfactory 
position,  permanent  deformity  may  ensue.  This  type  of  cure  is 
not  alwa3'S  satisfactory,  as  localized  tuberculous  foci  may  be  encap- 
suled  in  the  fibrous  tissue,  and  these  from  time  to  time  may  cause 
pain  and  trouble,  (r)  If  pyogenic  organisms  have  been  admitted,  the 
patient  will  probably  develop  hectic  or  amyloid  disease  from  chronic 
toxaemia,  and  to  this  he  may  succumb.  On  the  other  hand,  in  a 
few  instances  he  may  survive  such  dangers,  the  sinuses  alternately 
drying  up  and  discharging,  although  he  remains  a  permanent  in- 
vahd,  and  the  joint  is  crippled,  (d)  Acute  miliary  tuberculosis  is 
occasionall)'  met  with  as  a  complication  of  this  affection,  or  tuber- 
culous disease  of  the  lungs,  brain,  kidneys,  or  other  viscera,  may  be 
lighted  up. 


DISEASES  OF  JOINTS  645 

The  Diagnosis  is  bv  no  means  easy  in  all  cases,  although  sometimes 
it  is  tolerably  obvious.  One  can  never  insist  too  o  ten  on  the  impor- 
tance of  comparing  the  diseased  joint  with  the  healthy.nvhenever 
possible,  observing  the  differences  in  contour,  colour  temperature 
and  mobihty.  The  history  of  the  case  must  be  carefully  noted,  the 
amount  and  character  of  the  effusion,  and  whether  or  not  lympho- 
cytes predominate  in  a  cytological  examination ;  the  amount  of  move- 
ment must  be  ascertained  and  whether  the  limitation  is  general  or 
particular.  The  opsonic  index  to  the  tubercle  bacillus  may  also 
throw  light  on  the  case,  and  the  degree  and  character  of  the  reaction 
after  a  tuberculin  injection.  Finally,  radiogiaphy  may  help,  and 
particularly  in  distinguishing  a  sarcoma  of  the  cancellated  tissue  of 
one  or  other  of  the  bones  forming  the  joint.  A  mistaken  aiagnosi^ 
in  such  a  condition  may  result  in  loss  of  hfe  and  not  merely  m 
cripphng  or  loss  of  the  limb,  and  has  been  made  many  a  time  with 
disastrous  results  bv  unquahtied  (so-called)  bone-setters.  _ 

The  Prognosis  is^mainlv  influenced  by  the  condition  of  the  in- 
dividual and  his  surroundings.  In  children  of  the  better  classes, 
where  everv  hygienic  and  medical  assistance  can  be  given,  recovery 
generally  follows,  unless  there  is  a  strong  counterbalancing  heredi- 
tary tendencv.  Amongst  the  poorer  classes,  and  especially  m  slum 
children,'  the  outlook  ic  correspondingly  serious.  Moreover,  the  ex- 
tremes of  life  are  unfavourable:  babies  resist  tuberculous  invasion 
badly,  and  many  patients  over  fifty  have  comparatively  little  recuper- 
ative power.  .  ■  ^  T  uv.  +v,o 
The  Treatment  of  tuberculous  joints  varies  not  only  with  the 
articulation  affected,  but  also  with  the  type  of  patient,  and  the 
extent  to  which  the  disease  has  advanced. 

I  Hv^ienic  Treatment.—Loeslized  tuberculosis  can  often  be  cured 
in  the  eailv  stages  by  suitable  local  and  constitutional  treatment. 
The  limb  must  be  kept  absolutely  at  rest  by  means  of  splints 
plaster  of  Paris,  etc.,  and  elevated  if  there  is  much  pam.  Rest  should 
include  freedom  not  only  from  mobility,  but  also  from  pressure,  and 
therefore  in  the  lower  extremity,  if  the  patient  is  allowed  to  walk, 
the  limb  must  be  kept  from  the  ground  by  putting  a  patten  on  the 
other  boot.  An  endeavour  should  be  made  at  the  same  time  to  cor- 
rect any  faulty  position  of  the  limb  by  gradual  weight  extension, 
made  at  first  in  the  direction  of  the  displaced  hmb,  and  with  only 
just  sufficient  energy  to  keep  the  joint  surfaces  at  rest  and  counteract 
the  tonic  muscular  "contraction  which  is  tending  to  produce  a  fixed 
deformity.  Tenotomy  may  be  necessary  to  assist  in  this  proceeding ; 
but  any  form  of  apparatus  which  depends  upon  a  screw  mechanism  to 
straighten  out  a  hmb  is  certain  to  increase  intra-articular  tension, 
and  therefore  is  not  to  be  used.  The  sudden  apphcation  of  force 
under  an  anaesthetic  is  usually  unadvisable,  since  tuberculous 
material  may  thereby  be  disseminated  through  the  system.  Counter- 
irritation,  combined  with  pressure,  in  the  form  of  Scott  s  dressing,  is 
often  useful  in  promoting  repair.  The  general  health  should  be 
improved  by  sending  the  child  to  a  suitable  sanatorium  or  the  sea- 


646  A   MANUAL  OF  SURGERY 

side,  giving  plenty  of  good  food,  and  administering  cod-liver  oil  and 
syrup  of  tlie  iodide  of  iron.  The  process  of  cure  is  slow,  and  the 
patient's  friends  must  be  warned  as  to  the  necessary  length  of  the 
treatment. 

2.  As  accessories  to  this  hygienic  treatment  the  following  plans 
may  be  adopted: 

{a)  Parenchymatous  injections  of  iodoform  suspended  in  glycerine 
into  the  articular  cavity,  or  into  the  substance  of  the  synovial 
membrane,  have  been  much  employed  and  have  apparently  done 
good;  10  parts  of  iodoform  are  mixed  with  20  of  sterilized  water, 
and  made  up  to  100  with  sterilized  glycerine.  A  suitable  quantity 
of  this  fluid  carefully  sterilized  is  injected  into  the  joint  cavity,  or 
smaller  quantities  are  scattered  through  the  surrounding  tissues.  An 
inflammatory  reaction  usually  follows,  but  when  this  has  subsided 
• — after  perhaps  a  fortnight- — the  injection  may  be  repeated.  It  is 
perhaps  of  most  value  when  there  is  a  definite  effusion  into  the  joint. 

{b)  Bier's  plan  of  induced  hyperaimia  is  decidedly  useful,  and, 
indeed,  was  first  introduced  in  the  treatment  of  tuberculous  joints 
(p.  41).  The  method  employed  consists  usually  in  the  application 
of  a  rubber  bandage  above  the  joint  for  such  a  length  of  time  as  can 
be  tolerated  by  the  patient,  usually  not  more  than  two  or  three 
hours.  It  is  doubtful  whether  it  is  wise  to  employ  it  where  septic 
sinuses  are  present. 

3.  Abscesses  should  be  dealt  with  sufficiently  early  and  in  such  a 
manner  as  to  obviate  the  need  for  drainage.  To  this  end  they  ought 
never  to  be  left  until  the  skin  and  subcutaneous  tissues  are  involved, 
but  as  soon  as  a  collection  can  be  detected,  it  should  be  tapped  by  a 
large  trocar  and  cannula,  the  cavity  well  irrigated,  and  injected  with 
iodoform  emulsion.  It  is  wise  to  incise  the  skin  with  a  knife,  and 
not  to  puncture  it  with  the  trocar ;  the  irregular  wound  made  by  the 
latter  does  not  heal  quickly;  a  stitch  closes  the  incision  and  assists 
satisfactory  healing. 

Of  course,  when  the  skin  is  thin  and  reddened,  and  the  pus  sub- 
cutaneous, the  abscess  must  be  incised  and  drained  in  the  usual 
manner,  any  thin  and  undermined  skin  being  snipped  away. 

4.  If  hygienic  treatment  cannot  be  carried  out  satisfactoril}',  or 
if  the  disease  progresses  in  spite  of  such  measures,  opeyation  may 
become  necessary;  but  it  is  remarkable  how  seldom  the  surgeon  is 
required  to  undertake  such  cases  at  the  present  day.  In  this  con- 
nection it  must  be  remembered  that  each  joint  presents  peculiar 
features,  and  that  considerations  referable  to  one  do  not  necessarily 
hold  good  for  another. 

Arthrectomy  or  erasion  of  the  joint  consists  in  laying  open  the 
cavity  and  removing  all  the  diseased  tissues  that  can  be  reached. 
The  synovial  membrane  is  cut  away;  diseased  foci  of  bone  are 
gouged  out,  and  the  resulting  cavities  disinfected  by  carbolic  acid 
and  packed  with  sterilized  iodoform.  Ankylosis  is  the  usual,  though 
not  invariable,  result.  It  is  obvious  that  this  proceeding  is  not 
equally  applicable  to  all  joints.     Thus,  in  the  hip  the  opening  is 


DISEASES  OF  JOINTS  647 

usually  made  from  the  front,  and  unless  there  is  great  laxity  of  the 
caj)sule  and  some  increase  in  size  of  the  acetabulum,  the  back  and 
upper  part  of  the  joint  cannot  be  reached.  The  knee,  ankle,  and 
elbow  are  perhaps  the  most  favourable  situations  for  this  operation. 
The  chief  advantages  of  this  proceeding  are  that  it  interferes  neither 
with  the  immediate  length  nor  with  the  subsequent  growth,  whilst 
there  are  no  extensive  sections  of  healthy  bone  exposed  to  infection. 
Excision  is  a  more  radical  measure,  but  has  the  disadvantage  of 
removing  healthy  as  well  as  diseased  tissues;  whilst  the  fact  that  in 
children  it  encroaches  on  the  epiphyseal  structures  renders  it  un- 
desirable as  a  routine  procedure.  The  chief  conditions  for  which  it 
is  now  employed  in  tuberculous  disease  are  as  follows:  {a)  For  com- 
plete disorganization  of  the  joint,  or  when  extensive  bone  mischief 
is  present;  (&)  to  prevent  ankylosis  in  certain  joints,  such  as  the 
elbow  and  temporo-maxillary ;  (c)  to  determine  a  rapid  and  radical 
cure  with  synostosis  in  such  a  joint  as  the  knee,  as  soon  as  it  is 
evident  that  the  natural  result  of  the  disease  must  be  an  ankylosed 
limb.  Surgical  art  often  produces  a  more  efficient  cure  than  Nature 
under  these  circumstances,  since  all  foci  can  be  removed.  A  natural 
cure  often  leaves  many  tuberculous  foci  encapsuled,  and  these  may 
subsequently  cause  pain  and  lead  to  recurrent  attacks  of  inflamma- 
tion, [d)  Deformity  with  or  without  ankylosis  may  also  need 
excision. 

Amputation  is  required  in  cases  which,  in  spite  of  every  care,  are 
steadily  going  from  bad  to  worse,  and  where  the  patient's  health  and 
strength  are  being  sapped  by  the  disease.  It  is  needed  not  unfre- 
quently  in  old  people,  and  where  the  mischief  in  the  bones  and  soft 
parts  is  very  extensive.  It  is  indicated  in  patients  where  excision 
has  been  undertaken  and  failed,  either  from  the  limb  becoming  sub- 
sequently flail-like  or  useless,  or  from  recurrence  owing  to  incomplete 
eradication,  or  from  the  advent  of  pyogenic  infection.  Lastlj^  if  the 
disease  is  present  in  two  joints  at  one  time,  or  in  a  joint  and  some 
other  organ,  neither  of  which  is  improving,  total  removal  of  one  focus 
of  mischief  will  often  induce  a  rapidly  favourable  change  in. the  other. 
Ihe  choice  of  operation  in  any  particular  case  is  not  always  an 
easy  matter,  and  before  reaching  a  decision  several  factors  must  be 
taken  into  consideration:  (i.)  The  age  of  the  patient.  As  alrea.dy 
mentioned,  the  fact  that  typical  excisions  encroach  on  the  growing 
ends  of  bones  renders  them  undesirable  in  children.  Even  if  growth 
is  not  stopped  thereby,  it  may  be  rendered  irregular,  and  subsequent 
deformity  may  ensue.  As  regards  advanced  age,  opinions  differ 
somewhat ;  but  the  shoulder  and  knee  may  be  excised  satisf actorily- 
at  a  much  greater  age  than  the  elbow,  wrist,  and  ankle.  Probably 
forty  to  forty-five  years  would  be  looked  on  as  the  age  limit  for  the 
latter,  but  excellent  results  have  been  obtained  from  excising  the 
knee  and  shoulder  at  a  much  later  period  of  life,  (ii.)  The  general 
health  and  vitality  of  the  individual  must  be  fairly  good  if  either 
erasion  or  excision  is  to  be  undertaken.  In  weakly  individuals 
amputation  is  often  the  better  practice,  as  also  when  hectic  fever 


648  A    MANUAL  OF  SURGERY 

is  pronounced  and  amyloid  disease  of  the  viscera  advanced,  (iii.)  The 
extent  of  the  bone  mischief.  If  this  is  shght,  erasion  may  be  under- 
taken; if  more  extensive,  excision;  but  if  the  bone  trouble  is  con- 
sideralile,  so  that  the  removal  of  the  diseased  tissue  would  leave  a 
flail-like,  useless  limb,  then  amputation  is  required,  (iv.)  Extensive 
invasion  of  the  soft  tissues  may  also  render  impracticable  all  treat- 
ment other  than  amputation,  (v.)  No  conservative  operations  are 
justifiable  in  any  case  where  an  acute  or  subacute  pyococcal  or  tuber- 
culous abscess  exists,  or  where  pus  is  retained  under  pressure,  as 
indicated  by  discharging  sinuses  and  constitutional  reaction.  Free 
incisions  to  relieve  all  tension  are  first  required,  and  subsequently 
more  radical  operative  treatment  may  be  considered. 

Tuberculous  Disease  of  Special  Joints. 

The  Shoulder- joint  is  but  rarely  affected  in  children,  and  not  very 
commonly  in  adults.  The  disease  usually  starts  in  the  head  of  the 
humerus,  affecting  subsequently  the  synovial  membrane,  and  per- 
haps also  the  glenoid  cavity.  Not  unfrequently  it  results  in  anky- 
losis without  suppuration  (caries  sicca).  Effusion  with  the  forma- 
tion of  melon-seed  bodies  is  sometimes  observed.  If  abscesses 
develop,  they  are  likely  to  point  either  in  front  of  or  behind  the 
deltoid,  in  the  former  case  extending  along  the  synovial  membrane 
lining  the  bicipital  groove.  The  ultimate  result  is  usually  ankylosis, 
with  perhaps  considerable  shortening  of  the  arm,  or  some  forward 
displacement  of  the  upper  end  of  the  bone  simulating  a  subcoracoid 
dislocation.  The  case  is  often  slow  in  progress,  though  persistent, 
and  may  be  very  painful.  Treatment  consists  in  fixing  the  arm  to 
the  side  with  a  pad  in  the  axilla  to  prevent  inward  displacement  of 
the  head.  When  there  is  much  effusion,  the  joint  may  be  tapped 
and  washed  out  by  introducing  a  trocar  just  external  to  the  cora- 
coid  process  or  below  the  acromion.  For  extensive  bone  trouble 
(shown  radiographically),  or  if  the  disease  does  not  tend  to  improve, 
excision  must  be  undertaken,  and  the  result  is  often  satisfactory. 

In  the  Elbow  (Fig.  316)  the  disease  is  most  common  in  young 
adults,  commencing  usually  in  the  synovial  membrane,  especially 
that  of  the  superior  radio-ulnar  articulation.  The  swollen  synovial 
membrane  bulges  on  either  side  of  the  olecranon  and  tendon  of  the 
biceps,  and  can  often  be  felt  over  the  head  of  the  radius,  and  the 
joint  presents  the  typical  appearance  of  a  '  white  swelling. '  Abscesses 
form  by  the  side  of  the  olecranon,  or  may  burrow  upwards  along 
the  ulnar  nerve  and  open  on  the  inner  aspect  of  the  arm.  Treat- 
ment.-— Prolonged  immobilization  with  passive  hypersemia  and  suit- 
able hygienic  measures  should  be  adopted  in  the  first  instance.  The 
arm  is  kept  at  rest  by  means  of  a  proplastic  or  internal  angular 
splint  reaching  from  the  axilla  to  the  wrist,  and  with  the  elbow 
bent  to  rather  less  than  a  right  angle;  the  hand  is  kept  midway 
between  pronation  and  supination.  If,  in  spite  of  such  treatment, 
the  case  progresses,  the  joint  should  be  opened  in  children,  diseased 
tissues  cut  or  scraped  away,  and  iodoform  injected.     Ankylosis  may 


DISEASES  OF  JOINTS 


649 


follow,  but  no  attempt  to  relieve  it  by  excision  should  be  made,  or 
the  growth  of  the  limb  may  be  impaired.  In  young  adults  arthrec- 
tomy  or  excision  may  be  undertaken  with  advantage  in  suitable 
cases.  The  former  is,  perhaps,  best  effected  by  means  of  an 
H-shaped  incision  over  the  olecranon,  which  is  divided  at  its  base 
and  turned  up,  so  as  to  expose  thoroughly  the  interior  of  the  joint. 
After  removing  all  diseased  tissue,  the  olecranon  is  wired  back  in 
place.  Excision  is  often  the  better  practice,  especially  in  adults, 
as  the  more  extensive  removal  of  bony  tissue  improves  the  pro- 
spects of  gaining  a  useful  moveable  arm. 

In  the  Wrist  diffuse  disease  of  the  synovial  membrane  and  bones 
is  met  with,  starting  most  frequently  from  the  former  structure. 
If  primarily  osseous,  it  usually  commences  in  the  lower  end  of 
the  radius.  It  may  also 
extend  from  a  tubercu- 
lous affection  of  the  ad- 
jacent tendon  sheaths. 
A  characteristic  dough}' 
swelling  forms  over  the 
dorsum,  displacing  the 
extensor  tendons,  whilst 
the  palmar  aspect  of  the 
wrist  is  also  puffy,  and 
the  hand  itself  is  slightly 
flexed,  and  the  move- 
ments of  the  fingers  are 
impaired  by  adhesions. 
Sinuses  develop  most  fre- 
quently on  the  dorsal 
aspect  or  by  the  side  of 
the  flexor  carpi  radialis 
tendon.  Conservative 
measures  may  bring 
about  a  cure,  and  every 
effort  should  be  made  to 
avoid  excision,  since  the 
result  of  this  proceeding 
is  almost  always  the  production  of  a  weak  and  flail-like  hand,  so  that 
the  constant  use  of  a  leather  support  is  essential  after  healing  has 
occurred.     In  elderly  people  amputation  is  often  the  only  resource. 

Diseases  of  the  Hip-joint  and  of  the  Sacro-iliac  Articulation  are 
separately  considered  (pp.  668  and  677) . 

The  Knee-joint  is,  perhaps,  more  often  affected  with  tuberculous 
disease  than  any  other  articulation.  It  appears  to  start  in  the 
synovial  membrane  or  bone  with  almost  equal  frequency ;  if  the 
bones  are  first  attacked,  the  primary  focus  is  usually  situated  on  the 
inner  aspect  of  either  the  femur  or  the  tibia.  Sequestra  are  found  in 
nearly  one-half  of  the  cases  in  which  the  bone  is  involved,  becoming 
more  frequent  as  the  age  advances.     The  disease  runs  a  typical 


Fig.  316. — Tuberculous  Disease  of  the 
Left  Elbow-Joint. 


650 


A   MANUAL  OF  SURGERY 


course,  and  needs  no  special  comment.  When  the  joint  has  become 
disorganized,  the  tibia  is  Hable  to  be  displaced  horizontally  back- 
wards, flexed,  and  externally  rotated,  and  ankylosis  in  this  position 
is  difficult  to  remedy,  even  by  operation. 

Treatment.- — In  the  more  active  stages,  where  the  joint  is  painful 
and  perhaps  deformity  present,  the  patient  must  be  kept  in  bed,  and 
weight  extension  employed.  In  the  later  and  more  chronic  stages,  im- 
mobilization in  plaster  of  Paris  or  the  application  of  Thomas's  knee- 
splint  (Fig.  318)  will  prevent  movement,  and  the  use  of  a  patten 

on  the  other  foot  and  crutches 
will  obviate  the  harmful  ef- 
fects of  pressure  from  the 
weight  of  the  body.  The 
patient  is  then  allowed  to 
walk  about,  and  is  placed  in 
suitable  hygienic  conditions. 
Venous  engorgement  and  per- 
haps iodoform  injections  must 
also  be  employed,  if  thought 
desirable.  Abscesses  are,  of 
course,  dealt  with  in  the  usual 
way.  If  in  spite  of  such 
measures  symptoms  persist  _ 
and  the  case  is  progressive,  a 
modified  arthrectomy  may  be 
undertaken  in  children  where 
growth  is  still  continuing,  and 
to  carry  it  out  an  incision 
should  be  made  across  the 
front  of  the  joint  from  con- 
dyle to  condyle,  as  for  an 
excision,  dividing  either  the 
ligamentum  patellae,  or  per- 
haps the  patella,  which  is  sub- 
sequently wired  together. 
The  whole  of  the  synovial 
membrane  is  then  dissected 
away,  special  attention  being  directed  to  the  subcrureal  pouch 
and  the  back  of  the  joint.  A  thin  slice  should  be  removed 
from  the  surfaces  of  both  tibia  and  femur,  and  if  the  epiphyseal 
cartilages  are  not  encroached  upon,  the  growth  of  the  limb  is  not 
impaired  to  any  great  extent,  although  it  may  become  irregular 
and  lead  to  some  deformity^ — e.g.,  well-marked  flexion,  or  genu 
recur vatum.  In  adults,  where  the  bones  are  not  too  extensively 
involved,  so  that  on  section  broad  healthy  surfaces  can  be  apposed, 
excision  is  a  most  satisfactory  operation,  provided,  of  course,  that 
the  synovial  disease  is  also  removed.  As  soon  as  it  becomes  evident 
that  the  only  possible  natural  cure  is  by  ankylosis,  and  this  evidence 
would  be  given  by  fixation  of  the  patella  to  the  femur,  or  by  severe 


Fig.  317.  —  Tuberculous  Disease  of 
THE  Knee  in  an  Advanced  State. 

The  joint  is  flexed,  and  displacement  back- 
wards of  the  tibia  is  commencing;  the 
smooth  swollen  condition  of  the  articu- 
lation is  very  characteristic. 


DISEASES  OF  JOINTS 


651 


starting  pains  at  night,  excision  is  justifiable  and  advisable.  It  cuts 
short  the  disease,  minimizes  the  risk  of  general  dissemination,  and 
provides  a  quicker  and  more  radical  cure  than  Nature  can  possibly 
effect.  Incomplete  removal  of  the  disease,  either  in  the  synovial 
membrane  or  bone,  may  determine  recurrence;  if  this  cannot  be 
dealt  with  effectively,  amputation  may  be  required,  and  then  a  long 
posterior  flap  is  the  only  healthy  tissue  available  for  covering  the 
bone.  Under  other  circumstances  the  or- 
dinary supracondyloid  amputation  can  be 
adopted. 

The  Ankle-joint.  —  Tuberculous  disease  of 
this  joint  usually  commences  in  the  synovial 
membrane  rather  than  in  the  bone.  The 
whole  region  becomes  occupied  by  a  pulpy 
swelling,  which  first  pushes  forwards  the 
extensor  tendons  and  bulges  in  front  of  the 
malleoli,  and  subsequently  appears  on  either 
side  of  the  tendo  Achihis.  There  is  often 
but  little  pain,  and  the  movements  of  the 
ankle  are  often  but  little  impaired;  the  calf 
muscles  are  usually  wasted.  In  the  later  stages, 
when  the  bones  are  involved,  the  foot  is  main- 
tained in  a  position  of  slight  plantar-flexion,  so 
as  to  bring  the  narrower  portion  of  the  upper 
surface  of  the  astragalus  into  the  tibio-fibular 
mortice.  Flexion  and  extension  of  the  foot  are 
usually  hmited  or  lost,  but  with  care  the  lateral 
movements  (inversion  and  eversion)  which 
occur  at  the  mid-tarsal  and  sub-astragaloid 
joints  can  be  undertaken  without  pain.  If  the 
disease  is  primarily  osseous,  localized  painful 
areas  occur  over  the  lower  ends  of  the  tibia 
or  fibula,  or  over  the  astragalus,  and  the  osseous 
lesions  can  be  demonstrated  by  radiography. 
In  either  type  of  case,  abscess  formation  is  very  liable  to  follow, 
and  may  become  extensive,  owing  to  the  impHcation  of  tendon 
sheaths."  Treatment.— In  the  early  stages  prolonged  rest  and 
immobilization  in  plaster  of  Paris  or  a  Thomas's  splint  are  required. 
Operative  treatment  is  not  very  satisfactory.  Arthrectomy  can 
be  undertaken,  but  removal  of  the  astragalus  and  of  all  available 
synovial  membrane  is  probably  a  better  course  to  adopt.  When, 
however,  the  astragalus  is  involved,  it  is  often  difficult  to 
eradicate  the  disease,  which  has  probably  spread  to  the  articula- 
tions and  bones  beneath  it,  and  amputation  may  then  be 
required.  Where  the  disease  also  involves  the  tibia  and  fibula, 
a  supra-malleolar  amputation  of  the  foot  wifl  probably  be 
necessary. 

For  diseases  of  the  Bones  and  Joints  of  the  Foot,  see  p.  573. 


Fig.  318. — Thomas's 
Knee-Splint   ap- 


652  A   MANUAL  OF  SURGERY 

Syphilitic  Diseases  oi  Joints. 

Although  syphilitic  disease  of  joints  is  rare  in  proportion  to  the 
prevalence  of  sj^philis,  yet  several  varieties  have  been  differentiated 
and  recognised,     (i)  In  the  later  stage  of  the  secondary  period  a 
chronic  form  of  synovitis  occurs,  evidenced  by  passive  effusion  into 
the  joint,  with  or  without  pain,  and  usually  persisting  for  some  time. 
Any  joint  may  be  attacked  in  this  way,  perhaps  the  knee  most 
commonly,  and  the  affection  is  often  symmetrical  in  its  distribution. 
The  effusion  may  be  only  slight,  but  is  frequently  very  considerable 
(hydrarthrosis),  and  a  marked  feature  in  the  condition  consists  in  the 
rapid  variations  in  the  amount  of  swelling,  even  from  day  to  day. 
In  some  few  cases  this  affection  resists  all  treatment,  and  leads  to 
ultimate  disorganization.    (2)  Gummatous  inflammation  of  the  peri- 
synovial  fibrous  tissue,  which  may  or  may  not  extend  to  the  adjacent 
bone,  is  met  with  in  the  tertiary  period.     It  either  appears  as  a 
localized  hard  nodule,  resembhng  in  measure  a  fibrous  tumour,  and 
then  causing  but  little  trouble  beyond  a  sense  of  painful  weakness  in 
the  articulation;  or  it  is  more  diffuse  in  its  distribution,  leading  to  a 
moderate  effusion,  and  later  on  to  much  thickening  and  infiltration 
of  the  capsular  and  other  ligaments,  and  resulting  in  considerable 
impairment  of  its  movements  from  cicatricial  contraction.     Some  of 
these  gummatous  nodules  may  break  down  and  ulcerate.     (3)  A 
diffuse  gummatous  infiltration  of  the  synovial  membrane  itself  is  also 
seen,  usually  in  children.     It  closely  simulates  a  tuberculous  syno- 
vitis, from  which  it  is  often  impossible  to  distinguish  it,  except  by 
the  rapid  onset,  the  absence  of  pain,  the  greater  amount  of  effusion, 
and  the  symmetry  which  is  sometimes  present.     It  may  occur  apart 
from  other  evidences  of  congenital  syphilis.     (4)  A  chondro-arthritis, 
described  originally  by  Virchow,  is  the  syphilitic  analogue  of  osteo- 
arthritis.   It  commences  by  fibrillation  of  the  matrix  of  the  cartilage, 
and  proliferation  of  the  cells.     The  cartilage  softens,  and  becomes 
eroded  by  friction  of  the  articular  surfaces.    The  bone  thus  exposed 
is  worn  away,  and  curiously  '  pitted  '  or  excavated.     It  is  distin- 
guished from  osteo-arthritis  by  the  facts  that  there  is  usually  but 
little  or  no  pain;  that  the  eburnation  of  the  exposed  bone  is  less 
extensive,  and  therefore  crepitus  is  but  little  marked;  whilst  the 
typical  osteophytic  outgrowths  and  '  hpping  '  of  the  joint  margins 
are  absent.     The  eroded  areas,  moreover,  do  not  correspond  with 
the  sites  of  intra-articular  pressure,   and  are  more  rounded  and 
punched  out,  and  not  arranged  in  linear  grooves,  as  in  the  latter 
disease.     It    is   not   uncommonly   associated   with    a   gummatous 
thickening  of  the  synovial  membrane,  and,  indeed,  the  hollows  or 
pits  above  mentioned  may  be  filled  with  caseous  material,  derived 
from  degeneration  of  this  tissue. 

The  Treatment  in  the  early  manifestation  consists  in  the  adminis- 
tration of  mercury  or  salvarsan,  and  the  judicious  application  of 
pressure  with  or  without  immobilization,  according  to  the  require- 
ments of  the  case  and  the  joint  affected.     In  the  tertiary  forms 


DISEASES  OF  JOINTS  653 

iodide  of  potassium  in  gradually  increasing  doses  has  a  rapidly 
beneficial  action,  which  confirms  the  diagnosis;  it  may  be  occasionally 
combined  with  a  small  amount  of  mercury,  either  given  internally 
or  applied  locally  if  emy  ulcerative  lesion  exists.  In  the  most  pro- 
nounced cases,  where  the  pain  is  severe  and  disorganization  of  the 
joint  has  occurred,  excision  may  be  necessary,  and  the  results  are 
often  very  satisfactory. 

Osteo-Arthritis. 

Although  this  disease  is  extremely  common  in  this  country  and 
has  well-marked  characteristics,  its  nature  is  still  obscure,  as  is 
evident  from  the  number  of  names  applied  to  it,  such  as  chronic 
rheumatoid  arthritis,  rheumatic  gout,  arthritis  deformans,  arthritis 
senilis,  arthritis  sicca,  etc.  There  is  not  the  slightest  doubt  that 
several  types  of  disease  have  been  confounded  together  under  this 
title,  and  although  rheumatic  and  gouty  conditions  are  now  ex- 
cluded, yet  it  is  probable  that  we  are  still  including  more  than  one 
type  of  chronic  articular  trouble. 

Under  these  circumstances  it  is  a  little  difficult  to  speak  dogmati- 
cally as  to  etiology,  i.  Infection  plays  an  important  part  in  the 
production  of  certain  types  of  the  disease.  The  organisms  find  their 
way  into  the  joints  from  some  other  focus  of  infection,  and  in  this 
connection  it  is  interesting  to  note  the  statement  that  in  a  large  series 
of  cases  55  per  cent,  were  preceded  by  some  other  infective  disease, 
such  as  influenza  (Bannatyne).  The  bacteria  develop  in  the  joints, 
and  produce  toxic  bodies  which  act  locally  by  inducing  destructive 
phenomena  of  a  special  type,  whilst  by  their  general  absorption 
various  trophic  and  nervous  symptoms  are  caused,  whose  existence 
has  been  constantly  noted,  but  for  which  hitherto  there  had  been  no 
adequate  explanation.  Such  an  origin  will  also  explain  the  enlarge- 
ment of  the  spleen  and  of  lymphatic  glands  in  the  neighbourhood 
of  some  of  the  affected  articulations  (Still).  Several  observers  have 
found  bacteria  within  the  joints,  and  Bannatyne  amongst  others  has 
described  a  short  bacillus,  the  ends  of  which  stain  deeply,  whilst  the 
intervening  portion  remains  unstained,  causing  it  to  look  like  a 
diplococcus. 

2.  Auto-intoxication  is  another  probable  cause  of  many  cases.  It 
has  been  already  pointed  out  that  the  absorption  of  toxins  from 
the  mouth  or  elsewhere  may  lead  to  chronic  osteitis  and  arthritis 
(pp.  85  and  590),  and  it  is  probable  that  other  forms  of  intoxication 
may  suffice  to  determine  the  onset  of  osteo-arthritis.  It  may  be 
noted  that  the  affection  has  been  often  associated  with  uterine  and 
ovarian  disease,  and  with  various  forms  of  indigestion. 

3.  Exposure  to  damp  and  cold  is  an  important  setiological  factor, 
especially  in  elderly  people,  as  also  worry,  fatigue,  depressing  nervous 
and  mental  conditions,  deficient  food,  and  bad  hygiene.  It  is  quite 
possible  that  many  of  these  conditions  act  by  producing  some  form 
of  toxaemia,  perhaps  of  intestinal  origin. 


654  ^   MANUAL  OF  SURGERY 

4.  Truumaiism  is  frequently  responsible  for  a  chronic  inflammation 
of  joints,  which  may  be  known  as  chronic  traumatic  arthritis  ;  the 
changes  are  practically  identical  with  those  of  osteo-arthritis.  The 
injury  may  be  slight  in  nature,  such  as  a  sprain  or  strain,  or  more 
severe,  such  as  a  fracture  or  dislocation  involving  the  articular  sur- 
face; thus,  it  is  not  uncommon  to  see  it  following  Colles's  fracture 
or  one  of  the  cervix  femoris.  Abnormal  pressure  maintained  for  a 
long  time  also  causes  changes  of  a  similar  type,  and  thus  many  of 
the  joints  of  labouring  men  are  deformed  in  a  peculiar  fashion, 
according  to  the  special  type  of  work  and  the  particular  joints  that 

are  exposed  to  strain.  To  this  variety 
the  term  arthritis  deformans  may  well 
be  applied. 

5.  Lastly,  senile  defeneration  also 
seems  to  produce  articular  lesions  of 
a  very  similar  character. 

Pathological  Anatomy. — The  disease 
may  commence  either  in  the  synovial 
membrane  or  in  the  articular  cartilage, 
but  perhaps  more  frequently  in  the 
former,  particularly  in  the  acute  and 
subacute  varieties.  In  the  early  stages 
the  synovial  membrane  becomes  vas- 
cular and  thickened,  and  the  villi 
proliferate  so  that  the  surface  becomes 
shaggv  or  villous  in  appearance. 
Fig.  319.— Patella  from  Early  Sometimes  the  villi  reach  such  dimen- 
Case     of     Osteo- Arthritis,     •  ^.u    i.   j.u  i.      r  i^.   xi  u 

SHOWING  Fibrillation  OF  Car-  ^lOns   that   they   can   be   felt   through 
TiLAGE.    (Howard  Marsh.)      the   skin,    rolling   under    the    finger; 

they  are  red,  vascular,  and  succulent 
during  life,  but  after  removal  and  preservation  in  spirit  they  look 
shrunken  and  insignificant.  At  times  there  is  a  considerable 
development  of  fat  in  these  villi,  constituting  the  condition  known 
as  lipoma  arhorescens,  and  often  associated  with  an  added  element 
of  gout.  Occasionally  cartilaginous  nodules  are  found  in  the  villi, 
and  these  may  subsequently  undergo  ossification;  if  detached,  they 
may  constitute  one  form  of  loose  body  in  a  joint.  When  the  disease 
develops  along  these  lines  with  marked  synovial  changes,  effusion 
is  usually  considerable  and  early;  in  other  cases  there  is  often  but 
Uttle  effusion,  so  that  the  affection  has  been  termed  '  arthritis 
sicca. ' 

The  changes  in  the  cartilage,  whether  primary  or  secondary, 
consist  in  a  breaking  up  of  the  matrix  into  fibres,  the  so-called 
'  fibrillation,'  so  that  the  surface  becomes  rough  like  the  pile  on 
carpet  or  velvet  (Fig.  319).  Meanwhile  the  cartilage  cells  are 
arranged  in  longitudinal  rows  between  the  fihrillae  and  proUferate 
within  their  capsules,  which  become  distended  and  burst  into  the 
joint.  The  cartilage  thus  softened  is  readily  worn  away  by  the 
movements  of  the  articulation,  and  the  surface  of  the  bone  is  ex- 


DISEASES  OF  JOINTS 


655 


posed.  Concurrently  with  this  destruction  hyperplasia  is  taking 
place  at  the  margins  of  the  articular  cartilage,  resulting  in  the 
production  of  irregular  overgrowths  (ecchondroses),  which  have 
been  likened  to  the  gutterings  of  a  candle.  In  them  ossification 
occurs  secondarity,  and  when  such  overgrowths  have  been  produced 
more  or  less  evenl}^  around 
the  joint  margin,  a  charac- 
teristic lipping  of  the  edge 
of  the  articular  surface  re- 
sults (Fig.  320).  Sometimes 
these  osteophytes  attain  con- 
siderable dimensions,  and  by 
interlocking  may  lead  to 
ankylosis  of  the  joint. 

The  bone  exposed  by  the 
destruction  of  the  articular 
cartilage  is  altered  as  the 
result  of  the  movements  of 
the  joint.  The  chronic  irrita- 
tion causes  it  to  become 
hard,  sclerosed,  and  polished 
like  ivory  (eburnation) .  This 
usually  occurs  in  certain 
definite  directions ;  in  hinge 
joints  the  surfaces  become 
grooved  longitudinally, 
whereas  in  ball-and-socket 
joints  like  the  hip  the  head 
is  eburnated  in  a  circular 
manner.  This  condensed 
tissue  does  not  extend  very 
deeply,  and  immediately 
beneath  it  the  bone  is  of 
a  more  open  texture  than 
usual  and  filled  with  fatty 
medulla.  In  spite  of  the 
sclerosis  the  articular  end 
of  the  bone  is  being  constantly  w^orn  away,  and  this  may 
progress  to  such  an  extent  as  to  lead  to  actual  shortening]  of 
the  limb. 

Clinical  History. — Three  chief  types  of  this  disease  may  be  de- 
scribed: 

I.  The  chronic  monarticular  variety  is  that  most  frequently  seen 
by  surgeons,  and  is  constantly  brought  about  by  injury.  Pain  and 
creaking  of  the  joint  on  movement  are  the  early  sjnuptoras.  There 
may  be  very  little  swelling,  unless  effusion  is  present,  but  pain, 
especially  at  night,  is  most  troublesome,  being  usually  increased  on 
changes  of  weather,  particularly  if  rain  is  threatening.  The  pain 
and  stiffness  are  most  marked  after  keeping  the  parts  at  rest,  and 


Fig.  320. — Late  Stage  of  Osteo-Ar- 
THRiTis  OF  Knee,  showing  Destruc- 
tion OF  THE  Articular  Cartilage,  and 
Eburnation  of  the  Exposed  Bone 
IN  Longitudinal  Grooves.  (From 
College  of  Surgeons'  Museum.) 

The  margins  of  the  cartilages  are  distinctly 
lipped. 


656  A   MANUAL  OF  SURGERY 

diminish  when  the  Hmb  is  used.  As  the  disease  progresses,  the 
movements  become  more  and  more  impaired,  and  the  creaking  may 
be  transformed  into  a  true  bony  crepitus:  the  ends  of  the  bones  are 
felt  to  be  enlarged  and  lipped,  and  deformity  soon  becomes  obvious. 
Exacerbations  in  the  symptoms  occur  from  time  to  time,  resulting 
in  increased  crippling.  Finally,  the  limb  may  become  absolutely 
useless,  partly  from  the  pain  and  partly  from  the  limitation  of 
movement  produced  by  the  osteophytes.  Wasting  of  the  adjacent 
muscles  is  also  a  marked  feature. 

This  variety  is  usvially  seen  in  elderly  people,  and  may  supervene 
quickly  after  an  accident,  such  as  fracture  or  bruising  of  the  cervix 
femoris,  and  then  the  destructive  phenomena  may  progress  at  a 
rapid  rate.  When  it  appears  in  younger  people,  the  osseous  lesions 
are  much  less  evident. 

2.  The  chronic  polyarticular  variety  arises  independently  of  trau- 
matism, and  is  most  commonly  seen  in  females  of  middle  life.  It 
ma}'  commence  in  one  joint  and  spread  to  others,  or  it  may  appear 


Fig.  321. — Hands  of  Patient  with  Chronic  Polyarticular  Osteo- 
arthritis, SHOWING  Nodular  Condition  of  the  Joints  and  Marked 
Flexion  and  Ulnar  Adduction. 

in  many  joints  simultaneously.  Most  frequently  one  or  more  of  the 
phalangeal  articulations  is  the  starting-point,  particularly  the  ter- 
minal ones,  and  then  it  may  be  the  result  of  an  injury.  The  joints 
become  stiff  and  swollen,  are  tender,  and  in  the  milder  cases  small 
nodular  bony  outgrowths  develop  at  the  bases  of  the  phalanges, 
which  are  known  as  Heberden's  nodosities.  Gradually  some  degree 
of  flexion  occurs,  accompanied  by  increasing  stiffness  and  ulnar 
adduction  of  the  fingers,  which  renders  the  hands  very  helpless 
(Fig.  321).  The  trouble  gradually  spreads  to  other  joints,  and 
although  there  are  often  remissions,  yet  the  condition  progresses 
steadily  until  the  patient  may  be  entirely  crippled  thereby.  Well- 
marked  overgrowth  of  bone  and  eburnation  of  the  articular  ends 
are  characteristic  features  of  this  type.  Sometimes  there  is  con- 
siderable effusion,  accompanied  by  overgrowth  of  the  synovial  villi, 
but  this  is  unusual. 

3.  The  acute  polyarticular  variety  does  not  often  come  to  the  surgeon 
for  treatment,  at  any  rate  in  the  early  stages.     It  usually  attacks 


DISEASES  OF  JOINTS  657 

young  or  comparatively  young  people,  and  females  rather  than 
males,  frequently  following  some  infective  trouble,  such  as  influenza, 
scarlatina,  tonsillitis,  etc.  It  is  often  ushered  in  by  a  distinct  febrile 
attack  with  persistent  increase  in  the  rate  of  the  heart-beat ;  trophic 
and  vasomotor  phenomena  are  often  co-existent,  such  as  patches  of 
pigmentation,  clammy  cold  hands,  and  rapid  muscular  atrophy. 
The  smaller  joints  of  the  hands  and  feet  are  mainly  affected,  and 
that  more  or  less  symmetrically,  although  the  terminal  interphalan- 
geal  articulations  often  escape.  The  capsules  are  distended  with  a 
certain  amount  of  effusion,  causing  the  joints  to  look  spindle-shaped, 
and  at  first  there  is  but  little  osseous  mischief.  In  not  a  few  cases 
a  very  characteristic  deformity  in  the  shape  of  ulnar  adduction  of 
all  the  fingers  occurs.  Gradually  the  trouble  spreads  to  other  and 
larger  joints,  and  osseous  manifestations  appear;  but  the  progress 
is  slow,  and  may  be  to  a  large  extent  arrested  by  treatment.  Neigh- 
bouring lymphatic  glands  may  be  enlarged  in  the  early  stages. 

Ihe  peculiarities  of  this  affection,  as  it  involves  children,  have 
been  emphasized  by  Dr.  Still.  Girls  are  more  often  attacked  than 
boys;  many  joints  are  implicated,  and  neighbouring  l}Tiiphatic 
glands  are  enlarged.  The  cartilage  is  but  little  altered,  and  bony 
outgrowths  are  absent.  The  spleen  is  also  enlarged,  and  there  may 
be  pericardial  and  pleural  adhesions. 

It  is  important  to  note  that  gouty  and  rheumatic  troubles  may  be 
associated  with  osteo-arthritis:  the  rheumatic  affections  may  pre- 
cede, the  gouty  usually  follow. 

The  Diagnosis  of  osteo-arthritis  per  se  is  not  often  difficult  in  a 
well-marked  case,  the  crepitus,  pain,  and  enlargement  of  the  ends  of 
the  bones,  together  with  the  slight  amount  of  effusion,  constituting  a 
tolerably  characteristic  picture.  Radiography  may  show  the  charac- 
teristic lipping  of  the  articular  ends,  and  the  thinning  of  the  bony 
substance  beneath  the  cartilage.  From  simple  chronic  synovitis  it 
may  be  know^n  by  the  history  and  smaller  amount  of  effusion,  and  by 
the  pain  and  rigidity  being  frequently  more  marked  after  rest,  and 
diminishing  after  the  joint  has  been  actively  used.  There  is  more 
difficulty  in  distinguishing  the  form  associated  with  increased  effusion 
and  enlargement  of  the  synovial  villi;  careful  examination  may, 
however,  enable  the  surgeon  to  make  out  these  villi  moving  to  and 
fro  in  the  joint  under  his  hand,  whilst  possibly  the  ends  of  the  bone 
may  be  lipped.  For  diagnosis  from  chronic  rheumatism  and  Charcot's 
disease,  see  pp.  638  and  661. 

The  ProgBOsis  is  usually  unfavourable.  The  fact  that  many  joints 
are  affected  is  an  indication  that  there  is  a  considerable  constitutional 
element  in  the  evolution  of  the  disease,  and,  although  it  may  be 
temporarily  combated  with  success,  still,  sooner  or  later,  the  patient 
is  almost  certain  to  be  crippled  by  it.  The  affection  of  only  one  joint 
often  points  to  a  traumatic  origin,  and  the  outlook  is  correspondingly 
brighter;  but  where  the  disease  attacks  several  parts  of  the  body, 
there  is  but  httle  hope  of  checking  it,  and  indeed  cases  are  known  in 
which  every  joint  has  successively  become  implicated,  the  patient 

42 


658  A   MANUAL  OF  SURGERY 

dragging  on  ;i  weary  existence,  never  free  from  pain,  and  usually  in 
a  cramped  or  sitting  posture,  until  death  from  exhausti(jn  super- 
venes. 

Treatment.- — For  this  troublesome  complaint  there  is,  unfortu- 
nately, httle  that  can  be  effected  in  the  wa}'  of  cure,  although  much 
can  be  done  to  alleviate.  Locally,  the  articulations  should  be  pro- 
tected from  cold  and  injury  by  being  swathed  in  flannel,  whilst 
stimulating  embrocations  and  sedative  applications  may  be  bene- 
ficially employed.  It  is  not  advisable  to  maintain  the  joints  abso- 
lutely at  rest,  otherwise  their  mobility  is  likely  to  become  seriously 
limited  at  an  unnecessarily  early  date.  Moreover,  it  is  often  found 
that  the  more  a  joint  is  moved,  the  easier  and  less  painful  do  the 
movements  become,  and  hence  regular  massage  is  desirable.  Hydro- 
therapy, electrotherapy,  and  treatment  by  the  local  application  of 
heat  (Chapter  III.)  have  a  large  field  of  usefulness  in  this  affection. 
As  to  general  treatment,  the  individual  is  warned  against  exposing 
himself  to  cold  and  damp,  and  since  the  disease  is  often  considered 
to  be  due  to  perverted  or  diminished  nervous  activity,  all  possible 
sources  of  irritation  and  worry  should  be  removed.  At  the  same 
time  the  nutrition  must  be  improved,  and  plenty  of  good  food,  cod- 
liver  oil,  etc.,  administered.  A  large  number  of  different  drugs  have 
been  tried  for  this  complaint,  but  none  of  them  are  very  satisfactory. 
Perhaps  the  best  is  iodide  of  sodium  combined  with  some  alkaline 
purgative  and  hepatic  stimulant,  such  as  sulphate  of  soda.  Natural 
mineral  waters  and  baths  are  often  beneficial,  those  of  Bath  and 
Buxton  in  this  country  being  most  frequently  recommended,  though 
the  sulphur  waters  of  Harrogate  and  Strathpeft'er  are  also  beneficial. 
Arsenic  is  sometimes  useful. 

Occasionally  operative  treatment  in  the  shape  of  excision  may  be 
undertaken  in  this  complaint,  but  only  w^hen  the  disease  is  limited  to 
one  joint,  and  w^hen  it  has  progressed  to  such  a  stage  as  seriously  to 
cripple  the  patient's  usefulness,  as  in  the  knee-joint,  elbow,  or  the 
shoulder,  or  when  the  act  of  mastication  is  impaired,  owing  to  an 
affection  of  the  temporo-maxillary  articulation.  In  suitable  cases 
excellent  results  are  obtained.  The  possibility  of  excising  the  osteo- 
phytic  growths  has  also  been  mooted,  and  in  suitable  cases  it  may 
be  attempted. 

The  hip-joint  is  not  uncommonly  the  seat  of  osteo-arthritis  in  old 
people,  and  it  always  causes  a  considerable  amount  of  pain,  especi- 
ally on  flexion  of  the  limb,  rendering  sitting  difficult  and  walking 
uncomfortable,  whilst  the  movements  become  more  and  more  cur- 
tailed. The  limb  early  appears  to  be  shortened,  but  this  is  in  reality 
due  to  its  adduction  and  a  compensatory  tilting  up  of  the  pelvis  on 
the  affected  side  so  as  to  maintain  the  parallelism  of  the  legs.  The 
adductor  muscles  will  usuall}^  be  found  tense  and  contracted,  and 
abduction  of  the  limbs  is  markedly  diminished,  even  at  a  time  when 
flexion  is  scarcely  limited  at  all.  At  a  later  date  true  shortening 
follows,  with,  perhaps,  increased  deformity,  owing  to  erosion  of  the 
head  and  excavation  of  the  acetabular  cavity,  which  is  enlarged 


DISEASES  OF  JOINTS  659 

Upwards  by  the  absorption  of  its  posterior  lip.  Well-marked  lipping 
of  the  acetabular  margin  and  head  of  the  femur  occur,  and  thereby 
much  impairment  of  movement  is  produced  and  easily  elicited 
crepitus.  Ihe  trochanter  is  unduly  prominent  in  most  cases  where 
true  shortening  is  present,  and  this  is  an  important  diagnostic  sign, 
especially  when  a  fracture  of  the  neck  is  suspected  in  a  patient  who 
has  fallen  on  the  hip.  Treatment  in  these  patients  is  important, 
inasmuch  as  serious  cripphng  is  caused  by  the  disease.  In  cases 
which  have  progressed  beyond  the  stage  when  hydrotherapy  can 
help,  mechanical  means  must  be  adopted  to  diminish  intra-articular 
tension,  and  thereby  prevent  the  bones  from  mutual  attrition, 
although  it  is  still  desirable  to  permit  walking.  This  is  best  effected 
b}'  the  application  of  a  Ihomas's  splint  with  fixed  extension,  and  yet 
permitting  mobihty  of  the  joints.  The  limbs  must  first  be  extended 
under  an  anesthetic,  and,  if  need  be,  the  adductors  must  be  divided 
so  as  to  correct  the  deformity.  A  cast  of  the  pelvis  is  taken,  and  a 
leather-moulded  sphnt  fitted  to  it,  from  which  the  Thomas's  sphnt 
takes  its  point  d'appui.  Very  satisfactory  results  of  such  treatment 
have  been  obtained  in  suitable  cases,  and  that  with  but  little  re- 
cumbency. 

When  the  temporo-maxUlary  joint  is  affected,  the  condyle  of  the  jaw 
becomes  larger  than  usual  and  somewhat  flattened;  the  eminentia 
articularis  is  partially  absorbed  and  the  glenoid  cavity  increased  in 
size,  so  that  the  condyle  is  liable  to  shp  forwards  owing  to  the  action 
of  the  external  pterygoid  muscles.  If  only  one  joint  is  affected,  the 
bone  is  carried  towards  the  sound  side,  but  when  both  are  involved 
the  chin  becomes  prominent  owing  to  a  forward  displacement  of  the 
whole  bone.  Pain  and  crepitus  are  experienced  on  opening  the 
mouth,  rendering  mastication  difficult,  and  even  impracticable.  If 
ordinary  treatment  fails  to  give  relief,  the  affected  condyle  of  the  jaw 
should  be  excised. 

Neuropathic  Arthritis  [Syn.  :  Charcot's  Disease). 

This  disease,  bearing  the  name  of  the  late  Professor  Charcot,  is  a 
peculiar  aftection  of  joints  met  with  in  the  course  of  locomotor  ataxy. 
It  is  slightly  more  common  in  w-omen  than  men,  and  is  almost  always 
an  early  manifestation,  occurring  usually  between  the  lightning-like 
pains  and  the  onset  of  the  ataxic  symptoms.  The  most  typical  form 
is  lighted  up  by  some  slight  injury — e.g.,  a  strain  or  sprain — and  is 
characterized  by  a  rapid  painless  distension  of  the  joint  with  a  light- 
coloured  serum,  which  may  also  extend  into  the  communicating 
bursae ;  there  is  some  amount  of  effusion  into  the  surrounding  cellular 
tissue,  although  without  oedema.  This  distension  may  be  so  rapid 
that  abnormal  mobility  or  even  dislocation  may  occur  at  the  end  of  a 
few  hours.  The  joints  most  frequently  affected  are  the  knee,  hip, 
and  shoulder;  occasionally  more  than  one  articulation  is  involved. 
The  course  of  the  case  varies;  in  some  few  instances  the  fluid  is 
gradually  absorbed  and  the  joint  returns  to  its  normal  size  and  shape. 


66o 


A    MANUAL  OF  SURGERY 


although  somewhat  weakened.  Sometimes  the  attacks  of  distension 
recur,  and  after  each  the  joint  becomes  more  and  more  crippled.  Two 
chief  types  of  the  affection  are  described:  (i)  In  the  atrophic  variety, 
the  more  common,  the  bones  becomes  eroded  to  a  considerable  ex- 
tent, the  ligaments  stretched,  and  a  weak,  flail-like  articulation 
remains,  in  which  the  ends  of  the  bones  are  atrophied  and  displaced 
(Figs.  323  and  324) .  (2)  In  the  hyperlrophic  form  new  osseous  forma- 
tions occur  here  and  there  under  the  synovial  membrane,  especially 


^^  \      i 


Fig.  323. — ^ Atrophic  Variety 
OF  Charcot's  Disease  of 
Knee-Joint.  (From  College 
OF  Surgeons'  Museum.) 

The  bones  are  cleanly  eroded, 
and  no  new  formation  is 
present.  The  patella  is  re- 
duced to  a  mere  shell,  one- 
eighth  of  an  inch  thick. 


Fig.  322.- — Hypertrophic  Variety 
OF  Charcot's  Disease  of  Knee- 
Joint.  (From  College  of  Sur- 
geons' Museum.) 

The  patella  (pat.)  can  be  seen  poised 
on  the  top  of  a  mass  of  new  bone 
formed  by  the  welding  together  of  a 
number  of  smaller  portions  formed 
in  the  perisynovial  tissues. 

in  cases  where  there  is  much  distension,  so  that  on  compression  of  the 
swelling  between  the  hands  a  sensation  is  produced  similar  to  that 
imparted  by  grasping  a  bag  of  bones.  After  a  time  these  osseous 
masses  become  welded  together,  giving  rise  to  large  overgrowths, 
which  lead  subsequently  to  fixation  of  the  joint  (Fig.  322).  The 
disease  sometimes  runs  a  more  chronic  course,  and  then  closely 
resembles  osteo-arthritis,  since  there  is  but  little  effusion,  whilst  the 
ends  of  the  bones  become  eroded,  and  osteophytes,  perhaps  of  great 
size,  form  around  the  edges  of  the  cartilages,  leading  to  defective 
mobility  and  crepitus. 


DISEASES  OF  JOINTS 


66 1 


The  Diagnosis  of  Charcot's  disease  from  osteo-arthriti'^  is,  as  a  rule, 
readily  made  if  one  remembers  the  following  points:  Charcot's 
disease  is  usually  characterized  by  a  rapid  onset,  limitation  to  one 
joint,  considerable  effusion,  absence  of  articular  pain,  atrophy  of  the 
ends  of  the  bones,  and  a  tendency  to  the  production  of  a  weak,  fiail- 
like  joint,  whilst  the  early  general  signs  of  tabes  are  also  observed, 
especially  the  lightning  pains  and  the  Argyll-Robertson  pupil. 
Osteo-arthritis,  on  the  other  hand,  comes  on  slowly,  often  affects 
many  joints,  has  but  little  effusion,  is  very  painful,  and  is  attended 
with  marginal  overgrowth  or  lipping  of  the  cartilages.  In  the'more 
chronic  cases  the  distinguishing  features  are  much  less  evident. 


[^FiG.  324. — Charcot's  Disease  of  Left  Knee  and   Shoulder. 

The  great  atroph}'  of  the  ends  of  the  bones,  and  the  resulting  dislocations,  are 

clearly  e\ddent. 

As  to  pathological  anatom\',  the  changes  observed  are  practically 
identical  with  those  seen  in  osteo-arthritis,  except  that  the  erosion  is 
more  rapid,  the  effusion  greater,  and  the  formation  of  osteophytes 
less  constant. 

The  Treatment  of  Charcot's  disease  consists  in  keeping  the  limb  at 
rest  on  a  splint  and  applying  elastic  pressure.  The  effusion,  when 
considerable,  may  be  removed  by  an  aspirator,  but  is  very  likely  to 
re-collect.  Ionic  medication  with  salts  of  iodine  may  be  of  use.  In 
the  later  stages,  where  the  joint  is  entirely  disorganized,  some  form 
of  fixed  apparatus,  such  as  a  carefully  moulded  splint,  may  be  applied 
to  render  the  limb  more  useful,  and  it  is  remarkable  how  well  a 
patient  can  get  on  in  this  wa}^  with,  a  badly-affected  joint.  In  the 
worst  cases,  however,  amputation  may  be  required. 

The  same  t}'pe  of  articular  lesion  occurs  in  Syringomyelia,  a  disease  which 
consists  in  a  gliomatous  development  in  the  spinal  cord,  and  usually  in  the 
cervico-dorsal  region.  It  is  characterized  by  loss  of  the  senses  of  pain,  and  of 
heat  or  cold,  but  tactile  and  muscular  sensibility  persists.  Atrophj'  of  various 
muscles  of  the  hand  or  fore-arm  also  occurs,  whilst  trophic  lesions — e.g.,  whit- 
low, perforating  ulcer,  etc. — are  common.  Joint  troubles  are  observed  in 
at  least  one-third  of  the  cases,  mainly  in  the  upper  extremity,  tabes  generally 
afiecting     the    lower.      Either    atrophic    or    hypertrophic     phenomena    are 


662  A   MANUAL  OF  SURGERY 

developed,  and  the  course  is  identical  with  that  of  Charcot's  disease,  except 
that  suppuration  is  a  little  more  likely  to  follow,  owing  to  the  frequent  presence 
of  infected  sores. 

Somewhat  similar  in  nature  to  Charcot's  disease  is  the  chronic  arthritis  met 
with  in  many  conditions  where  the  nervous  supply  to  a  limb  is  impaired  as  a 
result  of  central  or  peripheral  disease  of  the  nervous  system.  Thus,  it  may 
follow  spina  bifida,  hemi-  or  para-plegia  of  cerebral  or  spinal  origin,  or  may  be 
secondary  to  a  peripheral  neuritis,  due  to  either  injury,  syphilis,  gout,  diabetes, 
leprosy,  etc.  The  terminal  articulations  of  fingers  or  toes  are  those  most  often 
affected  (acro-arthritis),  although  larger  joints  may  be  involved.  They 
become  swollen  and  painful,  and  after  a  time  ankylosis  ensues. 


Hgemophilic  Diseases  of  Joints. 

In  haemophilia  (p.  298)  aii}^  injury  to  a  joint  may  lead  to  a  copious 
effusion  of  blood  into  the  articular  cavity,  which  becomes  suddenly 
swollen  and  distended.  The  part  becomes  hot  and  tender,  whilst 
when  coagulation  has  taken  place  it  is  hard  and  firm.  Total  re- 
covery may  ensue,  or  the  joint  be  left  weak  and  liable  to  recurrence 
of  haemorrhage.  The  effects  of  recurrences  on  the  articular  surfaces 
are  curious:  the  cartilages  usually  retain  their  normal  colour,  but 
become  thin,  worn,  and  rough,  especially  at  the  points  of  greatest 
pressure ;  fibrillar  degeneration  of  the  matrix  may  occur,  and  in  some 
cases  the  cartilage  has  been  found  totally  absent,  being  replaced  by 
fibrous  tissue.  Ecchondroses  subsequently  developing  into  bone 
are  formed  at  the  margins  of  the  joint  surfaces,  the  changes  thus 
produced  being  somewhat  akin  to  those  of  osteo-arthritis.  The 
ligaments  and  synovial  membranes  are  slightly  thickened,  and 
usually  of  a  russet-brown  colour.  Adhesions  are  often  present, 
causing  considerable  impairment  of  mobility.  The  Treatment  con- 
sists in  keeping  the  part  at  rest,  and  applying  ice  in  the  early  stages; 
whilst,  later  on,  friction,  massage,  and  pressure  may  be  employed. 
The  surgeon  must  never  attempt  to  aspirate  the  joint,  even  with  a 
fine  needle. 

Loose  Bodies  in  Joints. 

Several  varieties  of  loose  body  are  met  with  in  joints,  which  may 
be  described  as  fohows:  (i)  The  so-called  '  melon-seed  bodies  '  con- 
sist of  fibrin  derived  from  altered  blot-clot,  or  more  frequently  from 
a  fibrinous  exudation  in  cases  of  very  chronic  tuberculous  disease. 
At  first  irregular  in  shape  and  laminated  in  texture,  they  are  gene- 
rally transformed  into  round  or  flattened  pellets  or  elongated  masses 
by  the  movements  of  the  articulation.  Bursae  and  tendon  sheaths 
are  much  more  frequently  affected  than  joints.  The  number  present 
is  usually  considerable,  whilst  there  is  also  some  glairy  effusion, 
causing  distension  and  a  certain  amount  of  creaking.  In  one  case 
the  knee-joint  was  occupied  by  a  number  of  rounded  yellowish- white 
translucent  foreign  bodies,  several  of  which  were  nearly  as  large  as 
walnuts;  they  were  probably  of  haemorrhagic  origin.  (2)  Portions 
of  articular  or  intra-articular  cartilage  may  be  broken  or  are  sepa- 
rated off  as  a  result  of  direct  mechanical  violence.     They  usually 


DISEASES  OF  JOINTS 


663 


(^ 


consist  of  a  smooth  rounded  mass  of  articular  cartilage  enclosing  a 
central  bony  nucleus  (Fig.  325).  The  most  common  situation  for 
this  to  occur  is  the  lower  end  of  the  femur;  when  the  knee  is  fully 
bent,  the  articular  surface  is  exposed  to  direct  violence.  If  not 
broken  off  immediately,  the  injured  fragment  may  be  separated 
without  pus  formation;  it  is  sometimes  found  attached  to  the 
under  side  of  the  femur  by  a  pedicle  of  fibrous  tissue,  which  allows 
of  only  a  limited  mobility.  (3)  They  are  sometimes  derived  from 
the  development  of  cartilaginous  ^ 

nodules  in  the  synovial  fringes  or 
villi,  which  either  may  become 
pedunculated,  then  occasionally 
wearing  a  bed  for  themselves  in 
the  articular  surface,  or  may  be 
totally  detached.  Such  structures 
are  usually  lobulated  and  ir- 
regular in  shape,  and  consist 
of  calcified  cartilage  or  bone, 
whilst  a  certain  amount  of  normal 
cartilage  is  also  present  (Fig.  326). 
This  condition  may  result  from 
osteo-arthritis,  but  sometimes  the 
cartilaginous  cells  from  which  they  are  derived  have  persisted  as  a 
'  foetal  residue.'  (4)  Ecchondroses  may  be  broken  off  in  cases  of 
osteo-arthritis,  or  even  portions  of  the  articular  cartilage  showing 
well-marked  villous  changes. 

Although  cut  off  from  all  vascular  supply,  the  growth  of  some  of 


,/' 


B 


Fig.  325. — Foreign  Body  in  Joint, 
probably  derived  from  a  por- 
TION OF  Articular  Cartilage. 
(From  College  of  Surgeons' 
Museum.) 

A,  Cartilage;  B,  bone. 


Fig.  326. — Loose  Cartilage  in  Joint,  probably  developed  in  a  Fringe 
OF  Synovial  Membrane.     (From  College  of  Surgeons'  Museum.) 

A,  Cartilage;  B,  bone. 

these  loose  bodies  is  said  to  continue,  owing  to  the  highly  nutritious 
fluid  which  bathes  their  surfaces. 

The  Symptoms  caused  by  this  condition  are  produced  by  the  loose 
body  being  occasionally  caught  between  the  articular  surfaces,  lead- 
ing to  a  temporary  locking  of  the  joint,  and  severe  pain,  owing  to  the 
stretching  of  the  ligaments.     The  fixation  is  but  momentary,  since 


664  '^   MANUAL  OF  SURGERY 

the  foreign  body  is  readily  displaced,  but  an  attack  of  subacute 
synovitis  follows.  When  this  has  happened  several  times,  the  liga- 
ments are  likely  to  become  relaxed,  and  the  joint  somewhat  loose  and 
distended.  Under  such  circumstances  it  may  be  possible  to  feel  the 
foreign  body  and  to  shift  its  position,  but  frequently  the  surgeon 
is  unable  to  detect  the  intruder  as  it  slips  away  into  the  interior  of  the 
joint,  owing  to  its  ready  mobility.  From  this  point  of  view,  the 
German  term  '  Gelenkmaus  '  (joint  mouse),  as  applied  to  this  affec- 
tion, is  most  happy.  The  knee-joint  is  that  most  frequently  affected, 
but  the  same  condition  occurs  in  the  elbow  and  temporo-maxillary 
articulation. 

The  Diagnosis  between  a  loose  body  and  a  torn  and  moveable  semi- 
lunar cartilage  in  the  knee-joint  is  not  always  easy,  since  in  both 
conditions  painful  locking  of  the  joint  occurs.  The  fixation,  how- 
ever, is  but  momentary  in  the  case  of  a  loose  body,  but  may  persist 
until  reduced  in  the  latter,  whilst  a  localized  spot  of  tenderness  may 
be  detected  corresponding  to  the  site  of  the  injury  to  the  inter- 
articular  cartilage.  Moreover,  the  history  of  the  case  is  very 
different,  since  the  dislocation  of  a  semilunar  cartilage  is  always 
primarily  referred  to  some  twist  or  sprain  of  the  joint,  whereas  with 
a  loose  body  no  such  traumatic  influence  need  be  present.  It  is 
sometimes  possible  to  detect  a  loose  body  by  the  X  rays  if  there  is 
any  osseous  tissue  in  it. 

The  Treatment  consists  in  the  removal  of  the  foreign  body  by  an 
open  operation.  In  the  knee-joint  a  vertical  incision  should  be  made 
about  2  inches  in  length,  extending  a  httle  above  and  below  the  hne 
of  the  articulation.  It  should  be  placed  about  i  inch  from  the 
patella,  on  whichever  side  the  loose  cartilage  presents  most  fre- 
quently, but  preferably  on  the  outer.  If  possible,  the  foreign  body 
should  be  fixed  by  the  finger  in  one  of  the  lateral  pouches  of  the  joint 
before  making  the  incision.  The  capsule  and  synovial  membrane 
are  opened,  the  loose  body  removed,  and  the  cavity  carefully  closed. 
For  precautions,  etc.,  see  p.  629. 

Neuralgic  Joints. 

In  neurotic  individuals,  especially  3'oung  women,  a  neuralgic  con- 
dition of  the  joints  is  commonly  met  with,  simulating  disease  of  the 
articulation.  On  careful  examination  the  pain  is  found  to  be  super- 
ficial, not  increased  by  jarring  the  articular  surfaces  together,  and 
often  not  strictly  confined  to  the  joint.  The  movements  are  ap- 
parently limited,  but  if  the  attention  of  the  individualis  diverted,  or 
anaesthesia  induced,  they  are  found  to  be  perfectly  free.  There  are 
no  signs  of  effusion  into  the  cavity,  and  no  starting  pains  at  night. 
Occasionally  a  similar  condition  is  met  with  in  men,  where  there  is 
no  suspicion  of  hysteria. 

The  treatment  is  constitutional  and  local.  The  former  is  directed 
towards  improving  the  general  health,  and  correcting  any  error  in 
the  uterine  functions.     The  latter  is  best  accomplished  by  the  use  of 


DISEASES  OF  JOINTS  665 

cold  douches  and  electricity,  although  counter-irritation  in  the  shape 
of  blisters,  or  even  the  actual  cautery,  apphed  over  the  joint,  has  an 
excellent  moral  effect. 

Ankylosis. 

By  ankylosis  is  meant  a  condition  of  immobility,  partial  or  com- 
plete, of  a  joint,  resulting  from  some  preceding  inflammation  of  the 
articular  structures. 

The  term  false  ankylosis  is  sometimes  apphed  to  a  condition  re- 
sulting from  extra-articular  lesions.  Such  may  be  either  fibrous  or 
osseous,  and  is  due  to  cicatricial  contraction  of  the  skin,  shortening 
or  fibrosis  of  muscles,  or  even  to  the  development  of  bony  tissue 
within  them  {myositis  ossificans).  Tnis  ankylosis  always  involves 
the  articular  structures,  and  is  either  fibrous  or  bony. 

Fibrous  or  incomplete  ankylosis  results  {a)  from  thickening  and 
contraction  of  the  ligaments,  such  as  often  occurs  after  gonorrhoea! 
or  rheumatic  affections ;  (&)  from  the  formation  of  cord-  or  band-like 
adhesions  within  the  joint,  after  acute  synovitis  or  fractures  involv- 
ing the  articular  surface;  (c)  from  erosion  of  the  cartilage  and  ex- 
posure of  the  bone  as  in  acute  or  tuberculous  arthritis ;  granulations 
sprout  up  on  each  side,  and  by  their  union  lead  to  dense  fibroid 
adhesions  between  the  articular  surfaces.  Some  amount  of  move- 
ment is  possible  in  most  of  these  cases. 

Complete  or  osseous  ankylosis  (synostosis)  arises  from  the  union  of 
either  the  w-hole  or  part  of  the  opposing  surfaces  left  by  the  destruc- 
tion of  the  cartilage,  the  bond  of  union,  at  first  fibro-cicatricial,  being 
subsequently  ossified  (Fig.  327) ;  it  may  also  be  due  to  the  inter- 
locking and  fusion  of  osteophytes,  formed  at  the  margin  of  the  bone 
in  osteo-arthritis  or  Charcot's  disease. 

The  position  in  which  ankylosis  occurs  and  the  effects  thus  pro- 
duced differ  according  to  the  joint  affected. 

In  the  shoulder  there  is  usually  but  Httle  displacement,  and  the 
existence  of  immobihty  is  of  less  importance  than  elsewhere,  owing 
to  the  free  movements  of  the  scapula  and  clavicle.  The  deltoid 
muscle  is  generally  much  atrophied.  The  elhow-joint  is  very  com- 
monly ankylosed  on  account  of  its  exposed  position,  and  the  fre- 
quency of  fracture-dislocations  in  its  neighbourhood.  The  forma- 
tion of  callus  filling  up  the  olecranon  and  coronoid  fossae,  and  the 
adhesions  likely  to  form  within  the  joint  in  these  cases,  readily 
explain  its  frequency.  The  most  favourable  position  for  ankylosis 
is  when  the  arm  is  flexed  to  a  little  more  than  a  right  angle,  with  the 
hand  midway  between  pronation  and  supination.  By  this  means 
access  to  the  mouth  is  possible,  and  the  patient  can  use  his  hand  for 
feeding  purposes.  Occasionally,  however,  the  patient's  work  is  such 
as  can  best  be  undertaken  by  a  straight  arm.  The  wrist  is  rnost 
commonly  fixed  as  a  result  of  gonorrhoeal  or  rheumatic  synovitis. 
In  the  hip-joint  (Fig.  327)  much  depends  upon  the  treatrnent  as  to 
whether  the  ankylosis  takes  place  in  a  good  or  bad  position.  In 
neglected  cases  the  thigh  may  be  in  a  position  of  adduction  and 


666 


A   MANUAL  OF  SURGERY 


internal  rotation,  crossing  in  front  of  tlie  other  leg.  Occasionally  a 
scissor-like  dcformHy  has  resulted  from  inflammation  of  both  hip- 
joints,  one  leg  lying  in  front  of  the  other;  progression  is  accomplished 
with  difficulty,  the  body  twisting  at  each  step,  and  crutches  are  often 
needed.  Tn  the  knee-joint  ankylosis  in  an  absolutely  straight  position 
of  the  limb  should  be  aimed  at,  unless  complete  synostosis  is  likely 
to  occur,  when  a  slight  degree  of  flexion  may  render  the  leg  more 

serviceable.  Unless  care  is  taken  in 
treating  the  causative  affection,  anky- 
losis is  only  too  likely  to  be  associated 
with  deformity.  The  knee  becomes 
bent,  and  the  tibia  is  displaced  back- 
wards on  the  femur,  whilst  external 
rotation  and  even  lateral  displacement 
of  the  tibia  externally  are  likely  to 
supervene  if  the  patient  is  allowed  to 
lie  with  his  leg  on  its  outer  aspect.  In 
the  ankle-joint  considerable  trouble  may 
arise  from  immobility,  unless  the  foot 
is  at  right  angles  to  the  leg. 

It  must  always  be  remembered  that 
in   a   case   of   long-standing   ankylosis 
the  changes  do  not   involve   only  the 
articular  surfaces.      The  bones   them- 
selves after  a  time   may  become  atro- 
phic and   break   easily;  ligaments  are 
shortened,  or    transformed   into   bony 
Fig.  327. — Ankylosis  OF  Hip-  tissue;   muscles  are  atrophied,  and  in 
Joint    in    Good    Position   ^jj^^g  undergo   complete  degeneration; 
AFTER  Early  Hip  Disease.    ,        ■,  ^1  ^-r    j  j  ;      ^^^^^ 

(Howard  Marsh.)  tendons  may  be  ossified;  and  m  cases 

of  deformity,  accommodative  shorten- 
ing occurs  in  all  the  tissue  involved,  muscles,  tendons,  nerves, 
vessels,  etc.  Hence  the  prognosis  of  all  operative  treatment  directed 
to  the  cure  of  the  ankylosis  involves  a  careful  consideration  of  the 
condition  of  the  soft  parts,  and  the  possibihty  of  their  being  restored 
to  functional  utility. 

The  Treatment  of  ankylosis  must  vary  considerably  according  to 
its  cause.  In  the  simple  forms  of  fibrous  ankylosis,  due  to  the 
presence  of  adhesions  of  no  density,  much  may  be  done  by  manipula- 
tion, massage,  and  exercises.  Some  adhesions  may  be  dealt  with  by 
forcible  movements  under  an  anaesthetic,  the  surgeon  ever  keeping 
in  mind  that  the  bones  involved  maybe  atrophic  and  easily  broken. 
Others  are  better  treated  more  gradually,  efforts  being  directed  to 
lengthen  and  loosen  the  adhesions  rather  than  to  break  them.  A 
course  of  fibrolysin  (p.  263)  may  sometimes  help  in  this  direction  by 
softening  the  fibro-cicatricial  bands. 

An  exception  to  all  vigorous  treatment  of  this  type,  as  also  to  the 
operative  methods  suggested  below,  is  made  in  the  case  of  ankylosis 
following  tuberculous  disease.     The  surgeon  can  never  be  certain 


DISEASES  OF  JOINTS  667 

tliat  infective  foci  are  not  encapsuled  in  the  librous  tissue,  and  active 
treatment  might  once  again  light  up  active  disease. 

It  is  useless  to  attempt  the  rupture  or  division  by  open  operation  of 
dense  adhesions,  as  they  are  certain  to  re-form.  These  cases,  as  also 
certain  non-tuberculous  forms  of  osseous  ankjdosis,  are  best  treated 
by  the  operation  of  arthroplasty,  elaborated  by  J.  B.  Murphy.  The 
procedure  is  based  on  the  recognised  fact  that  one  of  the  most  fre- 
quent causes  of  the  non-union  of  fractures  is  the  interposition  of 
fibrous  or  muscular  tissues  between  the  fragments.  If,  then,  the 
articular  ends  of  an  ank^'losed  joint  can  be  separated,  and  a  suitable 
flap  of  tissue  interposed,  the  free  movement  of  the  joint  should  be 
restored.  IMuch  experimental  work  has  been  undertaken  to  ascer- 
tain the  best  material  for  this  purpose:  gold  beater's  skin  (or  ox's 
peritoneum  =  Cargile  membrane),  Baer's  membrane  (chromicized 
and  sterilized  pig's  bladder),  and  free  or  pedunculated  fascial  flaps, 
have  been  chiefly  used;  on  the  whole,  the  best  results  have  been 
obtained  from  free  fascial  flaps  stitched  over  the  bone  ends.  It  is 
impossible  here  to  enter  into  lengthy  details  of  the  procedure* ;  it 
must  suffice  to  state  that  the  joint  affected  must  be  freely  exposed; 
the  articular  ends  are  set  free,  and  suitably  rounded  or  shaped;  the 
fascial  flap  is  placed  so  as  to  cover  completely  the  articular  end  of  one 
or  both  bones  involved,  and  stitched  in  situ  ;  and  then  the  wound  is 
carefully  closed.  It  is  immobilized  for  a  week  or  ten  days,  and  then 
movements  are  commenced.  The  result  in  many  cases  is  most 
gratifying,  but,  of  course,  all  infective  trouble  must  have  ceased 
before  the  operation  is  undertaken,  and  absolute  asepsis  is  essential 
if  the  fascial  flap  is  to  live. 

Transplantation  of  joints  has  also  been  attempted  in  a  few  in- 
stances, but  can  scarcely  be  expected  to  be  of  much  service  in  view  of 
the  successes  of  arthroplasty.  Excision  of  joints  for  ankylosis  is 
similarly  placed  on  a  fresh  footing  as  a  result  of  these  facts  At  the 
elbow  some  form  of  excision  will  be  frequently  required,  but  will  take 
on  the  form  of  an  arthroplasty  in  the  majority  of  cases.  In  the  knee 
osseous  ankylosis  with  deformity  will  frequently  require  the  removal 
of  a  wedge-shaped  fragment  (cuneiform  osteotomy)  in  order  to  over- 
come the  displacement,  but  even  then  an  arthroplastic  element  will 
be  sometimes  feasible.  Where,  however,  the  ankylosis  is  fibrous, 
arthroplasty  will  usually  be  practicable. 

At  the  hip-joint  ankjdosis  in  a  bad  position  is  most  commonly  due 
to  tuberculous  disease,  and,  as  already  stated,  arthroplasty  is  then 
not  desirable.  Most  frequently  the  thigh  is  flexed  on  the  pelvis  and 
possibly  adducted,  the  result  being  a  most  ungainly  method  of  pro- 
gression. In  the  majority  of  such  cases  it  is  unwise  to  attempt 
ch\asion  of  the  cervix  femoris  (Adam's  operation) ;  it  is  too  near  the 
diseased  area.  Subtrochanteric  osteotomy  of  the  femur  is  the 
operation  of  choice ;  the  bone  is  exposed  from  the  side,  and  either 
chiselled  across  or  divided  by  a  Gigli  saw.  To  put  the  limb  in  a  good 
position,  tenotomy  of  the  adductors  is  usually  required,  and  this  is 
*  For  further  details,  see  J.  B.  Murphy,  Annals  of  Surgery,  May,  1912. 


668 


A   MANUAL  OF  SURGERY 


easily  affected  subcutaneously  close  to  the  pubes.  The  after-treat- 
ment must  be  sufficiently  long  to  ensure  sound  and  solid  union  ol  the 
bone,  as  the  adductors  are  powerful,  and  can  readily  lead  to  displace- 
ment when  the  callus  is  soft.  In  non-tuberculous  ankylosis  of  the 
hip  the  joint  is  best  exposed  by  a  large  U-shaped  incision  with  its 
base  upwards,  and  the  trochanter  well  within  the  U.  This  flap  is 
raised,  including  the  deep  fascia.  The  base  of  the  trochanter  is 
chiselled  across,  the  joint  is  exposed,  and  the  head  of  the  femur 
separated  from  the  acetabulum  and  shaped  up  so  as  to  move  freely 
in  the  deepened  and  smooth  socket.  A  flap  of  fascia  is  then  carefully 
wrapped  round  the  head  of  the  femur  and  stitched  in  position. 
Divided  Hgaments  are  re-united;  the  trochanter  is  nailed  back  in 
position,  and  the  wound  closed.  The  limb  is  placed  in  a  position  of 
abduction  with  weight  extension,  and  passive  movements  are  com- 
menced in  ten  days. 

Hip-Joint  Disease. 

Although  the  term  '  hip-joint  disease  '  is  usually  apphed  to  a  tuber- 
culous arthritis,  it  is  not  the  only  affection  involving  this  articulation, 
^*»jsss=(-:  ^^  rheumatic,  gonorrhoeal,  or 


pyaemic  affections  are  not  very 
uncommon.  Acute  arthritis  is 
also  met  with  secondary  to 
an  acute  infective  osteo- 
myelitis of  the  upper  end  of 
the  femur,  and  is  evidenced 
by  all  the  ordinary  signs  of 
that  affection,  separation  and 
necrosis  of  the  upper  epi- 
physis being  a  frequent 
result.  Osteo-arthritis  is  fre- 
quently seen  (p.  658),  whilst 
Charcot's  disease  may  also 
occur. 

Tuberculous  Disease  of  the 
Hip  [Syn.  :  Morbus  Coxae, 
Tuberculous  Coxitis,  Coxalgia) 
differs  in  no  respect  from  the 
same  disease  as  it  affects 
other  joints,  and  hence  no 
detailed  notice  of  the  patho- 
logical anatomy  is  required. 
Suffice  it  to  say  that  it  may 
originate  in  the  synovial 
membrane  or  bone,  more  fre- 


^i.M 


Fig.  328. — Tuberculous  Disease  of 
THE  Head  and  Neck  of  the  Femur, 
SHOWING  Sequestra  in  an  Abscess 
Cavity,  and  Communication  on  the 
Under  Side  of  the  Neck  with  the 
Joint.     (Tillmanns.) 

The  epiphysis  of  the  head  has  been  in- 
vaded, and  the  articular  cartilage  en- 
tirely stripped  ofiE  by  the  disease;  the 
continuous  black  line  indicates  the 
amount  of  bone  which  it  would  be 
necessary  to  remove,  if  excision  were 
undertaken. 


quently  in  the  latter,  and  then 
commencing  either  beneath  the  articular  cartilage  or  on  the  under 
side  of  the  neck  distal  to  the  epiphyseal  cartilage  (Fig.  328).  Very 
rarely  the  disease  becomes  circumscribed  in  the  neck  of  the  bone. 


DISEASES  OF  JOINTS 


66g 


formiaK  a  chronic  abscess,  the  diagnosis  of  which  is  exceedingly 
diSt  %Iore  usually  the  disease  spreads  from  the  under  side  of 


Fig.  329. — Femur  and  Acetabu- 
lum IN  Hip  Disease.  (King's 
College  Hospital  Museum.) 

The  epiphysis  of  the  caput  femoris 
has  been  practically  destroyed 
and  the  acetabulum  is  enlarged 
by  absorption  of  its  posterior 
margin  and  displaced  upwards 
[travelling  acetabulum) .  The  rami 
of  the  ischium  and  pubes  have 
been  removed. 


Pjq  330. — Early  Stage  [of  Hip 
Disease  (LeJ-t  Side)  in  a 
Child.     (From  a  Photograph.) 

The  black  line  is  drawn  from  one 
anteriof  superior  spine  to  the 
other,  and  shows  not  only  the 
amount  of  abduction  present, 
but  also  the  tilting  down  of  the 
pelvis  on  the  affected  side. 


the  cavity  extended,  whilst  at  the  same  time  a  new  rim  of  bone  forms 
beneath  L  adj  acent  periosteum  at  a  slightly  higher  l-el  thus  giving 
rise  to  what  is  known  as  a  '  travelhng  acetabulum  (Fig.  329)-  /n 
fhTs  way  the  socket  is  increased  both  in  size  and  depth,  travell  ng 
backwards  and  upwards  with  the  head  of  the  b^^^^^^owards  the 
dorsum  ihi  Other  factors  assisting  in  the  displacement  of  the  head 
of  the^one  are:  the  tonic  action  of  the  muscles,  keeping  the  limb  m  a 
position  of  flexion,  adduction  and  inversion,  the-by  caus^^g  a  con^ 
siderable  portion  of  the  head  to  proiect  out  of  the  acetxbulum.  and 


670 


A    MANUAL  OF  SURGERY 


the  early  softening  and  destruction  of  the  posterior  ligaments,  which 
are  much  thinner  than  those  in  front  of  the  joint.  Occasionally  a 
mass  of  protuberant  granulations  sprouts  up  from  the  centre  of  the 
cavity,  and  may  also  assist  in  this  process.  Should  the  acetal)ulum 
be  perforated,  a  tuberculous  abscess  is  likely  to  form  within  the 
pelvis.  The  adjacent  pelvic  bones  may  either  become  thickened  by 
the  deposit  of  osteophytes,  or  carious;  if  a  j)yogenic  infection  is 
super-added,  necrosis  may  supervene. 

Clinical  History. — The  patient,  usually  a  child,  is  observed  to  limp, 
and  may  complain  of  pain  either  in  the  hip  or  more  often  on  the  inner 
side  of  the  knee,  the  latter  being  due  to  the  fact  that  both  joints  are 
supplied  by  the  same  nerves — viz.,  the  anterior  crural,  sciatic,  and 


li-jQ    331  — Diagram  to  illustrate  the  Positions  Assumed  by  the  Limb 

IN    THE    IlARLY    and    LATE    StAGES    OF    HiP    DISEASE. 

A  represents  the  positiou  of  abduction  taken  by  the  right  limb  in  the  early 
stage  of  hip  disease,  and  B,  Nature's  method  of  masking  this  by  tilting 
the  pelvis  down  on  the  affected  side,  while  the  other  leg  is  adducted;  the 
effect  of  this  on  the  spine,  in  causing  a  lateral  deflection,  is  also  indicated. 
C  shows  the  same  thing  in  the  later  stage,  when  adduction  is  present,  and 
the  pelvis  is  tilted  upwards  on  the  affected  side,  thus  producing  apparent 
shortening  (D). 

obturator  trunks.  There  may  be  some  history  of  injury,  but  not 
necessarily.  On  examining  the  limb  in  the  early  stage,  it  is  usually 
found  to  be  apparently  lengthened  (Fig.  330),  whilst  the  thigh  is 
shghtly  wasted.  The  nates  are  flattened,  and  the  gluteal  fold  lost, 
conditions  partly  due  to  atrophy  of  the  muscles,  partly  to  the  flexion 
of  the  limb.  T  he  joint  is  more  or  less  rigid,  and  pain  is  produced  on 
attempting  to  move  it,  or  on  jarring  the  leg,  as  by  striking  the  heel 
or  trochanter.  The  position  assumed  in  this  early  stage  is  one  of 
slight  and  increasing  flexion,  abduction,  and  eversion  (Fig.  331,  A), 
the  reason  for  this  being  that  thereby  the  ligaments,  and  especially 
the  ilio-femoral,  are  most  relaxed,  and  the  capacity  of  the  joint  is  at 
its  greatest.  I  he  latter  fact  has  been  demonstrated  in  the  healthy 
cadaver  by  inserting  the  nozzle  of  a  syringe  into  the  joint  through  the 
acetabulum,  and  forcibly  injecting  fluid,  when  this  position  is  at  once 
assumed.     The  flexion  and  abduction,   however,   are  not   always 


DISEASES  OF  JOINTS  671 

evident,  since  the  tiexion  is  masked  by  lordosis  of  tlie  spine  (Figs.  332 
and  333),  and  the  abduction  by  the  pelvis  being  tilted  down  on  the 
affected  side,  producing  thereby  apparent  lengthening  of  the  dis- 
eased limb  and  lateral  curvature  of  the  spine,  with  its  lumbar  con- 
vexity towards  the  affected  side  (Fig.  331,  A  and  B).  The  sound  leg 
being  brouglit  into  a  position  of  adduction,  the  parallelism  of  the 
limbs  is  maintained.     Ihe   flexion   can   be   demonstrated  by   any 


Fig.  332. — Hip  Disease,  with  the  Back  Flat  on  the  Couch,  and  the  Leg 
Flexed  to  a  Considerable  Degree. 


Fig.  333. — On  Pressing  Down  the  Diseased  Limb,  the  Spine  becomes 
Arched  (Lordosis)  in  the  Lumbar  Region,  so  that  the  Hand  could 

BE    readily    passed    BELOW    IT.         ThE    EvERSION    OF    THE    LiMB    IS    VERY 

Evident. 

method  which  obliterates  the  lumbar  curve  of  the  spine,  as  by  fully 
bending  up  the  sound  limb  on  the  abdomen,  the  affected  thigh  rising 
at  once  from  the  bed  and  forming  an  angle  which  indicates  the 
amount  of  flexion  (Fig.  332).  The  abduction  is  demonstrated  by 
laying  a  rod  across  the  two  anterior  superior  spines,  and  placing 
another  at  right  angles  to  its  centre.  This  will  not  correspond  with 
the  line  of  the  bod}^  or  of  the  limb,  but  makes  an  angle  with  it.  The 
eversion  cannot  be  masked.  The  rigidity  is  easily  demonstrable  in 
that  all  movements  of  the  hip-joint  are  greatly  limited;  thus  if  an 
attempt  is  made  to  bend  the  affected  thigh  on  the  abdomen,  the 
corresponding  side  of  the  pelvis  is  raised  with  it  from  the  bed. 


672 


A   MANUAL  OF  SURGERY 


As  the  disease  progresses,  and  the  bones  become  more  extensively 
affected,  the  pain  increases,  with  nocturnal  startings.  whilst  abscesses 
form,  and  a  certain  amount  of  fever  and  constitutional  disturbance  is 
caused  thereby.  '1  he  position  of  the  limb  also  changes ;  for  although 
the  flexion  is  maintained,  and  even  increased,  adduction  and  inver- 
sion are  now  associated  with  it.  The  pelvis  is  tilted  up  on  the 
affected  side  (Fig.  331,  C  and  D),  causing  apparent  shortening,  lateral 
curvature  with  a  lumbar  convexity  to  the  sound  side,  and  abduction 


Fig.  334. —  Position  of  the  Limb  in  the  Later  Stages  of  Hip  Disease. 

In  A  a  white  line  has  been  drawn  between  the  two  anterior  superior  spines  to 
indicate  the  tilting  of  the  pelvis  upwards  on  the  affected  side  necessitated 
by  the  adduction  of  the  limb.  Some  amount  of  flexion  was  present,  but 
this  was  not  marked.  In  B  the  secondary  curves  of  the  spine  axe  well 
seen. 


of  the  health}'  limb.  No  satisfactory  cause  for  this  position  can  be 
given,  but  it  is  usually  attributed  to  the  yielding  of  the  posterior  and 
outer  part  of  the  capsule,  together  with  infiltration  and  weakening 
of  the  small  external  rotator  muscles,  allowing  the  adductors  and 
internal  rotators  unopposed  play. 

When  an  abscess  has  formed,  the  most  usual  situation  for  it 
to  point  is  a  little  in  front  of  and  internal  to  the  great  trochanter, 
close  to  the  insertion  of  the  tensor  fascise  femoris.  It  may  reach 
tnat  spot  either  from  an  opening  in  the  anterior  part  of  the  capsule, 


DISEASES  OF  JOINTS  673 

coming  thus  to  the  surface  along  the  hne  of  least  resistance,  or  it  may 
burrow  from  the  posterior  portion  of  the  capsule  along  the  rotator 
muscles  and  superior  gluteal  nerve.  Less  frequently  abscesses  pass 
directly  backwards  to  open  in  the  gluteal  region,  or  forwards  along 
the  pubo-femoral  ligament,  pointing  on  the  inner  side  of  the  femoral 
vessels  below  Poupart's  ligament.  As  a  rare  complication,  the 
tuberculous  process  may  extend  to  the  bursa  under  the  psoas  tendon, 
which  sometimes  communicates  with  the  joint,  leading  to  the  forma- 
tion of  an  abscess  in  the  upper  part  of  Scarpa's  triangle,  and  occa- 
sionally to  a  typical  psoas  abscess  from  extension  upwards.  An 
intra-pelvic  abscess  following  perforation  or  disease  of  the  acetabu- 
lum may  either  burrow  upwards,  and  come  to  the  surface  above 
Poupart's  ligament,  or  may  gravitate  downwards,  and  burst  in  the 
ischio-rectal  fossa. 

The  final  stage  of  the  disease  is  one  of  real  shortening  (Fig.  334) ,  due 
to  erosion  of  the  head  of  the  bone  and  its  displacement  backwards 
upon  the  dorsum  ilii.  Ihe  position  assumed  is  one  of  increased 
flexion,  adduction,  and  inversion;  whilst  if  suppurating  sinuses  per- 
sist, hectic  fever  and  amyloid  changes  in  the  viscera  are  likely  to 
follow. 

At  any  stage  cure  by  ankylosis  may  be  obtained;  but  unless  the 
abnormal  position  has  been  corrected  by  extension,  deformity  is 
almost  certain  to  be  present,  whilst  interference  with  growth  may 
increase  the  shortening. 

The  Diagnosis  of  hip  disease  appears  to  be  a  matter  of  considerable 
difficulty  to  some,  if  we  may  argue  from  the  mistakes  which  com- 
monly occur.  The  pain  in  the  knee  present  in  the  early  stages  leads 
to  its  frequently  being  mistaken  and  even  treated  for  disease  of 
that  articulation;  all  cases  of  pain  in  the  knee  without  apparent 
cause  should  suggest  an  examination  of  the  hip-joint,  as  well  as  of 
the  knee;  a  very  slight  amount  of  care  in  the  examination  should 
prevent  such  an  error.  From  disease  of  the  opposite  hip,  it  is  recog- 
nised by  the  relative  mobility  of  the  thighs  on  the  two  sides.  The 
same  test,  viz.,  that  of  the  mobility  of  the  joint,  should  prevent  con- 
genital dislocation  of  the  hip  being  mistaken  for  tuberculous  disease, 
as  is  not  unfrequent.  The  diagnosis  from  sacro-iliac  disease  is  given 
at  p.  678.  Spinal  mischief  may  also  be  confounded  with  it,  if  a  psoas 
abscess  points  at  any  of  the  ordinary  situations  in  which  sinuses  form 
in  connection  with  the  hip-joint.  Ihe  presence  of  spinal  deformity 
and  the  ability  to  perform  the  test  movement  for  hip  disease  should 
readily  enable  the  surgeon  to  make  a  correct  diagnosis,  but  it  must 
not  be  forgotten  that  the  two  conditions  may  co-exist.  If  the  limb 
can  be  put  into  what  is  knov/n  as  the  tailor's  position — that  is, 
flexion  to  a  right  angle  with  marked  abduction  and  eversion — one 
may  be  practically  certain  that  hip  disease  is  not  present. 

It  is  difficult  to  distinguish  an  encapsuled  abscess  in  the  neck  of  the 
femur  from  true  hip  disease.  A  constant  deep  boring  pain  is  com- 
plained of,  which  is  increased  by  pressure  over  the  neck,  or  by 
jarring  the  trochanter;  but  if  the  limb  is  manipulated  gently,  it  can 

43 


674 


A   MANUAL  OF  SURGERY 


be  proved  that  the  movements  of  the  joint  are  not  really  impaired. 
Radiography  is  a  useful  aid  in  making  a  diagnosis  of  this  condition. 
It  is  often  impossible  to  be  certain  as  to  the  nature  of  the  inflam- 
matory attack  following  a  slighl  injury.  The  patient  is  treated  as  for 
the  graver  affection,  and  if  it  gets  well  in  a  week  or  two.  probably 
it  is  not  tuberculous.  Radiography  is  always  of  help  in  the  diag- 
nosis. 

Ihe  Prognosis  of  hip  disease  is  by  no  means  unfavourable  it  the 
condition  is  properly  treated.  Of  course,  the  patient  is  liable  to 
develop  acute  tuberculosis  or  tuberculous  disease  elsewhere;  or,  if 
abscesses  are  allowed  to  become  septic,  serious  complications— such 
as  pyaemia,  toxaemia,  hectic  and  amyloid  disease — may  ensue. 
Apart  from  these,  however,  no  serious  consequences  affecting  life 
need  be  feared,  although  the  usefulness  of  the  limb  may  be  seriously 
crippled  from  shortening  or  ankylosis,  especially  if  the  latter  occurs 
in  a  faulty  position. 

The  general  Treatment  of  hip  disease  must  be  conducted  along  the 
same  lines  as  for  tuberculous  lesions  generally.  In  the  early  stages 
the  limb  nmst  be  kept  at  rest  and  deformity  prevented.  This  is 
perhaps  best  accomplished  by  weight  ex- 
tension to  the  affected  limb,  and  the  applica- 
tion of  a  Liston's  splint  to  the  sound  side; 
or  the  child  may  be  fixed  down  by  sandbags, 
or  a  Bryant's  splint  employed.  For  weight 
extension,  the  strapping  must  be  carried  well 
above  the  knee,  and  only  enough  weight 
used  to  keep  the  limb  from  painful  starts. 
If  the  amount  of  flexion  is  slight,  the  limb 
may  be  allowed  to  lie  on  the  bed  in  the 
horizontal  posture;  this  will  possibly  induce 
some  compensatory  lordosis,  but  as  the 
muscular  spasm  relaxes,  the  curvature  of 
the  spine  disappears.  When,  however,  a 
considerable  degree  of  flexion  is  present, 
extension  must  be  made  along  the  axis  of 
the  flexed  limb,  which  is  supported  on  pillows. 
It  will  be  found  that  after  a  few  days  the 
flexion  diminishes,  and  the  limb  will  then 
gradually  assume  the  horizontal  position. 
Should  this  precaution  not  be  adopted,  the  extension  merely  produces 
lordosis,  and  the  pain  from  intra-articular  tension  is  increased  thereby. 
When  the  more  urgent  symptoms  have  disappeared,  as  indicated  by 
the  absence  of  pain  on  the  reduction  or  removal  of  the  weight,  a 
Thomas's  hip-splint  is  applied,  so  as  to  enable  the  patient  to  get 
about  (Fig.  335).  This  consists  of  a  flat  bar  of  malleable  iron,  about 
an  inch  and  a  half  wide,  extending  from  the  lower  part  of  the  axilla 
nearly  to  the  ankle;  it  is  shaped  so  as  to  fit  the  varying  curves  of  the 
body,  and  cross-pieces  embrace  the  trunk  at  the  level  of  the  nipples, 
as  also  the  thigh  and  the  calf;  it  is  firmly  bandaged  to  the  body  and 


Fig.   335.  —  Thomas's 
Hip-Splint  applied. 


DISEASES  OF  JOINTS 


675 


676  A   MANUAL  OF  SURGERY 

limb.  A  patten  is  placed  under  the  boot  of  the  sound  leg,  and  the 
patient  allowed  to  get  about  on  crutches.  '1  his  apparatus  should  be 
worn  for  at  least  six  months  after  all  signs  of  active  disease  have 
disappeared.  It  may  also  be  employed  in  the  earlier  and  more 
jxiinful  stages  if  it  is  at  first  bent  so  as  to  accommodate  itself  to  the 
flexed  position  of  the  limb;  as  the  effect  of  the  rest  becomes  evident 
in  a  diminution  of  muscular  s]msm.  the  splint  can  gradually  be 
straightened  out,  so  that  at  length  the  limb  is  fully  extended.  In 
the  case  of  very  small  children  it  is  probably  wise  to  put  them  in  a 
Phelps's  box  (p.  714)  for  some  months  after  the  active  manifestations 
have  quieted  down. 

When  abscesses  form,  they  may  be  opened  antiseptically,  or 
preferably  tapped  and  injected  witli  iodoform,  drainage  if  possible 
being  avoided;  of  course,  the  former  precautions  as  to  rest  and  con- 
stitutional treatment  are  still  maintained.  More  extensive  opera- 
tive measures,  such  as  excision  of  the  head,  are  nowadays  seldom 
undertaken. 

Many  surgeons  of  large  experience  maintain  that  if  suitable  treat- 
ment is  persisted  in  patiently  for  a  sufficient  time  cure  is  almost 
certain  to  follow,  and  that  therefore  operations,  other  than  tapping 
abscesses,  are  quite  useless.  Per  contra,  other  eminent  surgeons 
still  consider  that  operation,  even  excision  by  the  anterior  method 
(p.  682),  is  justifiable  and,  indeed,  advisable  in  many  cases.  Prob- 
ably the  truth  lies  halfway  between  these  two  opinions.  If  a  case, 
in  spite  of  rest  and  suitable  hygienic  measures,  is  not  progressing 
satisfactorily,  as  shown  by  the  persistence  of  pain,  especially  of 
starting  pains  at  night,  or  by  a  raised  temperature,  or  by  the  inci- 
dence of  a  local  swelling,  suggesting  the  formation  of  an^  abscess, 
and  especially  if  radiography  indicates  the  existence  of  a  localized 
lesion,  it  is  justifiable  to  cut  down  on  the  joint  from  the  front  and 
remove  all  the  caseous  debris,  degenerated  synovial  membrane, 
and  diseased  cartilage  arid  bone  that  can  be  reached  ^without  too 
great  a  disturbance  of  the  parts.  Sterilized  iodoform  is  then  rubbed 
in  and  the  wound  close;d.  In  some  cases  a  temporary  dislocation  of 
the  head  is  justifiable,  and  then  the  acetabulum  can  be  more  effec- 
tively treated.  The  epiphyseal  cartilage  of  the  upper  end  of  the 
femur  should  always  be  saved,  if  possible,  so  as  not  to  interfere  with 
the  growth  of  the  bone.  Occasionally  the  mischief  is  so  extensive 
as  to  necessitate  the  removal  of  the  whole  head ;  if  so,  the  limb  must 
be  subsequently  put  up  in  a  position  of  abduction,  so  as  to  prevent 
displacement  upwards  on  the  dorsum  ilii  and  increased  shortening 
at  a  later  date. 

In  the  later  stages,  when  the  case  has  been  neglected  and  sinuses 
have  formed  in  the  gluteal  region  or  behind  the  trochanter,  excision 
by  the  posterior  method  is  sometimes  required;  this  is  usually 
an  easy  matter,  since  the  head  is  probably  eroded  and  dis- 
placed. The  sinuses  should,  if  possible,  be  included  in  the  incision, 
but  under  any  circumstances  must  be  opened  up  and  scraped. 
When  the  acetabulum  is  extensively  implicated,  the  disease  can  only 


DISEASES  OF  JOINTS  677 

be  satisfactorilv  dealt  with  by  removing  the  head  of  the  bone,  and 
the  posterior  method  affords  the  best  means  of  subsequent  dramage; 
of  course,  this  presumes  that  the  general  condition  of  the  patient 
has  not  been  seriously  undermined,  and  that  there  is  a  good  pros- 
pect of  gaining  a  useful  limb.  Otherwise  amputation  through  the 
hip-joint  is  required,  especially  when  the  mischief  has  extended 
into  the  pelvis,  or  when,  after  excision,  a  weak,  flail-hke  limb  results 
or  osteo-myelitis  supervenes.  It  is  also  needed  when  after  excision 
sinuses  persist  and  lead  down  into  the  acetabular  cavity,  from  which 
there  is  a  plentiful  secretion  of  pus,  and  over  the  entrance  to  which 
the  upper  end  of  the  femur  is  drawn,  thereby  obstructing  the  escape 
of  the  discharge,  and  rendering  dressing  both  difficult  and  painful. 
The  operation  often  gives  most  excellent  results,  the  patient's  con- 
dition rapidly  improving.  Removal  by  the  anterior  racquet  method 
is  perhaps  the  most  convenient,  in  that  the  division  and  ligature  of 
the  vessels  can  sometimes  be  accomplished  through  a  separate 
incision,  or  at  any  rate  at  a  spot  where  drainage  is  most  complete, 
and  infection  least  likely  to  occur.  Happily,  amputation  for  hip 
disease,  and  even  the  posterior  type  of  excision,  are  at  the  present 
time  extremely  rare  operations. 

Disease   of   the   Sacro-iliac   Joint. 

Tuberculous  disease  of  this  joint  is  most  commonly  met  with  in 
adults,  but  rarely  in  children.  It  may  commence  in  the  synovial 
membrane,  but  is  frequently  the  result  of  mischief  starting  in  the 
pelvic  bones,  especially  the  ihum.  The  Pathological  Anatomy  calls 
for  no  description,  inasmuch  as  it  follows  the  ordinary  course  of 
tuberculous  disease. 

The  Clinical  Signs  consist  of  pain  and  a  sense  of  weakness  in  the 
lower  part  of  the  back,  increased  by  standing,  walking,  or  any  move- 
ment—such as  coughing,  sneezing,  and  the  like — which  calls  the  fiat 
abdominal  muscles  into  sudden  action  and  drags  on  the  ilium.  It  is 
of  a  very  unpleasant  character,  a  sensation  as  if  the  pelviswere 
coming  to  pieces  being  experienced  by  the  unfortunate  individual. 
Owing  to  the  fact  that  the  lumbo-sacral  cord  passes  in  front  of  the 
articulation,  pain  is  often  referred  to  the  gluteal  region  or  down  the 
leg  Movements  of  the  limb  cause  pain  if  the  pelvis  is  not  supported, 
but  can  be  freely  performed  if  the  pelvis  is  steadied.  Compression 
together  of  the  innominate  bones,  or  their  forcible  separation,  is  the 
means  of  demonstrating  most  effectually  the  existence  and  situation 
of  the  pain.  The  patient  is  unable  to  stand  or  to  put  any  weight  on 
the  affected  limb,  and  hence  Hmps  during  walking,  allowing  his  body 
to  lean  forwards,  and  making  use  of  a  stick.  There  is  apparent 
lengthening  on  the  affected  side,  but  on  measurement  from  the 
anterior  superior  spine  to  the  internal  malleolus  the  leg  is  found  to 
be  of  the  same  length  as  its  fellow.  This  appearance  is  due  to  the 
fact  that  the  whole  innominate  bone  is  tilted  downwards  arid  for- 
wards, so  that  the  anterior  superior  spine  is  at  a  lower  level  and  more 


678  A   MANUAL  OF  SURGERY 

prominent  than  that  on  the  opposite  side.  The  region  of  the  syn- 
chondrosis is  often  swollen,  puffy,  and  tender;  whilst  after  a  time  ab- 
scesses form,  which  may  either  point  immediately  over  the  articula- 
tion, or  burrow  upwards  into  the  lumbar  region,  or  forwards  into 
the  iliac  fossa,  or  downwards  into  the  pelvis,  opening  perhaps  in 
the  ischio-rectal  fossa.  The  last  is  a  most  serious  comphcation, 
since  it  is  almost  certain  to  introduce  a  pyogenic  element. 

The  Diagnosis  needs  to  be  made  from  sciatica,  hip  disease,  spinal 
disease,  and  some  other  sources  of  pelvic  pain.  Sciatica  is  known 
by  the  character  of  the  pain,  which  shoots  down  the  back  of  the 
thigh  in  the  course  of  the  great  sciatic  nerve,  which  may  be  dis- 
tinctly tender  on  pressure.  There  is  no  apparent  elongation  of  the 
limb,  and  compression  together  of  the  pelvic  crests  is  painless.  From 
affections  of  the  hip-joint,  sacro-iliac  disease  is  recognised  by  the  fact 
that,  if  the  pelvis  is  supported,  the  thigh  may  be  moved  in  all  direc- 
tions without  great  discomfort;  whilst  compression  of  the  pelvis  in 
hip  disease  causes  no  pain.  Moreover,  in  the  advanced  stages  of 
hip  disease  there  is  apparent  or  real  shortening  and  deformity,  con- 
ditions never  noticed  in  the  sacro-iliac  affection.  From  spinal  dis- 
ease, the  diagnosis  should  not  be  difficult  if  a  careful  examination  of 
the  spine  and  pelvis  is  made.  When  pain  is  the  most  marked  symp- 
tom, the  surgeon  must  exclude  other  possible  sources — e.g.,  rectal  or 
uterine  carcinoma;  it  is  a  useful  rule  to  remember  that  in  all  such 
cases  a  rectal  or  vaginal  examination  should  be  made.  It  is  quite 
possible  in  certain  cases  of  sacro-iliac  disease  to  detect  a  fulness 
on  the  anterior  wall  of  the  synchondrosis. 

The  Prognosis  of  sacro-iliac  disease  is  not  necessarily  unfavour- 
able if  asepsis  is  maintained;  the  admission  of  pyogenic  bacteria 
constitutes  the  main  danger.  In  young  women  it  may  lead  to  sub- 
sequent deformity  of  the  pelvis  and  trouble  in  parturition. 

Treatment  in  the  early  stages  consists  in  absolute  rest  in  bed,  with 
the  application  of  a  pelvic  support,  and  attention  to  the  general 
health.  Abscesses  may  sometimes  be  dealt  with  in  the  usual  con- 
servative fashion- — viz.,  by  tapping  and  injection^ — but  not  infre- 
quently it  is  necessary  to  lay  them  freely  open,  and  deal  with  the 
diseased  bone  by  scraping  or  gouging  it  away,  allowing  the  wound 
to  heal  by  granulation.  Occasionally  it  is  necessary  to  remove  the 
posterior  part  of  the  iliac  crest  in  the  neighbourhood  of  the  posterior 
superior  spine  in  order  to  gain  access  to  the  diseased  area;  this  may 
be  accomplished  by  the  chisel  or  trephine  through  a  vertical  incision, 
and  excellent  results  often  follow  this  proceeding. 

Excision  of  Joints. 

Excision  of  joints  is  an  operation  which  is  at  the  present  time  but 
little  seen,  except  at  examinations  as  a  test  of  operative  capacity; 
it  has  been  rendered  unnecessary  in  many  cases  owing  to  improved 
methods  of  treatment  of  injuries,  and  of  the  various  inflammatory 
affections  which  involve  joints.     The  conditions  which  necessitate 


DISEASES  OF  JOINTS  679 


to  cure  the  disease,  or  where  it  is  advisable  to  de^l  with  ^  ^^  tn 
earher  stages  in  order  to  shorten  its  course;  (5)  lor  ankylosis  01  cer 
UinToiiS  consecutive  to  arthritis,  especially  if  m  a  bad  position, 

^'^;^;SS?s^  W^S^eS?- vary  in  the  differei.  joi^. 

anSing  to^^^^^^^^^^^^^ 

good  position  IS  all  that  can  oe  expectcu,  ^.-^  rliQpa^pd  tissues 

students  to  special  works  on  Operative  Surgery  for  further  details. 

and  outwards  for   3  or  4  inches  .^l^^^g^Xld  than  to  pass  between  it  and 
(Fig    ^37,  D).     It  is  better  to  mcise  the  deltoid  ^^^^*^°  P^^f.^^^^  being  thus 
h?pec7oral!s  major,  the  '^ephaUc  vein  and  a  c         an  ^^^^^  ^^^ 

uninjured.     The  wound  is  thoroughly  oP^^f  J^P  ^y^^tTts  outer  border,  and 
the  bicipital  groove  looked  for:/^.|f^^^\°j;i%"^,^^e/o^^^^^  to  the  inner 

the  long  tendon  of  the  biceps,  if  ^^1?'?,^°  aS  Srcumfle^i  will  here  be 

side  by  a  blunt  hook.     A  twig  °f,  *\«^^^^f  "JJ^\'hoSughly  everted,  and  the 

divided,  and  need  a  ligature.   /Jf  ^"^^i^  °/^Jt  S  th^^^^^^  ^'^^  ^^^'^ 

tendon  of  the  subscapularis  ^nd  the  anterior  part^ot  tn        P  ^^^^^^^  ^^  ^^e 

it  is  incorporated,  freely  divided;  ^J^^.^^YSbSiosteally  a  proceeding  pre- 
muscle  to  the  bone  should  be  separated  ^^^p^^^^^^^^^^^^  The  arm 

senting  no  difficulty  where  i^fl^^^^fJ^^Xgide  of  the  table,  so  as  to  bring 
is  now  inverted  and  held  downwards  by  the  side  ottne  ^^^  ^^^^^ 

the  great  tuberosity  into  view ;  the  "^^^<;V^' .^^.^/^^^^Sg^^^^  opened.     The 

with  in  a  similar  way  and  the  ^PPfX^ewounTW  removed  by  the  saw. 
head  of  the  bone  is  then  Pr°t^;i^^f^^^°X  J^^^  the  substance  of  the 

It  will  often  suffice  to  apply  the  f  ^  °^^^^Xtf  of  the'whole  tuberosity  by  a 
tuberosity;  this  is  to  be  Preferred  to  "^^^^""^l^^J^^ Zmhvane  and  glenoid 
horizontal  incision  at  a  lower  level      ^he  syn^m'  advisable 

cavity  are  dealt  with  as  cn-cumstances  "^^J  J^f J^^^^J  f^ld  for  the  insertion 
to  make  a  counter-opening  through  ^^e  po^tenor  axma^y  ^^^^^^      j^ 

of  a  drainage-tube;   the  ^^^^^f^J.^n  to  put  a  good  pad  in  the  axilla   so 


68o 


A  MANUAL  OF  SURGERY 


to  the  bicipital  groove.  There  is  no  need  to  commence  passive  movements  before 
the  end  of  the  first  week.  Fibrous  union  usually  results,  and  the  movements  of 
the  shoulder  are  generally  very  good,  with  the  possible  exception  of  abduction. 
Excision  of  the  Elbow  may  be  required  for  simple  or  compound  fracture- 
dislocation,  or  for  subsequent  ankylosis,  especially  if  the  limb  is  in  a  bad 
position,  for  tuberculous  arthritis,  and  possibly  in  the  later  stages  of  acute 
arthritis.  The  best  plan  of  operating  is  as  follows:  A  single  longitudinal 
incision,  5  inches  in  length,  is  made  in  the  middle  line  of  the  posterior  aspect 
of  the  joint,  extending  for  equal  distances  above  and  below  the  tip  of  the  ole- 
cranon, and  a  little  to  the  inner  side.  The  limb  is  held  across  the  patient's 
body,  the  surgeon  standing  on  the  affected  side.  The  incision  extends  through 
the  substance  of  the  triceps  down  to  the  bone.  The  origin  of  the  flexor  carpi 
ulnaris  and  the  inner  half  of  the  triceps  tendon  are  detached,  and  the  hollow 
between  the  olecranon  and  the  internal  condyle  cleared,  the  knife  being  kept 
close  to  the  bone,  and  the  soft  partsjjeffectively  retracted.     By  this  means 


Fig.  337. — Incision  for  Excision  of  Shoulder. 

A,  Coracoid  process;  B,  tip  of  acromion;  C,  intermuscular  line  between  deltoid 
and  pectoralis  major;  D,  incision. 

the  ulnar  nerve  escapes  injury,  and,  indeed,  is  often  not  seen  at  all.  The 
internal  lateral  ligament  should  be  divided,  and  the  common  origin  of  the 
flexors  detached  from  the  front  of  the  inner  condyle.  The  outer  half  of  the 
joint  is  then  dealt  with  in  a  similar  way,  the  anconeus  being  divided  close  to 
its  insertion  to  the  ulna,  the  continuity  of  the  triceps  with  the  deep  fascia 
covering  it  being  also  maintained.  The  origin  of  the  extensor  muscles  is 
separated  from  the  back  of  the  outer  condyle,  and  the  external  lateral  liga- 
ment severed.  The  joint  can  now  be  freely  opened  by  dividing  any  of  the 
fibres  of  the  posterior  ligament  which  remain  intact,  and  the  denuded  ends 
of  the  bones  protruded  from  the  wound.  The  lower  end  of  the  humerus  is 
thoroughly  cleared,  and  the  articular  surface  removed,  the  section  passing 
through  the  centre  of  the  olecranon  fossa.  The  olecranon,  together  with 
the  upper  articular  surface  of  the  coronoid  process  and  the  head  of  the  radius, 
are  next  sawn  off.  care  being  taken  to  draw  aside  and  protect  the  soft  parts 
by   retractors,    especially   those    covering   the    ulnar    nerve.     The    synovial 


DISEASES  OF  JOINTS 


68 1 


membrane  can  be  dealt  with  as  may  be  necessary.  Even  if  the  head  of  the 
radius  is  free  from  disease,  nothing  is  gained  by  leaving  it  intact,  since  anky- 
losis is  very  likely  to  follow  unless  plenty  of  bone  is  removed.  As  a  general 
rule,  a  gap  of  2^  inches  should  intervene  between  the  divided  ends  of  the 
bones.  The  wound  is  carefully  sutured,  and  a  drainage-tube  inserted  for  a 
few  hours.  The  limb  is  kept  on  a  hinged  angular  splint  for  a  week,  by  which 
time  union  of  the  external  wound  should  be  complete,  but  the  position  is 
altered  each  day.  After  a  week,  the  splint  may  be  dispensed  with,  and  the 
limb  kept  at  rest  on  a  pillow,  free  passive  movement,  both  angular  and  rota- 
tory, being  daily  practised.  Considerable  attention  is  needed  in  order  to 
obtain  a  good  result,  but  in  a  successful  case  every  movement  of  the  joint  is 
perfectly  restored.  As  a  rule,  the  lower  end  of  the  humerus  develops  two 
lateral  bony  processes,  like  malleoli, 
within  the  grasp  of  which  the  upper 
rounded  ends  of  the  radius  and  ulna 
are  able  to  move. 

The  Wrist-joint  is  only  excised  for 
extensive  tuberculous  disease  when  ab- 
scesses and  sinuses  are  present.  Anky- 
losis of  the  articulation,  though  a 
troublesome  condition,  is  not  suffici- 
ently so  to  require  such  treatment.  The 
best  method  to  employ  is  that  known 
as  Lister's  operation,  a  somewhat  com- 
plicated proceeding,  but  which  in  suit- 
able cases  gives  excellent  results.  Prior 
to  operating  the  fingers  are  bent,  so  as 
to  break  down  any  adhesions  present. 
Two  incisions  are  made,  one  on  the  radial 
side  of  the  dorsum,  and  the  other  on 
the  inner  or  ulnar  aspect  of  the  wrist. 
The  dorsal  incision  is  angular  (Fig.  338, 
LL),  commencing  at  a  point  on  the 
back  of  the  radius  between  the  tendons 
of  the  extensor  secundi  internodii  pol- 
licis  (B)  and  the  extensor  communis 
digitorum  (D) ;  it  is  at  first  parallel  to 
the  former  tendon,  and  on  its  ulnar  side, 
till  it  reaches  the  base  of  the  second 
metacarpal  bone,  when  its  direction  is 
changed,  and  it  courses  downwards 
along  that  bone  for  an  inch  or  two.  It 
should  extend  to  the  bone,  and  in  doing 
so  the  tendons  of  the  extensor  carpi 
radialis  longior  and  bre\ior  (H  and  I)  are 
divided  as  close  to  their  attachments 
as  possible.  The  tendinous  structures 
are  then  stripped   oS  the  back   of   the 

dorsum  on  either  side  of  the  incision,  and  on  the  outer  side  a  pair  of  cutting- 
pliers  is  insinuated  so  as  to  detach  the  trapezium  from  the  rest  of  the  carpus. 
The  S3-no^^al  sheaths  of  these  tendons  should,  if  possible,  not  be  opened. 
The  hand  is  then  rolled  over,  and  the  ulnar  incision  made  on  the  inner  side 
of  the  limb,  extending  for  at  least  3  inches  between  the  extensor  and  flexor 
carpi  ulnaris  tendons.  The  separation  of  the  extensor  tendons  from  the  back 
of  the  carpus  is  now  completed,  and  the  attachment  of  the  exteasor  carpi 
ulnaris  (K)  divided.  The  tissues  on  the  palmar  aspect  of  the  joint  are 
detached,  the  pisiform  being  severed  from  the  rest  of  the  carpus,  and  where 
possible  left,  and  the  hook  of  the  unciform  clipped  off  with  cutting-pliers. 
The  carpus  is  now  free  front  and  back,  and  the  bones  are  either  removed  piece- 
meal or  taken  away  en  bloc  by  inserting  a  pair  of  cutting-pliers  above  and 
below,   and  di\'iding  their  upper  and  lower  connections;  more  usually  the 


Fig.  338.- 


-ExcisiON  OF  THE  Wrist 
(Lister.) 

A,  Radial  artery;  B,  extensor  se- 
cundi internodii  poUicis;  C,  ext. 
indicis;  D,  ext.  communis  digit- 
orum;   E,     ext.    minimi    digiti; 

F,  ext.  primi  internodii  pollicis; 

G,  ext.  ossis  metacarpi  pollicis; 
H,  ext.  carpi  radialis  longior; 
I,  ext.  carpi  radialis  brevior; 
K,  ext.  carpi  ulnaris;  LL,  line 
of  radial  incision. 


682  A   MANUAL  OF  SURGERY 

caxpal  bones  are  picked  out  in  fragments.  Attention  is  then  directed  to  the 
lower  ends  of  the  radius  and  ulna,  and  to  the  articular  ends  of  the  metacarpal 
bones,  all  the  cartilage  and  the  intervening  synovial  tissue  benig  cleared  away. 
Finally,  the  remaining  fragments  of  the  carpus  aie  dealt  with  as  the  case 
may  require.  The  radial  incision  may  often  be  entirely  closed,  whilst  a 
drainage-tube  is  inserted  through  the  ulnar  wound.  The  hand  is  placed  on 
a  special  splint,  with  a  thick  convex  cork  support  for  the  palm,  which  keeps 
the  wrist  slightly  extended,  and  with  a  short  lateral  projection  upon  which 
the  thumb  can  rest.  The  lingers  must  be  Hexed  and  extended  daily,  beginning 
on  the  seco.id  or  third  day,  but  the  wrist  should  be  kept  at  rest  until  it  is  quite 
firm.  There  is  a  much  greater  tendency  to  a  tiailTike  joint  than  to  undue 
fixity,  owing  to  the  amount  of  bone  removed,  and  the  necessary  division  of 
all  the  extensors  of  the  carpus;  if  such  occurs,  a  leather  support  must  be 
worn,  either  as  a  temporary  or  permanent  appliance. 

The  Hip-joint  is  rarely  excised  for  conditions  other  than  tuberculous 
disease,  and  even  for  this  it  is  but  seldom  required.  There  are  two  chief 
methods  of  operating,  the  anterior  and  the  posterior. 

1.  Excision  by  the  anterior  method  is  carried  out  as  follows:  The  incision 
(Fig.  io8,  D;  p.  336)  extends  from  immediately  below  the  anterior  superior 
spine  vertically  downwards  for  3  or  4  inches.  It  passes  between  the  tensor 
fasciae  femoris  and  sartorius  muscles  superficially,  and  between  the  glutei 
and  rectus  deeply,  a  small  arterial  twig  from  the  external  circumflex  being 
divided  at  this  stage.  The  neck  of  the  bone  and  capsule  of  the  joint  are 
exposed,  and  the  latter  is  freely  incised  along  its  attachment  to  the  anterior 
inter-trochanteric  line,  so  as  to  allow  of  the  admission  of  the  finger,  whereby 
the  joint  can  be  explored.  The  neck  of  the  bone  is  cut  through  hi  situ  by 
means  of  an  Adams  osteotomy  saw,  the  incision  through  the  bone  being 
placed  obliquely  downwards  and  inwards.  The  head  of  the  bone  is  now 
either  prised  out  of  the  acetabulum  by  an  elevator,  or  grasped  by  lion  forceps 
and  twisted  out,  a  matter  easily  accomplished  where  the  articular  structures 
are  diseased,  but  a  proceeding  of  some  difficulty  in  the  normal  joint  of  a 
cadaver.  As  much  of  the  infected  synovial  membrane  as  possible  is  clipped 
away  with  scissors,  and  the  acetabulum  scraped,  if  necessary.  The  external 
wound  is  either  closed,  with  the  exception  of  an  opening  for  a  drainage- 
tube,  or  packed  with  gauze  soaked  in  iodoform  emulsion.  The  limb  is  put 
up  in  a  position  of  abduction  so  as  to  keep  the  neck  of  the  bone  in  the 
acetabulum. 

2.  Excision  by  the  posterior  method  is  at  the  present  day  so  seldom  required 
that  it  seems  unnecessary  to  describe  it  here  (p.  676). 

The  Knee-joint  is  excised  for  tuberculous  disease,  osteo-arthritis,  or  de- 
formity due  to  osseous  or  fibrous  ankylosis  in  a  bad  position.  A  horse-shoe- 
shaped  incision  is  made,  extending  from  the  back  of  one  condyle  to  the  other, 
reaching  downwards  nearly  as  far  as  the  tubercle  of  the  tibia.  The  limb  is 
flexed,  the  ligamentum  patelte  divided,  and  the  joint  opened.  The  skin  and 
subcutaneous  tissues  are  then  separated  from  the  anterior  surface  of  the  patella, 
which  may  be  at  once  removed  by  a  curved  incision  above  it,  communicating 
on  either  side  with  that  already  made  below,  the  subcrureal  pouch  of  synovial 
membrane  being  also  removed  during  this  dissection.  The  flexion  is  now  in- 
creased, and  the  lateral  ligaments  divided;  by  this  means  the  interior  of  the 
joint  is  exposed,  so  that  the  attachments  of  the  crucial  ligaments  to  the  tibia  can 
also  be  severed.  The  lower  end  of  the  femur  is  then  cleared  of  diseased  synovial 
membrane,  so  as  to  allow  of  the  application  of  a  broad  excision  saw.  The 
usual  rule  given  as  to  the  direction  of  the  saw-cut  in  the  bone  is  that 
the  exposed  bony  surface  left  after  removing  its  articular  end  should  be 
absolutely  horizontal,  supposing  the  patient  to  be  standing  upright;  some 
surgeons  prefer  to  make  the  sections  so  that  the  limb  shall  be  left  very  slightly 
flexed  and  in-kneed,  a  position  which  greatly  adds  to  the  subsequent  comfort 
of  the  patient.  To  accomplish  this  the  saw  must  be  applied  parallel  to  the 
articular  surface — i.e.,  at  right  angles  to  the  axis  of  the  body,  not  of  the  femur, 
and  with  a  slight  upward  slant  from  before  backwards.  The  bone  should  be 
partially  sawn  through  by  a  side-to-side  movement,  but  the  posterior  surface 


DISEASES  OF  JOINTS  683 

of  the  condyles  should  be  divided  by  raising  or  depressing  the  handle  of  the 

instrument,  so  that  the  structures  lying  behind  in  the  intercondyloid  notch 
are  not  encroached  upon.  Sufficient  bone  should  be  sawn  otf  in  the  adult  to 
include  the  greater  part  of  the  articular  cartilage,  but  as  little  as  possible 
consistent  with  removing  all  the  disease,  otherwise  the  limb  is  shortened  to 
such  an  extent  as  to  interfere  with  its  subsequent  usefulness.  The  head  of 
the  tibia  is  then  protruded,  and  cleared  from  the  neighbouring  soft  parts;  it 
is  held  absolutely  vertical,  and  a  saw  applied  in  a  horizontal  position,  the 
bone  being  divided  from  before  backwards.  All  diseased  synovial  membrane 
is  dissected  away,  special  attention  being  directed  to  the  posterior  aspect  of 
the  joint.  Haemostasis  having  been  effected,  the  bones  are  fitted  together, 
and,  if  considered  advisable,  secured  in  position  by  thick  silver  wire,  nails, 
or  screws;  if  wire  is  employed,  it  should  be  introduced  horizontally  through 
the  bones  from  side  to  side  rather  than  antero-posteriorly.  A  Gooch's  splint 
is  applied  to  the  limb,  and  in  this  it  remains  until  sound  healing  has  occurred, 
after  which  an  immovable  case  either  of  plaster  of  Peiris  or  water-glass  is  kept 
on  for  eight  or  ten  weeks. 

The  Ankle-joint  is  excised  for  tuberculous  disease.  .  Two  incisions  are  made, 
an  inner  and  an  outer.  The  outer  incision  runs  along  the  anterior  border  of 
the  fibula  and  curves  round  the  outer  malleolus,  being  about  3  inches  in  length. 
The  lower  end  of  the  fibula  is  exposed,  and  by  preference  subperiosteally- 
The  external  lateral  ligament  is  split  vertically,  and  separated  from  its  attach, 
ments  to  the  fibula,  its  continuity  with  the  periosteum  being,  however,  main- 
tained .  The  fibula  is  then  divided  about  i  inch  above  the  tip  of  the  malleolus, 
and  the  latter  process  of  bone  removed.  The  periosteum  and  ligaments  are 
separated  as  far  as  possible  from  the  front  and  back  of  the  bones.  The  inner 
incision  is  T-shaped,  and  is  made  along  the  inner  surface  of  the  tibia,  with  a 
short  transverse  cut  at  its  lower  end,  which  reaches  just  below  the  inner 
malleolus.  The  periosteum  and  internal  lateral  ligament  are  dealt  with  as  on 
the  outer  side,  and  the  front  and  back  of  the  tibia  are  easily  denuded.  The 
inner  malleolus  is  projected  from  the  wound,  and  the  lower  end  of  the  tibia 
removed  by  a  keyhole  saw,  the  dorsal  structures  being  held  aside  by  a  re- 
tractor. The  articular  surface  of  the  astragalus  is  sawn  off  from  the  outer 
wound,  or,  if  advisable,  the  whole  of  the  bone  may  be  removed. 

The  above  subperiosteal  method  of  excision  is  probably  the  best  that  has 
been  suggested.  The  greatest  care  should  be  taken  not  to  open  the  sheaths 
of  the  tendons,  and  in  dressing  the  wound  the  foot  must  be  kept  at  right  angles 
to  the  leg,  and  no  lateral  deviation  permitted.  As  soon  as  possible  it  is  en- 
cased in  plaster  of  Paris,  windows  being  left  for  dressing  the  wounds,  if  necessary. 

In  non-tuberculous  cases  a  transverse  incision  extending  from  one  malleolus 
to  the  other  may  be  employed.  Sutures  are  placed  through  the  tendons 
above  and  below,  and  they  are  then  divided ;  the  anterior  tibial  nerve  is  simi- 
larly secured  above  and  below  before  division,  and  the  vessels  are  divided 
between  ligatures.  By  opening  the  capsule  a  very  free  exposure  of  the  joint 
surfaces  is  provided,  permitting  a  very  thorough  excision.  The  di\'ided 
tendons  and  nerve  are  carefully  sutured  together  before  closing  the  wound. 

Excision  of  the  Astragalus  is  sometimes  required  m  the  treatment  of  tuber- 
culous disease  of  contiguous  joints,  as  also  in  some  cases  of  talipes  and  of 
fractures  or  dislocations  of  the  bone.  Many  methods  of  operating  have  been 
described,  but  it  may  be  accomplished  through  a  single  vertical  incision  over 
the  front  of  the  ankle,  running  parallel  to  the  vessels  and  tendons,  which  are 
carefully  avoided  and  stripped  back  from  the  dorsum  by  means  of  periosteal 
detachers,  so  that  the  upper  surface  of  the  astragalus  can  readily  be  reached. 
The  astragalo-scaphoid  joint  and  ankle  are  then  freely  opened,  and  the  liga- 
mentous and  fascial  connections  on  either  side  severed.  The  neck  of  the 
bone  may  with  advantage  be  divided  at  this  stage,  and  its  head  removed, 
so  as  to  give  access  to  the  under  surface  and  allow  of  the  division  of  the  strong 
interosseous  ligament  extending  between  the  adjacent  surfaces  of  the 
astragalus  and  os  calcis.  It  may  be  possible  to  remove  the  rest  of  the  bone 
in  one  fragment,  but  it  is  sometimes  wiser  to  break  it  up  with  chisel  or  gouge, 
and  take  it  away  piecemeal. 


CHAPTER  XXIV. 

INJURIES  OF  THE  SPINE. 

The  spinal  cord  is  protected  from  injury  in  a  most  complete  and  efficacious 
manner,  {a)  Its  position  between  the  bodies  and  the  laminae  with  the  spinous 
processes  arising  therefrom  is  itself  mechanically  advantageous,  since,  whether 
the  spine  is  forcibly  flexed  or  extended,  the  cord  remains  midway  between 
the  points  of  chief  compression  or  extension,  and  hence  in  a  position  of  rest. 
(6)  The  buffer-like  action  of  the  intervertebral  discs,  and  the  varying  curves 
of  the  column,  serve  to  distribute  some  part  of  any  force  that  reaches  it. 
(c)  There  is  ample  space  in  the  medullary  canal,  in  which  the  cord  with  its 
membranes  is  slung  by  prolongations  of  dura  mater  around  the  issuing 
nerves,  whilst  the  cord  itself  hangs  loosely  within  the  dura  mater,  suspended 
by  the  ligamenta  denticulata,  and  surrounded  by  cerebro-spinal  fluid,  (d)  The 
cord  terminates,  in  an  adult,  at  the  lower  border  of  the  first  lumbar  vertebra, 
a  spot  well  above  the  junction  of  the  fixed  base  and  the  moveable  upper  part, 
a  point  where  the  effect  of  jars  and  wrenches  is  mainly  felt,  (e)  Nature  has, 
moreover,  introduced  a  whole  series  of  buffers  and  other  means  of  preventing 
shock  to  the  spine  when  a  person  falls  on  his  feet — e.g.,  the  arches  and  elas- 
ticity of  the  foot,  the  changes  in  direction  of  the  bones  at  each  joint,  the  inter- 
articular  cartilages  of  the  knee,  etc. 

The  parts  of  the  spine  most  exposed  to  injury  are  those  where  a  fixed  and 
moveable  portion  meet — e.g.,  the  dorsi-lumbar  and  the  cervico-dorsal  regions. 
Moreover,  the  upper  part  of  the  dorsal  curve,  which  projects  backwards,  is 
relatively  a  weak  spot,  and  fractures  are  not  at  all  uncommon  about  the 
fourth  dorsal  vertebra.  The  close  proximity  of  the  head  explains  the  fre- 
quency of  lesions  about  the  upper  cervical  region. 

Sprains  of  the  spine  are  very  common  accidents,  a  fact  not  to  be 
wondered  at,  when  its  comphcated  muscular  and  Hgamentous  ar- 
rangements are  considered.  They  are  produced  by  any  sudden  or 
unexpected  movements,  such  as  falls,  especially  from  horseback, 
railway  accidents,  and  the  like.  The  injury  affects  most  frequently 
mobile  parts  of  the  spine — e.g.,  the  cervical  and  lumbar  regions,  and 
may  be  limited  to  either  ligamentous  or  muscular  structures,  or  may 
involve  both.  The  resulting  Signs  are  simply  those  of  a  severe  but 
localized  trauma — viz.,  pain,  tenderness,  and  perhaps  a  little  swell- 
ing or  bruising;  the  subjective  phenomena  are  much  increased  by 
movement,  so  that  the  spine  is  kept  rigidly  quiet.  If  only  the 
muscles  or  interspinous  ligaments  are  involved,  no  further  conse- 
quences are  likely  to  arise;  but  when  the  ligamenta  subflava  are 
lacerated  and  the  spinal  canal  is  thus  opened,  pressure  symptoms 


.     INJURIES  OF  THE  SPINE  685 

may  arise  from  blood  finding  its  way  into  the  canal  outside  the  dura 
mater,  leading  possibly  to  a  temporary  or  permanent  paraplegia. 
Inflammation  of  the  damaged  fibrous  tissues  may  extend  to  the 
meninges  and  cord,  and  cause  organic  disease.  Moreover,  in  patients 
of  a  tuberculous  temperament  spinal  caries  may  follow  such  injuries; 
syphilitic  or  malignant  disease  has  also  been  known  to  ensue. 

In  the  cervical  region,  sprains  may  occur  as  a  result  of  severe  blows 
on  the  head,  causing  rupture  of  the  inter-transverse  ligaments,  and 
the  displacement  may  be  so  great  as  to  simulate  dislocation.  The 
head  and  neck  are  held  immoveable  and  rigid,  and  there  is  often  con- 
siderable loss  of  power,  the  patient  being  sometimes  unable  to  lift 
the  head  spontaneously  from  the  pillow.  Sprains  in  the  lumbar 
region  are  very  common,  both  as  a  consequence  of  overlifting,  when 
the  quadratus  lumborum  is  most  likely  to  be  affected,  and  as  a  result 
of  railway  injuries,  when  they  are  often  associated  with  nervous 
symptoms  (p.  695).  The  back  is  kept  fixed  and  rigid,  the  patient 
being  unable  to  turn  or  stoop  without  pain.  Sometimes  hsematuria 
results  from  injuries  in  the  lumbar  region,  arising  from  an  associated 
contusion  of  the  kidneys. 

Treatment. — The  patient  should  be  kept  at  rest,  and  fomentations 
applied  to  the  injured  part.  When  the  painful  or  inflammatory 
symptoms  have  disappeared,  massage  with  stimulating  liniments  is 
needed.  In  the  severer  cases  the  individual  should  be  kept  in  bed 
for  six  or  eight  weeks,  and  in  the  cervical  region  some  form  of 
mechanical  support  may  be  subsequently  necessary.  The  appear- 
ance of  inflammatory  symptoms  involving  the  meninges  calls  for 
even  greater  care;  the  patient  should  then  be  kept  as  much  as 
possible  in  the  prone  position,  and  a  spinal  icebag  applied.  The 
onset  of  paraplegia,  due  either  to  haemorrhage  or  inflammatory 
exudation,  would  raise  the  question  of  laminectomy  (p.  698). 

Penetrating  Wounds  of  the  Spine  are,  fortunately,  uncommon  in 
civil  practice,  being  generally  due  to  stabs  with  pointed  instruments, 
such  as  bayonets,  or  to  gunshot  wounds.  They  occasionally  result 
from  falls,  the  unfortunate  individual  becoming  impaled  on  area 
railings,  branches  of  trees,  etc.  The  Symptoms  produced  are: 
{a)  those  due  to  the  wound  in  the  soft  parts,  which  may  also  in- 
volve the  peritoneal  and  pleural  cavities,  or  damage  to  some  of  the 
viscera;  in  the  neck,  the  vertebral  artery  is  exposed  to  injury  from 
this  type  of  accident,  leading  to  serious  haemorrhage;  (&)  various 
forms  of  fracture,  the  cord  being  compressed  by  fragments  of  bone 
which  have  been  driven  inwards,  or  by  extravasated  blood;  (c)  those 
due  to  laying  op'en  the  spinal  membranes — e.g.,  loss  of  cerebro-spinal 
fluid,  which  in  itself  might  prove  fatal  by  draining  the  cerebral 
cavity,  and  so  causing  pressure  on  the  base  of  the  brain,  or  at  a 
later  date  may  determine  the  patient's  death  by  setting  up  diffuse 
septic  meningitis  (p.  694) ;  and  {d)  those  due  to  wounds  of  the  spinal 
cord.  The  effects  of  a  total  transverse  lesion  at  different  levels  of 
the  spine  are  given  at  p.  696.     Of  course,  the  division  of  the  cord 


686  A   MANUAL  OF  SURGERY 

may  be  only  partial,  or  it  may  escape  entirely,  whilst  nerve  roots  or 
trunks  may  be  involved,  and  in  the  lumbar  or  sacral  regions  the 
Cauda  equina  may  be  divided. 

Treatment  consists  in  exploring  thoroughly  the  wound  under  an 
anaesthetic,  removing  foreign  bodies  or  displaced  fragments  of  bone, 
and  attempting  to  rendei  it  aseptic.  Wounds  of  the  vertebral  artery 
or  other  structures  are  dealt  with  secundum  artem,  and  special  atten- 
tion is  naturally  given  to  the  cord  and  its  membranes.  Should  the 
dura  mater  have  been  opened,  and  the  cord  have  escaped  injury,  an 
attempt  may  be  made  to  close  the  wound  in  the  meninges,  and  the 
patient  should  subsequently  be  kept  in  the  prone  position  and  with 
the  head  low,  so  as  to  prevent,  as  far  as  possible,  the  escape  of 
cerebro-spinal  fluid.  If  the  cord  itself  is  divided  or  lacerated,  it  is 
useless  trying  to  unite  it,  since  its  function  in  conducting  impulses 
from  the  brain  downwards  is  inevitably  destroyed.  Where,  how- 
ever, the  Cauda  equina  has  been  injured,  it  is  perfectly  justifiable  to 
lay  open  the  spinal  canal  to  a  sufficient  extent  to  expose  the  divided 
nerve  trunks,  and  then  to  suture  them. 

Fractures  o£  the  Spine. — The  spine  may  be  broken  as  the  result  of 
[a]  direct  violence — e.g.,  a  fall  on  the  back  over  some  projecting  body, 
such  as  a  carpenter's  bench  or  a  raihng,  or  a  blow  on  the  back  with  a 
heavy  stone  or  with  a  swinging  baulk  of  wood,  or  a  gunshot  wound. 
This  type  of  accident  may  involve  any  part  of  the  spine,  and, 
excluding  those  arising  from  gunshot,  is  less  frequent  than  the  class 
next  to  be  described.  Of  necessity,  the  spine  breaks  at  the  point 
struck;  the  posterior  parts  of  the  vertebree  are  most  likely  to  be 
damaged  in  this  form  of  injury,  {b)  Fractures  are  also  due  to 
indirect  violence,  then  usually  occurring  in  the  lower  cervical  or 
upper  dorsal  regions.  They  are  caused  by  forcible  flexion  of  the 
spine,  as  by  a  fall  downwards  with  the  head  doubled  up,  or  by 
taking  a  '  header  '  in  shallow  water,  or  when  a  man,  being  driven 
under  a  bridge,  omits  to  stoop,  and  so  is  caught  between  the  arch 
and  the  cart,  or  sometimes  by  the  fall  of  a  heavy  weight  on  the 
back  of  the  neck.  The  spine  may  break  across  more  or  less  cleanly 
at  its  weakest  point,  or  the  lesion  may  be  limited  to  one  or  two 
bodies,  which  are  crushed  and  broken.  The  latter  type  (compres- 
sion fracture)  is  often  limited  to  the  bodies;  the  former  usually 
involves  injury  to  the  cord. 

Fractures  of  the  spine  may  be  divided  into  two  main  classes, 
according  to  whether  or  not  they  are  complete — that  is,  according 
to  whether  the  continuity  of  the  column  is  destroyed  or  not. 

(A)  Incomplete  Fractures  may  be  met  with  in  various  forms,  and 
are  most  frequently  due  to  direct  violence. 

(i.)  Fractures  of  the  Spinous  Processes  rarely  occur  except  in  the 
lower  cervical  or  dorsal  regions.  In  the  upper  cervical  region  the 
spines  are  short  and  retracted  to  allow  of  extension  of  the  head, 
whilst  in  the  lumbar  they  are  also  short,  but  very  strong.  The 
fracture  is  almost  always  due  to  direct  violence,  and  is  characterized 


INJURIES  OF  THE  SPINE 


687 


bv  the  signs  of  a  local  trauma,  together  with  great  mobility,  perhaps 
crepitus  and  irregularity  in  the  line  of  the  spines.  The  broken 
fragment  is  occasionally  much  depressed,  and  may  even  cause 
paraplegia  by  being  driven  into  the  spinal  canal. 

(ii.)  Fracture  of  the  Larnince  is  not  an  uncommon  accident,  always 
resulting  from  direct  violence.  Tf  only  one  lamina  is  broken,  the 
signs  are  not  very  distinct,  and  cord  svmptoms  are  rare.  When 
both  lamina  yield,  the  posterior  part  of  the  neural  arch,  carrying 
with  it  the  spinous  process,  is  very  likely  to  be  depressed  to  a 


Fig    q^q Radiogram  of  Fracture  of  Fifth  Cervical  Vertebra. 

■  (A.  D.  Reid.) 

The  patient  whilst  walking  in  the  street  was  struck  to  the  ground  by  the  fall 
of  an  outside  shop-blind ;  the  scalp  was  badly  cut,  and  complete  para- 
plet^ia  from  the  sixth  cervical  nerve  downwards  was  immediately  e\adent. 
He^lived  for  about  thiitv-six  hours,  and  died  in  a  condition  of  hx-per- 
p^T-exia.  In  the  radiogram  the  angle  of  the  lower  jaw  and  the  hyoid  bone 
are  also  visible. 

sufficient  extent  to  compress  the  cord  and  give  rise  to  paraplegia. 
Crepitus  is  often  obtainable,  and  a  gap  in  the  line  of  the  spinous 
processes  can  usually  be  felt. 

(iii.)  Fracture  of  the  Transverse  Processes  is  but  rarely  met  ^^^th 
apart  from  other  lesions  of  the  spine. 

(iv.)  Partial  Fracture  through  the  bodies  may  occur  m  the  form 
of  fissures,  which  produce  but  little  effect,  except  pain  and  rigidity, 
and  cannot  be  diagnosed  with  certainty. 


688 


A   MANUAL  OF  SURGERY 


Even  in  fractures  where  displacement  is  not  present,  paraplegic 
symptoms  may  arise,  either  immediately  from  concussion  of  the 
spinal  cord,  or  later  on  from  the  pressure  of  haemorrhage  or  inflam- 
matory effusions. 

The  Treatment  merely  consists  in  keeping  the  patient  at  rest  for 
a  time.  The  question  of  laminectomy  for  paraplegia,  due  either  to 
displacement  of  the  lamina;  or  to  haemorrhage,  will  be  discussed 
later  (p.  698). 

(R)  Complete  Fractures  are  usually  associated  with  displacement, 
and  loss  of  continuity  of  the  spinal  column,  and  hence  are  often 
termed  Fracture-Dislocations.     They  result  either  from  direct  or 

indirect  violence,  and 
are  most  common  in  the 
lower  cervical  or  upper 
dorsal  region.  Ihere  is 
always  a  tolerably  ex- 
tensive lesion  (Fig.  340) ; 
thus,  the  spinous  pro- 
cesses and  laminae  may 
or  may  not  be  fractured, 
the  ligamenta  inter- 
spinosa,  supraspinosa, 
and  subflava  torn,  the 
articular  processes  frac- 
tured in  the  lumbar  and 
dorsal  regions,  or  dis- 
placed without  fracture 
in  the  cervical,  and  either 
the  intervertebral  sub- 
stance torn  across,  or 
the  bodies  of  one  or 
two  adjacent  vertebrae 
broken,  thus  severing 
the  spine  into  two  halves. 
The  upper  or  moveable 
portion  is  usually  driven  forwards  over  the  lo\\er  or  more  fixed 
fragment,  and  impaction  or  comminution  is  often  present.  The 
spinal  cord  is  compressed  between  the  upper  end  of  the  lower 
fragm.ent  and  the  laminae  of  the  upper  fragment,  and  although 
the  displacement  may  he  naturally  remedied  by  the  falling  back 
of  the  bones  into  position  ('  recoil  '),  yet  the  effects  of  the  crush 
on  the  cord  are  usually  irremediable.  In  slighter  cases  the  spinal 
membranes  may  be  merely  punctured  by  a  splinter  of  bone,  or 
haemorrhage  may  occur  either  within  the  membranes,  or  outside 
them  in  the  fatty  theca  vertebralis.  Excessive  indirect  violence 
may  lead  to  an  associated  fracture  of  the  sternum. 

The  Signs  of  a  complete  fracture  are  usually  very  evident,  con- 
sisting of  local  pain,  swelling,  and  bruising,  and  a  certain  amount  of 
angular  deformity,  more  or  less  according  to  circumstances.    It  may 


Fig.  340. — Complete  Fracture-Dislocation 
".     OF  theSpine  in  the  Lower  Dorsal  Region, 
WITH  Displacement  and  Compression  of 
the  Cord.     (After  Keen  and  White.) 


INJURIES  OF  THE  SPINE  689 

be  possible  to  elicit  crepitus,  if  the  parts  are  not  impacted,  but  all 
unnecessary  movement  should  be  avoided  for  fear  of  adding  to  the 
injury  of  the  cord.  Paraplegia  below  the  part  injured  is  present  in 
most  cases,  and  with  it  some  amount  of  general  shock.  When  the 
cord  is  disintegreited  or  divided,  symptoms  of  spinal  myelitis  rapidly 
follow,  and  a  fatal  issue  often  occurs  at  an  early  date  from  toxcernia 
following  septic  cystitis  or  sloughing  of  the  nates.  The  special 
phenomena  of  paraplegia  are  dealt  with  at  p.  696.  It  may  be  stated 
here  that  lesions  of  the  cervico-dorsal  region  in  which  the  cord 
is  extensively  damaged  are  dangerous  to  life  in  that  they  cause 
paralysis  of  the  muscles  of  respiration,  with  the  exception  of  the 
diaphragm,  and  hence  predispose  to  static  pneumonia.  Complete 
lesions  at  or  above  the  level  of  the  fourth  cervical  segment  are 
usually  fatal  at  once  from  paralysis  of  the  phrenic  nerve.  The 
general  mortality  of  fracture-dislocations  of  the  spine  is  about 
70  per  cent. 

The  Prognosis  of  these  cases  turns  largely  on  the  situation  of  the 
injury  and  the  amount  of  mischief  sustained  by  the  cord.  The 
higher  the  lesion,  the  greater  the  danger,  although  patients  with 
paraplegia  from  cervical  fracture  may  live  for  years,  and  even 
partially  recover,  if  the  cord  has  not  been  totally  disintegrated. 

The  Treatment  naturally  varies  with  the  character  of  the  case. 
The  patient  is  carefully  placed  on  a  prepared  bed,  the  greatest 
gentleness  being  used  in  handhng  and  hfting  him,  for  fear  of  in- 
creasing the  damage  to  the  cord.  The  bed  must  be  firm,  though 
not  hard ;  perhaps  the  best  type  to  employ  is  a  horsehair  mattress 
placed  over  fracture-boards  f  nothing  more  soft  or  yielding  is  per- 
missible. Spring  beds  and  wire-wove  mattresses  are  most  undesir- 
able. A  water-bed  is  required  in  the  later  stages,  but  should  not  be 
used  at  first,  as  it  is  scarcely  firm  enough.  The  shock  resulting  from 
the  accident  is  treated  in  the  usual  way  by  warmth  and,  if  need  be, 
by  stimulants;  but  it  must  be  remembered  that  anaesthetic  regions 
of  the  body  can  be  easily  blistered  or  burnt  by  hot-water  bottles, 
unless  carefully  guarded  by  flannels.  When  reaction  has  occurred, 
a  more  thorough  examination  of  the  patient  can  be  made,  and  the 
subsequent  course  of  action  decided  on. 

(a)  In  a  small  minority  of  the  cases  operative  treatment  is  justi- 
fiable. The  indications  for  laminectomy  will  be  discussed  subse- 
quently (p.  698). 

{b)  When  the  displacement  persists  owing  to  impaction  of  the 
fragments,  reduction  under  an  anaesthetic  may  possibly  be  under- 
taken, provided  that  the  lesion  is  not  in  the  cervical  region,  and 
the  paraplegia  not  complete.  Of  course,  if  other  internal  injuries 
are  present  which  render  the  case  hopeless,  nothing  should  be  done. 
Great  care  must  be  used  in  attempting  reduction,  since  any  undue 
violence  may  readily  increase  the  mischief;  in  the  lumbar  region, 
however,  considerable  force  mav  be  employed  without  much  danger. 
Whether  reduction  is  accomplished  or  not,  the  further  treatment 
must  be  directed  in  accordance  with  the  indications  given  in  the 

44 


690  A   MANUAL  OF  SURGERY 

next  paragraph.  Where  the  surgeon  fails  to  reduce  the  deformity, 
it  may  sometimes  be  advisable  to  make  gradual  weight  extension 
from  the  feet  or  neck. 

(c)  In  many  cases,  as  soon  as  the  patient  is  laid  flat  on  a  bed,  the 
displacement  remedies  itself,  especially  if  the  spine  has  been  com- 
minuted, and  then  the  treatment  must  be  symptomatic,  as  also  after 
reduction  or  operation,  where  the  paraplegia  persists  or  is  only 
slowly  recovered  from.  He  is  kept  in  bed,  absolutely  flat,  and  with 
the  head  low;  perhaps  some  form  of  mechanical  support^ — e.g.,  a 
plaster  of  Paris  or  leather  jacket — may  be  considered  advisable; 
but  its  application  is  always  a  matter  of  difficulty,  and  in  the  early 
stages  it  does  but  little  good.  Food  is  regularly  administered,  and 
at  first  must  be  light  and  readily  assimilable. 

The  chief  care  of  the  attendants  must  be  directed  to  the  skin, 
bladder,  and  bowels.  Bedsores  are  extremely  liable  to  form  on  all 
points  of  pressure,  and  hence  the  nates  and  heels  must  be  carefully 
guarded  (p.  120).  In  turning  the  patient  to  attend  to  the  nates,  the 
body  must  be  rolled  over  as  a  whole,  and  not  merely  the  pelvis 
twisted.  It  will  often  be  found  advisable  to  have  a  divided  mattress 
placed  beneath  the  pelvis,  so  that  one  lateral  segment  may  be  re- 
moved at  a  time,  and  thus  rotation  of  the  body  will  not  be  needed. 
A  bedpan  can  also  be  used  in  this  way  without  disturl)ing  the  spine. 
When  the  bladder  is  paralyzed,  the  urine  must  be  withdrawn  by  a 
catheter.  One  of  the  chief  dangers  that  the  patient  runs  is  from 
the  supervention  of  septic  cystitis,  and  the  extension  of  the  inflam- 
mation upwards  to  the  kidneys.  This  is  always  due  to  infection 
from  without,  and  the  greatest  care  must  be  taken  to  prevent  it. 
The  penis  should  be  thoroughly  purified,  and  the  urethra  well  flushed 
out  before  passing  an  instrument  in  these  cases;  in  the  intervals 
between  instrumentation  the  penis  is  wrapped  in  a  dry  sterile  dress- 
ing. Only  soft  rubber  catheters  are  employed,  and  "these  must  be 
boiled  before  use,  and  lubricated  with  some  sterile  material.  Should 
infection  occur,  the  bladder  is  irrigated  twice  daily  with  some  mild 
antiseptic,  such  as  Condy's  fluid,  boric  acid,  boro-glyceride  (i  in  20), 
or  sanitas  (i  in  20),  whilst  urotropine,  salol  or  boric  acid  in  lo-grain 
doses  may  be  administered  by  the  mouth  thrice  daily.  Probably, 
in  spite  of  all  precautions,  the  condition  will  persist,  and  prove  fatal 
from  extension  to  the  kidneys.  Recognising  this  fact,  it  has  been 
recommended  by  some  authoiities  to  allow  the  condition  of  disten- 
sion with  overflow  to  occur  in  order  to  avoid  the  passage  of  catheters ; 
the  urine  is  permitted  to  flow  away  into  sterile  flasks  frequently 
changed.  The  bowels  are  always  obstinately  constipated,  and  must 
be  opened  either  by  purgatives  or  simple  enemata. 

Under  such  a  regime  the  patient  may  gradually  recover,  but  more 
often  succumbs  to  chronic  toxaemia  or  exhaustion.  Occasionally 
he  may  live  for  a  long  time,  although  paralyzed,  possibly  developing 
some  amount  of  reflex  micturition,  if  the  lumbar  centres  are  not 
involved.  Varying  degrees  of  restoration  of  power  in  the  lower 
limbs  are  observed. 


INJURIES  OF  THE  SPINE 


691 


Dislocations  of  the  Spine  can  only  occur  in  the  cervical  region. 
The  reason  for  this  depends  partly  on  the  greater  ftxity  of  the  dorsal 
and  lumbar  vertebrae,  and  partly  on  the  direction  of  their  articular 
processes.  In  the  cervical  region  these  look  mainly  upwards  and 
downwards,  with  a  slight  slope  forwards  and  backwards,  so  that 
it  is  not  difficult  for  one  to  slip  over  the  other;  in  the  dorsal  and 
lumbar  region  they  are  placed  nearly  vertically,  so  that  dislocation 
is  impossible  without  a  serious  concurrent  fracture. 

Any  part  of  the  cervical  region  may  be  the  seat  of  a  dislocation. 
The  occiput  has  been  displaced  from  the  atlas  in  a  few  cases,  result- 
ing in  sudden  death;  but  if  incomplete,  life  has  been  prolonged  for 
a  few  hours  or  days.     Dislocation 
of    the    atlas  from    the    axis    has 
followed  blows  on  the  neck,  or  has 
been  the  cause  of  death  in  hang- 
ing, whilst  the   attempt   to   lift    a 
struggling   child   by  the  head  has 
sometimes    led   to    this    calamity. 
In  almost  all  cases  the  odontoid 
process  has  been  fractured  or  the 
transverse  ligament   torn,  causing 
instant  death  from  compression  of 
the  cord,  owing  to  the  head  and 
atlas    slipping    forwards.      Lateral 
displacement    from    rotation    has 
also     been     observed,     the     cord 
symptoms  then  being  of  a  milder    Fig.  341.  —  Dislocation  of    the 
■j-ypg  Cervical  Spine.     (College   of 

Dislocation   may  occur  between        Surgeons'  Museum.) 
any  two  of    the    lower  five   cervical    The  fifth  cervical  vertebra  is  dis- 
vertehrcB,    but    perhaps    most    fre-       Pl^^^^d    forwards,   projecting   - 
quentl}'  between  the  fifth  and  sixth. 
It   is    most    commonly   unilateral, 
and  almost  invariably  the  result  of 
forcible  flexion  of   the    head    and 


neck,  together  wdth  rotation.     The 


front  of  the  sixth;  the  lower 
articular  process  of  the  fifth  ver- 
tebra can  be  seen  hitched  in  front 
of  the  upper  articular  process  of 
the  sixth,  the  body  of  which  is 
slightly  fissured. 


head  and  upper  portion  of  the  spine  are  displaced  forwards  and 
twisted,  so  that  the  articular  process  of  the  upper  vertebra  involved 
slips  over  the  front  edge  of  the  lower  opposing  articular  process,  and 
becomes  caught  by  it  so  that  it  cannot  return. 

When  the  lesion  is  unilateral,  the  head  is  turned  towards  the 
opposite  side,  and  more  or  less  fixed,  and  the  ear  is  raised.  There 
is  no  evidence  of  compression  of  the  cord,  although  tinghng  and 
neuralgic  pains  are  caused  by  pressure  upon  and  stretching  of  the 
nerve  roots  in  the  intervertebral  notch.  The  spinous  processes 
may  be  irregular  and  displaced  laterally,  whilst  the  line  of  the 
transverse  processes  is  similarly  altered.  Such  signs  are,  however, 
very  difficult  to  make  out  in  thick  necks,  and  in  consequence  the 
condition  is  sometimes  overlooked,  and  left  unreduced,  giving  rise 


692  A   MANUAL  OF  SURGERY 

to  deformity,  and  permanent  neuralgia  may  result.  In  early  cases 
replaceme-,it  may  be  accomplished.  The  patient  is  anaesthetized, 
the  body  fixed,  and  traction  made  upon  the  head  and  neck  away 
from  the  side  of  the  dislocation,  so  as  to  unlock  the  edges  of  the 
articular  processes.  Reduction  may  be  effected  with  a  definite 
snap  or  catch.  In  old-standing  cases  an  operation  may  sometimes 
be  attempted  to  relieve  pressure  on  the  nerves,  but  it  is  impossible 
to  replace  the  bones. 

If  the  condition  is  bilateral  and  complete  (Fig.  341),  there  is  a 
more  serious  involvement  of  ligaments,  and  the  anterior  displace- 
ment of  the  upper  segment  is  such  as  to  lead  to  grave  pressure  upon 
the  cord  and  paraplegia.  Occasionally,  however,  the  lesion  is  only 
partial,  and  then  the  cord  may  escape  without  immediate  injury, 
owing  to  the  large  size  of  the  canal  in  this  region,  although  haemor- 
rhage and  inflammation  may  subsequently  cause  grave  symptcjms. 
Treatment  is  of  but  little  avail  in  most  of  the  cases  of  complete 
double  dislocation,  since  probably  the  cord  is  irretrievably  damaged; 
but  when  paraplegia  is  incomplete,  it  is  possible  that  benefit  may 
arise  from  early  interference.  Replacement  by  traction  on  the 
head  with  the  neck  flexed  may  be  first  carefully  tried,  and,  failing 
that,  laminectomy  should  be  performed.  After  stripping  the 
muscles  from  the  bones,  the  surgeon  will  see  the  two  cartilage- 
covered  surfaces  of  the  upper  articular  processes  of  the  lower 
vertebra  standing  out  clearly  behind  the  laminse  of  the  displaced 
bone.  Upward  traction  on  the  head  may  now  again  be  m^ade,  and 
reduction  thus  attempted;  but  if  this  does  not  succeed,  a  small 
portion  of  the  upper  margins  of  the  exposed  articular  processes  is 
excised  in  order  to  allow  of  the  unlocking  of  the  bones.  If  the 
whole  processes  are  removed,  reduction  is  easier,  but  recurrence  is 
certain,  as  it  is  impossible  subsequently  to  fix  the  parts. 

Affections  of  the  Cord  associated  with  Spinal  Injuries. 

Injuries  of  the  spinal  column  are  frequently  associated  with,  or  followed 
by,  conditions  affecting  the  cord  and  its  membranes  which  may  lead  to  the 
gravest  results,  even  when  the  local  lesion  to  the  spine  has  been  comparatively 
slight.  These  are  frequently  combined  with  one  another  in  the  most  puzzling 
fashion,  so  that  it  is  often  difficult  to  state  the  exact  nature  of  a  certain  group 
of  symptoms;  for  simplicity's  sake  we  shall  discuss  them  here  separately 
without  attempting  to  describe  the  various  combinations  which  may  present 
themselves. 

Direct  Concussion. — This  condition  may  be  due  to  severe  blows  on  the 
back,  which  do  but  little  damage  to  the  spinal  column,  or  may  be  caused  by 
accidents  which  lead  to  the  infliction  of  greater  mischief,  but  without  any 
serious  displacement  of  parts.  There  can  be  little  doubt  that  the  condition 
is  due  to  the  presence  of  minute  extravasations  in  the  cord  rather  than  to  its 
'  molecular  shaking,'  as  was  formerly  supposed. 

The  Symptoms  produced  are  those  of  loss  of  function  of  that  portion  of  the 
cord  situated  below  the  point  struck.  The  patient  is  usually  prostrate  from 
general  shock  to  the  system,  and  the  reflexes  are  lost — at  any  rate  for  a  time. 
Death  may  be  caused  at  once  by  a  blow  in  the  cervical  region,  or  varying 
degrees  of  loss  of  power  and  sensation  may  be  produced  in  any  or  all  of  the 
limbs.     In  the  lumbar  and  dorsal  regions  the  patient  complains  of  weakness 


INJURIES  OF  THE  SPINE  693 

of  the  legs,  and  loss  of  control  over  the  sphincters.  Priapism  never  occurs 
in  simple  concussion.  The  temperature  of  the  body  is  depressed;  the  pulse 
is  rapiti  and  weak,  and  the  respirations  are  shallow.  The  Prognosis  is  generally 
good,  the  patient  recovering  after  a  time;  it  is  unusual  for  organic  disease  to 
follow. 

In  the  Treatment,  absolute  rest  to  the  spine  is  of  the  greatest  importance, 
and  this  should  be  maintained  if  possible  in  the  prone  position,  so  as  not  only 
to  diminish  static  congestion,  but  also  to  remove  any  pressure  on  the  spine, 
ami  to  allow  topical  applications  to  be  made.  A  spinal  icebag  may  be 
applied,  or  the  back  may  be  dry-cupped,  whilst  the  patient  is  kept  absolutely 
still,  and  on  a  low  diet.  The  bladder  and  bowels  may  require  attention,  but 
no  special  drugs  are  necessary.  Of  course,  local  injuries  require  suitable 
treatment. 

Spinal  Hsemorrhage  can  here  only  be  discussed  as  resulting  from  mjuries. 
Apart  from  traumatism,  it  is  interesting  to  note  that,  contrary  to  what  happens 
in  cerebral  ha3morrhage,  it  occurs  more  frequently  in  young  persons  between 
the  ages  of  ten  and  twenty  than  in  old  people.  The  bleeding  may  take  place 
either  into  the  cord  itself  or  outside  it,  and  hence  the  two  following  varieties 
are  described : 

{a)  Intramedullary  Haemorrhage,  or  spinal  apoplexy  {hcsmatomyelia),  is 
usually  met  with  in  the  lower  cervical  region,  and  results  from  some  accident 
that  causes  acute  flexion.  Extravasation  into  the  cord  is  rarely  extensive,  and 
may  occur  in  the  form  of  one  clot,  generally  not  larger  than  an  almond,  or 
more  commonly  in  many  spots,  the  grey  matter  being  more  or  less  ploughed 
up.  The  white  matter  is  compressed,  and  sometimes  the  blood  bursts  through 
it  into  the  subarachnoid  space.  Should  the  patient  survive  the  injury  for 
any  length  of  time,  secondary  degenerations  are  established,  and  run  the 
usual  course.  The  patient  is  suddenly  struck  down  with  a  more  or  less 
complete  paraplegia,  and  with  perhaps  pain  in  the  back,  shooting  round  to 
the  chest,  and  early  followed  by  a  rise  in  temperature.  The  paraplegia 
consists  of  a  flaccid  paralysis  of  the  arms  due  to  destruction  of  these  centres 
and  of  the  legs  from  interference  with  the  descending  columns.  Some  degree 
of  recovery  follows,  especially  dn  the  legs,  but  the  parts  supplied  from  the 
damaged  portion  of  grey  matter — i.e.,  the  arms — are  likely  to  remain  para- 
lyzed .  In  slighter  cases  only  involving  the  grey  matter,  the  arms  alone  may 
show  signs  of  paralysis  from  the  first.  The  Diagnosis  of  hemorrhage  turns 
on  the  rapid  onset  of  paralytic  symptoms  without  spinal  irritation;  fever 
may  ensue  for  a  few  days,  and  if  the  cervical  region  is  affected,  extreme  con- 
traction of  the  pupil  (myosis)  may  result  from  destruction  of  the  cilio-spinal 
centre.  There  is  retention  of  urine  and  faeces,  and  priapism  is  common. 
The  Prognosis  depends  on  the  size  and  situation  of  the  clot,  a  large  clot  pro- 
ducing more  injury  than  a  small  one;  haemorrhage  in  the  cervical  region  may 
be  immediately  fatal  by  interference  with  the  respiration,  w^hilst  in  the  lumbar 
region  it  is  unfavourable  on  account  of  the  effect  upon  the  sphincter  centres. 
The  outlook  is  best  when  the  dorsal  portion  of  the  cord  is  affected.  The 
Treatment  is  the  same  as  was  indicated  for  direct  concussion,  whilst  the 
administration  of  a  few  doses  of  ergot  may  be  beneficial. 

{b)  Extramedullary  Haemorrhage  (hcsmatorachis)  is  a  more  frequent  com- 
plication of  spinal  injuries,  such  as  sprains  or  limited  fractures,  than  the 
former.  The  blood  is  usually  extravasated  between  the  bones  and  the  dura 
mater,  especially  in  the  cervical  region,  but  may  occasionally  be  found  wathm 
the  dura.  The  symptoms  are  those  of  spinal  irritation — e.g.,  pain,  hyper- 
esthesia, spasms,  "cramps,  etc. — followed  after  a  time  by  loss  of  power  in  the 
muscles  supplied  from  the  damaged  area,  or  by  '  gravitation  paraplegia  ' 
(Thorburn),  which  gradually  extends  from  below  upwards,  causing  death  by 
asphyxia,  the  whole  series  of  phenomena  being  afebrile.  In  intramedullary 
haemorrhage  the  symptoms  of  paralysis  are  more  evident,  and  those  of  spmal 
irritation  less  marked.  If  a  diagnosis  can  be  made,  ergotin  may  be  injected 
in  the  hope  of  stopping  the  bleeding,  and  ice  applied  to  the  spine,  or  even 
laminectomy  performed   to  relieve  pressure;   later   on,   prolonged   rest  and 


694  A   MANUAL  OF  SURGERY 

possibly  the  administration  of  some  absorbent,  such  as  iotlolysin  (p.  2O3),  may 
cause  the  absorj)tion  of  the  clot. 

Spinal  Meningitis  may  spread  downwards  from  the  head,  or  commence  as 
a  local  alfoi  tion.     Two  forms  are  met  with  resulting  from  injury: 

(a)  In  Acute  Spinal  Meningitis  the  inflammation  mainly  affects  the  arach- 
noid and  pia  mater  (leptomeningitis).  It  is  usually  generalized  in  distribu- 
tion, and  not  unfrequently  extends  to  the  cerebral  membranes.  It  occa- 
sionally follows  simple  injuries,  but  is  always  infective  in  origin.  Patho- 
logically, it  is  evidenced  by  hyperaemia  and  loss  of  polish  of  all  the  membranes, 
with  an  abundant  exudation;  later  on,  lymph  or  even  pus  may  collect,  especi- 
ally about  the  posterior  surface  of  the  cord ;  should  the  patient  live,  organiza- 
tion of  the  effused  lymph  may  lead  to  extensive  adhesions.  Clinically,  the 
disease  is  usually  ushered  in  by  a  rigor,  and  runs  a  marked  pyrexial  course. 
The  symptoms  are:  pain  in  the  back,  deep-seated,  boring,  and  severe,  increased 
on  all  movements,  and  often  extending  down  the  limbs  or  around  the  body; 
rigidity  of  the  spine  and  limbs,  accompanied  by  painful  cramps  and  muscular 
spasms;  extreme  hyperaesthesia,  especially  of  the  legs,  and  increased  reflex 
excitability;  whilst  rapid  emaciation  from  pain  and  sleeplessness  is  soon 
produced.  If  the  condition  is  limited  to  the  spine,  it  is  probably  followed  by 
signs  of  myelitis,  viz.,  paraplegia,  together  with  bedsores  and  vesical  troubles, 
and  these  may  lead  to  a  fatal  issue ;  cases,  however,  are  met  with  which  pass 
into  a  chronic  state,  and  may  more  or  less  recover.  If  the  process  also  in- 
volves the  cerebral  membranes,  the  symptoms  of  diffuse  cerebral  meningitis 
are  also  present,  and  the  patient  dies  of  coma.  Treatment. — In  simple  cases 
an  icebag  should  be  applied  to  the  spine,  the  patient  remaining  in  the  prone 
position.  Ergot  and  belladonna  may  be  given  internally,  and  general 
measures  to  allay  inflammation  adopted.  The  bladder  and  rectum  must 
be  attended  to,  and  bromides  and  chloral  administered  to  gain  sleep.  Spinal 
puncture  may  be  of  some  use. 

{b)  Chronic  Meningitis  is  usually  localized,  and  may  involve  either  the  arach- 
noid and  pia  mater  (leptomeningitis),  or  be  mainly  limited  to  the  dura  mater 
(pachymeningitis).  It  may  originate  as  a  chronic  affection,  or  is  the  sequela 
of  an  acute  attack,  and  is  more  likely  to  supervene  in  syphilitic  individuals. 
The  membranes  become  thickened,  and  adhesions  to  the  cord  may  occur; 
a  chronic  sclerosing  myelitis  is  frequently  associated  with  this  affection. 
The  Symptoms  are  those  of  localized  pain  and  rigidity  in  the  back,  increased 
on  all  movements,  and  accompanied  by  shooting  pains  and  hyperassthesia, 
and  perhaps  muscular  pains  and  cramps.  The  reflexes  are  usuallv  exaggerated, 
and  vesical  complications  may  follow.  Treatment  consists  in  prolonged  rest, 
with  counter-irritation  in  the  form  of  blisters  or  the  button  cautery  applied 
to  the  back,  whilst  mercury  and  iodides  are  administered  internal^. 

Spinal  Myelitis  may  follow  injuries  of  the  spine,  either  as  a  direct  conse- 
quence of  depressed  or  displaced  bone,  or  from  haemorrhage;  it  may  also  be 
caused  at  a  later  date  by  extension  of  inflammation  from  the  meninges,  or 
result  from  compression  by  lymph,  pus,  granulation  or  cicatricial  tissue,  or 
callus.  It  may  be  acute  or  chronic.  In  the  former  the  cord  becomes  red 
and  softened;  the  nerve  elements  are  destroyed,  and  finalh'  replaced  by 
cicatricial  tissue  if  the  patient  live  long  enough.  In  chronic  cases  the  connec- 
tive tissue  becomes  thickened,  and  the  nerve  structures  compressed  and  dis- 
integrated, whilst  the  meninges  are  always  adherent  and  thickened. 

Symptoms. — Acute  myelitis  is  evidenced  by  the  presence  of  pain  in  the  back 
and  along  the  course  of  the  nerves  arising  from  the  inflamed  area,  soon 
followed  by  paraplegic  symptoms,  if  these  are  not  already  present  as  the 
result  of  the  injury.  Slight  irritative  symptoms  sometimes  precede  the 
paralysis.  Chronic  myelitis  gives  rise  to  a  great  variety  of  symptoms,  but 
those  most  marked  are  a  gradually  increasing  motor  weakness,  going  on  to 
paralysis,  together  with  various  sensory  phenomena  ending  in  anaesthesia, 
whilst  there  is  trouble  with  the  bladder  and  rectum. 

The  treatment  of  each  of  these  conditions  is  mainly  symptomatic. 

Spinal,  or  Traumatic,  Neurasthenia  {''^yn.  :  Railway  Spine).— Cases  are  not 
uncommonly  met  with  in  which,  although  there  has  been  no  direct  injury  to 


INJURIES  OF  THE  SPINE  695 

the  spinal  column  or  corti,  and  no  immediate  symptoms  of  importance,  the 
fact  is  manifestly  demonstrated  in  various  ways  that  considerable  commotion 
and  disturbance  have  been  produced  in  the  nervous  system.  Railway  acci- 
dents are  the  most  common  cause  of  this  condition,  but  it  may  arise  from  any 
jar  to  the  spinal  column,  or  even  after  injuries  to  other  parts  of  the  body. 
The  essential  features  are  cerebral,  and  not  spinal.  The  reason  why  railway 
accidents  are  so  often  responsible  for  this  state  is  that  the  forces  concerned 
are  very  great,  and  the  collision  unexpected,  so  that  the  muscles  and  liga- 
ments are  taken  at  a  disadvantage,  being  off  their  guard,  whilst  the  shock, 
(error,  and  mental  disturbance  are  also  important  factors.  Ligamentous 
and  muscular  lesions — i.e.,  sprains  and  strains — are  the  usual  local  phenomena 
produced  by  such  accidents. 

In  the  majority  of  cases  the  symptoms  are  mainly  due  to  excessive  irrita- 
bility and  weakness  of  the  spinal  and  cerebral  centres,  constituting  a  condition 
of  nerve  prostration,  or  Neurasthenia,  and  the  history  will  usually  be  some- 
what of  this  type:  The  individual  at  the  time  of  the  accident  is  thrown  from 
side  to  side,  or  severely  shaken,  but  does  not  lose  consciousness,  and,  although 
feeling  somewhat  dazed,  is  able  to  alight  without  help,  and  may  even  assist 
others.  He  perhaps  continues  his  journey,  and  goes  to  his  business,  but  finds 
in  the  course  of  a  few  hours  that  his  back  is  painful,  his  head  aching,  and  that 
he  cannot  apply  himself  to  his  work.  He  returns  home  and  goes  to  bed, 
sends  for  his  doctor,  who  will  probably  prescribe  rest  and  bromides.  His 
condition  remains  for  a  time  unaltered ;  he  complains  of  pain  and  tenderness 
over  certain  regions  of  the  spine,  especially  the  lumbar,  and  is  unable  to  walk, 
or  to  undertake  any  serious  mental  or  physical  effort,  whilst  all  excessive 
sensory  stimuli,  such  as  a  bright  light  or  noise,  are  unusually  disturbing. 
Neuralgia  is  often  present;  the  pulse  is  weak;  the  urine  may  be  retained  or 
dribble  away;  sexual  power  is  lost,  and  the  temperature  may  be  for  a  time 
subnormal.  Accommodative  asthenopia  (or  the  inability  to  accommodate 
for  near  objects),  resulting  in  a  temporary  condition  of  presbyopia,  is  also  a 
marked  feature  in  many  of  these  cases.  All  the  symptoms  are  aggravated  by 
mental  excitement  and  exertion,  such  as  are  produced  by  the  necessary  inter- 
views with  doctors  and  solicitors  pending  the  financial  compensation  by  the 
railway  company.  The  immediate  improvement  which  often  follows  the 
satisfactory  settlement  of  his  claim  for  damages  is  not  necessarily  due  to 
imposture,  but  may  result  from  the  removal  of  mental  tension  and  anxiety. 

This  condition  of  neurasthenia  may  develop  immediately  after  the  accident, 
as  an  acute  condition,  the  patient  lying  helpless  and  prostrate,  or  more  often 
chronically,  as  in  the  more  common  type  of  case  described  above.  To  it,  how- 
ever, is  frequently  added  a  considerable  element  of  Hysteria,  in  the  form  either 
of  an  acute  attack  of  hysterics,  or  of  a  chronic  unconscious  exaggeration  of  the 
sensory  symptoms.  If  the  patient  is  examined  in  the  supposed  hyperassthetic 
area  whilst  his  attention  is  distracted,  possibly  no  pain  will  be  complained  of. 

The  Prognosis  is  generally  favourable,  the  patient  recovering  in  time,  but 
in  a  few  instances  permanent  effects  may  be  produced,  or  even  a  condition 
of  chronic  myelitis. 

In  the  Treatment,  a  good  deal  of  care  is  needed  to  judge  rightly  when  the 
period  has  arrived  for  encouraging  movement  rather  than  rest,  and  thus  to 
prevent  the  patient  from  developing  a  condition  of  chronic  invalidism.  Rest 
in  bed  is  to  be  recommended  at  first,  bromides  given  in  moderation,  and 
fomentations  applied  locally.  Later  on,  friction  with  liniments  and  massage 
should  be  employed,  and  when  all  chance  of  secondary  inflammatory  dis- 
turbance is  at  an  end,  movement  should  be  encouraged,  and  change  of  air 
advised,  whilst  a  course  of  strychnine  and  iron  may  be  administered. 

Paraplegia  has  been  mentioned  so  frequently  in  discussing  the 
injuries  of  the  spinal  column  and  cord  that  a  more  detailed  refer- 
ence to  it  is  essential. 

Causes. — (i)  It  may  arise  as  the  direct  result  of  the  injury,  and 
then  is  due  to  displacement  of  bone  or  haemorrhage.     (2)  It  comes 


696  A   MANUAL  OF  SURGERY 

on  at  a  slightly  later  date  as  a  consequence  of  extra-medullary 
haemorrhage  (lucalized  or  of  the  gravitation  type),  and  that  usually 
without  pyrexial  phenomena.  (3)  It  may  be  due  to  the  pressure 
of  inflammatory  exudate — e.g.,  pus  or  lymph — and  then  is  late  in 
its  development,  and  preceded  by  the  pyrexia  and  irritative  phe- 
nomena of  that  conditif)n.  (4)  It  may  develop  late  in  the  case 
from  the  pressure  of  callus  or  cicatricial  adhesions  around  the  cord 
or  its  membranes  (peri-pachymeningitis). 

The  Phenomena,  whether  due  to  injury  or  inflammation,  are 
those  of  a  total  transverse  lesion  of  the  cord,  absolutely  destroying 
one  segment.     The  follov/ing  symptoms  result: 

1.  Paralysis  of  the  muscular  area  supplied  by  the  destroyed  seg- 
ment, followed  b}'  rapid  atrophy,  reaction  of  degeneration,  and  loss 
of  reflexes  in  this  particular  group  of  muscles. 

2.  Paralysis  of  all  the  muscles  supplied  by  the  segments  below  that 
which  has  been  destroyed.  The  trophic  condition  remains  normal, 
at  any  rate  for  a  time,  but  when  secondary  descending  degeneration 
in  the  antero-lateral  columns  has  occurred,  the  muscles  become  con- 
tracted, tense,  and  rigid  (late  rigidity).  The  deep  reflexes  are  en- 
tirely and  permanently  lost,  but  the  superficial  reflexes,  though 
absent  for  a  time,  ma\^  reappear.  If,  however,  a  portion  of  the  cord 
remains  intact,  both  superficial  and  deep  reflexes  may  persist  or 
reappear,  and  even  be  exaggerate!. 

3.  Complete  anaesthesia  of  the  sensitive  area  supplied  by  the 
destroyed  segment,  and  of  all  the  sensitive  areas  below,  and  loss  of 
the  muscular  and  thermal  senses. 

4.  A  narrow  zone  of  hypersesthesia  is  found  at  the  upper  level  of 
the  anaesthetic  area,  due  to  the  irritation  of  the  nerve  roots  at  the 
site  of  injury. 

5.  Vasomotor  paralysis  combined  with  trophic  disturbances  in 
the  parts  which  are  paralyzed. 

'').  \"isceral  changes,  especialh"  in  the  bladder  and  rectum. 

Phenomena  of  Paraplegia  at  Different  Levels,  i.  At  the  Upper 
End  of  the  Sacrum. — Total  transverse  lesions  at  this  spot  are 
exceedingly  rare;  they  only  involve  the  cauda  equina  and  cause 
paralysis  of  the  sacral  plexus.  The  effects  produced  are:  (i.)  Par- 
alysis of  all  the  muscles  of  the  legs,  except  those  supplied  by  the 
anterior  crural,  the  obturator,  and  the  superior  gluteal  nerves, 
whilst  the  perineal  and  penile  muscles  are  also  affected,  (ii.)  Anaes- 
thesia of  the  penis,  scrotum,  perineum,  lower  half  of  the  gluteal 
region,  and  the  whole  of  the  legs,  except  the  front  and  outer  parts  of 
the  thigh,  which  are  supplied  by  the  cutaneous  branches  of  the  an- 
terior crural,  and  the  region  supplied  by  the  long  saphenous  nerve, 
(iii.)  The  bladder  and  rectum  are  both  shut  off  from  their  spinal 
centres,  and  hence  there  will  be  temporary  retention  of  urine,  fol- 
lowed by  distension  with  overflow,  and  incontinence  of  faeces.  The 
bladder,  however,  gradually  contracts,  its  walls  become  thickened, 
and  its  capacity  steadily  diminishes,  so  that  incontinence  becomes 
more  and  more  absolute. 


INJURIES  OF  THE  SPINE  697 

2.  If  the  lesion  is  situated  in  the  Dorsi-lumbar  region,  or  passes 
tlirough  tlie  lumbar  enlargement,  which  corresponds  to  the  twelfth 
dorsal  and  first  lumbar  vertebne,  there  is  complete  paralysis  of  the 
muscles  of  both  limbs,  including  those  passing  to  them  from  the 
trunk;  total  anaesthesia  of  the  legs,  gluteal  and  perineal  regions,  and 
possibly  the  lower  part  of  the  abdomen ;  whilst,  if  the  vesical  centres 
are  destroyed,  there  is  total  paralysis  of  the  bladder,  with  relaxation 
of  the  sphincter,  dribbling  of  urine,  which  early  becomes  ammoni- 
acal,  and  cystitis,  due  to  trophic  changes;  if  the  centres  escape,  re- 
tention with  overflow  is  the  usual  result;  the  rectum  and  sphincter 
ani  are  paralyzed,  causing  incontinence  of  fseces,  the  passage  of  which 
is  unrecognised  from  the  anaesthetic  condition  of  the  anus. 

3.  In  the  Mid-dorsal  region  the  same  phenomena  are  met  with,  but 
to  them  are  added  a  more  extensive  region  of  anaesthesia,  limited 
above  by  a  hyperaesthetic  zone,  which  feels  hke  a  tight  painful  girdle 
round  the  waist ;  paralysis  of  the  flat  abdominal  muscles ;  and  reten- 
tion of  urine,  followed  by  distension  with  overflow.  Occasionally, 
however,  when  asepsis  is  maintained,  a  condition  of  reflex  micturi- 
tion develops,  in  which  the  patient  passes  water  unconsciously  and 
involuntarily,  whenever  there  is  sufficient  intravesical  pressure  to 
cause  sensory  stimuli  to  ascend  to  the  undamaged  centres.  The 
abdominal  paralysis  is  a  most  important  addition  to  the  gravity  of 
the  case,  for  all  straining  movements  are  thereby  prevented,  and 
thus  coughing  is  embarrassed  and  defaecation  hindered.  The  gases 
developing  from  the  stagnant  faeces  accumulate  and  cause  distension 
of  the  belly  (meteorism),  and  thereby  respiration  may  be  seriously 
impaired.  The  diaphragm,  moreover,  is  hampered  in  its  action, 
since  the  lower  ribs  cannot  be  fixed  or  steadied,  and  hence  its  con- 
tractions tend  to  pufl  them  inwards,  instead  of  increasing  the  dimen- 
sions of  the  thoracic  cavity. 

4.  In  the  Cervico-dorsal  region  aU  these  phenomena  are  present, 
but  the  anaesthesia  extends  over  nearly  the  whole  trunk,  and  the 
hyperaesthesia  may  involve  the  arms,  whilst  the  intercostal  and 
spinal  muscles  are  also  paralyzed,  and  there  is  some  weakness 
of  the  hand-grasp.  Respiration  has  to  be  carried  on  by  the 
hampered  diaphragm,  with  the  assistance  of  a  few  of  the  acces- 
sory respiratory  muscles  in  the  neck,  and  hence  is  much  impeded ; 
if  bronchitis  is  present,  it  \vill  prove  fatal  by  asphyxia  in  a  few  days 
from  the  inabihty  to  expectorate.  Priapism  is  a  marked  feature  of 
cervical  paraplegia,  as  also  contraction  of  the  pupil  from  interference 
with  the  lower  cilio-spinal  centre. 

5.  In  the  Lower  Cervical  region  the  arms  also  become  involved  in 
both  the  paralysis  and  anaesthesia,  and  the  patient  is  likely  to  die  in 
thirty-six  to  forty-eight  hours,  or  less,  in  a  condition  of  hyperpyrexia. 
If  the  lesion  is  situated  at  or  above  the  fourth  cervical  vertebra, 
instant  death  results  from  paralysis  of  the  phrenics  and  consequent 
stoppage  of  the  respiration.  If  the  fifth  cervical  segment  is  involved, 
the  arms  are  usually  found  completely  paralyzed,  lying  by  the  side 
of  the  trunk.     A  lesion  through  the  sixth  segment  causes  the  arms 


698  A   MANUAL  OF  SURGERY 

to  be  turned  out  and  abducted,  the  elbows  being  flexed  and  the 
hands  supinated  with  the  fingers  semiflexed.  Injury  to  the  seventh 
segment  results  in  the  hands  being  half-closed,  the  elbows  bent, 
and  the  forearm.-  lie  in  a  condition  of  pronation  over  the  chest. 

Death  from  Paraplegia,  therefore,  may  arise  from  a  variety  of 
causes  and  at  various  periods.  It  may  be  immediate,  from  respira- 
tory failure  in  lesions  above  the  fourth  cervical  vertebra;  or  it  may 
occur  from  accumulation  of  mucus  or  pus  in  the  air-passages,  when 
the  lesion  is  in  the  upper  dorsal  region;  or  it  may  be  delayed  for 
weeks,  or  even  months,  and  then  be  due  to  sloughing  of  the  nates,  or 
septic  absorption  from  an  inflamed  or  ulcerated  bladder,  which  is 
often  associated  with  suppurative  pyelonephritis. 

The  Prognosis  and  Treatment  both  depend  on  the  position  and 
character  of  the  lesion  causing  the  paraplegia,  and  on  the  previous 
habits  and  condition  of  health  of  the  individual. 

Laminectomy  is  an  operation  for  the  removal  of  the  laminae  and 
spinous  processes  of  one  or  more  vertebrae,  in  order  to  reheve  pressure 
on  the  cord,  whether  due  to  depressed  bone,  abscess,  granulation 
tissue,  excessive  callus,  cicatrices,  or  tumours.  The  operation  con- 
sists in  making  a  longitudinal  incision  in  the  middle  line  of  the  back, 
extending  to  the  spinous  processes;  the  muscular  and  tendinous 
structures  are  then  cleared  from  the  posterior  aspect  of  the  verte- 
brae as  far  as  the  transverse  processes,  a  proceeding  usually  attended 
with  considerable  haemorrhage,  which  can  be  checked,  perhaps, 
better  by  hot  sponge  pressure  than  by  attempting  to  secure  the 
individual  vessels.  1  he  neural  arches  are  then  examined  for  injury, 
etc.,  and  those  which  seem  to  be  most  affected  removed  bv  cutting 
pliers,  Hey's  saw,  or  laminectomy  forceps.  The  posterior  aspect 
of  the  membranes  of  the  spinal  cord  is  thus  exposed,  and  the  various 
conditions  which  may  be  present  are  dealt  with  according  to  circum- 
stances. In  this  place  we  have  merely  to  consider  the  use  of  this 
operation  after  injury  to  the  spine.  For  its  employment  in  other 
conditions  see  Chapter  XXV. 

It  must  be  remembered  as  a  fundamental  principle  that  repair  is 
impossible  after  the  spinal  cord  has  been  divided,  or  any  one  segment 
totally  disintegrated,  and  hence,  if  it  is  certain  that  a  total  transverse 
lesion  of  the  cord  has  been  caused  by  an  accident,  it  is  absolutely 
useless  to  operate.  Early  and  complete  disappearance  of  all  the 
reflexes  is  a  suggestive  phenomenon,  but  cannot  be  looked  on  as 
absolute  evidence  of  a  total  transverse  lesion ;  if,  however,  in  addition 
to  complete  sensory  and  motor  paralysis,  the  deep  reflexes  remain 
absent  for  any  length  of  time,  even  though  some  of  the  superficial 
ones  have  reappeared,  operation  is  useless.  The  presence  of  the 
deep  reflexes  is  always  an  evidence  that  at  any  rate  a  portion  of  the 
cord  remains  uninjured,  and  would  encourage  one  to  operate.  This 
question  cannot,  however,  be  absolutely  settled  in  the  early  stages  of 
the  case,  as  it  is  at  first  impossible  to  say  whether  the  symptoms  are 
due  to  concussion,  haemorrhage,  or  bony  pressure.     Fortunately, 


INJURIES  OF  THE  SPINE  699 

delay  does  not  appear  to  be  so  prejudicial  to  the  patient's  welfare  as 
one  might  at  first  expect,  and  many  cases  are  on  record  in  which  a 
good  result  was  obtained  even  after  months.  One  is  therefore  justi- 
fied in  waiting  a  while  in  doubtful  cases.  In  spite  of  this,  however, 
there  will  always  be  a  certain  number  of  patients  in  whom  it  is  a 
matter  of  doubt  as  to  whether  or  not  any  benefit  will  accrue  from 
operation.  The  final  decision  under  such  circumstances  depends  on 
the  special  predilections  and  opinions  of  the  surgeon,  and  the 
general  state  of  the  patient. 

Apart  from  these  doubtful  cases,  the  following  are  generally 
admitted  as  being  suitable  for  operation:  (i)  Penetrating  wounds  or 
fractures  with  displacement  which  involve  the  spine  below  the  first 
lumbar  vertebra;  the  cauda  equina  is  present  below  that  level,  and 
not  the  spinal  cord,  and  it  is  reasonable  to  treat  it  in  the  same  way  as 
one  would  treat  a  single  peripheral  nerve;  (2)  when  the  injury  is 
mainly  limited  to  the  neural  arch,  which  has  been  driven  in  by  direct 
violence;  (3)  in  all  cases  of  bilateral  dislocation  of  the  cervical  spine 
where  the  patient  is  not  moribund;  (4)  if  paraplegia  arises  with  or 
without  inflammatory  symptoms,  when  an  interval  has  elapsed  since 
the  accident ;  the  pressure  in  such  cases  may  be  produced  by  blood 
or  inflammatory  exudations,  and  benefit  may  possibly  arise  from  the 
operation;  if,  however,  it  is  due  to  a  total  transverse  myelitis,  no 
good  can  follow.  (5)  When  symptoms  of  irritation  or  paralysis 
supervene  at  a  later  date,  from  contraction  of  cicatrices  around  the 
cord  or  its  membranes  (peri-pachymeningitis),  or  from  excessive 
callus  formation,  laminectomy  may  be  performed  with  good  hopes 
of  a  successful  result. 


CHAPTER  XXV. 
DISEASES  OF  THE  SPINE. 

Spiua  Bifida. 

By  Spina  Bifida  is  meant  a  condition  of  imperfect  development  of 
some  portion  of  the  posterior  aspect  of  the  spine,  with  or  without  a 
similar  affection  of  the  spinal  cord  and  membranes. 

It  must  be  remembered  that  the  spinal  cord  is  developed  as  a 
linear  involution  of  the  epiblast,  the  edges  of  this  medullary  groove 
growing  up  and  uniting,  so  as  to  include  a  passage  lined  with  epi- 
thelium, and  subsequently  known  as  the  central  canal.  The  cord 
is  gradually  separated  from  the  overlying  skin  by  an  intrusion  of 
mesoblastic  elements,  from  which  the  vertebrae,  together  with  the 
spinal  muscles  and  ligaments,  are  developed.  The  ossification  of 
each  vertebra  originates  in  three  main  centres — one  for  the  body, 
and  one  for  each  half  of  the  neural  arch,  whilst  epiphyses  are  de- 
v^eloped  as  plates  above  and  below  the  body,  as  also  for  the  trans- 
verse and  spinous  processes. 

The  following  are  the  chief  forms  of  spina  bifida: 

1.  A  Myelocele  results  from  non-closure  of  the  primitive  medullary 
groove.  It  is  characterized  by  the  appearance  in  the  lumbo-sacral 
region  of  a  raw  surface,  which  consists  of  the  spread-out  structures 
of  the  cord,  at  the  upper  part  of  which  opens  the  central  canal.  The 
condition  is  incompatible  with  life,  and  the  child,  if  not  stillborn,  as 
is  usually  the  case,  does  not  live  beyond  a  dav  or  two. 

2.  A  Meningocele  (Fig.  342)  is  characterized  by  a  protrusion  of  the 
membranes,  containing  cerebro-spinal  fluid,  through  a  defect  in  the 
posterior  walls  of  the  vertebrae,  the  spinal  cord  and  nerves  being  in 
their  normal  position.     This  variety  is  not  very  common. 

3.  A  Meningo-Myelocele  (Fig.  343)  is  due  to  a  dev^elopment  of  fluid 
within  the  membranes  which  remain  adherent  to  the  skin,  the  spinal 
cord  or  nerves  of  the  cauda  equina  passing  down  the  posterior  aspect 
of  the  cavity  as  a  strap,  and  the  nerves  tra\-ersing  and  perforating 
the  sac  to  reach  the  intervertebral  foramina. 

4.  A  Syringo-Myelocele  (Fig.  344)  arises  from  a  distension  of  the 
central  canal  of  the  cord,  the  posterior  portion  of  which  usually 
remains  adherent  to  the  skin,  from  which  it  has  never  been  separated, 

700 


DISEASES  OF  THE  SPINE 


701 


owing  to  defective  development  of  the  mesoblastic  tissues  The 
soi  al  nerves  travel  round  the  walls  of  the  cyst  m  order  to  find  their 
wa V  to  the  intervertebral  foramina.  Trophic  phenomena  are  nearly 
always  a  prominent  feature  of  these  cases. 

5C 


Fig    342  -Horizontal  and  Vertical  Sections  of  a  Spinal  Meningocele. 

S  C     Spmal  cord  with  nerves  passing  through  the  intervertebral  foramma; 
b.C,  spmai  core  ^^^     ^^^  ^^r^  ^^.^^  cerebro-spmal  fluid. 


YiG.  343.— Diagram  of  Meningo-Myelocele. 
SC.  Spinal  cord  (black);  C.S.F.,  sac  filled  with  cerebro-spinal  fluid;  N,  nerves 

crossing  the  sac. 


Pig.  344.— Diagram    of   Syringo-Myelocele. 
S  C     Spinal  cord  with  central  canal  dilated   (C.S.F.)   to  form  the  sac;  the 
'co?d   has  purposely   been  represented  thick;   it  would  really  be  thm 
stretched,  and^  atrophic.     The  nerves  are  represented  passing  round  the 
sac. 

Of  these  forms,  the  meningo-myelocele  is  that  most  frequently 
seen  in  living  children,  although,  according  to  Bland-Suttoa  the 
first  is  really  the  most  common. 


702 


A  MANUAL  OF  SURGERY 


Clinical  Characters. — A  spina  bifida  (except  of  the  myelocele  type) 
is  recognised  by  the  presence  of  an  elastic  swelling  in  the  middle  line 
of  the  back  (Fig.  345),  most  commonly  involving  the  lower  part  of 
the  spine;  it  may  be  covered  by  normal  skin,  but  usually  that  over 
the  convexity  is  thin  and  translucent,  and  not  unfrequently  a 
number  of  small  dilated  vessels  are  seen  coursing  over  it.  On  com- 
pressing this  swelling,  its  size  can  sometimes  be  diminished,  and 
then  in  infants  distension  of  the  anterior  fontanelle  may  be  felt, 
showing  tliat  the  sac  is  filled  with  cerebro-spinal  fluid;  there  is  usu- 
ally a  distinct  impulse  on  coughing  or  crying.  The  defect  in  the 
posterior  portion  of  the  vertebrae  is  often  evident,  the  edges  of  the 
bones  being  felt  at  the  margins  of  the  swelling.     Other  deformities 

may  be  associated  with 
spina  bifida,  especially  hy- 
drocephalus and  paralytic 
talipes,  in  cases  of  syringo- 
myelocele ;  perforating  ulcer, 
ankylosis  of  phalanges,  and 
other  trophic  phenomena, 
are  also  frequently  deve- 
loped at  a  later  date. 

The  Diagnosis  is  usually 
evident,  but  sometimes  in 
the  cervical  region  a  small 
tense  meningocele  is  not 
readily  recognised.  Radi- 
ography may  be  of  assist- 
ance in  demonstrating  the 
defects  in  the  vertebraj. 

The  Prognosis  of  the  case 
depends  mainly  on  the 
thickness  and  character  of 
the  overlying  skin.  If  it 
is  thin  and  atrophic,  as  in 
many  cases  of  meningo- 
myelocele, the  sac  is  likely 
to  give  way,  causing  death 
from  sudden  escape  of  cerebro-spinal  fluid  or  from  infective 
meningitis.  If  the  spina  bifida  is  small,  and  covered  with  healthy 
skin  and  subcutaneous  tissue,  the  patient  may  reach  adult  life, 
but  even  then  trophic  phenomena  may  supervene,  possibly  as  the 
result  of  the  presence  of  foci  of  naevoid  tissue,  which  have  been 
known  to  develop  in  the  canal  when  the  cord  is  absent  Occasion- 
ally a  meningocele,  with  only  a  small  aperture  of  communication 
with  the  spinal  canal,  is  cured  spontaneously  by  the  gradual 
growth  of  the  bones  constricting  the  neck  of  the  sac. 

Treatment. — Many  cases  are  best  left  alone,  the  tumour  being 
merely  guarded  from  injury  by  the  application  of  a  suitable  cap; 
but  if  the  sac  is  gradually  increasing  in  size  and  threatening  to  give 


Fig.  345. — Lumbo-Sacral  Spina  Bifida  of 
THE  Meningo-Myelocele  Type  in  a 
Baby.     (From  a  Photograph.) 


DISEASES  OF  THE  SPINE  703 

way,  surgical  intervention  is  absolutely  necessary  if  life  is  to  be 
saved.  Acupuncture  through  the  thinned  integument,  the  cerebro- 
spinal fluid  being  allowed  to  drain  away  subsequently  into  an  anti- 
septic dressing,  or  tapping  through  the  healthier  integument  around 
the  base,  repeated  several  times,  and  followed  by  compression,  may 
lead  to  a  cure  in  favourable  cases.  Better  results,  however,  are 
obtained  by  tapping,  followed  by  the  injection  of  Morton's  fluid 
(R.  lodi,  grs.  x.;  pot.  iod.,  grs.  xxx. ;  glycerinum,  ad  51.).  A  small 
quantity  of  the  cerebro-spinal  fluid  is  withdrawn,  and  then  from 
half  a  drachm  to  a  drachm  of  the  iodine  solution  is  introduced.  It 
diffuses  itself  slowly,  and  its  action  is  localized,  so  that  if  the  child  is 
kept  quiet,  and  only  semi-recumbent,  its  effect  will  be  hmited  to  the 
sac  and  its  neighbourhood.  In  some  cases  persistent  leakage  may 
follow  this  treatment,  and  will  need  the  application  of  a  firm  anti- 
septic compress;  in  many  the  injection  needs  to  be  repeated  more 
than  once. 

Operative  treatment  is  chiefly  applicable  in  the  menmgocele  type, 
and  infants  or  those  suffering  from  trophic  phenomena  do  not  stand 
it  well.  An  incision  is  made  over  the  sac,  either  in  the  middle  line 
if  the  cord  is  not  there,  or  to  one  side  if  it  is.  The  child  should  be 
kept  with  the  head  low  when  the  sac  is  opened,  so  as  to  limit,  as  far 
as  possible,  the  loss  of  cerebro-spinal  fluid.  In  a  meningocele,  the 
protruding  membranes  are  cut  away,  after  tying  or  suturing  carefully 
the  pedicle,  and  the  spinal  muscles  drawn  together  by  deep  stitches, 
so  as  to  create  an  extra  protective  barrier,  in  addition  to  the  skin 
and  subcutaneous  tissues.  When  the  cord  runs  down  the  back  of 
the  sac,  it  is  freed  by  incisions  on  either  side,  and  if  it  cannot  be 
separated  from  the  skin,  the  whole  strip  is  replaced  in  the  vertebral 
canal,  the  membranes  are  closed  over  it,  and  finally  the  muscles 
and  skin  are  united  by  rows  of  sutures.  The  results  obtained  by 
this  means  in  the  treatment  of  meningoceles  have  been  most  en- 
couraging, .       ,  .  ,     , 

Spina  Bifida  Occulta  is  the  term  apphed  to  a  condition  m  which  the 
posterior  portion  of  the  vertebrae  is  absent,  but  without  any  protru- 
sion of  the  cord  or  its  membranes.  The  overlying  skin  may  be  cica- 
tricial in  character,  or  a  large  growth  of  hair  may  arise  from  it; 
occasionally  a  lipoma  develops  in  this  situation,  and  by  its  growth 
compresses'  the  spinal  cord  or  drags  upon  it,  and  causes  paraplegia. 
Unless  such  a  condition  is  present,  spina  bifida  occulta  calls  for  no 
treatment,  but  an  exploratory  operation  should  always  be  under- 
taken when  nervous  phenomena  supervene. 

Congenital  Sacral  Tumours. 

Other  congenital  conditions  of  the  lower  end  of  the  spine  are 
described  as  congenital  sacral  or  coccygeal  tumours.  The  majority 
of  these  arise  from  what  is  known  to  embryologists  as  the  nmrenteric 
canal.  In  early  foetal  hfe  the  neural  and  alimentary  canals  are  con- 
tinuous, the  passage  of  communication  being  known  by  the  above 


704  A   MANUAL  OF  SURGERY 

name.  Ordinarily,  it  disappears  entirely  after  the  union  of  the  proc- 
todeum with  the  intestine,  but  evidences  of  its  existence  are  occa- 
sionally met  with,  either  in  the  form  of  a  cicatricial  dimple  adherent 
to  the  tip  of  the  coccyx  {post-anal  dimple),  or  as  one  of  the  following 
conditions: 

(i.)  A  dermoid  cyst,  containing  the  usual  mixture  of  sebaceous 
material  and  epithelial  cells,  and  often  a  tuft  of  hair;  it  develops  in 
the  space  between  the  rectum  and  coccyx,  and  may  either  project 
below  or  by  the  side  of  the  coccyx,  or  open  into  the  rectum;  the  tult 
of  hair  may  then  find  its  way  out  of  the  anus.  In  a  case  under  the 
care  of  Mr.  W.  Turner,  at  Westminster  Hospital,  it  was  actually  con- 
nected with  the  spinal  meninges,  removal  involving  the  loss  of 
cerebro-spinal  fluid. 

(ii.)  A  congenital  adenoma  of  the  post-anal  gut  is  occasionally  found 
in  the  same  region.  It  is  characterized  microscopically  by  the 
existence  of  alveoli,  lined  by  cuboidal  epithelium,  held  together  by 
connective  tissue;  it  may  attain  a  large  size,  but  is  quite  innocent. 

Various  other  tumours  are  met  with  in  infants  in  this  region,  and 
the  same  title  of  congenital  sacral  or  coccygeal  tumour  has  some- 
times been  applied  to  them  : 

{a)  A  spina  bifida  of  the  meningocele  type,  which  may  communi- 
cate with  the  subdural  space,  oi  may  have  been  shut  off  by  a  natural 
process  of  cure. 

{b)  A  lipoma  may  also  form  here,  and  in  some  cases  has  simulated 
by  its  shape  a  caudal  appendage. 

{c)  A  partially-developed  foetus  may  be  met  with,  enclosed  within 
the  subcutaneous  tissues  of  the  sacral  region,  and  known  as  a  tera- 
toma (p.  228). 

(d)  Sarcoma  and  cystic  hygroma  have  also  been  observed. 

Inflammatory  Affections  of  the  Spine. 

I.  Acute  Osteomyelitis  of  the  Spine  is  uncommon.  It  usually 
affects  the  mobile  portions  of  the  spine  in  young  people,  and  is  due 
to  the  same  causes  as  similar  disease  elsewhere — viz.,  auto-infection 
with  pyogenic  organisms  after  a  slight  injury.  It  is  characterized 
by  severe  pain  in  a  localized  portion  of  the  back,  and  fever,  de- 
formity is  not  a  marked  feature,  since  massive  necrosis  occurs,  and 
not  a  gradually  destructive  caries.  Abscesses  foim  early,  and  there 
is  great  danger  of  an  extension  of  the  inflammation  to  the  spinal 
meninges,  leading  to  a  fatal  issue.  Ihe  prognosis  is  extremely  bad, 
owing  to  this  latter  complication,  and  the  only  possible  treatm.ent 
consists  in  early  incisions  to  give  exit  to  the  pus.  Sequestra  can 
easily  be  removed  from  the  back  of  vertebrae,  but  from  the  front 
only  in  the  lumbar  and  cervical  regions. 

II.  Tuberculous  Disease  oJ  the  Spine  or  Spinal  Caries  {Syn. :  Pott's 
Disease,  Angular  Curvature). — The  above  names  are  applied  to  a 
tuberculous  disease  of  the  vertebrae,  originating  almost  invariably 
in  their  bodies,  which  are  more  or  less  destroyed,  leading  to  the 


DISEASES  OF  THE  SPINE 


705 


so-called  '  angular  curvature.'     It  was  first  accurately  described  by 
Percival  Pott  in  1779. 

The  Causes  are  much  the  same  as  those  of  tuberculous  affections 
elsewhere,  and,  indeed,  it  is  often  associated  with  other  manifesta- 
tions of  the  same  disease.  It  most  frequently  occurs  in  children 
under  the  age  of  ten  years,  but  may  arise  at  any  age,  and  equally 
in  either  sex.  Any  part  of  the^spinal  column  may  be  involved,  but 
the  lower  dorsal  is  by  far  the  commonest.  The  cervical  region  is 
rarely  attacked,  except  in 
children,  whilst  in  adults  the 
dorsi-lumbar  vertebiae  are  the 
favourite  seat. 

Pathological  History. — The 
disease  commences  either  as  a 
periostitis  or  an  osteomyelitis. 
The  periosteal  variety  is  gener- 
ally seen  in  adults,  and  is 
therefore  the  less  common.  It 
involves  the  anterior  surface 
of  one  or  more  vertebrse,  and 
is  likely  to  spread  under  the 
anterior  common  ligament  from 
one  bone  to  another,  whilst  the 
intervertebral  discs  are  also 
attacked  and  destroyed.  The 
endosteal  form  is  much  the  more 
common,  and  is  almost  in- 
variably the  type  seen  in 
children.  The  tubercle  is  de- 
posited in  the  cancellous  bone, 
possibly  in  relation  with  the 
plate -like  epiphyses  of  the 
bodies,  and  produces  its  usual 
effect    in    softening    and    dis- 


FiG.  346. — -Tuberculous  Disease  of 
Spine,  showing  Destruction  of 
the  i30dies  of  the  vertebr.e 
AND  Abscess  Formation  beneath 
THE  Anterior  Common  Ligament. 
(Modified  from  Specimen  in  Col- 
lege OF  Surgeons'  Museum.) 


integrating  the  osseous  tissue. 
The  anterior  parts  of  the  bodies 
are  affected  more  than  the 
posterior,  and  hence  deformity  is 
common  and  nervous  affections 

rare.  The  deformity  produced  is  more  or  less  of  an  angular  type, 
due  to  the  bodies  falling  together,  either  as  a  result  of  the  weight 
of  the  trunk,  or  from  muscular  action,  or  when  the  patient  has  been 
in  the  recumbent  position  from  the  cicatricial  contraction  which  is 
associated  with  the  healing  of  the  granulation  masses  in  the  front 
of  the  bodies  of  the  bones.  The  disease  spreads  to  adjacent  ver- 
tebra, either  through  the  intervertebral  discs  which  are  destroyed 
in  the  process,  or  by  extension  under  the  anterior  common  ligament, 
when  it  may  become  widely  diffused,  body  after  body  being  eroded, 
and  the  cartilages  suffering  even  more  than  the  bones  (Fig.  346). 

45 


7o6 


A   MANUAL  UP  SURGERY 


In  such  a  case  the  deformity  ])roduced  is  not  angular,  but  ratlier  of 
a  general  kyphotic  nature.  Occasionrdly,  however,  the  disease 
starts  simultaneously  in  many  foci,  so  that  the  bodies  of  several 
vertebra",  become  pitted  and  carious,  without  producing  general 
destruction.  In  other  cases  the  process  is  limited  to  the  bodies  and 
intervertebral  discs  of  two  adjacent  vertebrse,  the  periosteum  being 
but  little  affected.  This  variety  is,  perhaps,  most  common  in  the 
lumbar  region,  where  the  bodies  of  the  vertebrse  are  large  and 
permit  a  limiting  zone  of  sclerosed  tissue  to  form;  it  is  also  not 
uncommon  in  this  situation  to  find  definite  sequestra  in  adults 

(Fig.  347)- 

Cure  is  effected  by  the  bodies  of  tlie  vertebrse  fallmg  together  and 
becoming  ankylosed,  so  that  a  deformed  and  immobile  condition  of 
the  diseased  portion  of  the  spine  is  often  the  best  result  that  can 

be  anticipated.  The  new 
bone  thus  formed  becomes 
in  time  sclerosed  and  very 
dense,  and  the  synostosis 
also  involves  the  spines 
and  laminae.  In  favourable 
cases  this  occurs  without 
suppuration,  but  not  un- 
frequently  abscesses  form 
and  add  much  to  the 
gravity  of  the  condition. 
Occasionally  the  tubercu- 
lous process  extends  back- 
wards through  the  body  of 
the  bone,  so  as  to  implicate 
the  posterior  common  liga- 
ment, and  paralytic  or  other 
symptoms  may  then  arise 
from  pressure  on  the  cord. 
Rare  cases  have  been  described  in  which  the  disease  mainly 
affected  the  sides  of  the  vertebrre,  as  a  result  of  which  lateral 
deformity  occurred;  still  more  uncommon  are  those  in  which  the 
posterior  portion  of  the  neural  arches  is  primarily  involved. 

In  the  upper  cervical  region  the  disease  usually  starts  in  the  large 
joints,  either  between  the  occiput  and  atlas,  or  between  the  atlas  and 
axis.  For  a  time  it  m.ay  be  limited  to  one  side,  but  the  body  of  the 
bone  is  attacked  at  an  early  stage,  and  the  trouble  then  spreads 
to  other  joints.  A  special  complication  of  this  variety  \\\\\  be 
mentioned  hereafter  (p.  712). 

The  Signs  and  Symptoms  produced  by  tuberculous  caries  of  the 
vertebrae  vary  considerably  in  different  situations,  but  for  practical 
purposes  may  be  described  under  the  following  five  headings: 

I.  Pain  is  a  constant  and  invariable  accompaniment  of  the  disease, 
although  in  the  early  stages  it  may  not  be  specially  piominent,  being 
only  elicited  by  careful  examination.     It  is  of  two  main  types,  the 


Fig.  347. — Tuberculous  Disease  of  Two 
Lumbar  Vertebr.^:,  showing  Seques- 
trum ON  THE  Anterior  Aspect,  and 
Lateral  Thickening  preventing  Angu- 
lar Deformity.  (College  of  Surgeons' 
Museum.) 


DISEASES  OF  THE  SPINE  707 

local  and  the  referred.  Local  pain  is  often  not  severe,  but  can 
usually  be  elicited  by  pressure  or  percussion  over  the  spines,  or 
perhaps  more  effectually  by  pressing  upon  the  transverse  processes, 
so  as  to  induce  rotation  of  the  vertebral  bodies  one  on  another. 
Movements  of  the  spine,  bending  or  twisting,  are  similarly  painful, 
whilst  the  same  result  can  be  brought  about  by  jarring  the  spine,  as 
by  a  blow  on  the  head  or  nates.  Referred  pain  is  produced  by  pres- 
sure upon,  or  irritation  of,  the  roots  of  the  nerves  as  they  emerge 
from  the  intervertebral  foramina;  consequently  its  distribution  is 
governed  by  the  arrangement  of  the  nerve -root  area  of  the  affected 
spinal  segment  (p.  395).  If  the  lumbar  region  is  affected,  the  pain 
is  referred  down  the  legs;  in  the  dorsi-lumbar  region  it  may  follow 
the  last  dorsal  nerve,  and  be  noticed  in  the  lower  part  of  the  abdo- 
men, or  in  the  gluteal  region;  in  the  lower  dorsal  region  pain  is 
referred  to  the  epigastrium,  children  who  are  unable  to  differentiate 
its  precise  nature  complaining  of  '  belly-ache  ';  in  the  cervico-dorsal 
region  the  pain  often  extends  into  the  arms. 

2.  Rigidity  of  the  spine  is  a  constant  accompaniment  of  Pott's 
disease.  In  the  early  stages  it  results  from  muscular  spasm,  the 
object  being  to  fix  and  immobilize  the  painful  part.  If  the  lower 
poi^tion  of  the  spine  is  involved,  the  back  is  held  stiff  and  straight, 
the  patient  abstaining  from  all  movements  which  would  bend  or 
stretch  it.  Thus,  in  order  to  pick  up  an  object  from  the  floor,  the 
knees  and  hips  are  flexed,  and  the  patient  gradually  lets  himself 
down  with  an  absolutely  rigid  back  into  a  sitting  or  squatting  pos- 
ture; the  body  is  raised  in  a  similar  manner  by  resting  the  hands 
upon  the  thighs,  the  patient,  as  it  were,  climbing  with  extended 
arms  up  his  own  legs.  In  a  child  rigidity  in  the  dorsi-lumbar  region 
can  be  demonstrated  by  laying  him  on  his  face,  grasping  the  ankles, 
and  ascertaining  the  amount  of  movement  of  the  spine  at  that  region 
by  lifting  the  legs  from  the  table,  and  also  by  moving  them  from 
side  to  side.  In  a  healthy  child  the  legs  can  be  elevated,  and  the 
spine  bent  back  in  the  dorsi-lumbar  region,  nearly  to  an  angle  of 
sixty  degrees;  whilst  lateral  mobility  to  the  extent  of  thirty  or  forty 
degrees  on  either  side  of  the  median  line  is  obtainable.  When  caries 
is  present,  neither  of  these  movements  can  be  made  without  in- 
cluding the  thorax  and  dorsal  spine.  In  cervical  caries  the  patient 
steadies  the  head,  and  at  the  same  time  raises  the  shoulders  by  the 
help  of  the  trapezius  and  sterno -mastoid  muscles,  whilst  the  chin 
is  often  supported  by  one  hand,  and  the  patient  twists  his  whole 
body  in  order  to  look  sideways. 

In  the  later  stages,  when  repair  is  taking  place,  or  has  occurred, 
rigidity  of  the  spine  is  due  to  osseous  ankjdosis.  After  a  cure  has 
been  established,  compensatory  movements  of  other  portions  of  the 
spine  mask,  to  a  certain  degree,  the  localized  rigidity. 

3.  Deformity  is  necessarily  present  in  almost  all  instances  owing 
to  the  character  of  the  reparative  process.  The  amount  of  the 
deformity  depends  on  many  circumstances,  and  perhaps  chiefly 
upon  the  number  of  vertebrae  affected.     Where  only  two  bones  are 


7o8 


A   MANUAL  OF  SURGERY 


involved,  a  true  angular  deformity  may  result,  the  body  of  the 
upper  vertebra  being  welded  to  that  of  the  lower,  so  as  to  produce 
a  wedge-like  mass,  the  surfaces  of  which  are  inclined  to  one  another 
at  an  angle;  compensatory  curves  of  the  spine  above  and  below 
enable  the  patient  to  assume  the  erect  posture.  When  a  large 
number  of  vertebrae  are  affected,  the  curvature  is  never  angular, 
but  the  whole  region  becomes  bent  forwards,  and  that  sometimes  very 
acutely  (Fig.  348).  In  the  lumbar  region  (and  to  a  less  extent  in 
the  cervical)  loss  of  the  normal  forward  convexity  is  often  the  most 

marked  feature,  the  vertebra;  being  piled, 
as  it  were,  one  above  the  other,  so  as  to 
constitute  an  absolutely  vertical  column 
(Fig.  350).  When  the  affection  is  limited 
to  two  lumbar  vertebrse,  there  is  usually 
little  or  no  displacement,  the  disease 
occup3nng  the  centres  of  the  bones,  so 
that  the  sides  may  escape  altogether,  and 
preserve  the  integrity  of  the  spinal 
column;  if  a  distinct  projection  of  the 
spine  is  present,  the  portion  of  bone  which 
appears  most  prominent  is  the  spinous 
process  of  the  lower  vertebra.  In  the 
dorsal  region  the  deformity  is  usually 
well  marked,  as  several  vertebrae  are  often 
involved;  the  length  and  obliquity  of 
the  spinous  processes  makes  the  posterior 
projection  very  considerable.  In  the 
cervical  region  there  is  rarely  much  de- 
formity, owing  to  the  small  size  of  the 
vertebral  bodies,  but  if  several  bones  are 
involved,  the  head  may  be  carried  for- 
wards and  flexed,  necessitating  consider- 
able compensatory  changes  in  the  dorsal, 
or  even  lumbar,  regions.  Lateral  devia- 
tion simulating  torticollis  is  also  not 
uncommon. 

Secondary  changes  in  the  shape  of 
the  thorax  necessarily  accompany  the 
more  advanced  cases  of  caries  in  the  dorsal  legion,  the  sternum 
becoming  convex  anteriorly  so  as  to  compensate  for  the  di- 
minished vertical  measurement  of  the  thorax,  and  the  ribs  crowded 
together  to  such  an  extent  as  almost  to  obliterate  the  intercostal 
spaces.  The  lower  floating  ribs  may,  however,  retain  their  normal 
position,  and  thus  a  horizontal  groove  may  be  produced  correspond- 
ing to  the  line  of  the  tenth  rib.  In  such  cases  the  patient  becomes 
much  stunted  in  growth  and  dwarfed,  constituting  the  typical 
'  hunch-back.' 

4.  Abscess  is  the  most  serious  result  of  spinal  disease,  for,  owing 
to  its  deep  origin,  it  often  attains  considerable  dimensions  before 


■\ 


i 


u^^ 


I-,. 


Fig.  348. —  Advanced  Tu- 
berculous Disease  of 
Spine  in  Dorsal  Region. 


DISEASES  OF  THE  SPINE 


709 


it  is  recognised  or  treated,  whilst  it  is  usually  impossible  to  deal 
with  the  causative  lesion  in  the  bones:  if  once  the  cavity  becomes 
invaded  by  pyococci,  an  exceedmgly  grave  complication  is  intro- 
duced into  the  case,  which  may  even  determine  a  fatal  issue.  It 
is  relativelv  more  common  in  adults  than  in  children.  The  pus 
collects  primarilv  on  the  anterior  aspect  of  the  vcrtebrse  beneath 
the  anterior  common  ligament  (Fig.  346),  which  may  be  stripped 
from  the  bones  for  a  considerable  distance,  owing  to  the  tension 


Fig.  349. — Lumbar  Abscess  arising 
FROM  Tuberculous  Disease  of 
THE  Dorsi-Lumbar  Spine. 


Fig.  350.  —  Lumbar  Abscess. 
Lateral  View  of  Same 
Patient. 


The    projection   of   the   spinous   processes   is  evident;   the   lateral    curve  is 
probablv  merely  an  associated  or  antecedent  deformity. 

within  the  abscess  cavity.  It  thence  finds  its  way  to  the  sides  of 
the  bodies  after  perforating  the  ligament,  and  burrows  in  various 
directions,  according  to  the  portion  of  the  spine  involved. 

In  the  cervical  region  a  chronic  retro- pharyngeal  abscess  is  first 
formed ;  it  pushes  the  posterior  pharyngeal  wall  forwards,  and  may 
be  detected  from  the  mouth  as  an  elastic  fluctuating  swelling, 
which,  by  its  size,  often  leads  to  some  difficulty  in  swallowing  and 
breathing,  whilst  oedema  of  the  glottis  may  be  induced.  Left  to 
itself,  it  may  burst  into  the  pharynx,  and  suffocate  the  child,  or  at 
best  pyococ'cal  infection  follows,  and  the  osseous  lesion  is  thereby 
aggravated.  Xot  unfrequently  the  pus  finds  its  way  to  the  side 
of  the  neck,  behind  the  vessels"  and  sterno-mastoid,  being  guided  to 


7IO 


A   MANUAL  OF  SURGERY 


the  posterior  triangle  by  the  prevertebral  fascia,  behind  which  it  is 
situated.  Less  frequently  it  pierces  this  fascia,  and  presents  in  the 
anterior  triangle,  or  travels  down  towards  the  mediastinum,  or  along 
the  brachial  nerves  to  the  axilla. 

In  the  dorsal  region,  the  abscess  starts  in  the  same  way  in  front 
of  the  vertebrae,  and  usually  extends  backwards  between  the  verte- 
bral ends  of  the  ribs  to  form  a  dorsal  abscess,  which  points  3  01  4 
inches  from  the  spinous  processes,  and  has  an  impulse  on  coughing. 
Sometimes  it  extends  further  forwards,  coming  to  the  surface  at 
the  spot  where  the  lateral  cutaneous  branches  are  given  off.  Tuber- 
culous disease  of  the  ribs,  leading  to  caries  or  necrosis,  or  even  a 
_....-  --—,..  locahzed  empyema,  may  be   in- 


\. 


^ 


duced  in  such  cases.  In  disease 
of  the  lower  vertebrse,  the  abscess 
generally  burrows  downwards, 
passing  under  the  ligamentum 
arcuatum  internum  of  the  dia- 
phragm, thus  entering  the  psoas 
sheath,  and  giving  rise  to  a  psoas 
abscess. 

In  disease  of  thv  dorsi-lumbar 
or  lumbar  regions,  either  a  lumbar 
or  a  psoas  abscess  may  result.  A 
lumbar  abscess  (Fig.  349)  is  due  to 
the  passage  backwards  of  the  pus 
t  ■  along   the  posterior  branches  of 

I  .  the  lumbar  vessels  and  nerves  to 

I  y  the  outer  border  of  the  erector 

*  '  spinse,  and  usually  presents  super- 

ficially in  Petit's  triangle — i.e., 
between  the  adjacent  borders  of 
the  latissimus  dorsi  and  external 
oblique  muscles.  It  there  forms 
a  tense  fluctuating  swelling,  with 
an  impulse  on  coughing.  A  psoas 
abscess  lies  within  the  sheath  of 
the  psoas  muscle,  the  pus  being 
usually  superficial  to  the  mus- 
cular fibres,  some  of  which  are 
probably  destroyed.  It  is  often  preceded  by  a  condition  of 
spasmodic  contraction  of  the  muscle  with  limited  extension  of 
the  thigh,  which  may  disappear  after  a  period  of  rest.  If  it 
progresses,  a  resistant  mass  of  a  fusiform  shape  is  at  length  felt, 
placed  deeply  in  the  abdomen;  as  it  enlarges,  it  usuahy  burrows 
outwards  under  the  fascia  iliaca  to  form  a  tense  rounded  swelling 
in  the  iliac  fossa  (Fig.  351).  It  thence  travels  under  Poupart's  liga- 
ment, behind  and  external  to  the  common  femoral  vessels,  being 
constricted  at  this  spot  so  as  to  form  a  narrow  neck.  The  sac  then 
expands  behind  the  common  femoral  sheath,  the  vessels  being  often 


Fig.  351. — ^PsoAs  Abscess  pointing 
IN  THE  Iliac  Fossa,  and  Burrow- 
ing AMONGST  Adductor  Muscles. 


DISEASES  OF  THE  SPINE  711 

displaced  forwards,  and  the  vein  flattened  out  and  compressed. 
Thence  passing  along  tlie  tendon  of  the  ilio-psoas,  to  the  neighbour- 
hood of  the  lesser  trochanter,  the  abscess  usually  burrows  amongst 
the  adductor  muscles,  forming  a  large  swelling  on  the  inner  side  of 
the  thigh,  and  comes  to  the  surface  at  or  near  the  saphenous  open- 
ing to  the  inner  side  of  the  main  vessels,  and  hence  may  be  mis- 
taken for  a  femoral  hernia.  Occasionally  the  pus  follows  backwards 
along  the  internal  circumflex  artery,  and  may  point  behind  the  great 
trochanter;  in  other  rare  cases  the  abscess  has  been  known  to  extend 
down  the  leg,  and  has  even  been  evacuated  by  the  side  of  the  tendo 
Achillis.  In  a  few  instances  the  pus  finds  its  way  down  into  the 
pelvis  instead  of  passing  under  Poupart's  ligament,  and  then  points 
in  the  ischio-rectal  fossa,  or  possibly  burrows  through  the  sacro- 
sciatic  foramen. 

In  the  most  typical  variety — viz.,  with  a  pouch  both  above  and 
below  Poupart's  ligament,  communicating  by  a  narrow  neck — the 
ca\'ity  is  more  or  less  shaped  like  an  hourglass,  and  fluctuation 
can  be  detected  in  the  lower  pouch  by  compressing  the  upper,  oi 
vice  versa.  There  is,  of  course,  an  impulse  on  coughing  in  the  por- 
tion that  projects  below  Poupart's  ligament. 

The  constitutional  disturbance  associated  with  the  formation  of 
these  abscesses  is  usually  but  slight,  and  there  is  no  leucocytosis : 
perhaps  there  is  a  small  rise  of  temperature  at  night,  but  if,  as 
occasionally  happens,  ordinary  pyogenic  organisms  find  their  way 
into  the  sac  from  within  the  body,  this  may  become  more  marked. 
As  the  pus  comes  to  the  surface,  considerable  pain  may  be  experienced 
from  the  tension  and  irritation  of  the  soft  parts,  and  fever  of  a  hectic 
type  is  induced. 

5.  Nervous  Symptoms  occur  in  about  one  out  of  every  thirteen 
cases  of  tuberculous  caries  of  the  spine,  and  then  generally  in  bad  or 
neglected  cases.  They  are  scarcely  ever  due  to  the  acuteness  of  the 
curve,  but  have  been  known  to  result  from  fracture  of  the  spine, 
the  integrity  of  which  had  been  weakened  by  the  inflammatory 
process.  The  more  usual  cause  is  an  extension  backwards  of  the 
disease,  so  that  a  nodule  or  button  of  tuberculous  material  forms 
beneath  the  posterior  common  ligament,  or  pushes  through  it,  com- 
pressing the  cord  against  the  laminae,  and  actually  invading  the 
dura  mater.  Occasionally  an  abscess  burrows  backwards  into  the 
spinal  canal  and  compresses  the  cord,  and  then  the  sj'-mptoms  may 
be  relieved  by  opening  the  abscess  even  at  a  distance. 

The  effect  produced  varies  with  the  rapidit}'  and  acuteness  of  the 
process.  When  the  pressure  is  rapidly  developed,  a  subacute 
myelitis  ensues;  but  more  frequently  it  is  of  a  chronic  or  sclerosing 
type.  The  cord  is  then  found  to  be  constricted  or  indented  by  the 
tuberculous  mass,  and  perhaps  considerably  reduced  in  size;  its 
texture  is  firmer  than  normal,  and  the  colour  grayish.  The  onset 
of  s\Tnptoms  msiy  be  suddenly  induced  by  haemorrhage  or  displace- 
ment of  bone,  but  is  more  usually  gradual.  The  dorsal  region  (about 
the  eighth  vertebra)  is  that  most  often  involved,  since  there  is  plenty 


712  A   MANUAL  OF  SURGERY 

of  space  in  the  cervicnl  region,  and  in  the  lumbar  the  cord  has 
broken  iij)  into  the  cauda  equina. 

The  symptoms  arising  from  pressure  on  the  cord  must  be  distin- 
guished from  those  due  to  irritation  of,  or  pressure  on,  the  nerve- 
roots.  Ihe  latter  causes  neuralgic  pain  within  the  area  of  distribu- 
tion of  some  nerve-root,  possibly  in  the  later  stages  associated  with 
anaesthesia  {anasfhesia  dolorosa),  or  a  limited  motor  weakness  if  the 
anterior  roots  are  involved.  In  compression  of  the  cord,  motor 
phenomena  aie  more  evident  than  sensory,  since  the  sensory  track 
lies  towards  the  centre  of  the  cord,  and  so  is  more  protected  from 
injury.  At  first  there  is  some  dragging  of  the  toes  on  walking,  and 
loss  of  power  in  the  legs,  combined  usually  with  neuralgia,  weak- 
ness of  the  sphincters,  and  exaggeration  of  the  reflexes ;  the  muscles 
are  sometimes  in  a  condition  of  spastic  contraction.  Later  on  the 
paralysis  becomes  complete,  and,  as  degeneration  of  the  cord  follows, 
secondary  contractions  and  rigidity  occur,  and  the  reflexes  diminish. 
Absolute  incontinence  sometimes  supervenes,  the  bladder  emptving 
itself  periodically  and  involuntarily,  or  the  urine  trickling  away 
continually  from  cither  a  full  or  empty  viscus. 

Special  mention  must  be  made  here  of  a  grave  complication  only 
occurring  in  the  upper  cervical  region,  which  may  result  in  sudden 
death.  Tuberculous  disease  of  the  upper  two  vertebrae  usually 
originates  in  one  or  more  of  the  large  articulations  on  either  side  of 
the  atlas;  if  these  joints  become  disorganized,  displacement  may 
occur  at  any  moment,  and  in  this  way  the  occiput  slips  forwards 
upon  the  atlas,  and  may  lead  to  gradual  or  sudden  compression  of 
the  cord  and  consequent  death.  The  disease  sometimes  spreads  to 
the  body  of  the  axis,  and  by  this  means  the  odontoid  process  becomes 
detached,  or  the  transverse  ligament  gives  way;  in  either  case,  the 
weight  of  the  head  carries  the  arch  of  the  atlas  forwards,  and  death 
ensues  at  once  from  compression  of  the  medulla. 

Course  of  the  Case  and  Prognosis. — Left  to  itself,  the  disease 
usually  progresses  more  or  less  steadily,  the  bone  lesion  becoming 
gradually  more  marked,  and  abscesses  are  likely  to  develop.  If 
treated  efficiently,  and  taken  in  hand  early,  repair  by  ankylosis  may 
be  confidently  expected.  Even  when  an  abscess  forms,  prolonged 
rest  may  lead  to  its  disappearance,  the  fluid  part  of  the  pus  being 
absorbed,  and  the  solid  elements  becoming  inspissated  and  drv, 
forming  a  putty-like  mass  Iving  on  the  front  of  the  vertebral  column ; 
this  may  subsequently  undergo  liquefaction,  probably  owing  to  in- 
fection with  pyogenic  cocci,  constituting  what  is  known  as  a  residual 
abscess.  Should,  however,  the  abscess  burst  or  be  opened,  and 
become  septic,  symptoms  of  chronic  toxaemia  supervene,  and  the 
patient  is  sooner  or  later  exhausted  by  the  discharge,  and  dies 
from  asthenia.  If  dealt  with  judiciously,  and  sepsis  avoided,  the 
abscesses  may  be  cured,  and  if  at  the  same  time  the  spine  is  kept 
at  rest,  and  suitable  hygienic  measures  are  adopted,  the  lesion  in 
the  bones  is  able  to  consolidate.  The  onset  of  paraplegia  must  not 
be  looked  on  as  rendering  the  case  hopeless,  since  with  prolonged 


DISEASES  OF  THE  SPINE  7^3 

rest  the  paralytic  phenomena  often  disappear  entirely-  Septic 
cystitis  and  bedsores  may  arise  as  complications,  and,  if  allowed  to 
progress,  cause  death.  Occasionally,  as  a  result  of  the  implication 
of  the  spinal  canal,  diffuse  meningitis  follows,  leading  to  a  rapidly 
fatal  termination.  As  in  tuberculous  disease  elsewhere,  the  patient 
also  runs  the  risk  of  acute  miliary  tuberculosis,  whilst  other  organs 
— e.g.,  the  lungs,  brain,  or  kidney — may  become  affected.  In  spite 
of  these  possibilities,  however,  the  prognosis  is  good  as  regards  life 
in  cases  free  from  complications,  and  where  suitable  treatment  is 
practicable. 

The  Diagnosis  of  spinal  caries  is  rarely  a  matter  of  difficulty  when 
the  characteristic  deformity  exists,  but  "in  the  early  stages,  when  the 
displacement  is  not  evident,  or  if  there  is  only  a  very  slight  promi- 
nence of  the  spinous  processes,  it  is  Hkely  to  be  mistaken  for  a  simple 
rachitic  or  statical  curve;  whilst  if  neuralgic  pain  is  a  prominent 
s\nTiptom,  it  may  possibly  be  looked  on  as  a  case  of  spinal  or  inter- 
costal neuralgia^  or  as  rheumatism,  or  even  be  ascribed  to  renal 
affections.  Tumours  of  the  spine,  such  as  cancer  or  hydatid  cysts, 
svphilitic  disease,  and  aneurismal  erosion,  also  produce  symptoms 
somewhat  resembling  those  of  spinal  caries,  and  in  adults  it  may  be 
impossible  from  the^'local  phenomena  alone  to  determine  which  of 
these  conditions  is  present,  although  a  careful  consideration  of  the 
general  history  and  of  the  onset  of  the  s\anptoms,  and  a  radiographic 
examination,  may  throw  light  upon  the  case.  Frequently  the  course 
of  the  disease  and  the  reaction  to  treatment  must  be  mainly  rehed  on 
in  forming  a  diagnosis.  The  spine  should  always  be  examined  from 
before  and  from  behind,  and  pain  on  pressure  over  the  transverse 
processes  and  rigidity  of  the  back  are  the  symptoms  on  which  most 
stress  should  be  laid. 

Local  Treatment. — In  order  to  promote  the  development  of  a 
suitable  and  sufficient  synostosis,  the  great  essential  is  absolute 
immobihzation  and  freedom  from  weight-bearing.  At  the  same 
time  it  is  desirable  that  means  should  be  taken  to  hmit  the  degree 
of  deformity.  These  objects  may  be  effected  in  the  following 
ways : 

{a)  By  the  Adoption  of  the  Recumbent  Posture. —The  patient  is 
kept  in  bed  Iving  on  his  back  without  a  pillow,  and  \nth  sheets 
passing  over  the  trunk  and  thighs,  secured  by  sandbags  on  either 
side  and  between  the  legs.  If  thought  necessary,  extension  by 
weight  and  pullev,  as  described  at  p.  534 ,  may  also  be  employed, 
together  with  extension  of  the  head  by  a  weight  attached  to  a 
chin-strap  and  occipital  band,  which  are  united  just  above  the  ears. 
For  children  a  weight  of  three  pounds  attached  to  each  of  these  usu- 
ally suffices  to  tire  the  muscles  and  prevent  serious  deformity.  The 
child  is  kept  h'ing  down  in  this  way  for  some  months  (probably  six 
as  a  minimum),  and  certainly  until  the  pain  has  ceased.  It  may 
then  be  possible  to  arrange  for  the  appHcation  of  a  suitable  jacket  or 
brace,  and  in  this  the  child  may  be  allowed  to  walk  about  until  the 
disease  is  absolutely  cured. 


714 


A   MANUAL  OF  SURGERY 


(b)  The  use  of  Phelps's  Box  is  specially  valuable  when  treating 
children.  The  child  is  placed  in  a  wooden  box  6  inches  deep 
(I'ig-  352).  the  lower  end  of  which  is  divided  into  two  portions,  one 
for  each  leg,  a  suitable  aperture  being  left  at  the  junction  of  the 
divided  parts  for  the  passage  of  the  excreta.  Careful  padding  is 
applied  to  the  whole  of  the  interior,  and  the  child  is  strapped  and 
bandaged  into  this  apparatus  (Fig.  353),  and  kept  there  for  a  period 
varying  from  six  to  twelve  months.  The  whole  trunk  is  thus  im- 
mobilized, and  the  child  can  be  carried  about  in  his  box,  and  taken 
into  the  open  air.  Extension  can  also  be  made,  if  necessary,  by 
elastic  accumulators  attached  to  the  head  and  neck,  or  legs.    Various 


Fig,  352. — Phelps's  Box  with- 
out THE  Pads. 


Fig. 


353. — The  Same  with  the 
Child  in  Position. 


modifications  of  this  plan  of  treatment  have  been  suggested  and 
practised,  and  measures  can  easily  be  arranged  for  keeping  the  body 
and  spine  hyper-extended,  so  as  to  limit  the  deformity.  The  '  back- 
door '  splint  devised  by  Dr.  Gauvain*  is  eminently  suitable  to 
achieve  this  purpose. 

(c)  In  very  young  children  perhaps  the  simplest  apparatus  is  a 
double  Thomas's  splint,  with  a  suitable  crutch  above  to  fix  and 
support  the  head. 

((/)  The  Application  of  a  Plaster  Jacket  is  desirable  in  children  in 
the  later  stages  of  the  disease,  but  in  adults  it  may  be  used  safely 
somewhat  earlier,  though  -never  in  the  acute  stage.  If  the  disease 
*   Gauvain,  Lancet,  March  4,  191 1. 


DISEASES  OF  THE  SPINE 


715 


exists  in  the  dorsal  region,  the  plaster  jacket  should  extend  from  the 
axilhe  to  just  below  the  iliac  crests;  if  situated  above  the  mid-dorsal 
region,  the  head  must  also  be  immobilized  by  the  formation  of  a 
suitable  collar  (Fig.  354)-  The  patient,  who  has  been  prepared  as 
for  an  operation,  is  stripped  to  below  the  waist,  and  a  closely  knitted 
woollen  vest  fitted  to  the  body,  and  fixed  by  straps  passing  over 
the  shoulders.  A  woollen  pad  is  placed  beneath  it  over  the  abdo- 
men to  allow  for  distension  after  meals,  and  in  women  similar 
smaller  pads  may  be  placed  over  the  mammae  to  protect  them. 
Coarse  canvas  bandages, 
into  the  meshes  of  which 
plaster  of  Paris  has  been 
rubbed,  are  thoroughly 
soaked  in  water,  and  then 
wound  evenly  round  the 
body  until  a  layer  of  five 
or  six  thicknesses  is  ob- 
tained. Over  this  a  paste 
of  plaster  of  Paris,  pre- 
pared as  described  at 
p.  483,  is  laid,  until  the 
jacket  has  attained  suffi- 
cient thickness  and  con- 
sistency, and  before  it  is 
quite  set  it  is  carefully 
moulded  to  fit  accurately 
to  the  pelvic  ring,  or  to 
the  chin  and  neck.  It  is 
allowed  to  dry  before  the 
patient'sposition  is  altered. 
Tf  the  disease  is  in  the 
lumbar  region,  the  jacket 
may  be  applied  with  the 
patient  in  the  horizontal  Fig.  354.— Plaster  Jacket  applied  for 
position;  but  above  this  Tuberculous  Caries  of  Upper  Dorsal 
f,  ,•      ,  ,1  Spine,  illustratingFixation  OF  theHead 

the   patient   must   be   ver-        ^nd  Neck  by  a  Collar,  and  Method  of 
tical,  so  as  to  extend  the        Lightening  the  Jacket  by  Cutting  out 
spine.       This    is     best    se-        a  Portion.     (After  Dr.  Gauvain.) 
cured  by  suspending  him 

by  means  of  a  bridle  attached  to  the  head  in  a  tripod  or  gallows, 
and  the  toes  may  be  allowed  to  touch  the  ground.  The  jacket  may 
be  reinforced  to  meet  particular  strains,  and  may  subsequently  be 
lightened  by  cutting  out  unnecessary  portions.  It  must  be  worn 
until  all  pain  and  evidence  of  active  disease  have  finally  dis- 
appeared, and  after  that  the  patient  should  be  fitted  with  a 
poroplastic  support  for  a  time. 

{e)  Some  surgeons  prefer  to  use  braces  rather  than  a  plaster  jacket 
in  the  treatment  of  Pott's  disease.  Many  such  appliances  have 
been  devised,  but  perhaps  the  most  satisfactory  is  that  known  as 


7i6 


A   MANUAL  OF  SURGERY 


Taylor's  brace.  For  a  full  description,  larger  textbooks  should  be 
consulted.  It  must  suffice  here  to  point  out  that  it  consists  of  two 
upright  steel  bars  (Fig.  355),  placed  one  on  either  side  of  the  spines 
of  the  vertebrae,  and  carefully  moulded  to  the  back.  They  are 
connected  below  to  a  U-shaped  piece  of  steel  which  runs  down  on 
either  side  to  about  the  level  of  the  middle  of  the  sacrum,  and  is 
secured  below  by  straps  passing  round  the  thighs  and  groins;  and 
above  they  are  attached  to  a  shallower  U-shaped  steel  frame  which 
passes  over  the  root  of  the  neck  and  the  clavicles.  In  front  a 
leather  apron  (Fig.  356)  covers  the  front  of  the  chest  and  upper 
part  of  the  abdomen,  and  is  secured  by  straps  and  buckles  to  the 


Fig.  355. — Taylor's  Brace  (Pos- 
terior View). 


Fig.  356. — Taylor's  Brace  (An- 
terior View),  with  Leather 
Apron  applied. 


brace  about  its  centre,  and  to  the  ends  of  the  upper  U-shaped 
cross-piece.  Carefully-fitted  pads  ore  placed  on  either  side  of  the 
spine  opposite  the  point  of  greatest  projection  and  secured  to  the 
steel  bars.  They  serve  as  points  of  pressure  against  the  spine  so 
as  to  prevent  or  limit  deformity,  whilst  at  the  same  time  the  upper 
part  of  the  spine  and  the  thorax  are  prevented  from  falling  forwards 
and  thus  increasing  the  deformity.  Should  the  cervical  or  cervico- 
dorsal  region  be  involved,  a  ring  or  collar  to  support  and  carry  the 
chin  in  a  suitable  position  of  extension,  and  fixed  by  a  vertical  rod 
to  the  brace,  must  be  added  to  the  apparatus. 

During  the  whole  course  of  treatment,  the  general  condition  of  the 
individual  must  be  carefully  attended  to,  and  suitable  food  and 


DISEASES  OF  THE  SPINE  717 

tonics  administered.  The  child  should  spend  as  much  time  as  pos- 
sible in  the  open  air,  and  preferably  at  the  seaside.  When  all  symp- 
toms of  pain  and  irritation  have  disappeared,  the  patient  may  be 
allowed  gradually  to  get  about  again  with  a  mechanical  support, 
and,  indeed,  this  should  not  be  dispensed  with  for  tv/elve  months 
after  apparently  com]5lete  recovery. 

The  Treatment  of  the  Chronic  Abscesses  is  always  a  matter  of 
anxiety,  since,  when  once  opened,  they  usually  take  a  considerable 
time  to  heai,  and  if  allowecl  to  become  septic  the  prognosis  of  the 
case  is  seriously  affected.  A  general  description  of  the  methods 
employed  has  already  been  given  at  p.  186. 

A  Retropharyngeal  Abscess  should  always  be  dealt  with  from  the 
neck,  as  described  in  Chapter  XXX. 

A  Dorsal,  Lumbar,  or  Psoas  Abscess  should  be  tapped  with  a  large 
aseptic  trocar  and  cannula,  and  then  irrigated,  injected  with  steril- 
ized iodoform  emulsion,  and  afterwards  closed  without  drainage. 
Occasionally  a  cure  can  be  obtained  in  this  way  by  one  tapping,  but 
only  when  no  active  disease  is  present,  and  when  the  patient's 
general  health  is  good;  more  commonly  the  fluid  will  re-collect,  and 
the  same  process  may  need  to  be  repeated  two  or  three  times. 
Sometimes  the  fluid  finds  its  way  along  the  track  of  the  cannula, 
and  a  sinus  results,  which  must  be  dressed  antiseptically  until  cica- 
trization has  occurred.  The  best  position  in  which  to  tap  a  psoas 
abscess  is  at  a  spot  just  above  and  internal  to  the  anterior  superior 
spine;  a  small  incision  is  made  through  the  skin  and  muscles,  suffi- 
cient for  the  insertion  of  the  trocar  and  to  make  certain  of  the  absence 
of  intestine  and  large  bloodvessels.  Should  the  abscess  point  below 
Poupart's  ligament,  close  to  the  saphenous  opening,  it  ma\^  be 
necessary  to  deal  with  it  there,  perhaps  in  addition  to  tapping  it  in 
the  usual  place.  It  must  be  remembered  that  the  femoral  vessels 
are  displaced  somewhat  and  stretched  over  the  sac,  and  precautions 
should  be  taken  to  prevent  puncture  of  the  vein,  an  accident  which 
has  occurred. 

Some  prefer  to  open  the  abscess  freely,  and  curette  its  interior 
gently  with  a  Barker's  flushing  gouge.  Certainly  by  this  means  the 
tuberculous  membrane  and  debris,  and  spicules  of  bone,  etc.,  can 
be  thoroughly  removed,  but  there  is  also  more  likelihood  of  a  sinus 
remaining.  Personally  we  are  not  in  favour  of  its  use  for  this  pur- 
pose, and  maintain  that  the  method  which  we  have  advocated 
above  is  better,  since  there  is  less  probability  of  the  wound  becoming 
infected  with  the  tuberculous  material,  and  hence  of  the  formation 
of  a  sinus. 

Occasionally  it  may  seem  advisable  to  open  freely  the  sac  of  a 
psoas  abscess,  and  where  the  disease  originates  in  the  lumbar  verte- 
brae, it  has  been  recommended  by  Sir  F.  Treves  and  others  to  cut 
down  along  the  outer  border  of  the  erector  spinse,  and  deal  with  it 
from  behind.  A  vertical  incision  is  made  in  this  situation,  down  to 
the  transverse  processes,  and  the  lumbar  fascia  and  quadratus  lum- 
borum  are  divided  by  a  transverse  cut  opposite  the  tip  of  one  of 


7i8  A   MANUAL  OF  SURGERY 

these;  the  abscess  sac  is  then  easily  reachod  and  opened.  The 
advantage  of  this  plan  is  that  the  bodies  of  the  vertebne  can  be 
examined,  and  even  scraped,  or  sequestra  removed. 

The  Treatment  of  Paraplegia  arising  in  the  course  of  Pott's 
disease  consists  in  maintaining  the  immobilization  of  the  spine  by 
recumbency,  combined  with  weight  extension  applied  to  both  legs. 
At  the  same  time,  extra  precautions  should  be  adopted  in  order  to 
prevent  bedsores  over  points  of  pressure.  Should  any  difticulty  in 
micturition  arise,  regular  catheterism  must  be  adopted,  and  the 
greatest  care  directed  to  the  sterilization  of  the  catheters,  septic 
cystitis  being  always  due  to  external  contamination.  In  such  cases 
the  penis  and  urethra  must  be  purified,  and  the  former  wrapped  in  a 
dry  aseptic  dressing  in  the  intervals  between  catheterism.  [laminec- 
tomy (p.  698)  is  required  in  order  to  relieve  pressure  upon  the  cord 
in  the  following  cases;  [a]  When  septic  cystitis  or  the  existence  of 
deep  bedsores  is  threatening  life;  {h)  when,  in  spite  of  complete  rest, 
the  symptoms  persist  or  increase,  and  particularly  when  the  para- 
lytic phenomena  come  on  ^apidl3^  suggesting  the  rupture  of  an 
abscess  or  displacement  of  a  fragment  of  bone;  ic)  when  paraplegic 
symptoms  manifest  themselves  late  in  the  case,  and  are  possibly  due 
to  a  development  of  fibro-cicatricial  tissue  outside  the  membranes 
(peri-pachvmeningitis).  {d)  Finally,  whenever  the  tuberculous 
process  mainly  aftects  the  neural  arches,  there  is  no  reason  for  not 
treating  it  by  operation,  if  necessary. 

in.  Syphilitic  Disease  of  the  spine  develops  in  the  shape  of  gum- 
mata,  commencing  beneath  the  periosteum  which  covers  the  bodies; 
it  is  of  unfrequent  occurrence,  and  gives  rise  to  symptoms  somewhat 
similar  to  those  ot  tuberculous  caries,  from  which  the  diagnosis  is  not 
always  easy,  apart  from  the  history  and  its  reaction  to  treatment. 
It  usually  occurs  in  adults,  and  is  said  to  affect  mainly  the  cervical 
vertebra  (Tubby) ;  cases  have  been  recorded  in  which  a  gumma 
opened  into  the  pharynx,  and  portions  of  bone  were  discharged 
therefrom  and  expectorated.  The  co-existence  of  a  syphilitic  his- 
tory and  of  specific  lesions  elsewhere  may  help  one  in  coming  to  a 
decision  as  to  the  nature  of  the  affection. 

Treatment  consists  in  the  administration  of  suitable  anti-syphilitic 
drugs,  and  in  the  use  of  a  spinal  support. 

IV.  Rheumatic  Spondylitis  is  a  condition  occasionally  met  with 
arising  from  the  same  causes,  and  associated  with  much  the  same 
phenomena  as  rheumatism  elsewhere.  It  may  involve  either  the 
ligamentous  or  muscular  tissues,  or  may  attack  the  intervertebral 
joints.  Any  part  of  the  spine  is  involved,  but  perhaps  the  most 
marked  features  are  presented  in  the  cervical  region.  Considerable 
impairment  in  the  movements  of  the  head  is  then  produced,  and  the 
neck  may  be  laterally  deflected,  somewhat  simulating  torticollis. 
If  untreated,  adhesions  form  between  the  bones,  and  the  loss  ot 
movement  may  be  permanent.  Considerable  pain  of  a  neuralgic 
type,  due  to  implication  of  or  pressure  upon  the  nerve-roots,  is 
usually    experienced        The    treatment    is    of    an    ordinary    anti- 


DISEASES  OF  THE  SPINE  719 

rheumatic  nature,  combined,  perhaps,  with  the  use  of  a 
support. 

rhe  so-called  Gonorrhoeal  Rheumatism  also  affects  the  spine 
occasionally,  and  brings  about  much  the  same  results. 

V^.  Spondylitis  Deformans  is  the  term  applied  to  a  condition  of 
the  spine  which  results  in  rigidity  and  kyphosis.  It  is  seen  most 
frequently  in  old  people,  who  become  bent  and  shorter  than  for- 
merly; but  it  also  develops  in  those  who  have  had  to  follow  laborious 
occupations,  especially  if  in  the  bending  position,  and  hence  is  not 
uncommon  in  country  workhouses  and  infirmaries  amongst  those 
who  have  had  to  live  and  work  in  the  fields.  It  is  more  or  less 
akin  to  osteo-arthritis,  and  characterized  by  very  similar  anatomical 
changes.  The  spine  is  stiff  and  rigid  (hence  the  name  '  poker-back  ' 
sometimes  applied  to  it),  and  this  results  from  absorption  of  the 
intervertebral  discs,  from  synostosis  of  the  vertebral  bodies,  some- 
times with  the  formation  and  interlocking  of  osteoph3^tes,  and  especi- 
all}^  from  ossification  of  the  spinal  ligaments.  Pain  is  sometimes, 
but  not  invariably,  a  marked  feature  of  the  case,  and  is  then  due  to 
irritation  of  nerve-roots.  A  large  portion  of  the  spine  is  usually 
involved,  and  marked  kyphosis  is  the  result.  Two  chief  varieties 
have  been  described,  but  it  is  likely  that  they  are  merely  modifica- 
tions of  the  same  process;  {a)  Von  Bechterew's  variety  is  one  in 
which  the  upper  cervical  and  dorsal  regions  are  mainly  involved, 
producing  a  limited  kj-phosis,  with  flattening  of  the  chest  and  fixa- 
tion of  the  ribs.  In  many  of  these  cases  evidences  are  present  of 
degenerative  changes  in  the  posterior  columns  of  the  cord  and  oi 
irritation  of  the  nerve-roots.  (&)  The  Striimpell-Marie  type,  some- 
times known  as  spondylose  rhizomeHque,  is  characterized  by  the  affec- 
tion first  attacking  the  lower  portion  of  the  spine,  but  it  also  involves 
the  hip  and  shoulder  joints.  In  both  forms  there  is  a  gradual  ex- 
tension of  the  process  through  the  whole  length  of  the  column,  and 
finally  it  attacks  the  articulations  between  the  ribs  and  the  verte- 
brae; when  these  become  fixed,  the  respiratory  movements  are 
considerably  impaired,  and  hence  death  is  likely  to  ensue  from 
pulmonary  mischief.  Treatment  must  follow  along  the  lines  laid 
down  for  osteo-arthritis. 

Tdmours  of  the  Spine  are  usually  malignant  in  character,  and  most  com- 
monly secondary  to  cancer  or  sarcoma  elsewhere.  Simple  tumours,  such  as 
chondroma,  osteoma  and  hydatid  cysts,  do  occur,  as  also  primary  sarcoma 
The  chief  sj-mptoms  are  severe  and  localized  pain,  which  is  constant,  and 
unrelieved  by  rest  in  the  recumbent  posture,  together  with  early  excurvation 
and  paraplegia.  Deformity  is,  however,  by  no  means  constant.  Neuralgic 
pain  and  motor  spasms,  due  to  involvement  of  the  nerve-roots,  may  con- 
siderably aggravate  the  patient's  sufferings.  These  phenomena  manifesting 
themselves  in  an  adult  should  always  suggest  the  presence  of  a  morbid  growth, 
and  the  more  rapid  the  onset,  the  more  likely  is  a  diagnosis  of  malignant  dis- 
ease. Treatment  necessarily  is  but  rarely  feasible,  although  an  exploratory 
operation  is  quite  justifiable  if  the  disease  is  primary  and  the  patient  not 
profoundly  cachectic. 

Tumours  of  the  Spinal  Cord  and  Membranes  develop  in  several  situations, 
and  the  symptoms  are  thereby  somewhat  modified,     (a)  Outside  the  spinal 


720  A   MANUAL  OF  SURGERY 

dura.  Lipoma  and  sarcoma  are  here  most  often  seen,  and  the  symptoms  of 
cord  pressure,  such  as  loss  of  power  and  sensation,  are  preceded  by  those  of 
spinal  irritation,  e.g.,  neuralgic  pain,  increased  on  movement,  and  are  often 
limited  for  some  time  to  one  side.  Multiple  neuro-hbromata  of  the  nerve- 
roots  are  by  no  means  uncommon,  (b)  They  may  grow  from  the  inner  aspect 
of  the  dura  mater,  and  thus  produce  symj)toms  of  cord  pressure  and  meningeal 
irritation  concurrently.  Sarcoma,  endothelioma,  fibroma  and  gumma,  are 
the  commonest  forms  of  neoplasm  in  this  situation,  (c)  From  the  spinal  cord 
itself,  myxoma,  psammoma,  and  sarcoma  may  originate.  The  symptoms 
are  those  of  paraplegia  combined  with  some  localized  and  referred  pain  or 
tenderness,  and  either  bilateral  from  the  start,  or  sometimes  of  the  crossed 
type,  anaesthesia  being  marked  on  one  side  of  the  body,  and  paralysis  and 
hyperaesthesia  on  the  other — i.e.,  on  the  side  of  the  tumour.  Left  to  them- 
selves, patients  suffering  from  any  of  these  growths  are  certain  to  die,  and 
hence  an  exploratory  laminectomy,  with  a  view  to  removal  of  the  growth,  if 
practicable,  is  always  indicated  when  a  diagnosis  has  been  effected.  The 
possibility  of  the  disease  being  syphilitic  in  origin  must  not  be  overlooked, 
and  hence  a  preliminary  thorough  course  of  iodide  of  potassium  and  mercury 
should  always  be  instituted  before  operating.  The  results  hitherto  obtained 
have  been  distinctly  encouraging,  although  many  of  the  cases  are  left  till  too 
late,  and  the  mortality  is  certain  to  be  high. 

The  only  inflammatory  disease  of  the  cord  which  need  be  alluded 
to  here  is  one  the  results  of  which  have  already  been  mentioned 
constantly  in  the  chapter  dealing  with  the  deformities  of  the  body 
(Chapter 'XIX. ),  viz.,  Infantile  Paralysis. 

This  condition  is  undoubtedly  infective  in  nature,  although  there 
is  still  some  doubt  as  to  the  actual  causative  organisms ;  the  meningo- 
coccus and  staphylococcus  have  been  isolated  from  the  cerebro-spinal 
fluid.  It  mainly  affects  children  in  the  first  three  years  of  hfe;  it 
is  especially  common  in  the  Iropics,  and  shows  a  seasonal  variation 
in  this  country,  three-quarters  of  the  cases  occurring  between  June 
and  October;  it  is  occasionally  epidemic,  and  may  attack  several 
members  of  a  family.  I  he  part  attacked  is  chiefly  the  anterior 
cornua  of  the  grey  substance  of  the  cord  [acute  anterior  polio- 
myeliiis),  as  a  result  of  which  the  multipolar  ganglion  cells  situated 
therein  are  destroyed,  and  this  is  followed  by  secondary  degenera- 
tion of  peripheral  nerves  and  muscles.  The  symptoms  come  on 
abruptly,  and  are  often  introduced  by  a  short  febrile  attack  with 
pain  in  the  back  and  head;  paralysis  usually  shows  itself  within 
three  to  ten  days;  occasionally  the  general  symptoms  are  scarcely 
noticeable,  and  the  onset  of  the  paralysis  is  merely  associated  with 
some  irritability.  In  all  cases  the  paralysis  quickly  reaches  its 
maximum,  perhaps,  indeed,  in  a  few  hours;  it  generally  remains 
stationary  for  a  period  of  from  one  to  four  weeks,  and  then  a  certain 
amount  of  recovery  ensues,  possibly  rapid  at  first,  but  slower 
subsequently.  The  portions  that  remain  paralyzed  early  lose  their 
nutrition,  owing  to  the  destruction  of  their  trophic  ganglionic 
centres,  and  become  cold  and  bluish  in  colour ;  they  do  not  respond 
to  the  faradic  current,  and  even  the  reaction  of  degeneration  is  lost; 
finally,  deformities  due  to  the  unbalanced  action  of  opposing  groups 
of  healthy  muscles  may  appear,  whilst  the  development  and  growth 
of  the  affected  limbs  are  impaired.     The  distribution  of  this  affection 


DISEASES  OF  THE  SPINE  721 

is  very  variable,  but,  speaking  generally,  the  legs  are  most  com- 
nn)nly  affected,  the  lower  halves,  and  not  the  upper,  being  mainly 
involved;  various  forms  of  talipes  may  result  therefrom,  as  also 
weak  and  flail-like  conditions  of  the  knee  and  ankle.  When  the 
thigh  is  included,  the  quadriceps  extensor  and  adductors  are  usually 
picked  out.  In  the  arm  the  deltoid  is  most  often  paralyzed,  and 
after  this  the  muscles  on  the  extensor  side  of  the  forearm,  including 
the  supinator  longus.  The  face  and  neck  are  rarely  involved,  but 
the  abdominal  and  back  muscles  may  be  attacked.  The  Treatment 
in  the  early  stages  is  directed  towards  improving  the  general  health, 
and  disinfecting  the  alimentary  canal,  from  which  the  infection 
probably  arises.  The  nutrition  of  the  affected  muscles  is  maintained 
as  far  as  possible  by  electricity  and  massage,  and  deformities  are 
prevented  by  suitable  splints  directed  to  keeping  the  affected 
muscles  relaxed  and  not  stretched.  In  the  later  stages,  when 
deformed,  or  weak  and  flail-like,  limbs  have  resulted,  various  means 
may  be  adopted  in  order  to  improve  the  functions  of  the  part. 
{a)  Mechanical  support  is  often  needed,  and  this  must  be  carefully 
regulated,  in  order  to  assist,  and  not  to  hamper,  the  movements 
of  the  individual  by  its  unnecessary  weight.  In  paralytic  talipes, 
irons  fixed  to  the  boots,  and  rising  above  the  knee,  or  even  some- 
times running  up  to  the  pelvis,  are  frequently  required,  {h)  Teno- 
tomy, or  division  of  muscles  or  f ascise,  may  also  be  needed  in  certain 
deformities,  (r)  Tenoplasty,  or  the  grafting  of  a  healthy  tendon 
into  a  paralyzed  one,  has  been  occasionally  utilized,  as  also  the 
transplantation  of  the  bony  attachments  so  as  to  put  the  relaxed 
and  weak  muscles  on  the  stretch  (p.  426).  (d)  Arthrodesis,  or  the 
fixation  of  joints,  is  a  useful  proceeding  under  circumstances  where 
the  unnatural  mobility  is  difficult  to  control,  or  would  necessitate 
considerable  increase  in  the  weight  of  the  apparatus  required,  or 
where,  from  the  poverty  of  the  patient,  the  apparatus  cannot  be 
obtained.  It  is  especially  serviceable  in  cases  where  two  joints  in 
a  limb  are  flail-like,  one  of  which  may  then  be  ankjdosed  with  ad- 
vantage. The  operation  consists  in  a  modified  excision,  the  car- 
tilage alone  being  sawn  or  scraped  from  the  ends  of  the  bones,  but 
it  must  ahvays  be  remembered  that  the  reparative  activity  in 
paralyzed  limbs  is  small,  {e)  Where  the  whole  limb  is  hopelessly 
powerless  and  a  great  inconvenience  to  the  patient,  amputation  is 
often  the  best  practice.  In  the  lower  extremity,  when  the  knee 
and  ankle  are  both  weak  and  flail-like,  arthrodesis  of  the  knee 
and  removal  of  the  foot  by  a  Syme's  amputation  will  often  provide 
the  patient  with  a  serviceable  limb. 


46 


CHAPTER  XXVI. 
AFFECTIONS  OF  THE  SCALP  AND  CRANIUM. 

Affections  of  the  Scalp. 

Wounds  of  the  scalp  are  produced  either  by  sharp  or  blunt  instru- 
ments, by  falls  on  the  head,  or  by  gunshot  injuries.  From  the 
tenseness  of  the  scalp  over  the  cranium,  it  sometimes  happens  that 
a  blunt  weapon,  such  as  a  policeman's  truncheon,  will  cause  a  wound 
nearly  as  cleanly  cut  as  if  it  had  been  made  with  a  sharp  instrument. 
So  long  as  the  wound  is  superficial  to  the  occipito-frontalis  aponeuro- 
sis, but  little  harm  is  done;  if,  however,  the  layer  of  loose  cellular 
tissue  between  the  aponeurosis  and  the  pericranium  (the  '  dangerous 
area  ')  is  opened  up  and  infected,  cellulitis  (p.  88)  is  likely  to  ensue. 
The  vascular  supply  of  the  scalp  is  so  good  that  sloughing  is  un- 
common ;  a  large  portion  may  be  torn  and  bruised,  and  yet,  if  it  is 
carefully  washed  and  rendered  aseptic,  there  is  every  probabiHty 
that  it  will  retain  its  vitality.  Complete  avulsion  of  the  scalp  usually 
occurs  in  women  from  their  hair  being  caught  in  machinery.  The 
skin  yields  just  above  the  ears  and  supra-orbital  ridges,  and  the 
aponeurosis  is  cleanly  torn  off.  Replacement  is  of  course  hopeless 
when  separation  is  complete,  and  Thiersch-grafting  must  be  relied 
on  for  obtaining  an  epithelial  covering  to  the  raw  surface. 

Treatment. — The  hair  should  be  cut  away  from  the  neighbour- 
hood of  the  wound,  which  is  purified  with  Lister's  strong  mixture; 
the  edges  may  be  excised  if  badly  bruised  or  very  dirty.  The 
iodine  method  of  gaining  asepsis  (p.  279)  is  particularly  useful  in 
injuries  of  this  nature,  and  may  limit  the  extent  of  skin  requiring  to 
be  shaved.  Stitches  are  introduced  to  draw  the  parts  together, 
and  for  choice  are  of  a  non-absorbent  variety,  e.f;.,  horsehair. 
Haemorrhage  from  the  scalp  is  often  severe,  owing  to  the  density  of 
the  tissues,  which  pre\'ents  contraction  and  retraction  of  the  divided 
vessels.  For  a  similar  reason  it  is  sometimes  difificult  to  secure  them 
by  ligature,  and  a  suture  must  then  be  passed  under  the  vessel  in 
such  a  way  as  to  control  it. 

Hsematoma  of  the  scalp  results  from  injuries  that  are  not  asso- 
ciated with  solution  of  continuity  of  the  surface.  A  similar  condi- 
tion is  found  in  infants;  it  is  due  either  to  pressure  or  injur}'  to  the 

722 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  723 

head  during  its  passage  through  the  mother's  pelvis,  or  to  the  com- 
pression of  obstetric  instruments.  Three  varieties  of  cephal- 
hieinatoma  have  been  described,  viz.:  (a)  the  Superficial,  Vk'hich, 
confined  to  the  dense  subcutaneous  tissue,  is  necessarily  small. 
(6)  The  Subaponeurotic  occupies  the  loose  tissue  under  the  aponeu- 
rosis, and  is  only  limited  by  the  attachments  of  this  structure.  It 
form's  a  large,  soft,  fluctuating  swelling,  upon  which  the  scalp 
appears  to  float,  bagging  down  over  the  eyes  or  occiput.  It  is 
often  due  to  fracture  of  the  underlying  bone,  (c)  The  Subperi- 
cranial  is  hmited  by  the  pericranium  dipping  down  into  the  sutures 
around  the  bone  with  which  it  is  connected.  Most  commonly  it 
forms  over  one  of  the  parietal  bones  in  infants,  presenting  a  soft, 
fluctuating  swelling,  which  soon  gains  an  indurated  margin  owing 
to  a  deposit  of  fibrin,  and  in  this  condition  may  simulate  a  depressed 
fracture  of  the  skull,  inasmuch  as  the  cup-like  fluid  centre  allows 
the  finger  to  sink  in  and  touch  bone  below.  The  indurated  margin, 
however,  can  be  readily  indented  by  the  finger,  whilst  the  edge  is 
definitely  raised  above  the  surface  of  the  cranium,  and  hence  the 
sensation  of  depression  of  bone  felt  through  the  fluid  is  only  ap- 
parent. In  old-standing  cases  ossification  of  the  walls  of  this  cavity 
has  even  been  known  to  occur.  Treatment.— All  that  is  required 
is  the  apphcation  of  evaporating  lotions.  There  is  hardly  ever  any 
need  to  lay  open  or  drain  these  swellings  unless  underlying  mischief 
is  present. 

Suppuration  of  the  scalp  is  of  common  occurrence,  arising  mainly 
from  external  infection,  but  being  occasionally  due  to  disease  of  the 
subj  acent  bones.  The  extent  of  the  abscesses  is  limited  by  the  same 
anatomical  features  as  obtain  in  connection  wth  hemorrhage. 
Thus,  a  subcutaneous  abscess  is  necessarily  small  in  size,  owing  to 
the  density  of  the  tissues  in  which  it  is  located;  it  arises  most  fre- 
quently as  a  result  of  eczema  or  impetigo,  and  is  often  due  to  the 
presence  of  pedicuh,  or  to  the  action  of  irritants  used  in  the  cure  of 
ringw^orm.  A  subaponeurotic  abscess  usually  results  from  a  pene- 
trating wound,  and  is  associated  with  cellulitis.  A  subpericranial 
abscess  is  rarely  seen  except  in  connection  with  injury  or  disease  of 
the  bony  calvarium;  the  pus  is  limited  to  the  affected  portion,  of 
bone. 

For  Erysipelas  and  Cellulitis  of  the  scalp,  see  pp.  131  and  8S. 

Tumours  of  the  scalp  are  of  many  types. 

Ordinary  traumatic  aneurisms  or  arterio-venous  wounds  of  the 
temporal  trunk  are  uncommon;  they  rarely  attain  any  considerable 
size,  and  are  readily  treated  by  excision.  A  curious  dilated  and 
tortuous  condition  of  one  of  the^  scalp  arteries,  most  often  the  tem- 
poral, is  occasionally  seen,  and  is  known  as  an  arterial  varix  ;  it 
may  be  treated  by  complete  excision. 

Nsevi  of  the  scalp  do  not  differ  in  their  characters  from  those  seen 
elsewhere,  except  that  when  situated  over  the  anterior  fontanelle 
they  may  derive  a  communicated  impulse  from  the  subjacent  dura, 
and  so  be  mistaken  for  a  meningocele- 


724  A   MANUAL  OF  SURGERY 

Cirsoid  Aneurism  is  more  frequently  met  vvitli  in  the  scalp  than 
elsewhere,  and  mainly  involves  the  auriculo-tem])oral  region,  but 
may  also  spread  in  all  directions,  even  downwards  into  the  neck. 
The  origin  is  very  uncertain ;  in  a  few  cases  it  has  been  preceded  by  a 
nsevus,  and  sometimes  there  is  a  history  of  injury.  A  tumour  of 
greater  or  less  size  is  seen  under  the  skin,  consisting  of  distended, 
tortuous,  pulsating,  bluish-looking  vessels,  the  arteries  opening 
directly  into  cavernous  spaces  without  the  intervention  of  capil- 
laries; it  is  easily  emptied  by  pressure,  but  quickly  refills,  owing  to 
the  abundant  arterial  supply.  1  he  rate  of  growth  is  variable,  and 
the  patient  often  complains  of  headache  and  giddiness;  the  skin 
becomes  thin  and  atrophic,  the  hair  falls  out,  and  finally  ulceration 
may  occur,  the  patient  probably  dying  from  haemorrhage.  The 
Treatment  is  eminently  unsatisfactory,  complete  excision  being  the 
ideal  cure,  but  this  in  the  worst  cases  is  impracticable.  If  it  be 
attempted,  the  incisions  should  be  made  wide  of  the  disease,  and 
the  supplying  vessels  secured,  if  possible,  between  double  ligatures 
before  dividing  them;  if  this  precaution  is  not  adopted,  frightful 
haemorrhage  may  result.  It  is  necessary  in  some  cases  to  deal  with 
the  tumour  in  separate  segments,  allowing  time  between  the  opera- 
tions for  the  patient  to  recover  from  the  loss  of  blood.  Probably 
electrolysis,  combined  with  ligature  of  the  main  nutrient  vessels, 
holds  out  the  best  chance  of  success.  (For  methods  of  electrolysis, 
see  p.  53.) 

Papillomata  are  not  uncommon  in  the  form  of  small  hard  warty 
outgrowths,  giving  rise  to  but  little  inconvenience,  unless  situated  on 
some  spot  where  the  hat  rests.     They  are  easily  removed. 

Lipomata  also  occur,  and  are  usually  situated  in  front,  arising  from 
the  deeper  layers  of  the  scalp  or  from  the  pericranium.  1  hey  generally 
expand  laterally  and  are  flattened.     Removal  is  readily  effected. 

Epithelioma  also  occurs,  arising  either  from  an  irritated  papilloma, 
or  possibly  in  connection  with  a  sebaceous  cyst.  As  soon  as  a 
diagnosis  is  made,  the  growth  should,  if  possible,  be  extirpated,  and 
the  resulting  raw  surface  may  be  either  left  to  granulate,  or  dealt 
with  by  Thiersch's  method  of  skin-grafting. 

Fibroma  may  occur  in  the  shape  of  a  localized  development  of 
hard  fibrous  tissue,  and  often  grows  on  the  forehead  where  the  hat 
crosses  it;  or  it  may  attain  much  larger  dimensions,  involving 
perhaps  hall  the  scalp,  and  giving  rise  to  an  irregular  nodulated 
outgrowth  of  soft  fibro-cellular  tissue,  which  has  sometimes  been 
termed  a  pachydermatocele  (p.  214),  and  is  then  of  neuro-fibromatous 
origin.     Either  form  may  be  dealt  with  by  excision. 

Sarcomata  of  the  scalp  are  uncommon  apart  from  a  similar  affec- 
tion of  the  underlying  bones.  They  present  as  large  fleshy  tumours 
which  may  pulsate  or  f ungate,  and  usually  develop  rapidly,  but 
are  limited  for  some  time  by  the  aponeurosis  of  the  occipito-frontalis. 
Treatment  by  a  wide  excision  and  Thiersch-grafting  may  be  possible, 
but  if  the  condition  is  at  all  advanced  this  is  hopeless,  and  rehance 
must  be  placed  on  radium  or  X  rays. 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM 


725 


Dermoid  Cysts  are  by  no  means  uncommon  in  this  region,  their 
favourite  situation  being  near  the  outer  canthus,  the  temple,  or  the 
root  of  the  nose.  For  a  general  description,  see  p.  229.  They  do 
not  attain  any  great  size,  and  may  not  become  evident  till  after 
puberty.  The  underlying  bone  is  often  hollowed  out  from  a  defec- 
tive development  of  the  mesoblastic  tissues  around  them;  and  a  con- 
genital opening  may  even  exist  through  which  a  narrow  neck  passes, 
bringing  the  cyst  into  direct  connection  with  the  dura  mater.  The 
treatment  consists  in  removal;  but  it  is  advisable  to  delay  this  till 
after  puberty  if  the  tumour  seems  at  all  fixed  to  the  skull,  or  if  the 
bone  is  felt  to  be  defective  beneath  it,  as  in  such  cases  the  communi- 
cation with  the  interior  of  the  cranium  is  often  shut  off  by  that  time. 

Sebaceous  Cysts  (p.  409)  find  their  most  usual  situation  in  the 
scalp,  where  they  not  only  are  frequently  multiple,  but  also  may 
reach  a  considerable  size.  Their  removal  is  best  accomplished  by 
transfixion,  squeezing  out  the  contents,  and  picking  out  the  cyst 
wall  by  a  pair  of  forceps  without  dissection.  The  wound  is  closed 
by  one  or  two  stitches. 

Sebaceous  Adenoma  is  most  frequently  seen  on  the  scalp  (p.  410) . 


Affections  of  the  Cranium. 

I.  Congenital  Affections. 

1.  In  babies  the  ossification  of  the  bones  may  be  incomplete,  con- 
stituting what  is  known  as  aplasia  cranii  congenita,  and  is  due  to  a 
cachectic  condition  of  the  mother.  Occasionally  a  similar  atrophic  con- 
dition of  the  bones  may 

persist  through  life, 
exposing  the  patient 
to  increased  risk  from 
injuries  which  other- 
wise would  do  but 
little  harm. 

2.  Meningocele,  En- 
cephalocele,  and  Hy- 
drencephalocele  consist 
of  a  protrusion  of  the 
dura  mater,  with  or 
without  part  of  the 
brain,  through  an  open- 
ing in  the  cranial  wall. 
They  are  due  to  defec- 
tive intrusion  of  the 
mesoblastic  tissues 
outside  the  primitive 

cerebral  vesicle,  so  that  part  of  the  brain  or  its  membranes  remains 
superficial  and  extracranial.  They  occur  most  frequently  at  the  root 
of  the  nose,  and  in  the  occipital  region  (Fig.  357),  occasionally  at  the 
anterior  or  lateral  fontanelle,  or  at  the  base  of  the  skull.     A  Menin- 


FiG.  357. — Congenital  Encephalocele  of  the 
Occipital  Region.     (Tillmanns.) 


726  A   MANUAL  OF  SURGERY 

gocele  is  simply  a  protrusion  of  the  brain  membranes  containing 
cerebro-spinal  fluid.  It  forms  a  soft,  rounded,  fluctuating  swelling, 
attached  to  the  skull  by  a  base  of  greater  or  less  size,  and  covered  by 
skin,  which  may  be  thick  and  healthy,  or  thinned,  bluish,  and  trans- 
lucent when  the  tumour  is  large.  The  vessels  present  in  the  skin  are 
often  dilated  and  naevoid.  It  increases  in  size  and  tension  on  any 
expiratory  effort,  such  as  coughing  or  crying,  and  it  may  be  partially 
reducible^  thus  allowing  the  margins  of  the  opening  in  the  cranium 
to  be  defined.  Symptoms  of  cerebral  compression,  convulsions, 
etc.,  are  likely  to  be  produced  by  such  manipulation.  An  Encepha- 
locele  is  a  similar  type  of  tumour,  but  contains  brain  substance,  and 
pulsates  almost  synchronously  with  the  heart ;  it  is  most  commonly 
situated  at  the  back  of  the  skull.  A  Hydrencephalocele,  or  Meningo- 
encephalocele,  is  a  condition  in  which  the  tumour  contains  both 
brain  substance  and  fluid.  Two  varieties  have  been  described — one 
in  which  there  is  a  small  protrusion  of  the  brain  associated  with  an 
ordinary  meningocele,  and  the  other  in  which  the  fluid  is  contained 
in  a  cavity  communicating  with  one  of  the  ventricles,  and  covered 
by  a  thin  layer  of  brain  substance.  They  are  usually  of  considerable 
size,  constituting  a  type  of  hydrocephalus,  and  are  situated  in  the 
occipital  region,  either  above  the  tentorium,  and  then  possibly 
associated  with  distension  of  the  posterior  cornu  of  one  of  the  lateral 
ventricles,  or  below  that  structure,  the  osseous  defect  extending  in 
some  cases  as  far  as  the  foramen  magnum,  and  a  portion  of  the 
cerebellum  being  within  the  sac. 

The  Prognosis  of  these  conditions  is  exceedingly  grave.  Fortu- 
nately, many  of  the  subjects  are  born  dead,  or  die  soon  after  birth. 
In  the  more  severe  cases,  idiocy  and  microcephaly  are  not  uncom- 
monly associated,  whilst  sometimes  true  internal  hydrocephalus  is 
present.  The  protrusion  may  increase  steadily  in  size  and  finally 
burst,  causing  death  by  purulent  meningitis,  or  in  more  favourable 
cases  it  may  remain  stationary.  In  a  meningocele,  the  subsequent 
growth  of  the  cranial  bones  may  suffice  to  close  the  communication 
between  the  interior  and  the  tumour,  which  thus  becomes  shut  off, 
and  remains  as  a  cyst-like  swelling,  with  the  base  fixed,  and  without 
pulsation  or  respiratory  impulse- 

Treatment. — Most  cases  should  be  left  alone;  but  if  the  tumour 
is  steadily  increasing  in  size,  aseptic  puncture  and  subsequent  com- 
pression may  hinder  the  process;  a  pure  meningocele  may  possibly 
be  cured  in  this  way.  Where  the  communication  with  the  skull  is 
small,  it  ma}'  be  feasible  to  excise  the  tumour,  taking  special  care  to 
suture  the  base  securely,  and  attempting  when  practicable  to  make 
good  the  cranial  deficiency  by  osteoplasty. 

II.  Acquired  Affections  of  the  skull  are  atrophic,  hypertrophic, 
inflammatory,  or  neoplastic  in  nature. 

Acquired  Atrophy  of  the  skull  occurs  in  many  forms: 

(a)  Craniotahcs  is  a  condition  met  with  during  the  first  year  of  life, 
usually  as  a  result  of  inherited  syphilis  (p.  581). 

[h)  Senile  atrophy  may  affect  the  whole  cranium,  which  becomes 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM 


727 


thinned  and  rarefied;  or  it  may  be  localized,  as  pointed  out  by  the 
late  Sir  G.  M.  Humphry,*  to  the  parietal  bones,  constituting  hollow 
depressions  which  extend  antero-posteriorly.  No  symptoms  are 
caused  thereby. 

[c]  Localized  loss  of  substance  may  result  from  the  pressure  of 
tumours,  such  as  Pacchionian  bodies  and  aneurisms,  or  from  necrosis, 
or  traumatic  and  operative  lesions.  If  these  are  at  all  extensive,  the 
cerebral  pulsations  can  be  felt  distinctly  through  the  skin.  It  is 
then  advisable  to  provide  the  patient  with  some  guard  to  protect  him 
from  injury.  This  may  be  accomplished  by  means  of  a  metal  plate 
worn  over  the  scalp ;  but  of  late  years  operative  measures  have  been 
introduced  to  obviate 
this.  Autoplnsty  is  the 
term  applied  to  a  pro- 
ceeding whereby  the  de- 
fect is  closed  by  a  plate 
of  bone  removed  from 
the  patient's  own  skidl. 
A  suitable  scalp  flap  1? 
turned  down,  and  then 
a  portion  of  the  outer 
table  is  chiselled  up 
sufficient  in  size  to  close 
the  aperture.  The  peri- 
cranium is  utihzed  on 
one  side  as  a  pedicle, 
and  by  means  of  this 
it  is  stitched  down  into 
the  gap,  the  margins  of 
which  have  been  pre- 
viously freshened.  By 
heteroplasty  is  meant  a 
similar  proceeding  when 
the  hole  is  closed  by  a 


A.^ 


-Hydrocephalus. 


Fig.  358.- 

(From  photograph,  by  permission  of  Mr.  F.  F. 
Burghaxd.) 

plate  of  gold,  platinum,  or  vulcanite,  fixed  by  wires  or  nails  to  the 
surrounding  bone.  The  results  of  these  procedures  have  been 
on  the  whole  satisfactory. 

{d)  Chronic  Internal  Hydrocephalus  is  always  associated  with 
atrophy  and  thinning  of  the  cranium;  it  may  be  congenital,  or  may 
commence  early  in  life.  It  is  produced  in  almost  all  cases  by  a  dis- 
tension of  the  lateral  ventricles  with  fluid,  the  result  of  congenital 
malformation  or  of  inflammatory  affections,  causing  exudation  from 
the  choroid  plexuses,  pressure  upon  the  veins  of  Galen  or  inferior 
longitudinal  sinus,  and  possibly  closure  of  the  foramina  of  Magendie 
and  Luschka.  The  head  becomes  more  and  more  distended  (Fig. 
358),  the  bones  expanded  and  thinned,  and  the  sutural  areas  in- 
creased, whilst  the  brain  is  subjected  to  such  pressure  as  may  be 
incompatible  with  life.  Fluctuation  is  distinctly  felt,  and  the  bones 
*    Med.-Chir.  Trans.,  1890,  p.  37 


728  A   MANUAL  OF  SURGERY 

may  crackle  under  the  fingers;  the  face  looks  abnormally  small,  and 
the  eyes  protrude,  owing  to  the  depression  of  the  orbital  plates. 
Treatment .—-1  dL\)\)mg  of  the  ventricles  is  useless,  as  even  if  a  con- 
siderable amount  of  the  fluid  is  withdrawn,  and  elastic  pressure  sub- 
sequently maintained,  recurrence  is  almost  inevitable.  The  only 
hope  is  to  establish  a  free  communication  between  the  ventricular 
and  subdural  spaces,  so  that  the  excess  of  fluid  in  the  ventricles  may 
escape;  it  will  be  absorbed  from  the  subdural  space  as  soon  as  the 
tension  rises  above  the  intravenous  pressure.  A  silver  tube  should 
be  inserted  between  the  two  spaces,  or  a  tube  of  decalcified  bone 
carrying  a  catgut  drain;  to  be  of  any  value,  the  operation  must  be 
undertaken  before  the  cerebral  cortex  has  been  so  thinned  as  to 
interfere  with  its  functional  activity. 

[e)  Bv  Microcephaly  is  meant  a  condition  of  diminished  size  of  the 
cranial  cavity  due  to  premature  ossification  of  the  sutures,  and 
resulting  from  non-development  of  the  brain.  It  is  usually  associated 
with  idiocy,  and  possibly  with  cretinism.  Attempts  have  been  made 
to  relieve  this  by  the  operation  of  linear  craniectomy  or  removal  of 
portions  of  the  cranium,  so  as  to  allow  of  the  expansion  of  the  brain. 
Temporary  improvement  has  followed  in  a  few  cases,  probably  from 
the  individual  attention  given  to  the  patient;  the  final  result  is 
extremely  uncertain,  most  of  the  patients  relapsing  owing  to  the 
contraction  of  the  dense  cicatricial  material  which  replaces  the  bone, 
and  to  the  atrophic  condition  of  the  brain. 

Hypertrophic  Changes  of  the  Skull  result  from  simple  chronic  in- 
flammator\'  affections,  or  from  injury,  etc.  Special  types  of  enlarge- 
ment are  seen  in  inherited  syphihs  (p.  580),  rickets  (p.  582),  osteitis 
deformans  (p.  587),  and  acromegaly  (p.  589).  In  leontiasis  ossea 
(p.  803)  the  cranium  becomes  thickened  and  enlarged;  but  the 
cranial  cavity  is  also  encroached  on,  constituting  what  is  known  as 
concentric  hypertroph^^  in  contrast  to  most  of  the  other  forms,  which 
are  eccentric  in  type. 

Inflammatory  Affections  of  the  Cranial  Bones. — The  cranium  is 
liable  to  any  of  the  diseases  which  generally  occur  in  bone. 

1.  Acute  Periostitis,  or  Pericranitis,  is  usually  infective  in  origin, 
following  cellulitis  ol  the  scalp;  it  is  likely  to  result  in  necrosis  of 
the  outer  table. 

2.  Acute  Infective  Osteo-myelitis,  or  acute  necrosis,  consists  of  an 
acute  inflammation  of  the  diploe,  due  to  pyogenic  organisms,  and 
either  following  an  infected  scalp  wound  or  compound  fracture,  in- 
fective inflammation  of  one  of  the  air-sinuses  or  the  operation  neces- 
sary for  its  treatment,  or  a  simple  contusion  of  the  bone  in  a  person 
of  low  germicidal  powers.  The  symptoms  and  signs  are  those  gener- 
ally characteristic  of  the  disease,  being  ushered  in  by  a  rigor,  followed 
by  headache,  fever,  and  the  development  of  a  localized  cedematous 
sweUing,  known  as  '  Pott's  puffy  tumour  '  (Fig.  367}.  The  pericra- 
nium is  stripped  up  by  diffuse  suppuration  beneath  it,  and  an  abscess 
often  forms  between  the  bone  and  the  dura  mater.  Necrosis  of  the 
whole  thickness  of  the  skull  is  likely  to  follow,  but  is  usually  limited 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  Tzg 

by  the  sutures  to  the  particular  bone  affected.  Pyaemia  and  exten- 
sion of  the  inflammation  to  the  membranes,  venous  sinuses  or  brain, 
are  the  chief  dangers  arising  from  it.  The  prognosis  is  always  grave, 
e\-en  when  early  operati\-e  treatment  is  undertaken;  apart  from 
operation,  it  is  almost  hopeless.  The  Treatment  consists  in  free 
external  drainage,  together  with  the  removal  of  the  outer  table  to 
enable  the  infected  diploe  to  be  curetted.  If  signs  of  subcranial 
suppuration  ensue  (p.  765),  the  inner  table  must  also  be  removed. 
It  is  not  alwavs  necessary  to  wait  for  the  spontaneous  separation  of 
the  sequestrum:  dead  bone  may  be  chiselled  away  at  an  earlier 
stage. 

3'  Chronic  Periostitis  of  the  cranium  is  occasionally  met  with  in 
the  form  of  a  node.  It  is  usually  the  result  of  some  long-continued 
irritation,  such  as  carrying  baskets  or  weights  on  the  head.  Treat- 
ment consists  in  the  removal  of  the  irritation,  and  there  is  no  objec- 
tion to  chiselling  away  the  node,  if  necessary. 

4.  Tuberculous  Disease  of  the  cranial  bones  is  not  common;  it 
occurs  as  a  primary  phenomenon,  or  is  secondary  either  to  a  cuta- 
neous lesion,  such  as  lupus,  or  perhaps  more  commonly  to  a  menin- 
geal focus.  It  may  start  in  the  periostemn  or  diploe,  leading  to  the 
formation  of  a  node,  or  perhaps  to  expansion  of  the  bone,  and 
followed  by  suppuration  and  caries.  When  of  meningeal  origin, 
there  is  a  considerable  amount  of  erosion  of  the  inner  table,  and 
possibly  some  necrosis;  sooner  or  later  the  outer  table  is  perforated 
and  a  subpericranial  abscess  forms.  The  amount  of  mischief  in  the 
outer  table  is  no  criterion  of  the  extent  of  the  disease  within,  and 
hence  very  thorough  exploration  is  necessary.  The  prognosis  in  this 
variety  is"  not  good.  The  mastoid  process  and  the  orbital  margin 
in  the' neighbourhood  of  the  external  angular  process  of  the  frontal 
bone  are  rather  favourite  situations  for  the  disease,  which  is  then 
often  accompanied  by  other  manifestations. 

5.  Syphilitic  Disease  of  the  craniimi,  on  the  other  hand,  is  exceed- 
ingly common,  occurring  usually  in  the  tertiary  stage,  and  affecting 
most  frequently  the  frontal  and  parietal  bones.  It  has  been  already 
described  (p.  syoV 

Tumours  of  the  Cranial  Bones.— The  chief  Tumours  affecting  the 
calvarium  are  osteomata  and  sarcomata. 

Osteoma  of  the  cranium  (Fig.  57)  occurs  as  a  localized  overgro\\i;h. 
of  compact  bone  from  the  outer  surface  of  the  calvarium,  from  the 
inner,  or  from  both.  The  frontal  bone  and  external  auditory  meatus 
are  the  sites  of  election.  If  arising  externally,  a  smooth,  rounded, 
globular  sweUing  is  produced,  hard  to  the  touch,  quite  painless,  and 
fixed  to  the  subjacent  bone  by  a  broad  base;  more  than  one  may 
be  present.  If  the  main  gro\vth  is  internal,  s\Tnptoms  of  cerebral 
irritation  or  pressure  may  be  produced.  Osteomata  are  to  be 
distinguished  from  inflammatory  h\-perostoses  (usually  of  sj^philitic 
origin)  bv  their  sharp  limitation,  absence  of  pain,  and  slower  pro- 
gress :  whilst  osteo-sarcomata  are  commonly  rapid  in  growth,  painful, 
and  of  unequal  consistency  in  different  parts.     Treatment  is  rarely 


730  A   MANUAL  OF  SURGERY 

necessary.  Small  growths  may  be  encircled  in  the  crown  of  a 
trephine  and  thus  removed.  Large  ones  must  be  dealt  with  by  a 
burr  driven  by  an  electric  engine,  the  bone  being  divided  just  outside 
the  dense  compact  tissue,  and  thus  the  tumour  is  set  free.  No 
attempt  should  be  made  to  chisel  away  these  growths,  as  symptoms 
of  concussion  may  follow  the  prolonged  use  of  the  chisel  and  mallet 
against  the  skull. 

Sarcoma  of  the  cranium  originates  either  from  the  pericranium, 
the  diploe,  or  from  the  dura  mater. 

The  pericranial  variety  consists  of  a  round  or  spindle-celled 
tumour  growing  from  the  pericranium,  and  possibly  attaining  a 
considerable  size.  It  may  contain  a  certain  amount  of  ossific  de- 
posit, or  the  tumour  remains  of  a  soft  consistency,  and  then  often 
pulsates.  Ihe  subjacent  bone  is  sometimes  absorbed,  and  the  dura 
mater  affected  secondarily.     General  infection  of  the  system  follows. 

Central  Sarcoma  commences  in  the  diploe  and  spreads  both  out- 
wardly and  inwards.  In  this  situation,  however,  a  myeloma  may 
develop,  and  simulates  a  sarcoma;  its  growth,  however,  is  slower, 
and  it  is  covered  with  a  thin  layer  of  bone,  which  may  crackle  be- 
neath the  fingers. 

Sarcoma  of  ihe  dura  mater  may  be  attributed  to  some  injury  to  the 
head,  and  is  characterized  by  the  occurrence  of  severe  cerebral  symp- 
toms— e.g.,  intolerable  localized  headache,  epileptic  fits,  double 
vision,  optic  neuritis,  etc. — prior  to  any  evident  appearance  of  a 
tumour.  Gradually  the  bones  become  expanded  and  perforated, 
and  a  soft  and  exceedingly  vascular  pulsating  growth  is  felt  beneath 
the  scalp.  This  fungates  sooner  or  latei ,  and  possibly  the  meningeal 
cavity  is  laid  open  by  ulceration,  death  from  septic  meningitis,  cere- 
bral compression,  or  exhaustion,  ending  the  chapter. 

Treatment. — These  cases  have  usually  gone  too  far  for  operative 
treatment  before  being  recognised.  As  a  rule,  radio-therapy  can 
alone  be  relied  on,  or  that  conjoined  with  a  course  of  Coley's  fluid. 

Secondary  Carcinoma  of  the  cranial  bones  is  by  no  means  un- 
common, and  may  follow  cancers  of  the  mamma,  thyroid  body, 
etc.  The  growths  are  usually  small  and  multiple,  and  may  show 
pulsation.     Neuralgia  and  persistent  headache  may  result  from  them. 

III.  Traumatic  Affections  of  the  Cranium. 

Contusions  of  the  Cranial  Bones  apart  from  fracture  may  lead  to 
serious  results,  i.  Many  of  the  inflammatory  conditions  of  bone 
just  described  may  be  originated;  e.g.,  if  the  patient  is  in  a  condition 
of  low  germicidal  power,  acute  osteo-myelitis  may  follow ;  or  chronic 
sclerosis  and  overgrowth  of  the  bone,  local  or  diffuse,  may  supervene. 
Syphilitic  or  tuberculous  manifestations  may  be  similarly  lighted  up 
if  the  patient  is  the  subject  of  either  of  these  diseases.  2.  In  addi- 
tion to  such  osseous  conditions,  pus  may  form  within  the  cranium 
outside  the  dura  mater  {siihcranial  abscess,  p.  764),  and  necessitate 
trephining.     3.  The  dura  mater  may  be  detached  by  a  simple  con- 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  731 

tusion,  leading  to  meningeal  luemorrliage  (p.  761).  4.  Any  of  the 
cerebral  lesions  detailed  hereafter  may  be  produced.  Contusions 
of  the  cranium  must  obviously  never  be  treated  lightly,  even  when 
they  are  associated  with  unbroken  skin;  much  more  are  they  serious 
when  compound,  owing  to  tlie  risks  of  infection. 

Fractures  of  the  Skull  may  be  described  for  convenience  under 
the  following  headings:  Fissured  Fractures  oj the  Vault;  Fractures  oj 
the  Base  (usually  fissured) ;  and  Depressed  or  Pimctured  Fractures. 

I.  Fissured  Fractures  o£  the  Vault  are  always  due  to  external 
violence,  direct  or  indirect.  In  the  former  case  the  skull  first  yields 
at  the  injured  spot,  but  the  fissure  may  extend  from  it  for  some 
distance-  in  the  latter  the  fracture  results  from  the  yielding  of  the 
skull  when  compressed  beyond  its  natural  limits  of  elasticity. 

A  simple  fissure  gives  rise  to  no  symptoms  indicating  its  presence 
with  certainty.  There  may  be  some  amount  of  superficial  ecchy- 
mosis,  but  nothing  more  definite.  When  compound,  the  line  ot 
fracture  may  be  seen  as  a  red  streak,  or  even  felt  with  the  hnger  as 
an  irregular  ridge.  It  consists  of  a  mere  longitudinal  fissure,  or  may 
be  starred-  if  uncomphcated,  it  is  of  but  little  importance,  and  needs 
nothing  beyond  general  treatment— of  course,  the  greatest  care  being 
taken  to  ensure  asepsis.  Occasionally,  however,  an  osseous  growth 
forms  from  protuberant  callus  on  the  inner  aspect  of  the  cranium  at 
the  site  of  fracture,  and  gives  rise  to  traumatic  epilepsy  or  insanity 

^Traumatic  Cephal-hydrocele  is  the  name  given  to  a  rare  condition 
following  simple  fractures  of  the  vault,  especially  in  children,  it  is 
characterized  by  the  formation  of  a  fluid  swelhng  under  the  scalp, 
which  pulsates  synchronouslv  with  the  heart-beat,  and  has  a  dehnite 
impulse  on  any  expiratory  effort ;  it  varies  in  size  from  time  to  time 
and  is  sometimes  partially  reducible.  It  contains  cerebro-spinal 
fluid,  and  communicates  with  either  one  of  the  lateral  ventricles  or 
the  subarachnoid  cavitv.  In  one  case  it  was  proved  on  operation  to 
be  connected  with  an  arachnoid  cyst,  due  to  a  localized  subarachnoid 
hemorrhage.  Probably  it  is  wise  to  leave  this  condition  alone 
although,  if  one  could  be  tolerably  certain  that  the  ventricle  was  not 
affected,  it  might  be  laid  open  and  drained.  •,  ^  ^ 

2.  Fractures  of  the  Base  of  the  Skull  are  almost  always  fissured, 
only  occasionallv  punctured  or  depressed.  ^  ,,,  ^/ 

Causes  — (a^  Violence  may  he  directed  to  the  vertex  or  to  some  part  of 
the  cranial  convexity,  as  from  a  blow  or  fall  upon  a  hard  substance. 
There  has  been  a  good  deal  of  discussion  as  to  how  a  fall  on  the  vertex 
causes  fracture  of  the  base.  Two  main  theories  hold  the  field  each 
being  probably  responsible  for  a  certain  number  of  cases.  (1.)  Aran  s 
theor/of  irradiation  maintains  that  a  fracture  of  the  base  is  always 
due  to  direct  extension  of  the  fissure  from  the  injured  vertex,  a  pro- 
position probablv  quite  true  in  many  cases,  but  msufiicient  to  exp  am 
all  (ii )  A  more  recent  idea,  known  as  the  bursttng  orcompresston 
theory,  is  based  on  the  fact  that  the  cranium  is  not  a  sohd  and  totally 
unimpressionable  body,  but  is  highly  elastic,  as  has  been  proved  by 


732  A   MANUAL  OF  SURGERY 

the  observation  that  hair  and  even  pieces  of  skin  have  been  found 
nipped  in  a  fissured  fracture  of  the  vault,  which  had  evidently  gaped 
open  and  closed  again.  Severe  compression  necessarily  diminishes 
the  diameter  of  the  skull  along  the  axis  of  greatest  pressure,  making 
it  bulge  in  other  diameters;  if  this  exceeds  the  limits  of  elasticity  of 
the  bone,  a  fracture  must  result.  The  direction  of  fractures  pro- 
duced in  this  manner  varies.  Most  commonly  the  lines  of  fracture 
are  parallel  to  the  direction  of  the  compressing  force,  the  bone  thus 
bursting  open  along  its  convexity  (fracture  by  bursting) ;  less  fre- 
quently it  gives  way  at  right  angles  to  the  direction  of  the  force 
(fracture  by  compression).  Inasmuch  as  the  force  is  transmitted 
equally  in  all  directions,  the  weakest  and  least  elastic  part  is  always 
most  likely  to  give  way,  viz.,  the  base.  Whether  these  ideas  are 
justified  is  a  question;  certainl}'  the  figures  quoted  by  Phelps*  in- 
dicate that  irradiation  is  responsible  for  a  very  large  proportion  of 
fractures  of  the  base,  {b)  Direct  or  indirect  injury  to  the  base  of 
the  skull  is  undoubtedly  the  cause  of  a  certain  number  of  fractures, 
and  some  of  these  are  depressed,  and  not  fissured,  in  character. 
Thus,  the  point  oi  an  umbrella  or  stick  may  be  thrust  through  the 
upper  wall  of  the  orbit,  or  up  the  nose  through  the  cribriform  plate 
of  the  ethmoid;  the  condyle  of  the  jaw  may  be  driven  through  the 
glenoid  cavity  into  the  middle  fossa  by  a  blow  on  the  chin;  direct 
injurv  from  a  fall  or  a  stab  may  penetrate  the  occipital  bone;  whilst 
a  gunshot  wound  in  the  mouth  is  another  illustration  of  this  kind 
of  injury,  (c)  The  impact  or  resistance  of  the  vertebral  column  against 
the  occipital  condyles  produces  fractures  in  the  posterior  fossa  which 
radiate  from  the  foramen  magnum,  and  may  even  occasion  a  ring- 
shaped  fracture  around  it  (Fig.  359).  They  result  from  falling  on 
the  vertex  into  a  soft  mass — e.g.,  a  bale  of  wool— or  by  ahghting 
from  a  height  on  the  heels  or  nates. 

The  fracture  may  run  in  any  direction,  longitudinal,  oblique,  trans- 
verse, etc.,  according  to  the  direction  of  the  compressing  or  fracturing 
force,  and  it  may  a:ffect  any  part  of  the  base,  either  being  limited  to 
one  of  the  fossse  or  involving  all ;  it  may  follow  the  sutural  lines  in 
part,  but  it  is  no  uncommon  thing  to  see  even  the  dense  petrous  bone 
traversed  by  a  fissure  (Fig.  360).  Naturally,  transverse  fractures 
are  more  likely  to  be  limited  to  one  of  the  fossse,  whilst  a  longitudinal 
fissure  may  involve  them  all. 

Some  fractures  of  the  base  of  the  skull  are  simple  in  nature,  but 
the  majority  are  compound.  In  the  anterior  fossa  the  fissure  extends 
through  the  cribriform  plate  and  nasal  mucosa,  and  then  lays  open 
the  nose ;  or  a  communication  may  be  established  with  the  external 
air  through  a  penetrating  wound  in  the  orbit,  or  through  the  eth- 
moidal or  sphenoidal  sinuses.  In  the  middle  fossa  a  fracture 
through  the  base  of  the  sphenoid  opens  the  roof  of  the  naso-pharynx, 
or  the  fracture  may  involve  the  tympanic  cavity.  In  the  posterior 
fossa  the  basi-occipital  may  be  broken,  and  again  the  naso-pharynx 
opened,  although  the  fracture  here  is  more  commonly  simple. 
*  'Traumatic  Lacerations  of  the  Brain.'     London:  Henry  Kimpton;  1898. 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM 


733 


Fractures  of  the  base  of  the  skull,  though  very  serious,  are  by  no 
means  necessarily  fatal,  and  since  the  introduction  of  antiseptic  work 
the  results  have  immensely  improved.  The  main  dangers  to  be 
apprehended  are:  (i.)  Damage  to  the  base  of  the  brain,  including  the 
pons  and  medulla,  especially  in  cases  where  the  foramen  magnum 
is  splintered  from  the  impact  of  the  spine  against  the  condyles; 
(ii.)  haemorrhage  arising  either  from  the  venous  sinuses,  or  from  the 
meningeal  or  cerebral  arteries;  and  (iii.)  infective  meningitis,  due  to 
the  fact  that  the  injury  not  only  fractures  the  bones,  but  also  lays 
open  the  dura  mater,  a  grave  addition  to  a  compound  fracture. 


Fig.  359. — Fracture  of  the  Base  of        Fig.    360.  —  Transverse      Frac- 
THE    Skull    from    Force    acting  ture  across  the  Base  of  the 

AGAINST    the    OcCIPITAL   CONDYLES,  SKULL. 

AND  PRODUCING  ALMOST  AN  ANNU- 
LAR Fracture  around  the  Fora- 
men !Magnum. 

The  Signs  of  a  fractured  base  are  sometimes  exceedingly  equivocal 
but  for  convenience  may  be  arranged  under  four  heads : 

(i)  Signs  of  severe  cerebral  mischief,  such  as  concussion  of  the  brain 
and  prolonged  unconsciousness.  This  is,  however,  by  no  means 
always  present ;  thus,  in  a  case  we  had  in  hospital  some  years  back, 
the  patient  was  capable  of  going  about  his  work  for  ten  days  after 
the  accident. 

(2)  HcBinorrhage  manifests  itself  in  various  directions,  according  to 
the  situation  of  the  fracture. 

In  the  anterior  fossa  there  may  be  free  bleeding  from  the  nose, 
owing  to  the  fracture  extending  through  the  cribriform  plate  of  the 
ethmoid;  but  a  portion  of  the  blood  may  pass  backwards  into  the 
pharynx,  and,  being  swallowed,  is  perhaps  subsequently  vomited. 
More  often,  however,  the  line  of  fracture  runs  across  the  roof  of  the 
orbit,  causing  escape  of  blood  into  the  areolar  tissue  of  this  cavity. 
The  ecchymosis  shows  itself  as  a  gradually  developing  subcutaneous 


734  A   MANUAL  OF  SURGERY 

distension,  involving  the  lower  lid,  bluish-purple  in  colour  at  first, 
but  passing  later  through  the  other  stages  of  a  bruise;  there  is 
probably  no  contusion  of  the  skin,  as  in  the  ordinal  y  black  eye, 
which  is  at  first  reddish-purple;  the  ocular  conjunctiva  is  consider- 
ably involved,  but  the  effusion  rarely  extends  above  the  cornea,  and 
its  posterior  limits  cannot  be  seen.  The  bleeding  usually  arises  from 
laceration  of  the  dura  mater  and  bone,  but,  when  abundant, may  come 
from  the  cavernous  sinus,  and  the  eye  may  even  be  pushed  forwards 
(proptosis) ;  in  some  cases  pulsation  is  to  be  felt  within  the  orbit,  and 
then  a  traumatic  orbital  aneurism  or  aneurismal  varix  is  present. 

In  the  middle  fossa  the  blood  may  enter  the  nose  or  mouth,  a  part 
being  swallowed,  but  more  commonly  it  escapes  from  the  ears.  If 
abundant,  it  probably  comes  from  one  of  the  vascular  channels  at  the 
base  of  the  brain ;  but  if  only  slight  in  amount  and  of  short  duration, 
it  may  be  induced  by  any  of  the  following  lesions,  as  well  as  by  a 
fractured  base,  viz. :  (a)  A  simple  rupture  of  the  membrana  tympani ; 
\h)  separation  of  the  cartilage  of  the  pinna,  with  tearing  of  the  lining 
of  the  external  meatus;  (c)  fracture  of  the  anterior  and  lower  part  of 
the  tympanic  plate,  as  by  a  blow  on  the  jaw,  which  drives  the  condyle 
forcibly  against  it. 

In  the  posterior  fossa  the  bleeding  is  usually  subcutaneous,  show- 
ing itself  around  "the  mastoid  process,  and  extending  downwards 
amongst  the  muscles  at  the  back  of  the  neck. 

(3)  Discharge  of  cerebrospinal  fluid  is  an  indication  that  a  com- 
munication exists  with  the  subdural  space.  The  fluid  may  be  dis- 
charged from  one  or  both  ears,  but  has  also  been  met  with  commg 
from  the  nose  or  cranial  vault ;  when  from  the  ear,  the  dura  mater 
has  probably  been  laid  open  through  the  prolongation  which  accom- 
panies the  auditory  nerve  in  the  internal  meatus  by  a  fracture 
traversing  the  petrous  bone.  It  is  watery  and  limpid  in  character, 
with  a  specific  gravity  of  about  1006  to  1008,  slightly  alkaline,  and 
containing  a  fair  quantity  of  chloride  of  sodium,  with  traces  of 
albumen,  and  of  a  substance  which,  like  grape-sugar,  reduces  cupric 
salts  on  boihng.  At  first  it  is  probably  blood-stained,  but  soon 
becomes  quite  clear.  The  amount  discharged  may  be  small,  but  not 
unfrequently  it  comes  away  in  large  quantities,  soaking  the  pillow 
and  dressings,  and,  indeed^  can  sometimes  be  caught  in  a  test-tube 
as  it  trickles  from  the  meatus.  As  a  rule,  the  flow  commences  soon 
after  the  injury,  and  quicklv  ceases;  but  some  years  back  a  curious 
case  occurred,'  under  the  care  of  Lord  Lister  at  King's  College 
Hospital,  of  a  man  who  had  fahen  backwards  off  a  high  bed  upon 
his  occiput;  he  was  temporarily  stunned,  but  returned  to  bed,  and, 
on  awaking  the  next  morning,  found  that  both  eyes  were  black. 
He  continued  work  for  ten  days,  complaining,  however,  of  headache, 
and  at  the  end  of  that  time  of  earache,  which  grew  steadily  worse; 
until  relieved  by  something  giving  w^ay  in  his  left  ear.  This  was 
followed  by  a  copious  discharge  of  cerebro-spinal  fluid,  which  was 
maintained  for  some  time,  and  from  the  after- history  there  can  be 
no  doubt  that  it  was  due  to  a  fractured  base. 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  735 

Escape  of  brain  substance  from  the  car  has  also  occurred  in  a  few 
instances,  most  of  them  fatal. 

(4)  Lesions  of  the  newes  issuing  from  the  base  of  the  skull  are 
occasionally  produced.  For  symptoms,  etc.,  see  Chapter  XVI. 
The  nerve  most  commonly  involved  is  the  facial,  as  it  passes  through 
the  aqueductus  Fallopii;  the  paralysis  may  develop  either  imme- 
diately, or  moie  often  about  the  second  or  third  week  after  the 
injury,  disappearing  in  about  a  month,  and  then  evidently  due  to 
its  implication  in  the  callus.  A  certain  amount  of  deafness  is  often 
associated  with  it  from  injury  to  the  auditory  nerve. 

The  Prognosis  of  a  fractured  base  has  much  improved  during  recent 
years,  as  a  result  of  the  application  of  antiseptics  to  the  auditory 
meatus.  If  the  patient  escapes  death  from  cerebral  comphcations, 
the  bones  of  the  skull  unite  rapidly,  and  a  good  result  may  be 
expected,  although  troublesome  sequelae  may  follow,  from  the  injury 
sustained  by  nerves  or  vessels,  or  of  their  compression  in  callus  or 

new  bone.  .  .       , 

Treatment.— Seeing  that  the  chief  danger  to  the  patient  arises  from 
septic  contamination  of  the  meninges,  the  greatest  care  must  be 
directed  towards  preventing  decomposition  of  the  discharges.     Un- 
fortunately, it  is  impossible  to  applv  dressings  to  the  naso-pharynx, 
or  even  to  wash  it  out  thoroughly  with  antiseptics,  and  the  only 
satisfaction  about  such  cases  is  that  the  rarity  of  the  loss  of  cerebro- 
spinal fluid  suggests  that  the  membranes  of  the  bram  are  not  very 
often  damaged  in  that  situation,  whilst  it  has  also  been  shown  that 
in  the  majority  of  cases  the  upper  part  of  the  nasal  cavity  is  aseptic 
(St     Clair   Thomson^.     With   the   ear,   however,   things   are   very 
different-  the  meatus  should  be  well,  but  gently,  irrigated  with 
carboHc  lotion  (i  in  20),  and  a  strip  of  sterile  gauze  passed  down  it, 
a  large  pad  of  the  same  being  bandaged  over  the  affected  side  of  the 
head      This  must  be  replaced  as  often  as  necessary.     Beyond  this, 
the  treatment  of  fractured  base  is  directed  to  the  cerebral  condition, 
and  does  not  differ  from  that  usually  apphed  to  head  injuries,  viz., 
cold  to  the  shaved  head  (preferably  by  means  of  Leiter  s  tubes),  a 
smart  calomel  purge  to  start  with,  low  diet,  and  absolute  quiet  in  a 
dark  room.     In  the  absence  of  signs  of  cerebral  irritation  or  inflam- 
mation (viz.,  increased  rapidity  of  pulse,  persistent  headache,  giddi- 
ness etc.),  the  patient  may  be  allowed  to  sit  up  m  bed  at  the  end  of 
a  week,  and  his  diet  is  gradually  increased;  but  he  should  not  be 
allowed  to  get  out  of  bed  for  a  fortnight,  and  even  then  must  keep 
very  quiet,  and  not  think  of  returning  to  work  for  four  or  six  weeks. 
3.  Depressed  or  Punctured  Fractures  usually  involve  the  vault  of 
the  cranium,  and  are  due  to  direct  violence,  either  from  a  fall  or 
blow  causing  a  simple  or  compound  fracture,  or  from  a  penetrating 
injury  occasioning  a  punctured  fracture.    In  both  cases  there  is  often 
a  considerable  amount  of  comminution. 

It  is  quite  possible  for  the  outer  table  to  be  broken  and  depressed, 
without  any  injury  to  the  inner,  where  an  air  cavity  exists  in  the 
bone   or  if  the  diploe  is  very  thick;  thus,  the  bone  may  be  driven 


736 


A   MANUAL  OF  SURGERY 


,-.>- 


■ST^x^a--^^ 


in  over  the  frontal  sinus  without  iniury  to  its  inner  wall,  or  the 
mastoid  may  be  similarly  affected.  The  inner  table  has  also  been 
broken,   and  fragments  even  separated,    as  a  result  of  a  simple 

depression  without 
fracture  of  the  outer 
table;  this  rarely  oc- 
curs in  adults,  but 
'<,  is  not  uncommon  in 

children.  Amongst 
the  latter,  it  is  also 
possible  for  a  con- 
siderable depression 
to  exist  without  any 
fracture  of  the  inner 
table. 

More  usually  both 
inner  and  outer  tables 
are  involved,  and 
when  such  is  due  to 
force  reaching  it  from 
without,  the  inner 
table  is  always  more 
damaged  than  the 
outer,  especialty  in 
the  punctured  variety 
(Fig.  361 ,  A  and  B). 
When,  however,  the 
force  is  applied  from 
within,  as  by  a  bullet 
which  has  traversed 
the  brain,  the  outer 
table  suffers  more 
than  the  inner.  The 
causes  of  this  condi- 
tion are  similar,  from 
whichever  side  the 
force  comes,  but  need 
only  be  considered 
when  the  violence 
acts  from  without. 
[a]  The  inner  table  is 
less    supported    than 

Fig.  361.— Depressed  Fracture  of  Skull  seen  *^^  outer,  having 
FROM  Without  and  from  Within.  (King's  merely  the  soft  bram 
College  Hospital  Museum.)  and  dura  mater  with- 

in, and  hence  is  exten- 
sively splintered,  just  as  a  nail  driven  through  an  unsupported  piece 
of  wood  causes  ripping  up  of  its  under  surface,  ib)  The  loss  of 
momentum  of  the  fracturing  body  will  assist  this;  the  greater  the 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  737 

momentum  of  a  bullet,  the  more  cleanly  it  cuts,  a  smaller  momentum 
breaking  or  splintering  rather  than  cutting;  of  course,  a  considerable 
amount  of  force  is  expended  in  penetrating  the  outer  table, 
(c)  The  debris  caused  by  the  injury  to  the  outer  table  will  add  to 
the  bulk  of  the  penetrating  body,  and  its  wedge-like  action  still 
further  increases  the  injury  to  the  inner  table,  {d)  All  force  tends 
to  radiate  and  diffuse  itself  from  the  spot  struck,  and  hence,  if  the 
outer  table  is  first  injured,  the  force  will  be  disseminated  over  a 
more  extensive  area  of  the  inner. 

The  Symptoms  and  Signs  arising  from  a  depressed  fracture  vary 
widely  in  their  nature,  and  are  partly  due  to  the  injury  inflicted  on 
the  bone,  partly  to  that  sustained  by  the  brain,  whilst  the  infection 
or  not  of  the  wound  is  of  the  gravest  significance. 

Locally,  when  an  external  wound  is  present,  one  sees  blood  or 
cerebro-spinal  fluid  escaping,  or  even  brain  substance  protruding. 
The  damage  to  the  bone  may  be  seen  or  felt,  and  the  extent  of  the 
depression  or  comminution  thus  ascertained.  When  there  is  no  ex- 
ternal wound,  a  haematoma  of  variable  size  forms  under  the  scalp, 
more  or  less  obscuring  the  fracture.  The  character  of  the  lesion  is 
a  matter  of  considerable  importance  from  a  prognostic  point  of  view. 
When  the  bone  shelves  evenly  in  all  directions,  a  pond  or  saucer 
fracture  is  said  to  be  present,  and  such  is  tolerably  amenable  to 
treatment;  when,  however,  the  depression  is  sudden  and  complete, 
the  detached  portion  lying  below  the  level  of  the  rest  of  the  bone, 
it  is  termed  a  g^liter  fracture,  and  the  prognosis  is  increasingly 
grave.  The  two  forms  are,  however,  often  associated.  Necessarily, 
considerable  variations  are  met  with  in  this  type  of  fracture,  accord- 
ing to  the  nature  of  the  injury  and  the  means  by  which  it  was  in- 
flicted. Thus,  if  it  is  due  to  a  fall  on  the  vertex,  there  is  often  a 
ragged,  irregular  scalp  wound,  through  which  the  depression  can  be 
seen  or  felt;  if  caused  by  the  puncture  of  a  sharp  tool,  such  as  a 
pickaxe,  there  is  only  a  small  external  opening  corresponding  to  the 
hole  in  the  skull,  in  which  the  point  of  the  instrument  may  be  found 
embedded.  A  slicing  cut  with  a  sabre  or  hatchet  produces  a  clean 
incision  through  the  scalp,  together  with  a  linear  groove  in  the 
skull,  perhaps  somewhat  bevelled,  which  may  or  may  not  pene- 
trate its  whole  thickness.  Sometimes  detached  portions  of  the 
skull  are  raised  above  their  ordinary  level,  constituting  an  elevated 
fracture;  it  is  usually  associated  with  depression  of  surrounding 
parts. 

Gunshot  injuries  of  the  skull  manifest  any  degree  of  severity, 
according  to  the  velocity  and  angle  of  incidence  of  the  projectile.  A 
non-penetrating  wound  produces  either  a  severe  localized  contusion 
or  a  depression  with  or  without  comminution.  If  a  modern  conical 
bullet,  travelling  at  a  high  rate  of  speed,  strikes  the  skull,  it  will 
probably  penetrate,  and  possibly  may  traverse  both  sides  and  thus 
escape,  doing  comparatively  little  harm,  except  along  its  immediate 
track.  If,  however,  the  bullet  is  of  an  expanding  type,  or  if  it  is 
travelling  slowly,  it  may  cause  a  much  more  serious  lesion. 

47 


738  A   MANUAL  OF  SURGERY 

In  a  simple  depressed  fracture  the  patient  usually  suffers  from  con- 
cussion, followed  almost  immediately  by  compression,  the  latter  due 
in  part  to  the  depressed  bone,  but  mainly  to  exudation  of  blood 
and  bruising  of  the  brain;  if  this  is  at  all  extensive  and  remains 
unrelieved,  a  fatal  result  quickly  follows.  Where,  however,  the 
depression  is  but  slight,  the  symptoms  of  compression  may  be  absent 
or  not  marked,  and  the  patient  recovers,  perhaps  to  become  the 
subject  of  traumatic  epilepsy  or  insanity  at  a  later  date,  induced  by 
the  irritation  of  the  dura  mater  and  of  the  subjacent  cortex.  If  the 
depressed  fragments  irritate  the  motor  area,  convulsions,  spasms,  or 
paralysis  may  be  thereby  induced. 

In  a  compound  depressed  or  punctured  fracture  the  immediate  effects 
are  not  necessarily  severe,  the  patient  perhaps  not  even  suffering 
from  concussion,  though  brain  substance  presents  in  the  wound ;  the 
more  limited  the  spot  injured,  the  less  the  concussion.  The  ex- 
planation of  this  fact  is  that  the  blow  has  expended  its  force  in 
fracturing  the  cranium,  and  hence  does  little  harm  to  the  brain,  in 
the  same  way  that  a  watch  may  receive  but  slight  damage  from  a 
fall  if  the  glass  is  broken,  whilst  if  the  latter  remains  intact  the 
works  are  liable  to  suffer. 

Left  to  itself,  such  a  fracture  is  sure  to  become  infected,  and 
inflammation  of  the  bone,  brain,  or  membranes  will  follow. 

Septic  osteitis  leads  to  necrosis  of  the  fragments,  which  may  be 
seen  King  dead  and  yellow  at  the  bottom  of  the  wound,  whilst  the 
infiamimation  may  either  spread  along  the  diploe  to  the  surrounding 
bone,  causing  extensive  necrosis  with  pyaemia,  or  between  the  bone 
and  the  dura  mater,  leading  to  a  subcranial  abscess. 

When  once  the  dura  mater  has  been  penetrated,  inflammation  is 
liable  to  spread  to  the  meninges,  and  then  a  diffuse  oi  localized 
suppurative  meningitis,  accompanied  or  not  with  a  localized  sup- 
puration of  the  brain,  will  ensue.  Even  if  the  dura  mater  has  not 
been  opened  b}^  the  injury,  the  irritation  of  depressed  spicules  of 
bone  and  the  presence  of  a  purulent  exudation  often  lead  to  its 
ulceration  at  a  later  date.  If  there  is  a  free  external  opening,  allow- 
ing a  ready  exit  to  the  discharge,  and  thus  preventing  tension,  the 
process  may  be  quite  limited,  and  compression  of  the  brain  or  diffuse 
septic  meningitis  is  avoided;  but  if  the  bones  are  locked  together  as 
well  as  depressed,  and  the  external  wound  is  small,  retention  of 
inflammatory  products  may  lead  to  their  diffusion,  and  the  symp- 
toms of  compression  will  soon  become  evident.  A  hernia  cerebri 
may  also  form  subsequently. 

When  the  fragments  of  depressed  bone  are  early  removed,  even  if 
perfect  asepsis  is  not  attained,  the  patient  has  a  good  chance  of 
recovery;  whilst  laceration  of  the  dura  need  not  result  in  menin- 
gitis, since  the  opening  in  the  subdur-al  space  can  be  shut  off  by 
adhesions  of  the  arachnoid  in  a  very  short  time. 

\Mien  an  aseptic  condition  of  the  wound  is  obtained  by  early  inter- 
ference, and  depressed  fragments  of  bone  are  successfully  elevated  or 
removed,  the  prognosis  becomes  much  better,  and  the  case  may 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  739 

run  an  uncomplicated  course  towards  recovery,  unless  some  deeper 
cerebral  lesion  co-exists. 

The  Treatment  of  these  cases  has  been  much  changed  by  the 
introduction  of  antiseptics,  the  opinion  now  prevalent  being  that  a 
patient  runs  greater  risks  from  leaving  a  slight  depression  unrelieved 
than  bv  making  even  what  may  prove  to  be  an  unnecessary  explora- 
tion. The  object  of  the  operation  in  all  cases  is  to  elevate  depressed 
bone  and  to  remove  sharp  edges  of  fragments  which  might  injure  the 
dura  mater.  The  indications  for  operation  may  be  epitomized 
thus: 

(i.)   In  all  punctured  fractures,  operate. 

(ii.)   In  all  compound  depressed  fractures,  operate. 
(iii.)   In  simple  depressed  fractures:   In  adults,  always  operate; 
in  children,  if  gutter-shaped,  operate;  if  pond-shapep, 
wait  for  symptoms,  unless  the  fracture  is  a  bad  one. 

The  most  debatable  of  these  propositions  is  that  relating  to  the 
simple  depressed  fracture  in  an  adult.  It  may  be  objected  that 
many  such  cases  have  recovered  without  operation,  and  that  there- 
fore in  shallow  depressions  one  should  wait  for  symptoms;  but, 
whilst  the  existence  of  such  cases  must  be  admitted,  the  fact  remains 
that  serious  after-effects,  such  as  traumatic  epilepsy  and  insanity, 
are  not  uncommon  sequelse  of  an  unrelieved  depression.  The 
operation  in  itself  is  slight,  and  the  risk  insignificant  when  asepsis 
is  maintained,  so  that  one  cannot  but  insist  that  the  patient  should 
be  given  the  benefit  of  an  exploration,  especially  since  one  can  never 
be  certain  of  the  amount  of  injury  sustained  by  the  inner  table. 

When  an  operation  has  once  been  decided  on,  the  sooner  it  is 
undertaken  the  better.  The  scalp  should  be  shaved  and  thoroughly 
purified.  An  anesthetic  may  or  may  not  be  given,  according  to  the 
condition  of  the  patient.  In  a  simple  depressed  fracture  the  surgeon 
should  ne\'er  incise  the  skin  directly  over  the  wound,  but  should 
turn  down  a  flap  to  avoid  the  presence  of  a  cicatrix  over  the  lesion 
in  the  bone.  Having  cleared  away  blood-clot  and  exposed  the 
fracture,  some  loose  fragments  may  be  exposed,  and  the  removal  of 
these  maj^  permit  of  the  introduction  of  an  elevator ;  if  more  room  is 
required,  Hoffmann's  bone  rongeur  will  suffice  to  enlarge  the  opening. 
If  there  are  no  loose  fragments,  it  is  sometimes  possible  to  make  an 
opening  by  sawing  off  a  corner  of  bone  with  a  Hey's  saw.  If  neither 
of  these  plans  is  feasible,  an  opening  must  be  made  with  a  trephine. 
The  centre-pin  is  placed  upon  some  firm  undepressed  bone  as  near 
the  margin  as  possible  (Fig.  362),  and  a  circle  of  bone  removed.  An 
elevator  can  now  be  introduced,  the  fragments  prised  up  into  posi- 
tion, and  the  condition  of  the  inner  table  investigated.  Care  must 
be  taken  in  removing  loose  fragments  not  to  tear  the  dura  mater 
by  injudicious  violence,  especially  is  this  the  case  when  the  fracture 
lies  over  one  of  the  venous  sinuses.  Sufficient  bone  must  be  taken 
away  to  allow  the  whole  of  the  damaged  area  to  be  examined.  The 
bony  tissue  removed  during  the  operation  should  be  kept  in  warm 


740 


A   MANUAL  OF  SURGERY 


saline  solution,  or  may  be  tucked  in  under  the  flap  and  thereby 
protected.  When  the  loss  of  substance  is  small,  there  is  no  need  to 
replace  the  fragments;  but  when  it  is  of  considerable  size,  it  is  wise 
to  attempt  this,  wedging  them  accurately  together,  so  that  none  lie 
loose  in  the  wound.  An  opening  for  drainage  may  be  left  between 
them,  if  need  be.  In  other  cases  they  may  be  chipped  up  into  small 
pieces  and  powdered  over  the  wound. 

If  the  dura  mater  has  been  injured,  brain  substance  mixed  with 
blood  may  escape  as  soon  as  the  flap  is  raised.  When  the  bone  has 
been  dealt  with,  any  protruding  portion  of  cerebral  material  is 
removed,  and  the  dura  mater  lightly  stitched  across  the  gap.     In  the 

majority  of  cases  no  attempt  should 
be  made  to  replace  the  bony  frag- 
ments, as  they  would  certainly 
interfere  with  free  drainage;  but 
occasionally  it  may  be  possible  to 
replace  them  as  indicated  above, 
with  a  small  opening  for  drainage 
between  them.  If  the  dura  mater 
cannot  be  closed,  an  attempt  must 
be  made  to  prevent  the  formation 
of  adhesions  between  the  brain  sub- 
stance and  the  superjacent  tissues 
by  introducing  a  piece  of  sterile 
gold-foil  (or  some  similar  substance) 
between  the  brain  and  the  dura 
mater. 

In  a  compound  depressed  fracture 
the  conditions  var}^  so  much  that 
it  is  only  possible  to  give  general 
indications  for  treatment.  The 
scalp  is  first  shaved  and  purified; 
a  flap  is  then  turned  down  so  as 
to  expose  the  bony  lesion.  Loose 
Fig.  362.— Punctured  Fracture  fragments  of  bone  are  removed,  and 
OF  Skull,  showing  Spot  for  depressed  portions  elevated.  It  is 
Application  of  Trephine.  often    unwise    to    replace    bone    in 

.  these   cases,    as  thev   are  probabh' 

mfected,  and  any  attempt  to  purify  them  by  antiseptics  would 
destroy  their  vitality.  The  margins  of  the  defect  are  carefully 
cleansed,  and  fragments  of  living  uncontaminated  bone  may  be 
sown  over  the  surface  of  the  dura  mater.  The  scalp  flap  is  replaced, 
and,  if  possible,  the  original  wound  sutured  after  trimming  up  or 
excising  its  edges.  An  opening  for  drainage  may  be  made  through 
the  lower  part  of  the  flap. 

Exposed  or  protuberant  brain  substance  is  dealt  with  as  in  simple 
fractures,  except  that  it  is  necessary  to  purify  it  by  washing  with 
some  efficient  antiseptic,  such  as  5  per  cent."  carbolic  lotion,  or  a 
I  in  2,000  sublimate  solution;  of  course,  drainage  is  essential  in 


^   *^^  Hi  "— " 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  741 

these  cases,  but  the  drainage-tube  should  be  removed,  if  possible,  in 
forty-eight  hours,  so  as  to  minimize  the  chances  of  hernia  cerebri. 

In  a  punctured  fracture,  although  the  opening  in  the  bone  may  be 
small,  a  large  circle  is  removed,  since  the  inner  table  is  almost 
always  extensively  damaged.  The  centre-pin  should  rest  on  sound 
bone,  as  near  the  opening  as  possible  (Fig.  362),  and  care  must  be 
taken  to  include  all  depressed  fissures  in  the  field  of  operation.  If 
need  be,  the  dura  mater  must  be  opened  up  and  the  brain  explored. 

In  all  cases  the  patient  should  be  confined  to  bed  with  the  head 
shghtly  raised  on  a  single  pillow,  and  the  general  rules  suitable  to 
head  injuries  followed.  It  is  b}^  no  means  certain  that  elevation  of 
the  depressed  bone  will  relieve  the  symptoms,  as  they  may  be  due  to 
haemorrhagic  effusion  into  the  brain  which  cannot  be  reached. 

For  treatment  of  gunshot  injuries  of  the  skull,  see  pp.  249  and  760. 

The  symptoms  and  treatment  of  the  intracranial  compHcations  of 
head  injuries  are  dealt  with  in  the  next  chapter. 

Affections  o£  the  Frontal  Sinuses. 

These  sinuses  are  cavities  in  the  frontal  bones  fined  with  a  mucous 
membrane  continuous  with  that  of  the  nose.  They  can  hardly  be 
said  to  exist  in  children,  not  developing  much  before  the  age  of 
puberty.  In  adults  they  vary  much  in  size  and  shape,  and  are  often 
very  asymmetrical;  the  prominence  of  the  superciliary  ridges  is  no 
guide  to  their  extent.  A  good  deal  of  information  as  to  these  points 
may  be  gained  by  radiography,  the  rays  being  directed  from  behind, 
and  the  plates  placed  in  front.  The  presence  of  pus  and  of  tumours 
ma\^  sometimes  be  determined  in  this  way,  whilst  transillumination 
(p.  801)  is  also  useful. 

Fracture  of  the  anterior  wall  is  not  uncommon  as  the  result  of  a 
direct  blow,  depression  of  the  fragments  being  produced,  but  with- 
out cerebral  compfications.  If  the  mucous  membrane  is  torn, 
surgical  emphysema  of  the  scalp  and  face  ma}'  follow,  and  is  naturally 
increased  on  blowing  the  nose.  In  compound  fractures,  suppuration 
usually  occurs,  leading  to  septic  osteitis  and  necrosis  of  the  frontal 
bone,  and,  if  the  posterior  wall  is  involved,  to  a  subcranial  or  even 
a  cerebral  abscess.  In  rare  cases,  when  the  anterior  wall  has  been 
destroyed,  a  localized  collection  of  air  may  form  under  the  skin,  and 
remain  as  a  permanent  tumour,  constituting  what  is  known  as  a 
pneumatoceh  capitis  ;  it  rises  and  faUs  with  forced  respirations.  A 
similar  condition  may  also  result  from  a  fracture  into  the  mastoid 
cells;  in  either  situation  it  should  be  treated  by  compression,  or, 
faifing  this,  incision. 

Inflammation  of  the  frontal  sinus  is  caused  by  extension  of  catarrh 
from  the  nose,  by  penetrating  wounds  or  fractures,  by  foreign  bodies, 
or  it  may  be  secondary  to  disease  of  neighbouring  bones. 

Acute  Inflammation  is  usually  of  a  catarrhal  type,  and  produces 
frontal  headache,  tenderness  and  pain  on  pressure,  both  above  and 
below  the  eyebrow,  and  a  feeling  of  dulness  or  apathy.  Constitutional 


742  A   MANUAL  OF  SURGERY 

conditions,  pyrexia,  etc.,  may  also  be  present.  In  such  cases  the 
forehead  should  be  constantly  fomented,  and  the  patient  inhales 
steam  from  hot  water  to  which  eucalyptus  and  menthol  have  been 
added;  rest  in  bed  and  suitable  purgatives  are  also  necessary. 

Acute  Suppuration  of  the  sinus  is  generally  traumatic,  and  then 
is  liable  to  extend  into  the  frontal  bone,  giving  rise  to  an  acute 
osteo-myelitis,  which  may  spread  rapidly.  The  posterior  wall  of  the 
sinuses  is  extremely  thin,  so  that  the  membranes  of  the  brain  are 
easily  invaded,  and  an  abscess  may  develop  in  the  frontal  lobe. 
Occasionally  extension  of  mischief  to  the  cavernous  or  other  venous 
sinuses  may  follow. 

The  case  must  be  treated  by  laying  the  cavity  open  and  draining 
it.  For  this  purpose  a  curved  incision  is  made  along  or  immediately 
below  the  e^^ebrow,  and  the  soft  parts  stripped  from  the  bone, 
through  which  a  sufficient  opening  is  made  with  a  gouge  close  to  the 
middle  line ;  the  pus  or  mucus  is  removed,  and  the  passage  into  the 
nose  explored  and  dilated  so  as  to  allow  of  free  drainage.  The 
cavity  is  syringed  out  for  some  days,  and  the  wound  usually  closes 
readily,  although  a  fistula  occasionally  remains.  A  median  vertical 
incision  is  useful  if  there  is  any  doubt  as  to  which  sinus  is  involved, 
or  if  both  are  affected. 

Should  acute  osteo-myelitis  develop,  vigorous  measures  are 
necessary.  In  a  case  of  this  type  under  treatment,  incisions  were 
made  along  each  eyebrow  from  the  middle  line,  and  a  vertical  one 
extending  from  the  hair  to  the  root  of  the  nose.  The  flaps  thus 
formed  were  thrown  back,  the  sinuses  freely  opened,  and  their 
anterior  walls  entirely  removed:  a  large  amount  of  the  frontal  bone 
was  also  taken  away  until  healthy  diploe  free  from  purulent  infiltra- 
tion was  reached.  During  the  process  the  posterior  wall  of  the 
right  sinus  was  removed,  and  a  large  cerebral  abscess  opened.  The 
patient  made  a  good  recoverv,  although  a  considerable  amount  of 
dead  bone  had  subsequently  to  be  taken  away. 

Chronic  Empyema  of  the  frontal  sinus  may  be  the  outcome  of  an 
acute  catarrhal  inflammation,  or  may  be  chronic  from  the  first, 
extending  upwards  from  the  nose.  Pus  is  constantly  found  in  the 
anterior  portion  of  the  middle  meatus,  and  its  discharge  is  not  much 
influenced  by  the  position  of  the  head.  Frontal  headache  is  often 
complained  of,  and  there  may  be  some  localized  tenderness  on 
pressure.  If  the  infundibulum  becomes  blocked,  the  pus  may  collect 
and  lead  to  distension  of  the  cavity,  the  bony  walls  gradually  thinning 
and  yielding  before  the  pressure.  A  similar  condition  occasionally 
results  from  distension  of  the  cavity  with  mucus  [hydrops). 
When  the  walls  are  sufficiently  thinned,  '  eggshell  crackling  '  may 
be  noticed.  Owing  to  its  anatomical  relations  to  the  lower  orifice 
of  the  infundibulum,  the  maxillary  antrum  is  often  involved  second- 
arily, if  it  has  not  been  already  infected. 

In  the  Treatment  of  chronic  empyema  external  operation  must,  if 
possible,  be  avoided,  since  experience  has  shown  that  it  is  associated 
with  a  definite  mortality,  due  to  acute  osteo-myelitis.     The  intra- 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  743 

nasal  condition  is  carefully  treated ;  the  anterior  portion  of  the  middle 
turbinal  is  removed  so  as  to  give  a  better  exit  to  the  discharge,  and 
a  skilled  rhinologist  is  usually  able  to  pass  a  tube  up  the  infundib- 
ulum  and  wash  out  the  cavity.  Should  these  measures  fail  to  give 
relief,  and  should  urgent  symptoms  appear,  then  the  cavity  must  be 
opened  as  described  above,  and  a  tube  passed  through  into  the  nose, 
the  external  wound  either  being  closed  at  once  (Luc),  or  left  open  for 
a  few  days  and  packed  with  gauze. 

The  chief  Tumours  growing  from  the  frontal  sinuses  are  mucous 
cysts  or  polypi,  and  ivory  osteomata;  they  may  also  be  involved  in 
diffuse  sarcoma  or  carcinoma,  but  the  disease  is  then  not  limited  to 
the  sinus.  The  main  symptoms  and  signs  result  from  distension  of 
the  walls  of  the  cavity,  which  may  yield  anteriorly,  causing  a  large 
frontal  swelling;  or  the  posterior  wall  is  absorbed,  leading  to  cerebral 
compression ;  or  the  upper  wall  of  the  orbit  may  be  depressed,  causing 
dislocation  of  the  eyeball,  and  possibly  blindness  (Fig.  57,  p.  210). 
Tumours  which  have  attained  considerable  dimensions  can  rarely 
be  removed,  death  then  resulting  from  cerebral  compression;  but 
occasionally  bony  masses  may  necrose,  and  become  loosened  by 
suppuration  around  them,  and  in  a  few  cases  they  have  been  taken 
awav  successfully. 


CHAPTER  XXVII. 
AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES. 

Cranio-cerebral  Topography. 

It  is  scarcely  necessary  or  desirable  in  a  students'  manual  to  deal 
exhaustively  with  this  subject.  1  he  main  facts  can  alone  be  referred 
to,  and  larger  text-books  of  operative  surgery  or  surgical  anatomy 
referred  to  for  further  details.* 

The  Fissure  of  Rolando  may  be  found  topographically  by  the  fol- 
lowing methods :  (a)  The  upper  extremity  of  the  fissure  corresponds 
to  a  point  i  centimetre  (or  |  inch)  behind  the  centre  of  the  line 
extending  from  the  fronto-nasal  suture  to  the  external  occipital 
protuberance.  The  direction  of  the  sulcus  is  downwards  and  for- 
wards at  an  angle  of  about  67°  to  the  middle  line.  This' may  be 
indicated  by  laying  a  half-sheet  of  letter-paper  over  the  skull,  the 
long  side  corresponding  to  the  middle  line,  and  with  its  centre  over 
the  upper  limit  of  the  fissure;  the  anterior  half  is  now  folded  over 
obliquely  from  this  point,  leaving  an  angle  of  45°  between  the  front 
of  the  paper  and  the  middle  line  of  the  skull;  and  then  the  same 
process  is  again  repeated,  bisecting  the  angle  and  leaving  one  of 
about  67°,  so  that  the  anterior  hmit  of  the  folded  paper  corresponds 
to  the  line  of  the  fissure,  which  is  about  3f  inches  in  length.  A 
'  Rolandometer,'  consisting  of  two  strips  of  flexible  metal  united 
at  the  appropriate  angle,  is  now  sold  by  many  instrument-makers. 
As  a  general  rule  this  '  Rolandic  line  '  crosses  the  fissure  about  its 
centre,  being  in  front  of  the  fissure  above  and  a  little  behind  it  below; 
but  it  is  sufficiently  accurate  for  practical  purposes,  [h]  A  less 
exact  method  is  that  defined  by  Dr.  Reid,  the  measurements  for 
which  are  all  worked  from  the  so-called  Reid's  base-line,  which  is 
one  drawn  on  the  skull  from  the  lower  margin  of  the  orbit  backwards 
through  the  centre  of  the  external  auditory  meatus,  reaching  the 
middle  line  behind  just  below  the  occipital  protuberance  (Fig.  363). 
From  it  are  drawn  upwards  two  perpendiculars,  one  (CD)  corre- 
sponding to  the  small  depression  in  front  of  the  external  auditory 
meatus,  the  other  (EF)   to  the  posterior  border    of    the    mastoid 

*  For  a  review  of  the  relative  accuracy  of  various  methods,  see  a  paper  by 
Berry  and  Shepherd,  Brit.  Med.  Journ.,  p.  1382,  November  19,  1904. 

744 


AFFECTIONS  OF  THE  BRAIN    AND  ITS  MEMBRANES      745 


process.  The  fissure  of  Rolando  extends  from  the  upper  Hmit  of 
the  posterior  vertical  line  to  the  point  where  the  anterior  line  inter- 
sects the  fissure  of  Sylvius. 

To  map  out  the  Fissure  of  Sylvius,  (i)  Reid  utilizes  a  line  drawn 
from  a  point  ij  inches  directly  behind  the  external  angular  process 
of  the  frontal  bone  (Fig.  363,  A),  and  about  the  same  distance  above 
the  zygoma,  to  a  spot  |  inch  below  the  most  prominent  part  of  the 
parietal  eminence.  The  undivided  portion  of  the  fissure  is  repre- 
sented by  the  first  _ 
f  inch,  and  from  here  'ff.,....-.,T 
the  anterior  limb  (Sy. 
A.  Fiss.)  rises  verti- 
cally upwards  .for 
about  an  inch,  whilst 
the  posterior  limb  ex- 
tends backwards  for 
the  rest  of  the  line. 
If  prolonged  to  the 
middle  line  behind,  it 
indicates  with  toler- 
able accuracy  the 
situation  of  the 
parieto-occipital  fis- 
sure (P.  O.  Fiss.). 
Careful  investigation, 
however,  has  shown 
that  no  great  relia- 
bility can  be  placed 
on  this  method. 

(2)  Hare  and  Thane 
suggest  the  following 
measurements,  which 
in  the  majority  of 
adult  skulls  may  be 
looked  on  as  substan- 
tially accurate:  To 
find  the  Sylvian  point 
{i.e.,  the  point  of  bifur- 
cation of  the  fissure), 
a  line  is  drawn  hori- 
zontally     backwards 


Fig.  363. — Diagram  of  Head  to  indicate 
Method  of  finding  the  Fissures  of  Rolando 
AND  Sylvius  by  Reid's  Method. 

Sy.  A.  Fiss.,  Anterior  branch  of  Sylvian  fissure; 
P.  O.  Fiss.,parieto-occipitaV  fissure;  Trans.  Fiss., 
transverse  fissure  along  line  of  tentorium;  A,  ex 
ternal  angular  process  of  frontal  bone ;  B,  occipi- 
tal protuberance;  CD,  anterior  perpendicular  in 
front  of  tragus;  EF,  posterior  perpendicular 
through  back  of  mastoid  process. 


from  the  fronto-malar  suture  for  a  distance  of  35  millimetres,  and 
from  the  posterior  end  of  this  a  vertical  Hne  upwards  for  12  milli- 
metres; the  upper  extremity  of  this  line  is  the  Sylvian  point.  The 
posterior  limb  of  the  Sylvian  fissure  is  indicated  by  a  line  drawn 
backwards  from  the  fronto-malar  suture  through  the  Sylvian  point 
to  the  lower  part  of  the  parietal  eminence. 

The  external  limb  of  the  parieto-occipital  fissure  corresponds  almost 
exactly  to  the  lambda. 


746 


A    MANUAL  OF  SURGERY 


(3)  Kronlein's  method  (Fig.  364)  of  locating  the  Kolandic  and 
Sylvian  hssures  is  useful,  and  not  so  complicated  as  many  others. 
Two  horizontal  lines  arc  drawn  round  the  skull,  one,  the  lower  (AB), 
through  the  infra-orbital  border  and  upper  margin  of  the  external 
auditory  meatus;  the  other  (CD)  above  it  and  passing  through  the 
supra-orbital  margin.  Perpendiculars  are  carried  upwards  from  the 
lower  of  these  (i)  through  the  centre  of  the  zygoma,  (2)  through  the 
condyle  of  the  lower  jaw,  and  (3)  at  the  posterior  border  of  the  mastoid 
process.  The  posterior  of  these  is  prolonged  to  the  vertex  at  R;  the 
anterior  cuts  the  upper  horizontal  line  at  S ;  and  the  middle  perpen- 
dicular intersects  the  line  joining  S  and  R  at  R'.     The  angle  RSD  is 

finally  bisected  by  a  line 
fJ  SS'      which      represents 

the  posterior  limb  of  the 
Sylvian  fissure,  whilst 
RR'  corresponds  to  the 
fissure  of  Rolando. 

Methods  of  Opening 
the  Cranium. 

In  the  old  days  but 
one  instrument  was  em- 
plo^'ed  for  this  purpose, 
viz.,  the  trephine;  but 
our  increasing  know- 
ledge of  cerebral  lesions 
and  the  security  given 
by  aseptic  methods  have 
necessitated  a  consider- 
able elaboration  in  the 
methods  of  operating  on 
the  cranium. 

I.  Simple  trephining  is 
still  employed  in  dealing 
with  many  traumatic 
lesions  where  an  extensive  exposure  of  the  brain  is  not  required. 
The  modern  trephine  is  often  fitted  with  a  solid  metal  handle  to 
render  sterilization  easy,  and  the  crown  is  usually  bevelled  and 
not  straight,  so  as  to  check  the  liability  to  slip  inwards  and  wound 
the  dura.  The  scalp  is  incised  and  turned  aside  by  raising  a  flap 
which  has  its  base  downwards,  so  as  to  ensure  its  vitality.  Bleeding 
is  abundant,  and  it  may  save  time  to  prevent  this  by  encircling  the 
base  of  the  scalp  with  rubber  tubing  drawn  tight  and  fixed  by  a 
pair  of  Spenser-Wells  forceps.  The  pericranium  is  stripped  from 
the  bone,  and  the  trephine  applied  with  the  centre-pin  projecting. 
As  soon  as  a  well-marked  groove  has  been  made,  the  centre-pin  is 
withdrawn  or  removed,  and  the  instrument  carried  through  the 
cranium.  An  increased  flow  of  blood  will  often  indicate  when  the 
diploe  is  reached,  and  care  must  be  taken  not  to  injure  the  dura. 


Fig.  364. — Kronlein's  Method  of  locating 
THE  Fissure  of  Rolando  (RR').  and  the 
Posterior  Limb  of  the  Fissure  of  Syl- 
vius (SS'). 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      747 

To  this  end  tlic  groove  in  the  bone  is  carefully  examined  from  time 
to  time  by  a  flattened  probe  or  the  blunt  end  of  a  needle,  and  the 
more  so  when  the  operation  is  undertaken  in  a  region  where  the 
bone  is  known  to  be  of  irregular  thickness.  The  disc  is  removed  by 
an  elevator.  Considerable  bleeding  sometimes  takes  place  from  the 
section  of  the  bone,  but  can  usually  be  controlled  by  crushing  the 
spot  with  powerful  forceps,  or  by  rubbing  in  Horsley's  wax  (carbohc 
acid,  I  part;  oil,  2  parts;  wax,  7  parts).  If  the  opening  is  not 
sufificiently  large,  it  may  be  increased  by  the  bone  rongeur.  Key's 
saw  or  cutting  pliers,  or  even  by  the  trephine. 

2.  In  many  cases  of  cerebralabscess  the  trephine  is  unnecessary, 
as  the  causative  focus  (e.g.,  mastoid  disease  or  frontal  sinus  empyema) 
can  be  opened  up,  and  the  cranial  cavity  reached  by  removing  por- 
tions of  bone  with  a  gouge.  When  well  inside  the  skull,  a  bone 
rongeur  or  de  Vilbiss'  punch  will  suffice  to  enlarge  the  opening. 
Even  when  the  cranium  is  intact,  the  gouge  is  used  by  some  in 
preference  to  the  trephine  to  make  the  first  opening. 

3.  When  a  considerable  area  of  the  brain  needs  exposure,  as  in  the 
case  of  cerebral  tumours,  various  plans  are  adopted: 

(a)  Some  surgeons  utihze  a  large  2-inch  trephine,  but  this  is 
obviously  undesirable  owing  to  the  irregular  thickness  of  the  skull, 
and  the  difdculty  which  attends  the  equal  deepening  of  the  groove 
in  all  directions  over  such  a  large  circumference. 

(b)  When  there  is  no  hkehhood  of  being  able  to  replace  the  bones,  a 
small  trephine  hole  and  enlargement  by  the  rongeur  should  be  adopted. 

(c)  Of  late,  however,  some  form  of  Wagner's  osteoplastic  method 
has  been  chiefly  used.  In  this  a  flap  of  scalp  tissues  is  turned  down 
together  with  the  underlying  bone,  laying  bare  the  dura  mater. 
Some  surgeons  divide  the  bone  along  the  hne  of  incision  with  a  chisel 
and  wooden  mallet ;  this  requires  great  care  and  skill,  as  the  dangers 
of  concussion  of  the  brain  from  such  a  plan  are  not  to  be  overlooked. 
Others  use  a  circular  saw ;  but  probably  the  simplest  way  is  to  make 
four  small  trephine  openings  at  the  corners  of  the  flap,  and  connect 
these  either  by  the  use  of  a  Key's  saw,  or  by  a  Gigh  saw  (i.e.,  a 
piano-wire  with  a  screw-thread  turned  on  it,  and  with  handles  at- 
tached at  each  end),  passed  by  means  of  a  probe  under  the  bone 
from  one  opening  to  another,  or  by  the  use  of  a  rongeur  on  two  sides, 
whilst  the  upper  end  is  sawn  through  by  a  Key's  saw  set  on  the 
slant,  so  that  the  incision  is  bevelled,  thereby  preventing  the  bone 
from  slipping  in  when  replaced,  and  the  base  is  divided  by  a  Gigh  saw. 
This  procedure  is  a  serious  one,  attended  by  considerable  shock  and 
haemorrhage,  and  therefore  is  often  undertaken  as  a  preliminary 
measure  a  week  or  ten  days  before  the  lesion  in  the  brain  is  attacked. 

Lumbar  Puncture  in  Cerebral  Lesions. 

The  removal  of  cerebro  -  spinal  fluid  from  the  lumbar  region 
has  been  much  employed,  since  Quincke  first  suggested  it 
in    1891,    in    connection  with  affections  of   the   cranium   and  its 


748  A   MANUAL  OF  SURGERY 

contents,  and  both  diagnostically  and  therapeutically  it  is  of  the 
greatest  value. 

'  The  method  of  withdrawal  is  quite  simple.  A  stout  antitoxin  or 
exploring  needle  should  be  selected  and  sterilized  by  boiling,  and  the 
skin  in  the  region  of  the  third  and  fourth  lumbar  interspaces  (the 
spinous  process  of  the  fourth  vertebra  is  on  a  line  joining  the  iliac 
crests)  is  to  be  carefully  purified.  The  patient  sits  or  lies  with  the 
body  well  flexed.  The  needle  is  then  inserted  in  the  fourth  inter- 
space, either  in  the  middle  line,  or  a  third  of  an  inch  from  it ;  it  must 
be  pointed  forwards,  with  a  very  slight  inclination  upwards.  In 
most  cases  the  needle  will  go  straight  into  the  spinal  canal  below  the 
termination  of  the  cord,  and  the  fluid  will  escape.  If  bone  is 
encountered,  it  is  advisable  to  withdraw  the  needle  and  re-insert  it 
at  a  slightly  different  angle.  In  cases  of  repeated  failure  the  third 
interspace  ma\'  be  tried.  Under  ordinary  circumstances  the  fluid 
escapes  quietly,  drop  by  drop;  but  in  cases  of  increased  tension  it 
may  gush  out  freely. 

Normal  cerebro-spinal  fluid*  is  slightly  alkaline  and  as  clear  as 
water,  with  a  specific  gravity  of  1006  to  1008;  it  contains  a  trace 
of  globulin  and  of  a  copper-reducing  substance,  and  perhaps  a  few 
lymphocytes.  It  is  calculated  that  from  100  to  130  c.c.  are  present 
in  the  normal  adult,  but  the  amount  is  readily  increased  where  free 
exit  is  possible,  as  in  fractures  of  the  skull,  when  quantities  of  the 
fluid  escape.  It  is  probably  secreted  by  the  choroid  plexuses,  and 
removed  by  absorption  into  the  venous  sinuses.  It  not  only  sur- 
rounds the  brain  and  spinal  cord,  but  occupies  the  ventricles,  and 
passes  into  direct  communication  with  the  lymphatics  of  the  cortex 
and  of  the  peripheral  nerves. 

In  acute  meningitis,  due  to  organisms  other  than  the  tubercle 
bacillus,  the  fluid  is  turbid  and  contains  much  albumen.  Many 
cells  are  present,  most  of  which  are  polynuclear  leucocytes.  Bac- 
teria ma}'  be  detected  by  suitable  methods  of  staining  or  by  cultures. 
In  tuberculous  meningitis  the  fluid  is  almost  clear,  and  contains  a 
slight  excess  of  albumen  and  of  lymphoc\^tes.  Tubercle  bacilli  are 
rarely  found.  In  all  varieties  of  meningitis  the  fluid  is  secreted 
under  pressure,  and  usually  issues  from  the  needle  in  a  stream. 

In  cerebral  abscess  and  lateral  sinus  thrombosis  the  fluid  is  normal, 
but  may  be  under  excessive  pressure. 

In  fracture  of  the  base  of  the  skull  or  of  the  spinal  column,  and  in 
injuries  of  the  surface  of  the  brain,  blood  usually  appears  in  the 
cerebro-spinal  fluid  within  a  few  hours  of  the  accident  and  is  inti- 
mately mixed  with  it. 

The  Therapeutic  value  of  this  procedure  has  not  been  so  fully 
recognised  as  its  use  in  diagnosis.  In  many  cases  of  meningitis  the 
coma  is  due  mainly  to  excessive  cerebro-spinal  fluid,  and  if  the 
amount  of  this  can  be  diminished  the  symptoms  often  abate.  The 
value  of  lumbar  puncture  will,  therefore,  depend  on  whether  or  not  it 

*  For  further  details,  see  Sir  David  Ferrier :   '  The  Cerebro-Spinal  Fluid  in 
Health  and  Disease,'  Lancet,  October  18,  1913. 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      749 

is  possible  to  influence  the  intracranial  tension  thereby  and  that,  in 
turn  is  dependent  on  the  situation  and  character  of  the  adhesions 
present  The  puncture  must,  therefore,  be  obviously  experimental, 
as  one  can  never  be  certain  as  to  the  adhesions;  but  it  is  a  simple 
proceeding,  and  may  well  be  employed  in  all  cases  of  memngitis,  in 
the  hope  that  some  good  may  follow.  In  traumatic  conditions  it 
mav  be  useful  when  the  lesion  is  not  very  serious,  and  the  pressure 
on  the  brain  not  hopelessly  exaggerated.  In  cerebral  tunriours  it 
must  be  emploved  with  the  greatest  caution  if  at  all,  as  fatal  results 
have  followed  the  removal  of  a  comparatively  smaU  amount  of  fluid 
owing  to  undue  pressure  on  the  base  thereby  induced. 

It  ?s  also  possible  to  introduce  drugs  within  the  spinal  theca  after 
lumbar  puncture,  e.g.,  antitetanic  serum  in  tetanus  solutions  of 
magnesium  sulphate  in  tetanus,  or  of  sodium  bromide  in  dehrium 
tremens.  Attempts  have  also  been  made  to  influence  by  this  means 
parasvphihtic  ner^•ous  affections  where  the  cerebro-spmal  flmd 
remains  positive  to  the  Wassermann  reaction  m  spite  of  general 
medication;  such  treatment  has  not  yet  met  with  much  success. 

General  Conditions  of  the  Brain  after  Head  Injuries. 

Concussion  of  the  Brain,  or  stunning,  is  a  clinical  condition 
characterized  bv  a  more  or  less  complete  suspension  of  its  functions 
as  a  result  of  injurv  to  the  head,  which  leads  to  some  commotion  of 
the  cerebral  substance,  and  may  or  may  not  be  associated  with 
hEemorrhage.  It  varies  with  the  severity  of  the  cause  from  a  slight 
momentarv  giddiness  and  confusion  of  thought  to  the  most  complete 
insensibilitv,  and  is  closely  allied  to  shock,  from  which  it  is  often 
distinguished  with  difficult  v.  .       . 

In  fatal  cases,  one  finds  on  post-mortem  examination  mere  y  the 
same  conditions  as  obtain  in  shock,  viz.,  engorgement  of  the  lungs, 
viscera,  and  the  right  side  of  the  heart,  whilst  the  bram  presents  some 
lesion  of  varving  severitv,  from  mere  punctiform  ecchymoses  to 
actual  disintegration  and  disorganization.  The  symptoms  can 
scarcelv  be  attributed  to  the  injury  itself  or  to  a  reflex  stimulation 
of  the  vagus,  as  thev  often  bear  so  little  proportion  to  the  degree  ot 
mischief.  Buret's  theorv  is  probably  correct  which  attributes  the 
phenomena  to  stimulation  of  the  restiform  bodies  m  the  medulla  by 
the  sudden  displacement  of  cerebro-spinal  fluid  o^^•lng  to  the  tem- 
porar^•  driving  in  of  the  skull  by  the  injury  Apparently  the  fluid 
is  forcibly  expeUed  from  the  lateral  ventricles  along  the  iter  to  the 
fourth  ventricle,  the  roof  of  which  has  been  ruptured  the  floor 
bruised,  or  the  iter  torn  in  experiments  confarmmg  the  theorv. 
The  grouping  of  the  vital  centres  about  the  floor  of  the  fourth 
ventricle  wiU  explain  the  gravity  of  the  symptoms  often  present. 

The  Symptoms  varv  considerablv  in  degree,  but  m  a  well-marked 
case  the  stage  of  concussion  is  evidenced  by  unconsciousness,  niore 
or  less  complete,  although  the  patient  can  sometimes  be  roused  by 
shouting-  he  hes  on  his  back,  with  the  muscles  relaxed  and  flaccid; 


750  A   MANUAL  OF  SURGERY 

the  eyelids  are  closed,  and  the  conjunctivae  may  be  insensitive;  the 
pupils  vary,  but  are  equal  and  often  contracted,  usually  reacting  to 
light;  but  in  bad  cases  they  are  dilated,  and  do  not  contract  when 
light  is  admitted.  The  surface  of  the  body  is  pale,  cold,  and  clammy. 
The  respirations  are  slow,  shallow,  and  sighing,  whilst  the  pulse  is 
rapid,  weak,  fluttering,  and  scarcely  sensible  to  the  fingers;  the 
temperature  is  at  first  subnormal;  the  sphincters  are  relaxed,  with 
perhaps  unconscious  evacuations  from  both  bladder  and  bowel. 
The  reflexes  are  present  in  the  milder  cases,  though  sluggish;  in 
the  more  severe  they  may  be  entirely  absent. 

This  condition  may  last  for  a  considerable  time,  and  then  pass 
slowly  into  more  profound  unconsciousness  and  death,  or  be  followed 
by  the  phenomena  of  inflammation,  compression,  or  cerebral  irrita- 
tion. In  the  simpler  cases,  however,  reaction  soon  begins  to  manifest 
itself.  The  patient  is  presumably  put  to  bed,  and  warmth  carefully 
applied  to  the  extremities.  'Ihe  first  sign  of  reaction  is  probably  a 
slightly  increased  rate  of  both  breathing  and  pulse,  whilst  he  may 
be  able  to  tell  his  name  and  address;  sometimes  he  turns  on  his 
side,  and  pulls  the  bedclothes  up  to  his  face,  since  he  feels  cold 
and  chilly  as  a  result  of  the  cutaneous  anaemia.  Gradually  he 
becomes  more  and  more  rational,  and  the  functions  of  both  mind 
and  body  are  restored,  reaction  being  fully  established  by  the  occur- 
rence of  vomiting,  due  to  a  condition  of  cerebral  hypersemia  follow- 
ing the  anaemia.  Probably  he  suffers  from  headache  for  some  days, 
and  a  slight  amount  of  fever  will  follow;  but  this  passes  off,  and 
leaves  the  patient  either  quite  well,  or  with  a  somewhat  irritable 
brain  requiring  prolonged  rest.  Subsequent  events  may,  however, 
prove  that  more  mischief  has  been  done  than  appears  at  first.  Thus, 
some  special  function  of  the  brain  may  be  permanently  lost  or 
impaired,  such  as  memory,  hearing,  or  vision;  a  patient  may  forget 
the  names  of  places  or  persons,  or  may  lose  all  memory  of  time; 
speech  may  become  defective  or  stammering,  or  a  certain  amount  of 
asthenopia  (weakness  of  vision)  may  supervene.  Such  individuals 
are  very  liable  to  develop  signs  of  mental  instability,  and  even 
delusional  insanity  or  melancholia,  if  placed  in  positions  of  responsi- 
bility or  strain.  Others  seem  to  suffer  from  a  general  loss  of  nerve 
tone  (neurasthenia),  rendering  them  incapable  of  fulfilling  their 
ordinary  duties  in  life.  In  all  the  more  severe  cases  there  is  a 
complete  lapse  of  memory  as  to  the  accident,  and  even  as  to  the 
events  which  preceded  and  followed  it,  extending  sometimes  to  a 
fortnight  or  more,  and  perhaps  including  a  period  during  which  the 
patient  was  apparently  quite  rational. 

The  Treatment  of  concussion  very  closely  resembles  that  of  shock, 
viz.,  the  patient  is  at  once  put  to  bed,  with  the  head  low,  and  is 
covered  with  warm  blankets;  hot-water  bottles  may  be  apphed  near 
the  extremities,  and  friction  to  the  surface.  Any  needless  stimulation 
must  be  avoided  for  fear  of  exciting  hctmorrhage;  an  enema  of  hot 
coffee  may  be  given,  or,  if  in  extremis,  brandy,  or  a  hypodermic  injec- 
tion of  strychnine.     A  good  purge,  such  as  5  grains  of  calomel,  or  a 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      751 

drop  or  two  of  croton  oil  on  sugar,  should  be  administered  after 
reaction  in  the  milder  cases,  but  whilst  still  unconscious  m  the 
graver  forms.  It  is  most  important  that  the  patient  be  kept  quietly 
in  bed  for  at  least  ten  days  or  a  fortnight  after  a  moderately  bad 
concussion  and  free  from  all  sources  of  worry  and  irritation,  even 
though  he 'feels  quite  well.  The  diet  must  be  restricted,  and  the 
bowels  kept  open.     '  Make  haste  slowly  '  is  here  a  golden  rule. 

When  the  unconsciousness  is  prolonged,  and  no  signs  of  fracture 
of  the  cranium  exist,  lumbar  puncture  should  be  employed, 
and  may  be  most  beneficial.  Thus,  a  lady  who  had  attempted 
suicide  by  throwing  herself  from  a  window  lay  for  two  or  three  days 
on  the  borderland  of  unconsciousness,  frequently  relapsing  into  a 
comatose  state.  Lumbar  puncture  resulted  in  the  drawing  off  of 
some  drachms  of  blood-stained  fluid,  and  at  once  restored  her  to 
complete  consciousness,  which  was  not  again  lost.  Should  this 
treatment  fail,  the  head  should  be  shaved,  and  an  icebag  or 
Leiter's  tubes  apphed;  the  bowels  are  opened  regularly,  and  the  state 
of  the  bladder  attended  to;  the  room  must  be  kept  dark  and  quiet, 
the  attendants  making  as  Httle  noise  in  walking  and  talking,  etc.,  as 
possible  •  sufficient  nourishment  must  be  given  either  by  a  spoon  if 
the  patient  can  thus  take  it,  or  by  nutrient  enemata  or  a  nasal  tube. 

Cerebral  Irritation.— By  cerebral  irritation  is  meant  a  clinical  con- 
dition which  sometimes  follows  concussion,  characterized  by  great 
irritability  of  both  mind  and  body.  It  usually  results  from  blows  or 
falls  on  the  temple,  forehead,  or  occiput,  and  is  probably  due  to  a 
superficial  laceration  of  the  brain,  possibly  in  the  frontal  region,  and 
to  the  hyperemia  caused  by  its  subsequent  repair. 

The  Symptoms  are  very  characteristic,  and  usually  manifest  them- 
selves two  or  three  days  after  the  injury,  though  sometimes  earlier. 
The  patient  lies  on  his  side  in  a  condition  of  general  flexion,  the  back 
arched,  the  legs  drawn  up  to  his  abdomen  with  the  knees  bent,  and 
the  hands  and  arms  drawn  in.  He  is  restless,  and  may  toss  about, 
but  never  extends  himself  fully  or  lies  supine.  The  eyes  are  closely 
shut,  and  he  resists  all  attempts  to  open  them;  the  pupils  are  con- 
tracted" the  temperature  is  usually  a  little  raised,  but  the  surface 
of  the  body  and  head  are  both  cool;  the  pulse  is  quiet  but  weak;  the 
sphincters  are  usually  in  a  normal  condition,  and  the  excreta  are 
often  passed  in  the  bed,  but  the  bladder  may  occasionally  need  to 
be  emptied  by  catheter.  In  some  mild  instances  the  patient  may 
get  up  to  empty  his  bladder  and  then  return  to  bed.  He  is  by  no 
means  unconscious,  but  takes  no  heed  of  what  is  passing  around,  and 
is  intensely  and  morbidly  irritable.  When  disturbed,  he  will  gnash 
his  teeth,  frown,  swear,  and  resent  the  intrusion  m  the  most  expres- 
sive manner.  At  the  end  of  a  few  days,  or  perhaps  after  a  week  or 
two,  a  marked  alteration  in  the  condition  of  the  patient  usually  shows 
itself.  He  is  less  irritable,  begins  to  stretch  himself  out,  and  with 
this  is  conjoined  an  improvement  in  both  pulse  and  temperature. 
Sometimes  he  becomes  childish,  and  needs  to  be  taught  the  names  of 
persons  and  things;  at  other  times  he  is  garrulous,  perhaps  giving  a 


752  A   MAl^UAL  OF  SURGERY 

fresh  story  of  his  accident  every  day,  but  generally  there  is  an 
absolute  lapse  of  memory  in  this  direction.  Usually  the  brain 
recovers  in  time,  but  serious  after-effects  in  the  direction  of  chronic 
meningitis  or  mental  aberration  are  likely  to  ensue. 

Treatment.- — The  patient  is  kept  quiet  and  free  from  noise  or 
excitement ;  his  diet  must  be  light  and  nourishing.  The  head  should 
not  be  too  low,  and  Leiter's  tubes  may  be  fitted  on  if  the  patient 
will  permit  it;  but  it  is  better  to  omit  this  entirely  than  to  apply 
cold  intermittently.  The  bowels  are  kept  well  open,  and  possibly 
small  doses  of  bromide,  or  even  opium,  may  be  useful.  If  any  signs 
of  meningeal  inflamjnation  follow,  such  as  rise  of  temperature  and 
pulse,  heat  of  head,  and  great  sleeplessness,  blisters  or  leeches  may 
be  applied  locally,  and  mercury  administered  internally. 

Compression  of  the  Brain. — Compression  is  the  term  given  to  a 
clinical  condition  due  to  some  abnormal  and  excessive  intracranial 
pressure  which  disturbs  the  functions  of  the  brain.  In  the  earlier 
stages  a  displacement  of  cerebro-spinal  fluid  from  the  cranium  to  the 
vertebral  canal,  and  increased  absorption  in  various  directions,  may 
relieve  the  symptoms ;  but  as  the  pressure  increases,  the  brain  sub- 
stance itself  suffers,  the  cortical  centres  being  involved  first,  and  the 
medulla  last.  The  effect  of  such  increased  pressure  is  to  paralyze 
after  temporarily  stimulating.  When  of  traumatic  origin,  it  may 
arise  from  the  following  causes:  [a)  Depressed  bone  or  the  presence 
of  a  foreign  body,  in  which  case  the  symptoms  of  concussion  merge 
directly  into  those  of  compression,  and  usually  without  any  interval 
of  consciousness.  It  is  probable,  however,  that  in  these  cases  the 
symptoms  are  due  more  to  the  associated  haemorrhage  than  to  the 
actual  cranial  lesion.  (&)  Extravasation  of  blood  within  the  cranium, 
either  outside  the  membranes,  or  on  the  surface  of  the  brain,  or 
within  its  substance.  If  the  bleeding  is  extradural,  there  will  prob- 
ably be  a  short  interval  of  consciousness  between  the  concussion  and 
the  compression;  if  the  bleeding  is  cerebral,  the  symptoms  of  com- 
pression may  manifest  themselves  at  once  without  any  interval 
being  noticed,  (c)  It  may  be  due  to  an  acute  spreading  oedema,  the 
explanation  of  which  is  subsequently  given  (p.  755).  (d)  It  may 
arise  from  the  pressure  of  inflammatory  exudation  or  pus,  in  which 
case  the  symptoms  are  preceded  by  those  of  inflammation,  and  at  the 
earliest  will  not  manifest  themselves  before  the  third  day,  whilst  they 
may  be  deferred  for  a  week  or  two. 

Compression  also  arises  as  a  result  of  idiopathic  hsemorrhage, 
tumours,  gummata,  or  abscesses — e.g.,  of  middle-ear  origin. 

The  Symptoms  of  compression  are  essentially  those  of  coma.  When 
the  condition  is  well  established,  the  patient  lies  on  his  back  abso- 
lutely unconscious,  and  cannot  be  roused  either  by  shouting  or 
shaking.  His  breathing  is  slow,  laboured,  and  stertorous,  the  lips  and 
cheeks  being  puffed  in  and  out.  The  stertor  arises  from  paralysis  of 
the  soft  palate,  and  the  pufftng  of  the  cheeks  from  paralysis  of  the 
facial  muscles.  In  the  later  stages  the  respirations  become  irregular, 
and  take  on  the  Cheyne-Stokes  type.     Gradually  breathing  becomes 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      753 

more  shallow  and  difficult,  and  death  finally  arises  from  cessation 
of  the  respiratory  act.  The  pulse  is  full  and  slow  at  first  from  irrita- 
tion of  the  vagus  and  vasomotor  centres,  but  later  on  becomes  rapid 
and  irregular,  owing  to  increased  pressure  upon  and  exhaustion  of 
these  medullary  centres.  The  surface  of  the  body  may  either  be  cool, 
hot,  or  perspiring;  the  temperature  similarly  varies,  often  being  low 
in  the  early  stages  and  higher  at  a  later  date.  Not  unfrequently  the 
fatal  end  is  associated  with  marked  hyperpyrexia.  In  some  cases 
where  the  compressing  force  is  unilateral,  there  may  be  some  differ- 
ence of  temperature  on  the  two  sides  of  the  body.  The  pupils 
become  dilated  without  responding  to  light,  but  vary  according  to 
the  degree  of  compression  and  the  situation  of  the  compressing 
agent.  If  the  cerebral  pressure  is  equally  diffused,  both  pupils  first 
contract,  and  then  gradually  dilate  and  become  reactionless ;  but  if 
one  hemisphere  is  affected  more  than  the  other,  the  pupil  on  that 
side  passes  rapidly  through  these  changes,  whilst  on  the  opposite 
side  they  are  not  developed  until  later.  Thus,  it  is  a  common  thing 
to  find  the  pupils  unequal  in  size,  and  reacting  differently  to  light. 
The  whole  body  in  the  later  stages  is  in  a  condition  of  motor  paralysis, 
but  at  an  earlier  period  of  the  case  there  may  be  some  difference  on 
the  two  sides,  if  the  lesion  is  unilateral ;  thus,  if  the  left  side  of  the 
brain  is  primarily  affected,  a  right-sided  hemiplegia  is  likely  to  be 
present  at  a  time  when  the  muscles  on  the  left  side  can  still  respond 
to  cerebral  stimuli.  A  localized  compression  involving  the  motor 
area  may  lead  to  convulsions  in  the  corresponding  group  of  muscles. 
The  bladder  is  paralyzed,  and  hence  retention  ensues,  whilst  the 
sphincter  ani  is  relaxed,  and  fseces  pass  involuntarily,  although 
marked  constipation  is  usually  present. 

The  symptoms  in  some  cases  are  ushered  in  by  severe  pain  or 
headache,  which  is  partly  due  to  pressure  upon  and  tearing  of  the 
dura  mater,  and  partly  to  the  altered  vascular  conditions  of  the 
brain ;  the  brain  substance  itself  is  not  sensitive,  and  hence  the  pain 
is  not  directly  referable  to  any  lesion  of  or  pressure  upon  it.  Natur- 
ally, the  clinical  picture  is  modified  according  to  the  cause  of  the 
compression,  even  as  the  course  of  the  case  varies  widely  according 
to  whether  or  not  the  compressing  agent  can  be  removed  by  the 
surgeon,  or  absorbed  by  natural  processes. 

The  Diagnosis  of  coma  from  compression,  when  a  complete  history 
of  the  case  can  be  obtained,  is  often  easy,  and,  indeed,  the  whole 
clinical  aspect  may  be  so  typical  that  no  question  as  to  the  cause  of 
unconsciousness  can  be  raised.  But  when  a  person  is  found  in  the 
streets  unconscious,  and  no  history  either  of  the  patient  or  of  an 
accident  is  obtainable,  and  no  serious  lesion  of  the  skull  is  present, 
the  diagnosis  is  often  extremely  obscure,  since  coma  may  be  due  to 
many  other  causes,  e.g.  :  {a)  Cerebral  lesions,  such  as  apoplexy, 
whether  the  result  of  haemorrhage,  embolus,  or  thrombosis;  or  it 
may  be  the  consequence  of  a  preceding  epileptic  fit,  or  due  to  a 
rapidly  spreading  oedema  in  cases  of  cerebral  tumour  or  abscess. 
[b)  Various  toxic  agents  may  induce  coma;  they  may  be  introduced 


754  A   MANUAL  OF  SURGERY 

into  the  system  from  without,  as  in  the  case  of  alcohol,  opium,  or 
other  narcotics,  or  may  be  developed  within  the  body,  as  in  ureemia 
or  diabetic  coma,  (c)  Heatstroke  or  exposure  to  cold  may  also  lead 
to  unconsciousness.  In  the  latter  case  there  can  be  but  little  doubt 
as  to  the  cause,  since  the  patient  is  cold,  pale,  and  in  a  state  of 
severe  prostration;  in  the  former  the  diagnosis  may  for  a  time  be 
doubtful,  {d)  Lastly,  it  must  not  be  forgotten  that  two  or  more  of 
these  conditions  may  co-exist.  Thus  a  drunken  man  may  fall  and 
break  his  skull,  and  then  the  smell  of  liquor  in  his  breath  may  lead 
to  an  erroneous  diagnosis. 

It  is  therefore  evident  that  a  very  careful  examination  of  the 
patient  is  required  before  any  conclusion  can  be  arrived  at  as  to  the 
cause  of  the  coma,  and  it  is  often  impossible  to  make  an  immediate 
diagnosis.  In  such  cases  the  patient  should  be  carefully  tended  and 
watched,  and  not  shut  up  for  the  night  in  a  police-cell  without 
attendance. 

The  following  points  should  always  be  observed  in  the  examina- 
tion: (i)  A  rapid  note  should  be  made  as  to  the  surroundings  of 
the  patient — whether  there  is  blood  or  vomit  near  him,  how  the 
bod}'  is  lying,  and  the  nature  of  the  ground.  (2)  The  depth  of  the 
coma  should  be  ascertained,  and,  if  possible,  the  man  should  be 
roused,  and  asked  to  give  an  account  of  himself.  (3)  A  most 
thorough  and  complete  investigation  should  be  made  as  to  his  con- 
dition. His  skull  must  be  first  examined,  to  settle  if  possible 
whether  or  not  a  fracture  is  present ;  the  surface  temperature  of  the 
body  is  noted,  as  also  the  character  of  the  pulse  and  respirations. 
The  tongue  should  be  looked  at,  as  it  is  often  bitten  in  an  epileptic 
fit,  and  the  smell  of  the  breath  should  also  be  noted.  Be  it  remem- 
bered that  the  smell  of  alcohol  in  the  breath  is  not  sufficient  warrant 
in  itself  to  diagnose  merely  drunkenness,  as  the  alcohol  may  have 
been  given  after  the  accident  to  revive  the  patient.  The  condition 
of  the  pupils  may  throw  some  light  on  the  case;  in  opium-poisoning 
they  are  small  and  equal,  a  condition  also  seen  in  haemorrhage  into 
the  pons;  in  alcoholism  they  are  often  dilated  and  fixed,  but  vary 
considerabty  in  different  cases.  The  amount  of  power  and  the  state 
of  the  reflexes  are  then  observed,  any  inequality  probablv  indicating 
a  unilateral  lesion  in  the  brain.  The  urine  must  be  drawn  off,  and 
carefully  examined  for  albumen  and  sugar.  (4)  In  dubious  cases, 
and  especially  where  there  is  any  suspicion  of  drunkenness  or  poison, 
the  stomach  should  be  emptied  and  washed  out.  (5)  Finally,  if  the 
cause  is  still  uncertain,  the  patient  should  be  put  to  bed  and  carefully 
watched. 

The  Treatment  of  compression  must  be,  where  possible,  directed 
to  removing  the  cause.  When  it  is  due  to  depressed  bone  or  a 
foreign  body,  immediate  operation  is  required;  collections  of  pus 
should  be  opened,  and  blood-clots  removed.  Failing  such  measures, 
and  if  lumbar  puncture  gives  no  relief,  the  treatment  of  the  con- 
dition resolves  itself  into  keeping  the  patient  quiet,  with  the  head  low 
ar.d  cool,  the  room  dark  and  noiseless,  the  bowels  open  (using  croton 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      755 

oil  on  sugar,  or  encmata,  for  this  purpose),  and  tlie  bladder  empty. 
Tlie  patient  may  have  to  be  fed  by  the  rectum,  and  if  the  breath- 
ing or  pulse  is  very  laboured,  and  cyanosis  begins  to  show  itself, 
venesection  may  be  advisable.  Considerable  interference  with  the 
respiration  arises  from  falling  back  of  the  tongue,  as  often  occurs 
in  profound  ansesthesia  during  surgical  operations,  and  if  due  to  this 
cause  the  head  mav  be  rolled  over  to  one  side,  or  the  tongue  pulled 
forwards. 

Laceration  of  the  Brain. — ^Injuries  to  the  brain  and  its  membranes 
are  frequent  complications  of  head  injuries,  and  all  the  most  serious 
results  of  these  accidents  arise  from  this  source.  They  are  produced 
in  many  different  ways,  and  cause  varied  symptoms ;  but  the  most 
important  distinction  to  draw  is  between  those  wounds  which  com- 
municate with  the  exterior  and  those  which  do  not. 

I.  Non-penetrating  Wounds  of  the  Brain  result  from  blows  and 
falls,  which  may  or  may  not  produce  simple  fissured  or  depressed 
fractures  of  the  skull,  but  not  unfrequently  the  most  serious  cerebral 
symptoms  follow  injuries  in  which  the  bones  do  not  participate.  In 
depressed  fractures  the  brain  is  usually  most  contused  or  torn  imme 
diately  below  the  injured  spot;  but  in  cases  where  there  is  no 
depression,  the  greatest  mischief  is  frequently  found  at  a  point 
exactly  opposite  to  that  struck  (point  of  contrecoup),  whilst  the  local 
bruise  may  be  much  slighter.  Thus,  in  the  case  of  one  of  our 
students  who,  in  an  epileptic  fit,  fell,  striking  the  left  occipital 
region  on  a  stone  pavement,  we  found  post-mortem  a  fissured  fracture 
at  the  spot  struck  and  a  bruise  on  the  left  occipital  convolution, 
whilst  the  anterior  portion  of  the  right  frontal  lobe  was  severely 
contused,  and,  indeed,  disintegrated.  The  explanation  of  this  fact 
is  that  the  force  of  the  injury  is  transmitted  to  the  brain  substance 
in  a  wave  which  concentrates  its  violence  against  the  opposite  side 
of  the  skull.  In  very  sharp  sudden  locaHzed  blows,  as  from  a  spent 
bullet,  local  bruising  of  the  subjacent  brain  may  be  alone  produced. 

Pathological  Anatomy.- — The  immediate  effects  of  such  an  injury 
vary  considerably.  There  may  be  a  mere  bruise,  evidenced  by  a  few 
points  of  extravasation,  on  the  surface  or  in  the  gray  matter;  or  the 
more  superficial  parts  of  the  brain  may  be  totally  disintegrated  and 
mixed  with  clots ;  or,  if  laceration  has  occurred,  clots  may  be  found 
adhering  to  the  injured  spot,  or  extending  from  it  widely  into  the 
subarachnoid  space,  or  even,  under  rare  circumstances,  into  the 
lateral  ventricle.  The  later  effects  in  cases  where  the  wound  does 
not  communicate  with  the  exterior  are  mainly  those  of  inflammation 
or  degeneration.  Soon  after  the  accident  considerable  exudation 
follows,  causing  the  ecchymosed  brain  substance  to  swell  and 
become  oedematous;  this  may  speedily  subside,  but  in  the  more 
serious  cases  a  spreading  oedema  may  be  caused,  owing  to  the  pressure 
of  the  swollen  tissues  upon  the  superficial  veins  in  the  pia  mater; 
the  circulation  in  these  is  hindered,  and  increased  exudation  follows, 
leading  to  general  cerebral  pressure  and  even  death,  a  consequence 
hastened  by  the  excess  of  cerebro-spinal  fluid  usually  induced  by  the 


756  A   MANUAL  OF  SURGERY 

process.  Under  such  circumstances  the  greater  part  of  the  brain 
IS  oedematous  and  ghstening,  the  injured  area  being  yellowish-red  in 
colour,  with  evident  points  of  extravasation  scattered  through  it. 
Still  later,  degeneration  of  the  brain  substance  may  follow  owing  to 
the  disturbance  of  its  circulation,  and  is  indicated  by  the  presence 
of  a  pulpy  yellowish  mass,  soft  enough  to  be  washed  away  by  a 
stream  of  water,  and  containing  fat  globules  and  granular  cells,  with 
debris  of  nerve  fibres  {yellow  softening) .  If  the  area  involved  is  small 
and  unimportant,  the  patient  may  recover,  the  softened  tissue  being 
absorbed,  and  replaced  by  a  scar;  if  large  or  implicating  important 
centres,  death  or  paralysis  must  ensue.  In  cases  of  laceration 
of  the  brain  which  recover,  a  tough  depressed  cicatrix  is  formed, 
usually  adherent  to  the  membranes,  and  containing  hsematoidin 
crystals,  whilst  extravasated  blood  may  be  organized  into  a  dirty 
brownish  lamina,  adherent  to  the  pia  mater,  or  into  an  arachnoid 
cyst. 

Clinical  History. — The  symptoms  necessarily  differ  with  the 
severity  and  locality  of  the  lesion. 

Whenever  concussion  occurs  after  a  head  injury,  and  the  patient 
recovers  slowly  from  it,  the  surgeon  will  rightly  suspect  contusion 
or  laceration  of  the  brain.  In  the  slighter  cases  recovery  is  often 
inaugurated  by  an  attack  of  vomiting,  and  this  is  followed  by  a  rise 
of  temperature  to  about  ioo°  F.  for  a  few  days,  whilst  the  patient 
complains  of  fixed  pain  and  headache,  which  under  suitable  treat- 
ment may  entirely  disappear.  Some  impairment  of  sense  or 
function  may,  however,  persist. 

More  serious  lesions  give  rise  to  various  symptoms  resulting  from 
haemorrhagic  effusion,  and  these  will  manifest  themselves  either  at 
once  or  within  twenty-four  to  forty-eight  hours  of  the  injury.  Thus, 
if  the  phenomena  of  compression  supervene  at  once,  without  any 
interval  of  consciousness,  a  diagnosis  of  depressed  bone  or  a  serious 
haemorrhage  into  the  cerebral  substance  may  be  safely  made.  If,  on 
the  other  hand,  the  patient  rallies  for  a  time  before  the  incidence 
of  compression  phenomena,  an  extradural  haemorrhage  from  the 
meningeal  vessels  or  venous  sinuses  may  be  suspected,  or  a  rapidly 
spreading  cedema. 

Haemorrhage  into  the  cortex  is  characterized  by  irritative  or 
paralytic  phenomena,  which  vary  with  the  cortical  area  involved. 
The  degree  of  unconsciousness  depends  on  the  amount  of  the 
hsemorrhagic  effusion. 

In  the  Upper  and  Middle  Frontal  Convolutions  neither  motor  nor 
sensory  symptoms  are  noted,  but  cerebral  irritation  and  subsequent 
weak-mindedness  are  likely  to  follow,  especially  if  the  left  side  is 
involved;  lesions  to  the  right  frontal  lobe  do  but  little  harm  to  a 
right-handed  individual.  Apparently,  the  intellectual  faculties  are 
limited  to  one  side  of  the  brain,  in  the  same  wa}-  as  the  power  of 
speech. 

Wounds  of  the  Third  Left  Frontal  Convolution  lead  to  motor 
aphasia — i.e.,  the  inability  to  produce  or  articulate  words,  in  right- 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      757 

handed  individuals;  in  left-handed  people  wounds  of  the  right  side 
have  a  similar  result.  Injury  to  the  opposite  convolution  has  no 
effect.  If  onl}^  one  side  is  damaged,  the  other  convolution  can  after 
a  time  be  educated  so  as  to  take  on  the  function  of  the  damaged 
region. 

Hemorrhage  into  the  Motor  Area  (Fig.  365)  results  in  locahzed 
convulsions  or  paralysis,  according  to  the  degree  of  mischief.  If  the 
bleeding  is  progressive,  a  regular  extension  of  the  convulsions  may 
be  witnessed,  the  movements  commencing,  perhaps,  in  some  region 
which  is  at  the  time  incapable  of  voluntary  movement,  and  spreading 
to  other  parts  of  the  body.  Thus,  if  bleeding  is  occurring  into  the' 
cortical  centres  for  the  face  on  the  left  side  of  the  brain,  paralysis  of 


POT. 

AtfCrVLAT-. 
CYRUS. 


CEKEBELLUM 


Fig.  365.— Diagram   representing  the  Functions  of  the  Cerebral 

Cortex. 

F.  R.,  fissure  of  Rolando;  P.  O   F.,  Parieto-occipital  fissure 

the  right  side  of  the  face  may  be  present,  and  it  is  here  that  the 
convulsions  will  start,  spreading  regularly  to  the  right  side  of  the 
neck,  arm,  and  leg,  and  then  involving  the  left  leg,  arm,  and  side  of 
the  head  in  order,  finally  becoming  general,  as  in  an  epileptic  fit. 
After  each  convulsion  the  paralysis  is  found  to  have  spread. 

It  is  sometimes  very  difficult  to  diagnose  between  a  true  cortical 
hsemorrhage  and  one  which  extends  diffusely  over  thecortex  in  the 
subarachnoid  space  from  the  rupture  of  a  vein  in  the  pia  mater.  In 
the  latter,  however,  the  symptoms  develop  earher,  the  paralysis  is 
less  marked,  and  the  convulsions  are  less  regular,  though  perhaps 
more  generalized. 

An  irritative  lesion  of  the  motor  area  for  the  head  and  eyes  causes 


758  A   MANUAL  OF  SURGERY 

a  conjugate  deviation  of  the  eyes  towards  the  other  side;  a  destruc- 
tive lesion  causes  both  eyes  to  be  deflected  towards  the  injured  side. 

Wounds  of  one  Occipital  Lobe  may  cause  a  temporary  hemiopia, 
but  no  persistent  loss  of  vision,  unless  the  angular  gyrus  is  also 
destroyed.  Lesions  of  the  latter  region  are  always  associated  with 
permanent  disturbances  of  vision. 

The  Upper  T emporo-sphenoidal  Lobe  contains  the  cortical  auditory 
centre,  and  lesions  in  this  region  cause  deafness.  The  sense  of 
smell  is  located  in  the  anterior  portion  of  the  lower  temporo- 
sphenoidal  lobe  which  constitutes  the  uncinate  process. 

Injury  to  the  Corona  Radiata  leads  to  paralysis  of  the  regions  repre- 
sented by  the  overlying  cortex,  but  without  convulsions  or  other 
irritative  phenomena.  If  the  corpus  striatum  or  internal  capsule  is 
torn  or  involved  in  a  haemorrhage,  coma  rapidly  supervenes,  accom- 
panied by  hemiplegia  and  perhaps  hemiansesthesia.  Occasionally 
the  effused  blood  bursts  into  the  lateral  ventricle,  and  causes  a  rapid 
rise  of  temperature,  increasing  until  the  patient's  death,  together 
with  a  very  rapid  weak  pulse  and  increased  respiratory  rate  (40  to 
60  per  minute). 

Wounds  of  the  Cerebellum  cause  giddiness,  vertigo,  and  ataxy,  the 
patient  reeling  about  in  characteristic  cases,  as  if  drunk. 

A  wound  of  the  Crus  Cerebri  occasions  more  or  less  complete 
hemiplegia  of  the  opposite  side  of  the  body,  associated  with  some 
amount  of  hemiansesthesia,  and  total  paralysis  of  the  3rd  (oculo- 
motor) nerve  on  the  side  of  the  injury. 

Laceration  or  contusion  of  the  Pons  Varolii,  if  not  immediately 
fatal,  may  lead  to  paralysis  of  the  opposite  side  of  the  body  to  the 
injury,  together  with  paralysis  of  the  5th,  6th,  7th,  or  9th  nerves,  on 
the  same  side  as  the  lesion,  constituting  the  so-called  '  crossed 
paralysis.'  Marked  contraction  of  the  pupils  (myosis)  may  also  be 
present. 

Wounds  of  the  Medulla  are  usually  fatal .  If,  however,  the  patient 
should  escape,  he  is  liable  to  suffer  from  disturbed  functions  of  the 
circulatory  and  respiratory  centres,  with  perhaps  Cheyne-Stokes 
respiration  and  glycosuria. 

The  later  results  of  a  cerebral  laceration  vary  much.  The  patient 
may  recover  perfectly  after  a  more  or  less  prolonged  period  of  un- 
consciousness, but  not  unfrequently  some  loss  of  power  persists, 
which  will  seriously  impair  the  patient's  subsequent  usefulness. 

The  febrile  phenomena  already  mentioned  as  characteristic  of  the 
first  few  days  of  convalescence  after  an  attack  of  concussion  may  pass 
into  a  condition  of  subacute  or  chronic  localized  inflammation  of  the 
injured  area,  as  indicated  by  pain  and  headache.  In  such  cases  the 
inflammator}/  effusion  may  be  so  abundant  as  to  determine  the  onset 
of  unconsciousness  in  four  or  five  days.  Occasionally  an  abscess 
forms  deeply  in  the  white  substance,  and  this  will  be  indicated  by  the 
usual  phenomena  of  such  a  condition,  coming  on  ten  or  fourteen 
days  after  the  injury. 

The  formation  of  cicatrices  between  the  brain  and  membranes  may 


AFFECTIONS  OF  THE  BRAF"^  .l.VD  ITS  MEMBRAMES      759 

determine  the  development  of  traumatic  epilepsy  or  insanity  at  a 
later  jx^riod  (p.  780). 

The  Treatment  of  these  cases  is  always  an  exceedingly  anxioai 
matter  for  the  surgeon.  In  the  majority  of  instances  it  is  merely 
symptomatic,  following  the  usual  course  adopted  in  concussion,  com- 
pression, cerebral  irritation,  etc.,  as  indicated  elsewhere.  Depressed 
bone,  if  present,  will,  of  course^  be  dealt  with  by  operation.  Early 
convulsions  and  paralysis  are  carefully  watched  to  see  if  any  indica- 
tion as  to  the  site  of  the  bleeding  can  be  obtained,  since  it  is  possible 
that  trephining  over  the  injured  spot  and  removing  blood-clots  or 
securing  bleeding-points  might  be  advisable;  but  the  clinical  records 
as  to  such  treatment  are  not  very  encouraging.  Late  convulsions 
and  paralysis  due  to  inflammation  are  best  treated  by  shaving  the 
head  and  applying  an  ice-cap,  and  by  lumbar  puncture.  If  the 
pulse  is  full  and  hard,  and  the  patient  otherwise  young  and  healthy, 
general  venesection  may  be  adopted ;  the  bowels  must  be  moved  by 
a  smart  purgative,  such  as  croton  oil,  whilst  bromide  in  full  doses 
may  be  administered.  If  the  convulsions  continue  in  spite  of  such 
treatment,  and  become  more  severe  and  extensive,  the  patient  will 
almost  certainly  die  of  coma;  trephining  over  the  injured  area  is 
then  distinctly  indicated,  the  surgeon  hoping  to  find  and  remove 
some  clot,  or,  at  any  rate,  to  relieve  tension  by  decompression. 

II.  Penetrating  Wounds  of  the  Brain  result  from  blows  or  falls,  as 
in  compound  depressed  fractures;  or  from  the  entrance  of  foreign 
bodies,  such  as  bullets;  or  from  stabs  or  punctures,  which  most 
commonly  occur  in  the  weaker  parts  of  the  cranium — e.g.,  the  temple 
or  upper  wall  of  the  orbit;  or  from  sabre-cuts  or  axe-wounds,  in 
which  an  oblique  or  almost  valvular  incision  is  made  through  the 
scalp  and  cranium,  laying  bare  and  wounding  the  brain  and  its  mem- 
branes. 

In  these  cases  the  general  disturbance  is  often  slight,  compared 
with  the  extent  of  the  local  injury,  so  that,  although  brain  substance 
may  protrude  from  the  wound,  there  is  sometimes  but  little  con- 
cussion. Any  of  the  conditions  due  to  haemorrhage  detailed  below 
may  follow,  but  they  may  be  slight,  since  the  blood  can  escape  from 
the  wound.  The  inflammatory  phenomena  due  to  infection  of  the 
wound  may  be  locahzed  or  diffuse.  In  the  latter  instance  general 
meningo-encephahtis  manifests  itself  in  the  course  of  two  or  three 
days,  and  is  rapidly  fatal;  in  the  former  case  adliesions  prevent  the 
extension  of  the  trouble  beyond  the  neighbourhood  of  the  wound. 
Hernia  cerebri  is  very  likely  to  follow,  and  possibly  a  deep  cerebral 
abscess  may  complicate  matters  at  a  later  date.  In  cases  that  have 
been  successfully  rendered  aseptic,  the  course  is  similar  to  that  run  by 
a  non-penetrating  wound,  except  that,  if  anything,  the  immediate 
prognosis  is  better,  since  the  opening  in  the  skull  diminishes  the 
likelihood  of  compression  from  simple  or  spreading  oedema.  Where 
the  lesion  has  involved  the  motor  area,  permanent  monoplegia  may 
persist,  and  traumatic  epilepsy  is  always  liable  to  result  owing  to  the 
formation  of  cori"ical  adhesions. 


76o  A   MANUAL  OF  SURGERY 

Treatment. — In  all  cases  of  punctured  or  compound  depressed 
fracture,  a  thorough  exploration  of  the  wound  should  be  made,  and 
all  depressed  or  injured  bone  removed.  Foreign  bodies  should  be 
taken  away,  if  found  close  to  the  wound;  but  it  is  doubtful  whether 
a  bullet  should  be  sought  for,  if  it  has  penetrated  deeply  into  the 
brain,  or  if  it  has  traversed  the  brain  and  fractured  the  bone  on  the 
other  side.  Probably  an  aseptic  incision,  with  removal  of  the 
spHntered  fragments  and  a  limited  search  for  the  bullet,  is  the  best 
treatment  to  adopt,  and,  even  if  unsuccessful,  will  do  but  little  harm, 
if  the  patient's  general  state  warrants  an  operation.  Protruding 
brain  tissue  is  gently  removed,  and  the  whole  wound  thoroughly 
purified  with  carbolic  lotion ;  even  the  i  in  20  solution  may  be  used 
without  fear.  The  dura  mater  should,  if  possible,  be  drawn  together 
by  one  or  two  sutures,  and  a  small  drain-tube  or  a  gauze  wick  inserted 
wathin  it.  It  is  often  advisable  to  introduce  a  portion  of  sterilized 
gold  or  silver  foil  between  the  cortex  and  the  dura,  so  as  to  prevent 
the  formation  of  adhesions.  The  scalp-wound  is  closed,  except  at 
the  drain  opening ;  the  gauze  or  tube  should  be  removed,  if  all  is  going 
well,  in  about  tw'o  days'  time.  If  the  temperature  rises  as  a  result 
of  infection,  the  wound  must  be  reopened,  and  every  effort  made  to 
relieve  tension,  and  thus  localize  the  mischief.  Should  diffusion 
occur,  as  indicated  by  an  increasing  severity  of  the  symptoms,  the 
patient  must  be  treated  in  accordance  with  the  general  principles 
laid  down  for  dealing  with  acute  meningitis. 

In  this  description  of  lacerations  of  the  brain  the  fact  that 
symptoms  may  arise  from  inflammatory  conditions  affecting  the 
bones  (p.  728)  has  been  purposely  omitted.  In  actual  practice  the 
course  of  events  is  often  considerably  modified  by  such  complications. 

Injuries  to  the  Intracranial  Bloodvessels. 

I.  Wounds  of  the  Venous  Sinuses  are  by  no  means  uncommon, 
being  torn  across  in  fractures,  or  punctured  either  by  some  sharp 
instrument,  or  by  spicules  of  bone.  The  superior  longitudinal, 
petrosal,  lateral,  and  cavernous  sinuses  are  those  most  frequently  in- 
volved, especially  the  first,  because  it  is  more  intimately  connected 
with  the  bones  than  any  of  the  others.  Not  unfrequently  a  depressed 
fragment  of  bone  is  driven  into  a  sinus,  and  no  bleeding  occurs  until 
the  fragment  is  displaced  with  a  view  to  elevating  it,  when  a  serious 
gush  of  dark  venous  blood  will  follow.  When  there  is  no  external 
wound,  and  the  outer  wall  of  the  sinus  has  been  torn,  the  hsemorrhage 
may  strip  up  the  dura  mater  and  compress  the  brain,  producing 
effects  resembling  those  due  to  a  wound  of  a  meningeal  artery;  but 
generally  the  bleeding  is  not  great,  since  comparatively  little 
pressure  suffices  to  arrest  it  by  determining  thrombosis.  If,  how- 
ever, the  inner  wall  of  the  sinus  is  torn  across,  the  blood  finds 
its  way  between  the  meninges,  and  gives  rise  to  the  symptoms  of 
diffuse  intrameningeal  haemorrhage.  When  an  external  wound 
exists,  there  is  the  usual  evidence  of  venous  bleeding,  but  it  is  readily 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES     761 


checked  and  rarely  fatal.  Infective  thrombosis  and  pyaemia  are  the 
chief  dangers,  but  entrance  of  air  has  also  led  to  a  fatal  issue  in  a 
few  cases.  Treatment,  when  practicable,  consists  in  plugging  the 
sinus  with  aseptic  gauze,  and  applying  an  antiseptic  compress,  pos- 
sibly removing  fragments  of  bone  in  order  to  expose  it.  Where  the 
outer  wall  alone  has  been  torn,  it  may  be  possible  to  suture  it  with- 
out interfering  with  its  continuity.  For  symptoms  and  treatment 
of  infective  thrombosis,  see  p.  768. 

2.  Wounds  of  the  Middle  Meningeal  Artery. — This  vessel  enters 
the  skull  at  the  foramen  spinosum,  and  subsequently  divides  into  two 
branches  which  ramify  between  the  skull  and  the  dura  mater.  The 
anterior  branch  is  most 
frequently  torn  as  it  crosses 
the  antero-inferior  angle  of 
the  parietal  bone,  as  the 
result  of  any  type  of  frac- 
ture in  that  locality.  The 
artery  is,  however,  some- 
times ruptured  by  a  blow 
on  the  side  of  the  head, 
sufficiently  severe  to  detach 
the  dura  mater,  but  without 
causing  any  injury  to  the 
bone ;  this  membrane  always 
carries  the  vessel  with  it, 
and  if  it  emerges  from  a 
bony  canal  just  at  that 
spot,  as  so  often  happens, 
the  artery  is  torn  across  by 
the  projecting  inner  lip  of 
the  canal.  Whether  or  not 
the  dura  is  primarily  de- 
tached, the  blood  soon  col- 
lects between  it  and  the 
bone,  pressing  the  brain 
inwards,  and  burrowing  down  towards  the  base  of  the  skull 
(Fig.  366).  This  is  due  mainly  to  the  force-pump-like  action  of 
the  arterial  pressure,  for  when  fluid  is  driven  into  a  closed  cavity, 
the  power  of  the  jet  is  multiplied  by  the  area  occupied.  The 
clot  rarely  measures  more  than  4  inches  in  diameter.  The  posterior 
division  is  only  wounded  in  about  5  to  10  per  cent,  of  the 
cases. 

The  Symptoms  are,  unfortunately,  often  obscured  by  some  co- 
existent cerebral  lesion  or  complication ;  but  in  a  typical  case  three 
stages  should  be  present,  viz. :  (a)  A  primary  concussion,  as  the  result 
of  the  blow;  (b)  a  temporary  return  to  consciousness;  and  (c)  the 
gradual  supervention  of  coma  within  twenty-four  hours,  and  that 
usually  without  any  considerable  rise  of  temperature,  though  it  may 
be  associated  with  severe  pain  in  the  head  and  vomiting.      The 


Fig.  366.  —  Meningeal  Hemorrhage. 
(From  Specimen  in  College  of  Sur- 
geons' Museum.) 


762  A   MANUAL  OF  SURGERY 

interval  of  consciousness  varies  widely,  but  it  is  not  often  longer  than 
an  hour  or  two,  whilst  in  many  cases  it  is  scarcely  recognisable.  On 
the  other  hand,  cases  are  known  where  symptoms  were  delayed  for 
days  or  even  weeks  after  an  injury.  As  accessory  signs,  the  follow- 
ing may  be  mentioned:  (i)  Since  the  blood-clot  is  situated  close  to 
the  motor  area  of  the  cortex,  and  especially  over  the  centres  of  the 
head  and  arm,  twitching  of  these  parts,  followed  perhaps  by 
paralysis,  may  be  a  well-marked  feature,  and  usually  supervenes 
before  the  onset  of  coma;  (2)  when  the  clot  extends  to  the  base  of 
the  skull,  it  presses  on  the  cavernous  sinus,  and  may  induce  passive 
congestion  of  the  eyeball,  paresis  of  some  of  the  ocular  muscles,  and 
proptosis,  with  possibly  a  dilated  pupil  and  high  temperature;  and 
(3)  when  a  fissure  exists  in  the  bone,  blood  may  filter  through  into 
the  temporal  fossa,  and  cause  a  marked  fulness  in  that  region.  The 
Prognosis  is  extremely  unfavourable,  Von  Bergmann  stating  that 
out  of  ninety-nine  cases  only  sixteen  recovered. 

The  Diagnosis  of  extra-dural  as  distinct  from  intra-dural  haemor- 
rhage is  by  no  means  simple.  The  latter  is  usually  more  rapid  in  its 
onset,  and  if  involving  the  motor  area  may  be  associated  with 
definite  cortical  phenomena ;  it  is  hkely  to  be  associated  with  blood- 
staining  of  the  cerebro-spinal  fluid.  Unfortunately,  the  two  con- 
ditions not  unfrequently  co-exist,  and  even  if  an  extra-dural  haemor- 
rhage is  diagnosed  it  is  difficult  to  be  certain  whether  it  is  arterial  or 
venous  in  origin. 

The  Treatment  consists  in  trephining  in  order  to  remove  the 
blood-clot  and  secure  the  artery,  if  still  bleeding.  The  spot  selected 
for  dealing  with  the  anterior  division  of  the  artery  is  i|  inches 
behind  the  external  angular  process  of  the  frontal  bone,  and 
I J  inches  above  the  zygoma  (Fig.  370,  F),  and  this  point  may  be 
marked  on  the  bone  w4th  a  bradawl  through  the  scalp  before 
commencing  the  operation.  The  scalp  is  shaved  and  thoroughly 
purified,  and  a  flap  turned  down,  including  everything  as  far  as  the 
pericranium  (Fig.  105,  A).  A  crucial  incision  is  then  made  over  the 
selected  spot,  and  the  pericranium  reflected  sufficiently  to  allow 
a  i-inch  trephine  to  be  applied.  On  removing  the  disc  of  bone, 
a  mass  of  blood-clot  presents,  which  should  be  broken  up  with  the 
finger  and  washed  or  scraped  away.  If  the  artery  is  seen  bleeding 
on  the  dura  mater,  it  may  be  possible  to  pick  it  up,  and  tie  or  twist 
it,  or  a  fine  curved  needle  threaded  with  catgut  may  be  passed  under 
it,  and  thus  a  ligature  applied.  If,  however,  the  blood  comes  from 
a  canal  in  the  bone,  the  outer  table  must  be  clipped  away  sufficiently 
to  enable  the  canal  to  be  seen  and  plugged  by  a  small  piece  of 
aseptic  wax,  sponge,  or  gauze,  which  may  be  left  without  danger. 
The  flap  is  then  replaced,  and  stitched  down,  a  drain-tube  being 
inserted  for  a  time. 

The  posterior  branch  of  the  artery  can  be  reached  by  trephining 
immediately  below  the  parietal  eminence  at  the  same  level  as  for  the 
anterior  branch — i.e.,  i|  inches  above  Reid's  base-line;  or,  again, 
it  can  be  exposed  nearer  its  origin  at  a  spot  i|  inches  behind  the 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      763 

external  angular  process  of  the  frontal  bone,  and  I  inch  above  the 
upper  margin  of  the  zygoma  (Fig.  370,  G). 

3.  Wounds  of  the  Internal  Carotid  Artery,  in  its  intracranial 
portion,  are  rare,  but  if  complete  are  necessarily  fatal.  They  usually 
result  from  penetrating  wounds  of  the  orbit,  or  from  a  gunshot 
wound,  or  the  vessel  may  be  torn  by  a  splinter  of  bone  in  a  fracture 
of  the  base  of  the  skull.  Mere  fissures  through  the  carotid  canal  do 
little  harm,  since  there  is  plenty  of  room  within  it  around  the  artery. 
Occasionally,  however,  the  artery  is  slightly  torn,  and  an  aneurismal 
varix  develops  between  it  and  the  cavernous  sinus.  Treatment.— 
The  injury  is  fatal  in  the  majority  of  cases  before  help  can  be 
obtained;  if  not,  compression  of  the  carotid  trunk  or  ligature  of  the 
internal  carotid  in  the  neck  is  the  only  hope.  See  also  on  orbital 
aneurism  (p.  323). 

4.  Intrameningeal  Hsemorrhage  arises  from  wounds  of  the  cerebral 
cortex  or  membranes  in  cases  of  fractured  skull,  or  from  concussion 
without  fracture.  The  blood  may  be  derived  from  the  veins  and 
capillaries  so  abundantly  present  in  the  pia  mater,  or  from  lesions  of 
the  inner  wall  of  venous  sinuses,  or  even  from  the  middle  meningeal 
artery,  if  the  dura  mater  is  also  opened.  It  may  be  widely  diffused 
over  the  surface  of  the  hemispheres,  or  be  more  locahzed.  It  is 
often  but  slowly  absorbed,  and  may  become  encapsuled,  constituting 
what  is  known  as  an  arachnoid  cyst- — i.e.,  a  closed  cavity  containing 
serum,  the  walls  of  which  are  formed  of  fibrous  tissue  stained  brown 
with  haematin. 

The  Symptoms  are  those  of  concussion  or  compression,  and  need 
not  be  discussed  further. 

The  Treatment  is  symptomatic,  the  patient  being  kept  absolutely 
quiet,  and  all  excitement  and  noise  which  might  induce  cerebral 
congestion  excluded.  Should  there  be  any  focal  symptoms  indicating 
the  position  of  greatest  pressure,  or  should  there  be  some  concurrent 
lesion  of  the  skull,  the  trephine  may  be  apphed  at  this  spot.  It 
must  not  be  forgotten,  however,  that  the  chief  hsemorrhage  often 
occurs,  not  at  the  point  to  which  the  injury  was  directed,  but  at  an 
exactly  opposite  spot  on  the  other  side  of  the  cranium,  and  hence 
considerable  uncertainty  may  arise  both  as  to  the  advisabiHty  of  an 
operation  and  as  to  its  site.  Should  the  right  locality  have  been 
exposed,  the  dura  mater  will  probably  bulge  into  the  wound,  after 
the  circle  of  bone  has  been  removed;  it  is  blackish-blue  in  colour, 
owing  to  the  clot  lying  beneath  it,  and  the  cerebral  pulsations  will 
not  be  detected.  It  is  carefully  incised,  and  the  blood-clot  removed ; 
any  bleeding-points  should  be  tied  or  compressed,  and  it  may  be 
necessary  to  insert  a  small  wick  of  aseptic  gauze  for  a  day  or  two, 
in  order  to  drain  off  serum  and  blood. 

5.  Cerebral  Haemorrhage  occurs  more  frequently  from  idiopathic 
causes  than  from  trauma,  except  in  the  case  of  severe  lacerations. 
In  the  more  aggravated  forms,  death  is  almost  certain  to  follow  in 
a  short  time  from  coma. 


764  A  MANUAL  OF  SURGERY 

Intracranial  Inflammation. 

Inflammation  of  the  cranial  contents  is  almost  always  bacterial  in 
origin,  and  may  follow  a  great  variety  of  lesions,  e.g. :  (i)  Injuries 
of  all  types,  but  especially  compound  or  punctured  fractures. 
(2)  Middle-ear  disease  is  perhaps  the  most  frequent  origin  of  these 
affections,  the  infection  reaching  the  brain  through  an  opening  in 
the  tegmen  tympani,  or  spreading  from  the  mastoid  process  along 
the  sigmoid  groove  in  which  lies  the  lateral  sinus.  (3)  It  may  extend 
inwards  from  scalp,  face,  nose,  or  neck  by  way  of  the  emissary  veins, 
or  even  along  the  sheaths  of  nerves.  (4)  It  may  accompany  simple 
contusion  of  the  cranial  bones  (p.  730),  as  a  result  of  an  auto- 
infective  inflammation  in  these  structures.  (5)  It  may  develop  as 
a  complication  of  pyaemia,  septicsemia,  pneumonia,  scarlet  fever, 
small-pox,  and  other  general  infective  diseases. 

The  causative  bacteria  are  generally  of  the  usual  pyogenic  type, 
viz.,  staphylococci  and  streptococci,  when  the  inflammation  is  due  to 
traumatism;  but  the  pneumococcus  is  present,  as  a  rule,  when  the 
mischief  extends  from  the  middle  ear  or  accessory  nasal  sinuses.  In 
the  so-called  idiopathic  form  of  diffuse  meningitis  the  Diplococcus 
intracellulans  of  Weichselbaum  is  generally  the  causative  organism. 

It  must  be  remembered  that  in  actual  practice  the  different  forms 
of  inflammation  described  below  run  into  one  another,  and  that 
the  resulting  symptoms  are  often  a  complex  mixture  of  several 
types.  For  descriptive  purposes  the  following  groups  may  be 
differentiated: 

(i.)  Subcranial  Inflammation  manifests  itself  either  as  a  simple 
thickening  of  the  dura  {pachymeningitis) ,  or  as  an  effusion  of  pus 
between  the  dura  and  the  bone  {subcranial  abscess). 

Simple  Pachymeningitis  results  either  from  a  slight  simple 
depressed  fracture,  or  from  a  contusion  with  or  without  a  fissured 
fracture,  or  from  the  gradual  spread  of  a  mild  infective  inflammation 
from  the  overlying  bone.  I  he  process  is  really  protective  in 
character,  the  dura  becoming  thickened.  It  may  extend  to  the 
under  surface  of  the  dura,  and  lead  to  a  localized  lepto-meningitis, 
characterized  by  adhesions  between  the  cortex  and  the  dura.  If  the 
process  extends  no  further,  the  clinical  manifestations  are  slight, 
consisting  merely  of  pain  and  localized  headache.  For  treatment, 
see  chronic  meningitis  (p.  768). 

Subcranial  (or  Extradural)  Abscess  results  from  either  a  compound 
depressed  or  a  punctured  fracture,  in  which  the  dura  mater  is  only 
separated  from  the  bone  and  not  lacerated,  especially  when  the 
external  wound  is  small  and  efficient  drainage  is  not  obtained.  It 
sometimes  occurs,  however,  in  consequence  of  a  simple  contusion  or 
fracture  of  the  skull,  leading  to  a  detachment  of  the  membranes  and 
a  collection  primarily  of  blood  and  later  of  inflammatory  fluids  in  the 
cavity  thus  produced.  Microbic  invasion  is  here  due  to  auto-infec- 
tion, or  to  the  passage  of  organisms  through  the  bone  (Fig.  367). 
Any  form  of  osteo-myelitis  of  the  cranial  bones  may  determine  its 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      765 

onset,  but   apart  from  injury,  its  most  common  cause  is,  without 
doubt,  extension  of  intiammation  from  the  middle  ear. 

A  perforation  of  the  tegmen  tympani  (Fig.  369,  B)  allows  of  the 
invasion  of  the  cranial  cavity,  and  an  abscess  forms  above  the  attic, 
which  perhaps  discharges  through  the  ear;  in  other  cases  the  sup- 
puration extends  along  the  groove  for  the  lateral  sinus.  In  the 
fomier  instance,  a  locahzed  subdural  abscess  may  subsequently 
develop,  Hmited  bv  meningeal  adhesions,  and  the  intervening  dura 
mater  may  slough;  in  the  latter,  thrombosis  of  the  lateral  sinus 
mav  follow.  .    . 

the  Symptoms  produced  are  (i)  those  generally  characteristic  ot 
suppuration,  viz.,  a  high  temperature,  with  perhaps  rigors.  (2)  The 
signs  of  intracranial  pressure  in  the  form  of  fixed  headaches  followed 
by  coma  are  also  present,  if  the  abscess  is  large,  or  if  it  affects  the 
cerebral    membranes    sufficiently    to    cause    a    serous    meningeal 

Collection  Inflamed      CEdematous 

of  pus.  bone.  scalp  tissue. 

"*^        ^.''t^.  ■*^'"         J^'S^^  /Subdural  space 


Fig  367 —Subcranial  Suppuration,  involving  Overlying  Bone  and 
CA.USING  an  CEdematous  Condition  of  the  Scalp— Pott's  Puffy 
Swelling  (Semi-diagrammatic)  .    (Frojm  Treves'  '  System  of  Surgery.  ) 

effusion.  (3)  If  there  is  no  open  wound,  an  oedematous  swelling  of 
the  scalp,  known  as  Pott's  puffy  tumour,  may  develop  over  the  site 
of  the  abscess  (Fig.  367).  When  there  is  a  compound  fracture  of  the 
skull,  the  margins  of  the  wound  look  unhealthy,  and  at  its  base  may 
be  seen  bare  bone,  yellow  and  dry,  from  which  the  pericranium  has 
separated,  ^^dth  perhaps  pus  oozing  out  between  the  fragments.  If 
the  pus  burrows  towards  the  base  of  the  skull,  optic  neuritis  may 
develop.  (4)  Focal  s\Tnptoms  of  spasm  or  paralj^sis  may  complicate 
the  case  if  the  dura  over  the  motor  area  is  involved.  The  Treatment 
of  such  a  condition  consists  in  evacuating  the  abscess  cavity  through 
a  sufacient  opening  made  bv  trephining,  or  by  remo\dng  loose  or 
diseased  portions  of  bone,  and  providing  for  drainage.  Sometimes 
more  than  one  opening  is  required  for  this  purpose. 

When  the  affection  follows  middle-ear  mischief,  the  mastoid 
antrum  is  usually  opened  up,  as  also  the  attic,  and  a  sufacient 
amount  of  bone  gouged  or  cut  away  to  give  effective  drainage. 


766  A   MANUAL  OF  SURGERY 

(ii.)  Acute  Diffuse  Meningitis  (lepto-meningitis)  is  always  infective 
in  nature.  1  1r-  symptoms  vary  consi(UTal)ly  in  their  intensity 
according  to  the  site  and  method  of  inoculation  and  the  activity  of 
the  organisms,  but  the  whole  pio-arachnal  space  is  quickly  involved. 
The  superficial  part  of  the  brain  is  also  invaded  in  the  inflammation 
as  well  as  the  meninges,  and  the  term  '  meningo-encephalitis  '  would 
perhaps  be  the  better  appellation. 

The  Symptoms  appear  about  forty-eight  hours  after  an  injury, 
although  sometimes  infection  may  be  delayed  beyond  this  period.  In 
the  early  stages  the  patient  complains  of  severe,  constant,  and  in- 
creasing headache,  associated  with  heat  of  head,  a  forcible  pulsation 
of  the  carotids,  a  quick  pulse,  and  general  irritability  of  the  brain, 
as  indicated  by  vomiting,  intolerance  of  light  and  sound,  delirium, 
and  perhaps  convulsive  twitchings  of  the  muscles,  not  only  of  the 
head  and  back,  but  also  of  the  extremities.  The  vomiting  is  of  the 
usual  cerebral  type^ — i.e.,  it  occurs  apart  from  nausea,  and  has  no 
relation  to  the  ingestion  of  food.  High  fever  is  generally  present, 
and  possibly  a  rigor  may  occur  at  the  onset.  As  the  disease  pro- 
gresses, the  patient  gradually  becomes  comatose,  the  pulse  slow  and 
full,  the  respirations  laboured,  and  death  usually  ensues  in  three  or 
four  days. 

According  to  the  site  of  infection,  the  inflammatory  phenomena 
may  manifest  themselves  more  acutely  over  one  part  than  another, 
and  for  descriptive  purposes  two  chief  varieties  have  been  dis- 
tinguished, viz.,  meningitis  of  the  convexity  and  meningitis  of  the 
base.  The  general  symptoms  are  alike  in  both  forms,  but  when  the 
convexity  is  involved,  convulsions  are  a  more  prominent  feature  in 
the  case,  and  may  at  first  be  limited  to  localized  groups  of  muscles ; 
whilst  in  basal  meningitis  the  temperature  tends  to  run  higher,  the 
head  and  neck  are  more  retracted,  optic  neuritis  is  more  frequent, 
and  some  form  of  squint  is  not  uncommonly  observed. 

On  post-mortem  examination  the  skull-cap  is  separated  from  the 
meninges  with  some  difficulty ;  the  dura  mater  is  thick  and  congested, 
and  the  subjacent  veins  are  manifestly  distended;  the  cerebro-spinal 
fluid  is  increased  in  amount,  and  turbid  from  admixture  with  lymph 
or  pus;  the  arachnoid  is  thick  and  opaque;  the  surface  of  the  con- 
volutions is  flattened  and  (edematous,  and  l\TTiph  occupies  all  the 
sulci,  matting  them  together;  the  cortical  gray  matter  is  usually  red 
and  congested ;  the  underlying  white  substance  of  the  centrum  ovale 
is  injected,  numerous  puncta  cruenta  being  evident;  the  ventricles 
are  distended  with  cerebro-spinal  fluid,  and  the  choroid  plexuses  are 
engorged  with  blood. 

The  Treatment  consists  in  shaving  the  head  and  applying  cold 
by  means  of  an  icebag  or  Leiter's  tubes,  care  being  taken  that  the 
application  is  continuous,  and  not  intermittent.  In  the  robust 
general  venesection  is  useful,  but  in  weaker  mdividuals  cupping  or 
leeching  may  replace  it.  The  bowels  are  freely  opened  and  a  bland 
diet  ordered.  The  patient  should  be  kept  absolutely  quiet  in  a  dark- 
ened room,  and  every  source  of  irritation  and  excitement  removed. 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      767 

Even  if  recovery  ensues,  it  is  somewhat  delayed,  and  similar  pre- 
cautions as  to  quiet,  etc..  must  be  maintained  for  some  time.  In  the 
later  stages,  blistering  of  the  scalp, or  neck,  and  the  admmistration 
of  mercury,  are  advisable. 

If  the  condition  is  due  to  a  localized  infective  lesion,  this  must, 
of  course,  be  dealt  with  by  suitable  means— e.g.,  the  middle  ear  must 
be  opened  up  and  diseased  bone  removed,  depressed  fractures  must 
be  operated  on,  and  locahzed  drainage  effected,  etc.  Apart  from  this 
attempts  have  been  frequently  made  to  reUeve  the  symptoms  and 
determine  a  cure  by  means  of  operative  measures,  directed  towards 
reducing  the  intracranial  tension;  the  subarachnoid  space  has  been 
opened  below  the  tentorium,  whilst  others  have  successfully  em- 
ployed lumbar  puncture,  repeating  it  frequently  (p.  748).  When 
one  considers  the  intricate  character  of  the  space  to  be  drained,  the 
fact  that  it  is  sure  to  be  subdivided  into  separate  cavities  by  deposits 
of  lymph,  and  especially  when  it  is  remembered  that  the  bram  sub- 

Collection  of 

pus  beneath         Inflamed 

dura  mater.  bone. 

I 

<^^^^^^^^->.^_  Scalp. 

I^»K' V:J^'"i-—    Cranium. 

Subdural  space, 


Fig    :!68 —Superficial  Abscess   of   Brain,    spreading   from   Subdural 
Space  "(Semi-diagrammatic).     (From  Treves'  '  System  of  Surgery.  ) 

Stance  is  itself  swollen,  and  that  the  important  fourth  ventricle  has 
only  a  small  communication  with  the  subarachnoid  space— all  these 
considerations  suggest  that  it  is  unhkely  that  much  success  will 
follow  such  treatment.  ,••-,•      n          x          1+ 

Acute  Meningo-encephalitis  is  sometimes  hmited  m  character,  it 
can  only  occur  in  the  absence  of  tension,  diffusion  along  the  meninges 
being  prevented  by  the  formation  of  adhesions.  It  usually  results 
from  a  locahzed  inflammation  of  bone  (Fig.  368),  due  to  a  contusion, 
a  penetrating  wound,  or  possibly  to  middle-ear  mischief.  The  pro- 
cess ends  in  the  formation  of  adhesions  between  the  bram  and  its 
membranes,  preceded  or  not  by  suppuration.  Of  course,  where  pus 
forms,  a  cure  can  only  be  established  by  operation. 

(iii)  A  Subacute  form  of  meningitis  is  occasionally  met  with, 
coming  on  at  a  somewhat  later  date.  The  patient  may  have  ap- 
parently recovered  from  his  injury,  with  the  exception  of  a  fixed  pain 
m  the  head.  The  onset  of  the  symptoms  is  often  due  to  some  in- 
discretion, and  may  be  gradual  or  sudden.     In  all  probabihty  this 


768  A   MANUAL  OF  SURGERY 

affection  is  also  microbic  in  origin,  and  the  delay  in  its  appearance 
depends  either  on  the  small  number  of  bacteria  present,  or  on  their 
being  in  a  low  state  of  virulence;  or  possibly  they  have  been  latent 
for  a  time,  and  are  aroused  into  activity  by  secondary  causes;  or, 
again,  they  may  have  gradually  worked  their  way  inwards  along 
h-mphatics  or  vessels  from  the  periphery  to  the  meninges.  The 
symptoms  are  similar  in  character  to  those  of  acute  meningitis, 
though  somewhat  less  severe ;  but  a  fatal  result  is  very  apt  to  follow. 
In  the  treatment  of  this  form,  no  active  antiphlogistic  measures  should 
be  adopted,  since  the  patient's  condition  is  somewhat  asthenic. 
Absolute  rest  and  quiet  are  essential;  counter-irritation  should  be 
applied  to  the  scalp  and  neck,  and  possibly  mercury  administered,  or 
some  absorbent  organic  salt  of  iodine. 

(iv.)  Chronic  Lepto- meningitis  arises  from  very  similar  causes  to 
the  pachymeningitis  already  described  (p.  764),  but  in  addition  may 
be  associated  with  deep  lesions,  and  may  serve  to  limit  the  spread  of 
infection ;  it  is  usually  of  a  protective  character.  Syphilitic  patients 
are  perhaps  more  liable  to  its  development  than  others.  It  is 
evidenced  by  infiltration  and  thickening  of  the  membranes,  which 
are  usually  adherent  to  one  another  and  to  the  cerebral  cortex.  It 
gives  rise  to  a  localized  headache,  which  is  constant,  and  increased 
on  excitement  or  the  injudicious  use  of  stimulants,  whilst  tenderness 
is  often  noted  on  deep  pressure,  and  traumatic  epilepsy  may  ensue. 
The  treatment  consists  in  attention  to  the  general  health,  free  action 
of  the  bowels,  abstinence  from  excitement  or  stimulants,  the  local 
application  of  counter-irritants,  and  the  administration  of  mercury 
or  iodolysin  (p.  632).  For  the  question  of  operating  for  traumatic 
epilepsy,  see  p.  780. 

(v.)  Tuberculous  Meningitis  is  a  condition  usually  seen  in  children, 
due  to  an  invasion  of  the  meninges  with  tubercle.  The  pial  vessels 
are  chiefly  affected,  and  the  base  of  the  brain  is  mainly  involved. 
Inflammatory  adhesions  follow,  and  the  free  circulation  of  the 
cerebro-spinal  fluid  is  checked  by  the  blocking  of  the  foramina  of 
Magendie  and  Luschka,  so  that  the  ventricles  are  often  distended. 
For  symptoms  and  clinical  history,  medical  text-books  must  be 
consulted. 

Many  attempts  have  been  made  to  deal  with  this  affection  by 
surgical  means,  especially  by  trephining  through  the  occipital  region 
and  draining  away  the  cerebro-spinal  fluid,  so  as  to  relieve  pressure 
on  the  fourth  ventricle,  or  by  lumbar  puncture.  One  or  two  cases 
have  recovered  post  hoc,  but  the  prospects  of  success  are  poor. 

(vi.)  Infective  Thrombosis  of  the  Sinuses,  though  occasionally  seen 
after  injuries,  is  more  commonly  associated  with  suppurative 
diseases  of  the  bone  apart  from  trauma,  and  one  variety,  viz.,  that 
affecting  the  lateral  sinus,  is  almost  exclusively  caused  by  disease  of 
the  middle  ear.  It  is  also  induced  by  extension  from  scalp  injuries 
as  a  complication  of  subaponeurotic  cellulitis,  or  may  spread  inwards 
from  erysipelatous  or  pyogenic  lesions  of  the  face,  or  suppurative 
conditions  of  the  nose.    Putting  aside  the  results  of  chronic  otorrhoea, 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      769 

the  cavernous  sinus  is  much  more  frequently  involved  than  any 
other,  and  the  affection  is  often  secondary  to  suppuration  in  the 
sphenoidal  sinus. 

Pathologically,  the  same  manifestations  are  observed  as  in  any 
case  of  infective  phlebitis.  The  sinus  becomes  impervious  owing  to 
thrombosis,  and  the  clot  becomes  disintegrated  and  gives  rise  to 
multiple  emboli,  whilst  various  inflammatory  conditions  of  the  sur- 
rounding tissues  necessarily  result — e.g.,  necrosis  or  caries  of  bones; 
subcranial  abscess;  meningitis,  simple  and  localized,  or  infective  and 
diffuse;  or  even  cerebral  or  cerebellar  abscess. 

The  symptoms  are  mainly  of  a  pysemic  nature.  The  temperature 
is  high,  but  wdth  remissions,  and  often  with  repeated  rigors;  fixed 
headache  and  early  and  continuous  vomiting  are  also  marked 
features  of  the  case.  With  these  may  be  associated  evidences  of 
meningeal  mischief,  or  of  pulmonary  trouble  in  the  shape  of  dyspnoea, 
but  sometimes  diarrhoea  and  septicaemic  manifestations  may  be  the 
more  prominent. 

If  the  cavernous  sinus  is  involved,  marked  exophthalmos,  with 
congestion  of  the  orbit,  and  even  of  the  eyelids  and  face,  may  result, 
and  ptosis  or  squint  may  also  be  set  up  by  implication  of  the  nerves 
which  lie  in  the  walls  of  the  sinus. 

If  the  superior  longitudinal  sinus  is  affected,  there  may  be 
turgescence  of  the  veins  of  the  scalp  and  forehead,  together  with 
tenderness  along  the  line  of  the  sinus  and  epistaxis,  whilst  convul- 
sions may  be  induced  by  irritation  of  the  neighbouring  motor  area. 
For  local  results  and  treatment  of  thrombosis  of  the  lateral  sinus, 
see  p.  882. 

Treatment,  except  for  the  lateral  sinus,  is  but  rarely  possible,  and 
hence  the  importance  of  preventing  this  disease  by  a  most  careful 
attention  to  asepsis  in  the  surgery  of  the  face  and  of  the  nasal  cavity. 
For  the  lateral  sinus  much  can  be  done,  but  for  the  other  sinuses  all 
that  is  feasible  is  attention  to  general  measures. 

Abscess  of  the  Brain. 

Causes. — -Pyogenic  infection  is,  of  course,  the  ultimate  cause  of  all 
cerebral  suppuration,  but  the  manner  in  which  the  organisms  find 
their  way  to  the  brain  varies  considerably. 

(i.)  It  ma}'  be  due  to  traumatism,  either  in  the  early  or  late  stages 
of  head  injuries.  In  the  early,  it  is  usually  superficial,  and  connected 
with  some  infective  lesion  of  the  scalp,  cranium,  or  membranes,  wdth 
or  without  a  penetrating  wound  (Fig.  368).  In  the  later  stages  the 
pus  forms  deeply  in  the  white  substance.  It  may  be  due  to  a  pene- 
trating wound,  whether  a  foreign  body  is  present  or  not,  the  microbes 
finding  their  wav  into  the  interior  of  the  brain  either  through  the 
track  of  the  missile,  or  along  bloodvessels  or  l3Tnphatics.  Some- 
times it  occurs  apart  from  penetration,  and  then  one  can  only  suppose 
that  it  is  due  to  auto-infection  of  a  contused  or  lacerated  area. 
Chronic  abscess  of  this  type  is  most  frequently  seen  on  the  same 

49 


770 


A   MANUAL' OF  SURGERY 


side  of  the  brain  as  the  lesion,  and  the  parietal  and  frontal  lobes  are 
most  often  affected;  occasionally,  however,  it  may  occur  on  the 
opposite  side  in  the  same  way  as  a  contusion. 

(ii.)  It'arises  by  extension  of  an  infective  lesion  from  without,  the 
organisms  reaching  the  brain  by  direct  continuity  of  tissue,  or  by  way 
of  the   bloodvessels  or  lymphatics.     The  commonest  cause  of  all 

abscesses  in  the  brain  is  chronic 
otorrhcea  (Fig.  369),  and  the 
cerebellum  is  nearly  as  fre- 
quently involved  as  the  cere- 
brum. In  the  former  the  ab- 
scess is  usually  in  the  anterior 
portion  of  the  lateral  lobe 
(D),  close  to  the  back  of 
the  petrous  bone,  whilst  in 
the  latter  the  posterior  portion 
of  the  temporo-sphenoidal  lobe 
is  most  frequently  affected  (C). 
The  inflammation  may  spread 
directly  from  the  tympanic 
cavity  or  inner  aspect  of  the 
mastoid  process  through  the 
bone  to  the  membranes,  which 
become  adherent  to  the  brain, 
and  then  into  the  cerebral 
substance.  Occasionally  a  sub- 
cranial abscess  is  first  developed 
(Fig.  369,  B),  and  the  cerebral 
affection  follows  ;  sometimes  a 
direct  opening  has  been  found 
through  the  tegmen  tympani 
into  an  abscess  cavity,  and 
the  abscess  has  even  discharged 
itself  and  been  drained  in  this 
direction.  More  commonly  a 
layer  of  brain  tissue  intervenes 
between  the  membranes  and 
the  pus,  and  then  infection  must 
have  been  carried  along  vessels 
and  lymphatic  sheaths  running 
between  the  meninges  and  the 
brain. 
Abscesses  of  a  similar  type  occur  in  connection  with  suppuration 
in  the  frontal  sinus,  the  abscess  being  usually  acute  and  secondary 
to  a  frontal  osteo-myeHtis,  and  occupying  the  anterior  portion  of  the 
frontal  lobe ;  it  may  also  follow  purulent  infection  of  the  sphenoidal 
and  ethmoidal  sinuses,  or  thrombosis  of  the  cavernous  sinus. 

(iii.)  The  infective  material  may  be  brought  to  the  brain  by  the 
blood  in  pyaemia,  or  after  some  of  the  exanthemata,  such  as  scarla- 


FiG.  369.  —  Diagram  to  represent 
THE  Course  of  Inflammatory 
Trouble  from  Suppurative  Dis- 
ease OF  THE  Middle  Ear. 

A,  dilated  and  infected  mastoid  antrum ; 
B,  subcranial  (extradural)  abscess 
from  infection  through  the  roof  of 
middle  ear  or  mastoid;  C,  abscess 
in  temporo-sphenoidal  lobe;  D,  cere- 
bellar abscess;  E,  lateral  sinus;  F, 
Eezold's  abscess  through  perfora- 
tion of  tip  of  mastoid  process. 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      771 

tina,  typhoid,  etc.     Abscess  of  the  occipital  lobe  is  almost  always  of 
P3^aemic  origin. 

(iv.)  A  chronic  abscess  of  tuberculous  origin  may  also  occur. 
A  cerebral  abscess  is  usually  single;  occasionally  more  than  one 
is  present,  e.g.,  a  cerebral  and  cerebellar  may  co-exist  in  connection 
with  middle-ear  mischief.  The  course  taken  by  the  case  is  generally 
chronic,  and  then  the  pus  is  encapsuled;  in  acute  cases  there  is 
usually  no  limiting  membrane.  A  chronic  case  not  uncommonly 
terminates  in  an  outbreak  of  acute  symptoms,  due  either  to  the 
abscess  bursting  into  one  of  the  lateral  ventricles,  or  to  the  super- 
vention ot  spreading  oedema. 

The  Symptoms  vary  somewhat  with  the  method  of  onset  and  the 
characters  of  the  abscess.  If  traumatic  and  due  to  infection  from 
\\-ithout,  the  case  runs  an  acute  course,  associated  ^vith  intense  pain 
in  the  head,  recurrent  rigors,  and  rapid  development  of  coma. 
Diffuse  meningitis  is  often  present,  and  the  two  conditions  can 
scarcely  be  distinguished.  In  not  a  few  of  the  cases  of  chronic 
abscess,  all  that  the  patient  complains  of  is  headache,  until  suddenly 
the  temperature  rises  with  a  bound;  he  becomes  unconscious  and 
dies  within  a  day  or  two.  Such  a  course  of  events  is  probably  due 
to  the  bursting  of  the  abscess  into  the  lateral  ventricle  or  meningeal 
cavit}-,  or  to  the  onset  of  an  acute  spreading  oedema. 

When  the  s\-mptoms  are  more  characteristic.  Sir  W.  Macewen 
describes  them  in  three  well-marked  stages,  (i.)  In  the  Initiatory 
Stage,  which  lasts  from  twelve  hours  to  two  or  three  days,  the  patient 
is  suddenly  seized  with  severe  pain  in  the  region  of  theear,  radiating 
perhaps  throughout  the  head,  and  accompanied  by  a  rigor  of  some 
severity.  The  temperature  and  pulse  are  both  raised,  and  vomiting 
of  a  cerebral  type  is  present ;  the  tongue  is  foul,  whilst  anorexia  and 
constipation  are  w^ell  marked.  During  this  period  the  otorrhcea 
diminishes,  or  ceases  entirely. 

(ii.)  In  the  Fully -developed  Stage  the  patient  lies  quietly  in  bed  in  a 
duU,  apathetic  condition,  able  to  answer  questions  but  slowly,  and 
with  his  brain  evidently  in  a  torpid  state.  The  headache  has  to  a 
great  extent  ceased,  but  tenderness  over  the  temporo-mastoid  region 
stiU  remains.  The  temperature  gradually  faUs  and  becomes  sub- 
normal; the  pulse  is  slow  and  full;  and  respiration  is  usually  slow. 
The  vomiting  and  constipation  continue,  and  the  patient's  mouth 
and  breath  become  very  offensive.  Loss  of  muscular  power  scarcely 
amounting  to  paralysis  occurs  in  many  cases  where  the  motor  track 
is  involved,  and  the  order  in  which  this  paresis  appears  is  of  localizing 
value.  Thus,  if  a  temporo-sphenoidal  abscess  is  not  far  from  the 
cortex,  the  face  is  first  affected,  then  the  arm,  and  finally  the  leg; 
but  if  the  abscess  is  deeper  and  presses  on  the  motor  fibres  in  the 
internal  capsule,  the  order  in  which  these  parts  are  involved  is 
reversed.  Motor  aphasia  is  sometimes  well  marked  when  the  abscess 
is  on  the  left  side.  If  the  abscess  is  placed  posteriorly,  it  may  press 
on  the  cerebellum  through  the  tentorium,  and  cause  symptoms  of  a 
cerebellar  type.      Optic  neuritis  (p.  776)  is  a  somewhat  unrehable 


772  A   MANUAL  OF  SURGERY 

sign,  but  if    present   is  more  marked  on  the  affected  side,  whilst 
the  corresponding  pupil  is  dilated  and  fixed. 

(iii.)  The  Terminal  Singe  is  marked  by  a  gradually  increasing 
unconsciousness  and  death;  or  the  abscess  may  burst  into  the  lateral 
ventricle,  causing  sudden  coma,  a  rapid  rise  of  temperature  and 
pulse,  irregular  respirations  (often  of  a  Cheyne-Stokes  type),  and 
death ;  or  it  may  burst  into  the  subarachnoid  space,  and  then  death 
is  preceded  by  symptoms  of  diffuse  lepto-meningitis. 

The  signs  connected  with  a  small  Cerebellar  Abscess  (Fig.  369,  D) 
are  often  very  indefinite  and  vague,  but  if  the  abscess  increases  in 
size,  the  symptoms  may  become  very  characteristic.  The  patient 
complains  of  giddiness,  and  staggers  when  attempting  to  walk, 
falling  towards  the  opposite  side.  The  head  and  neck  are  retracted ; 
respiration  is  irregular  and  feeble;  the  pulse  is  often  slow  and  weak; 
paralysis  may  be  noted  on  one  or  both  sides  of  the  body,  and  may 
only  affect  the  upper  extremity ;  of  course,  vomiting,  optic  neuritis, 
and  a  low  temperature  are  present. 

Diagnosis. — From  meningitis,  a  cerebral  abscess  is  usually  recog- 
nised by  the  fact  that  in  the  former  condition  irritative  phenomena, 
such  as  acute  and  active  delirium,  contraction  of  the  pupil,  photo- 
phobia, rigidity  and  spasm  of  muscles,  especially  in  the  back  of  the 
neck,  and  severe  pain,  are  more  evident  and  are  produced  earlier. 
The  temperature  is  usually  high,  and  mental  dulness  comes  on 
mthin  three  or  four  days  of  an  injury,  whereas  an  abscess  rarely 
forms  before  the  end  of  the  first  week.  Extradural  abscess  (sub- 
cranial) is  associated  with  a  high  temperature,  earlier  onset  after  an 
injury  in  traumatic  cases,  and  more  rapid  compression  symptoms; 
optic  neuritis  is  unusual,  and  the  vomiting  is  less  troublesome. 
There  is  also  likely  to  be  some  localized  oedema  or  tenderness  on 
deep  pressure.  In  thrombosis  of  the  lateral  sinus  the  temperature  is 
high  and  oscillating,  optic  neuritis  may  be  absent,  and  there  may  be 
the  characteristic  tenderness  in  the  neck  along  the  course  of  the 
internal  jugular;  in  abscess  symptoms  of  compression  are  associated 
with  a  low  temperature  and  marked  optic  neuritis.  It  must  not  be 
forgotten  that  the  two  conditions  may  co-exist.  It  is  often  impos- 
sible to  diagnose  between  a  chronic  abscess  and  a  tumour  of  the  brain  ; 
the  symptoms  in  the  latter  usually  come  on  more  slowly  than  in  the 
former,  but  the  progress  is  steady  and  unrelenting ;  the  temperature 
remains  near  the  normal,  and  there  is  less  gastric  disturbance.  The 
history  of  the  case  may  throw  some  light  upon  its  nature,  since  in 
cases  of  cerebral  abscess  there  is  generally  some  causative  focus  of 
infection.  Tumour  is  more  common  in  the  frontal  and  parietal 
regions,  abscess  in  the  temporo-sphenoidal  lobe.  Optic  neuritis  is 
more  marked  and  more  common  in  tumour  than  in  abscess. 

Treatment  necessarily  follows  the  usual  rule,  viz.,  to  give  an  exit 
to  the  pus  as  soon  as  possible ;  no  delay  is  permissible  when  once  the 
diagnosis  is  certain.  The  patient  is  prepared  in  the  same  way  as  for 
operation  on  a  cerebral  tumour  (p.  yyj)-  A  flap  of  scalp  tissue  is 
raised,  and  in  such  a  manner  as  will  most  effectually  serve  for  subse- 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      773 

quent  drainage  purposes.     The  trephine  is  apphed  according  to  the 
rules  given  below,  or  in  accordance  with  the  special  indications  given 
by  the  symptoms  of  the  case.     Sir  W.  Macewen  recommends  that, 
when  the  circle  of  bone  has  been  removed,  the  exposed  surface  and 
cut  edge  should  be  well  rubbed  over  with  powdered  iodoform  and 
boric  acid,  so  as  to  guard  them  from  infection.     The  dura  mater, 
which  bulges  into  the  wound  and  does  not  pulsate,  is  then  carefully 
incised.     A  mere  slit  often  suffices,  and  this  may  open  the  abscess; 
but  more  usually  the  brain  substance  protrudes.     It  is  carefully 
explored  with  a  pair  of  sinus  forceps,  which  is  passed  directly  into 
it  in  various  directions,  or  with  a  fine  trocar  and  cannula.     In  a 
temporo-sphenoidal  abscess  the  most  likely  direction  to  explore  is 
downwards  and  inwards  towards  the  tegmen  tympani.     Pus,  when 
discovered,  is  allowed  to  escape  by  opening  the  blades  of  the  sinus 
forceps.     Sloughs  are  not  uncommonly  present  in  the  cavity,  and  are 
removed  by  the  gentle  introduction  of  a  curette,  whilst  it  is  wise  to 
wash  out  the  interior  by  gentle  irrigation  with  sterilized  salt  solution, 
A  drainage-tube  is  advisably  inserted,  and  may  be  kept  in  position  by 
stitching  it  to  the  margins  of  the  incision  in  the  dura,  which  is  closed 
except  for  the  passage  of  the  tube.     Sometimes  it  is  wiser  not  to 
close  the  flaps  around  the  tube,  but  to  pack  gauze  round  it,  thereby 
determining  the  formation  of  adhesions,  which  will  serve  to  shut  off 
and  guard  from  infection  the  meningeal  cavity.     The  scalp  flap  is 
replaced  in  position,  the  tube  being  brought  out  through  its  centre, 
if  need  be.     The  tube  is  retained  in  position  for  two  or  three  days, 
and  is  then  removed.     Symptoms  of  re-accumulation  or  of  extension 
of  the  mischief  to  the  meninges  will,  of  course,  necessitate  a  re-open- 
ing of  the  wound,  and  the  institution  of  free  and  effective  drainage. 
Occasional!}^  a  hernia  cerebri  develops  as  the  result  of  opening  a 
cerebral  abscess. 

For  an  abscess  in  the  temporo-sphenoidal  lobe,  the  centre-pin  of 
the  trephine  may  be  placed  i^  inches  above  Reid's  base-line,  and 
directly  above  the  external  auditory  meatus;  but  a  better  situation 
is  a  spot  I  inch  above  the  posterior  root  of  the  zygoma,  and  directly 
above  the  posterior  border  of  the  osseous  meatus  (Macewen; 
Fig.  370,  D).  For  an  abscess  in  the  cerebellum  the  point  selected 
is  1 1  inches  behind  the  centre  of  the  external  auditory  meatus,  and 
1  inch  below  the  base-line  (Fig.  370,  E) .  In  the  latter  case  the  soft 
parts,  including  the  muscles  and  periosteum,  should  be  stripped  off 
the  occipital  bone,  and  turned  downwards,  and  it  is  usually  inadvis- 
able to  apply  a  trephine,  as  the  bone  is  very  thin,  and  may  be  broken 
through  with  a  gouge.  It  is  often  necessary  to  carry  through  the 
cerebellar  operation  rapidly,  as  the  respirations  sometimes  stop  under 
an  ansesthetic,  though  the  heart  continues  to  beat  forcibly;  as  soon 
as  the  dura  is  opened,  the  respirations  recommence. 

In  middle-ear  disease  the  diagnosis,  both  as  to  the  presence  of  an 
abscess  and  its  situation,  is  often  doubtful.  The  antrum  and  attic 
are  then  opened  and  explored  thoroughly,  and  according  to  whether 
the  disease  is  more  marked  in  the  former  or  latter,  the  further  steps 


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AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      775 

of  the  operation  are  directed  towards  the  cerebellum  or  cerebrum. 
By  carefully  removing  bone  behind  and  above  the  antrum,  the  lateral 
sinus  is  exposed;  and  by  working  above  or  below  it,  the  cerebrurn  or 
cerebellum  can  be  examined,  and,  if  need  be,  incised.  A  sirnilar 
result  can  be  obtained  by  applying  a  |-inch  trephine  to  a  spot  i  inch 
behind  the  meatus  and  h  iii^h  above  the  base-hne  (H.  P.  Dean). 
The  lateral  sinus  lies  in  the  lower  portion  of  the  opening,  and  the 
dura  over  the  temporo-sphenoidal  lobe  in  the  upper  ;  by  enlarging 
the  opening  downwards  by  Hoffman's  rongeur,  the  cerebellum  can 
also  be  explored. 

Cerebral  Tumours. 

The  chief  Varieties  of  new  growth  met  with  in  the  brain  are  as 
follows:  (i.)  Glioma,  which  consists  of  a  small  round-celled  neoplasm 
with  a  verv^  dehcate  intercellular  substance,  similar  in  character  to 
the  neuroglia  (p.  214) ;  it  may  occur  in  any  part  of  the  brain.  It  is 
alwavs  continuous  with  the  surrounding  cerebral  tissue,  and  is 
scarcelv  ever  encapsuled,  so  that  to  the  naked  eye  it  may  be  indis- 
tinguishable from  brain  substance,  although  rather  harder,  and 
hence  its  limits  can  seldom  be  accurately  defined,  or  its  removal 
completelv  effected,  (ii.)  Sarcomata  and  secondary_  carcinomata 
also  occur,  and  are  as  unfavourable  as  the  gliomata  in  their  char- 
acters, (hi.)  Endotheliomata  are  not  uncommon  tumours  of  the 
brain,  growing  usuaUv  from  the  membranes,  and  may  attain  con- 
siderable dimensions  before  causing  symptoms.  They  press  upon 
and  excavate  by  pressure  rather  than  infiltrate  the  brain,  and  their 
situation  at  the'  base  of  the  skull  and  their  size  are  often  such  as  to 
preclude  removal.  In  some  cases  they  present  the  characteristic 
features  of  a  psammoma  (p.  228).  (iv.)  Tuberculous  fod  are  met 
with  either  associated  with  or  apart  from  any  meningeal  infiltration, 
varving  in  size  considerably,  and  may  be  either  firm  and  caseous, 
or  \\-ith  a  diffluent  centre,  (v.)  Gummafa  of  the  brain  usually  spring 
from  the  meninges,  and  are  more  irregular  in  shape  than  tuberculous 
masses.  They  are  frequently  multiple,  and  are  seldom  seen  in 
children,  (vi.)  Occasionally  'hydatid  cysts  are  found,  as  also  other 
less  common  conditions. 

Cerebral  tumours  are  more  often  observed  in  males  than  in 
females,  and  the  different  forms  occur  at  varying  periods  of  hfe. 
Thus,  ghoma  and  sarcoma  are  most  common  at  puberty  or  in  middle 
hfe;  tuberculous  foci,  in  children;  gummata,  in  the  fourth  or  fifth 
decade;  carcinomata,  in  middle  or  late  hfe;  and  parasitic  tumours 
in  the  second  and  third  decades. 

The  local  effects  of  a  cerebral  tumour  may  be  to  cause  some 
amount  of  sclerosis  of  the  surrounding  brain  substance,  whilst,  il 
superficial,  the  membranes  may  become  adherent  and  the  overlying 
bone  thickened  or  eroded.  Erosion  and  enlargement  of  the  sella 
turcica  can  be  shown  by  the  X  rays  in  cases  of  tumour  of  the 
pituitarv  bodv. 

The  Symptoms  of  a  cerebral  tumour  in  the  early  stages  are  com- 


776  A   MANUAL  OF  SURGERY 

paratively  seldom  brought  under  the  notice  of  the  surgeon,  but  it 
is  of  the  greatest  importance  that  their  significance  should  be  recog- 
nised by  the  general  practitioner,  who  ought  in  case  of  doubt  at 
once  to  obtain  the  assistance  of  a  skilled  neurologist,  as  it  is  only 
through  improved  and  earlier  diagnosis  that  we  may  hope  for  better 
surgical  results.  When  the  later  phenomena,  which  are  almost 
entirely  the  result  of  intracranial  tension,  are  observed,  the  time 
has  often  gone  for  successful  interference.  '  The  old  classical 
s^TTiptoms  of  tumour  of  the  brain  which  are  given  in  most  of  our 
text-books,  although  often  found,  are  not  always  present,  and  if 
one  waits  for  such  symptoms  we  may  wait  too  long  '  [Macewen  at 
International  Medical  Congress,  1913). 

The  early  s^miptoms  consist  in  some  localized  modification  of 
the  cerebral  function,  probably  combined  with  headache  and  per- 
haps vomiting.  The  character  of  the  localizing  phenomena  varies, 
of  course,  with  the  part  of  the  brain  involved;  thus,  if  the  cortex 
of  the  motor  area  is  affected,  Jacksonian  epilepsy  is  likely  to  result, 
in  which  a  definite  aura  associated  with  a  particular  group  of 
muscles  precedes  the  fit,  which  develops  in  an  orderly  fashion; 
in  the  later  stages  the  fits  are  replaced  by  paralysis,  and  a  localized 
monoplegia  may  be  an  important  sign  of  a  cerebral  tumour.  A  sub- 
cortical lesion  produces  localized  paralysis  \\-ithout  convulsions. 
Motor  aphasia  would  suggest  an  affection  of  Broca's  lobe;  word- 
deafness,  an  implication  of  the  hinder  end  of  the  temporal  lobe; 
and  hemianopsia  of  the  occipital  region.  Interference  with  co- 
ordination, vertigo,  and  nystagmus  point  to  mischief  in  the  cere- 
bellum, and  the  association  of  these  phenomena  with  localized 
lesions  of  cranial  nerves,  especially  of  the  seventh  or  eighth,  points 
to  the  cerebello-pontine  angle,  a  rather  favourite  site  for  tumours. 
The  headache  varies  much  in  character,  but  is  usually  localized, 
occurs  in  paroxysmal  attacks,  and  may  be  associated  with  local 
tenderness  on  deep  pressure.  It  is  increased  by  anything  that 
causes  passive  congestion  of  the  brain,  such  as  coughing,  and  it  is 
important  to  note  that  the  sites  of  maximum  pain  and  of  the  tumour 
often  correspond.  Vomiting,  if  present,  is  of  the  usual  cerebral 
type — i.e.,  it  bears  no  relation  to  the  ingestion  of  food,  and  is  not 
preceded  by  nausea. 

The  later  phenomena  are  purely  those  due  to  intracranial  tension, 
which  may  aggravate  or  to  some  extent  mask  the  locahzing  signs. 
Headache  becomes  more  severe  and  persistent;  vomiting  and  con- 
stipation are  well  marked;  the  patient  becomes  drowsy  and  apa- 
thetic, wasting  rapidly,  and  the  temperature  is  subnormal.  Optic 
neiiriiis  (choked  disc  or  papilloedema)  is  generally  present,  and  at 
first  more  marked  on  the  side  of  the  tumour.  It  is  due  to  increased 
tension  of  cerebro  -  spinal  fluid,  which  is  thereby  forced  into 
the  sheath  of  the  optic  nerve,  and  produces  a  condition  of  oedema, 
which  extends  to  the  lamina  cribrosa,  and  causes  serious  inter- 
ference with  the  return  of  blood  and  lymph  from  the  retina.  There 
is  in  reality  no  inflammatory  element  about  it.     In  the  earlier  stages 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      777 

the  margin  of  the  disc  becomes  blurred  and  indistinct,  and  the 
retinal  veins  congested  and  tortuous;  the  neighbouring  retina  is 
cedematous,  and  the  vessels  are  only  seen  at  intervals ;  linear  ecchy- 
moses  mav  also  occur.  The  vision  ma\'  at  first  be  but  little  affected ; 
but  if  the  case  persists,  atrophy  of  the  disc  and  blindness  follow, 
even  in  cases  of  gummata  which  have  progressed  to  cure  by  means 
of  medicine,  if  that  cure  has  not  been  attained  quickly. 

The  terminal  phenomena  of  a  cerebral  tumour  are  gradually 
increasing  coma,  and  the  supervention  of  sj-mptoms  similar  to  those 
of  compression  (p.  752),  whilst  the  temperature  may  be  subnormal 
or  occasionally  very  high. 

Treatment. — In  every  case,  the  possibility  of  the  symptoms  being 
due  to  gummatous  disease  must  not  be  forgotten,  and  a  test  for  the 
Wassermann  reaction  should  alwa^'s  be  undertaken;  if  positive, 
an  intravenous  injection  of  salvarsan  may  be  given,  or  large  and 
increasing  doses  of  iodide  of  potassium  (even  up  to  40  or  60  grains 
three  or  four  times  a  day)  should  be  administered,  together  with  the 
inunction  of  mercury,  before  undertaking  operative  proceedings. 
S^Tnptoms  of  gastric  irritation  must  be  prevented  by  giving  some 
alkaline  carbonate  (especialty  the  ammonium  or  soda  salts) ,  whilst 
the  dose  should  be  freely  diluted  with  water. 

Operation  should  be  undertaken  as  early  as  possible,  since,  even 
if  no  tumour  exists,  the  patient  runs  but  little  serious  risk,  whilst 
delay  may  prevent  the  removal  of  the  gro\\i;h. 

The  scalp  should  be  entirely  shaved  a  day  or  two  previously,  and 
very  thoroughly  purified.  A  quarter  of  a  grain  of  morphia  is  injected 
about  half  an  hour  before  the  operation,  with  the  idea  both  of 
reducing  the  vascularity  of  the  brain  and  of  dulling  the  patient's 
sensations,  so  that  a  smaller  amount  of  anaesthetic  is  subsequently 
needed.  Chloroform  should  be  employed  rather  than  ether,  as  it 
produces  less  congestion  of  the  head.  The  surgeon  marks  the 
supposed  site  of  the  growth  on  the  skull  with  a  bradawl  through  the 
scalp.  A  large  semicircular  flap  is  then  turned  down,  exposing  a 
considerable  area  of  the  calvarium,  so  that,  if  a  larger  amount  of 
bone  than  is  expected  needs  to  be  removed,  no  fresh  scalp  incisions 
are  required;  moreover,  the  cicatrix  will  in  this  way  be  prevented 
from  forming  over  the  defect.  One  of  the  methods  of  opening 
the  cranium  already  described  (p.  746)  is  then  employed;  the  further 
proceedings  on  the  brain  are  carried  out  at  once,  or  the  intracranial 
portion  of  the  procedure  is  delayed  for  a  week  or  so.  Under  such 
circumstances  the  wound  is  re-opened,  and  the  dura  mater  exposed. 

The  dura  mater  when  laid  bare  under  normal  conditions  is  firm, 
but  yields  slightly  to  the  finger,  and  allows  the  pulsation  of  the  sub- 
jacent brain  to  be  felt,  if  the  latter  is  healthy  and  no  undue  pressure 
is  present  within;  but  if  the  intracranial  tension  is  markedly  in- 
creased, the  dura  mater  bulges  into  the  wound,  feels  firm  and 
unresisting,  and  the  cerebral  pulsations  are  diminished  or  absent. 

The  dura  mater  is  next  incised  crucially,  or  a  flap  turned  down, 
care  being  taken  to  avoid,  if  possible,  the  main  meningeal  vessels; 


778  A   MANUAL  OF  SURGERY 

the  brain  substance  protrudes  if  the  intracranial  pressure  is  ex- 
cessive. The  region  is  gently  explored  by  the  finger,  and  any 
areas  of  abnormal  hardness  or  softening  noticed;  failing  this,  a 
grooved  needle  is  inserted  in  different  directions,  or  a  fine  trocar 
and  cannula.  In  introducing  such  instruments,  care  must  be  taken 
to  make  direct  stabs,  and  never  any  lateral  movements,  which 
necessarily  lead  to  laceration  of  the  brain.  The  opening  of  the 
skull  may  be  enlarged,  if  need  be,  either  by  the  use  of  the  bone 
rongeur  or  by  additional  small  trephine  holes.  It  is  but  rarely  that 
a  cerebral  tumour  is  so  placed  that  enucleation  is  possible;  it  is 
estimated  that  not  more  than  lo  per  cent,  of  all  cerebral  tumours 
are  removeable.  If,  however,  a  cortical  neoplasm  is  found,  it  is 
isolated  from  the  surrounding  brain  substance  by  blunt  instru- 
ments— e.g.,  the  handle  of  a  scalpel  or  a  flexible  knife  made  of 
platinum,  as  suggested  by  Horsley- — ^and  the  mass  freely  removed. 
Haemorrhage  is  controlled  by  the  application  of  fine  ligatures,  or 
by  pressure  with  a  hot  sponge  for  a  few  minutes.  The  dura  mater 
is  then  loosely  stitched  together,  and  a  drainage-tube  inserted, 
reaching  to  the  bottom  of  the  wound,  and  brought  out  at  one  angle 
of  the  incision  in  the  skin,  which  may  be  closed  by  a  continuous 
suture,  or  through  the  centre  of  the  flap.  After  the  operation, 
the  patient  must  be  kept  absolutely  quiet,  with  the  head  slightly 
raised.  The  drainage-tube  is  removed  in  twenty-four  or  forty- 
eight  hours,  and  the  scalp  wound  is  usually  healed  in  six  or  seven 
days. 

When  the  tumour  is  inaccessible  or  irremoveable,  or  its  situation 
doubtful,  temporary  benefit  often  results  from  decompression — an 
operation  which  consists  in  removing  large  areas  of  the  cranium, 
and  incising  the  dura  mater,  so  as  to  allow  a  hernia  cerebri  to  form. 
The  decompression  is  best  undertaken  over  the  supposed  site  of 
the  tumour,  but  has  sometimes  been  subtentorial,  with  a  view  to 
influencing  beneficially  the  vital  centres.  A  considerable  measure 
of  benefit  follows  such  operations,  as  evidenced  by  an  improved 
mental  condition,  loss  of  pain,  retrogression  of  the  optic  neuritis, 
and  the  preservation  of  sight.  Of  course,  sooner  or  later  the 
continued  growth  of  the  tumour  results  in  the  patient's  death. 

In  dealing  with  cerebellar  tumours,  or  those  in  the  neighbour- 
hood, either  by  removal  or  decompression,  Cushing's  cross-bow 
incision  may  be  employed.  It  consists  of  a  curved  incision,  with  its 
concavity  downwards,  passing  along  the  superior  curved  line  of 
the  occipital  bone,  and  from  its  centre  passes  down  a  vertical 
incision  as  far  as  is  necessary  in  order  to  reflect  the  muscles  from 
the  posterior  aspect  of  the  atlas.  A  considerable  mortality  is 
associated  with  this  operation  owing  to  the  close  proximity  of  the 
vital  centres;  rapid  relief  of  tension  produces  serious  shock,  and  it 
is  well  sometimes  to  delay  the  opening  of  the  dura. 

Tumours  of  the  Hypophysis  Cerebri  or  Pituitary  Body  may  affect 
tlie  anterior  or  posterior  portion.  Most  frequently  the  affection 
is  an  adenoma  with  cystic  degeneration  (resembling  somewhat  a 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      779 

goitre),  but  malignant  disease  is  not  unknown.  Increased  func- 
tional activity  of  the  anterior  lobe  results  in  hyperpituitarism  or 
acromegaly  (p.  588);  defective  activity  causes  hypopituitarism,  as 
manifested  by  an  increased  deposit  of  fat  in  the  body,  together  with 
loss  of  function  or  an  infantile  condition  of  the  genital  organs. 
In  women  amenorrhea  is  usually  present.  These  conditions  may 
follow  extrinsic  pressure  on  the  hypophysis,  as  well  as  mtrmsic 
growths.  The  close  proximity  of  the  optic  chiasma  explains  the 
association  of  these  phenomena  with  varying  forms  of  visual  dis- 
turbance, most  commonly  with  bilateral  temporal  hemianopsia. 

Operative  Treatment  has  been  successfully  undertaken  in  a 
number  of  cases.  Von  Eiselsberg*  reports  sixteen  operations  with 
four  deaths,  and  certainly  one  cure  of  seven  years'  duration.  The 
growth  is  approached  through  the  nose  by  chiselUng  away  the  pos- 
terior wall  of  the  sphenoidal  sinus. 

The  Surgical  Treatment  o£  Epilepsy. 

It  would  be  waste  of  time  to  discuss  the  many  surgical  procedures 
which  have  been  suggested  in  this  connection,  mainly  with  the  idea 
of  modifying  the  cerebral  circulation.  The  only  operation  now 
seriously  considered  is  that  deahng  directly  with  the  cerebral 
cortex,  a  proceeding  dependent  on  the  supposition  that  the  epileptic 
convulsion  is  a  syrnptom,  and  not  in  itself  a  disease,  and  that  it 
results  from  an  irritable  condition  of  the  cortex,  which  niay  be 
excited  into  convulsive  activity  by  various  stimuH,  originating 
either  in  the  brain  or  elsewhere.  Sir  Victor  Horsleyt  classifies 
epilepsy  as  follows: 

(i)   Idiopathic  (with  no  gross  lesion) . 

(a)   Onset  localized  (focal). 

(&)    Onset  generalized. 

(2)  Jacksonian  (always  some  gross  lesion  or  traumatism). 

(a)  Traumatic  (with  local  or  general  convulsion). 

(&)   Congenital. 

(c)    Neoplastic  (tumour,  abscess,  aneurism). 

(3)  Reflex  (injury  of  spine,  nerves,  etc.). 

(4)  Hystero-epilepsy. 

As  regards  the  characteristic  symptoms  and  pathological  pheno- 
mena found  in  many  of  these  conditions,  students  must  refer  to 
medical  text -books. 

Before  discussing  the  individual  groups  from  the  surgical  stand- 
point, one  or  two  general  considerations  must  be  noted.  In  the  first 
place,  the  prognosis  is  gravely  modified  by  the  length  of  time  that 
the  epileptic  habit  has  persisted,  and  if  traumatic  cases  have  lasted 
two  years  the  outlook  is  very  unsatisfactory.  A  careful  study 
should  also  be  made  of  the  family  history  as  to  the  existence  or  not 

*  Von  Eiselsberg:  Report  of  the  International  Medical  Congress,  London, 
1913.     Section  VII.,  Pt.  II. 

t  Trans.  Medical  Society  of  London,  February  9,  1903. 


78o  A   MANUAL  OF  SURGERY 

of  a  neurotic  predisposition;  in  many  cases  of  traumatic  epilepsy 
this  is  well  marked,  and  then  the  outlook  is  correspondingly  bad. 

It  is  now  generally  recognised  that  operation  is  useless  in  the 
idiopathic  variety,  even  when  the  onset  is  accompanied  by  focal 
symptoms. 

Congenital  epilepsy  is  often  more  or  less  of  the  Jacksonian  type, 
and  usually  depends  on  some  injury  sustained  during  birth.  It  is 
frequently  associated  with  other  evidences  of  cerebral  mischief 
(spasm,  paralysis,  etc.)  and  with  defective  growth.  If  taken  early, 
and  if  the  convulsions  still  remain  localized,  some  good  may  follow 
operation ;  but  if  allowed  to  persist  too  long,  the  disease  is  irremedi- 
able by  surgical  means. 

When  due  to  tumours,  abscess,  etc.,  epilepsy  is  accompanied  by 
other  manifestations,  which  should  guide  the  surgeon  to  a  correct 
opinion  as  to  the  nature  of  the  case  and  the  operative  outlook. 

Reflex  epilepsy  is  rare,  and  may  perhaps  be  cured  by  dealing  with 
the  causative  focus.  As  regards  hystero-epilepsy,  the  surgeon  must 
never  be  tempted  to  undertake  such  a  measure  as  double  oophorec- 
tomy, which  has  been  tried  again  and  again,  and  found  wanting. 

Traumatic  Epilepsy  is  the  term  applied  to  an  epileptic  condition 
resulting  from  injuries.  It  may  arise  from  any  of  the  following  con- 
ditions: (i)  A  neuralgic  and  irritable  cicatrix  in  the  scalp;  (2)  a 
slight  unrelieved  depression  of  the  skull;  (3)  excessive  formation  of 
callus  after  a  fissured  fracture,  or  chronic  thickening  of  the  bone 
from  osteitis  after  a  contusion,  whereby  the  dura  mater  is  pressed 
upon  and  irritated;  (4)  chronic  meningitis,  usually  associated  with 
an  adherent  cicatrix  in  the  brain,  and  particularly  liable  to  occur  in 
syphilitic  patients;  (5)  a  single  depressed  spicule  of  bone  projecting 
into  the  cerebral  substance. 

The  Symptoms  produced  are  epileptic  seizures  of  the  Jacksonian 
type,  the  exact  manifestations  varying  with  the  portion  of  cerebral 
cortex  which  is  involved.  Localization  of  the  lesion  depends  partly 
on  the  character  of  the  aura,  partly  on  the  associated  symptoms, 
such  as  a  fixed  headache  or  the  presence  of  a  cicatrix.  The  convul- 
sions are  localized  to  begin  with,  but  often  become  general. 

Operative  Treatment  is  only  applicable  in  those  cases  in  which  the 
convulsions  remain  localized;  general  convulsions  place  the  patient 
in  the  category  of  idiopathic  epileptics  with  a  focal  onset.  The  skull 
is  opened  over  the  site  of  the  supposed  injury,  and  it  may  be  that 
some  depressed  fragment  or  spicule  of  bone  is  found;  it  will,  of 
course,  be  removed.  If,  however,  nothing  is  found  but  an  adherent 
cicatrix  between  the  membranes  and  the  underlying  brain,  it  is  still 
an  open  question  as  to  whether  the  surgeon  should  proceed  further. 
In  a  considerable  number  of  cases  the  cicatrix  and  underlying  brain 
substance  have  been  removed;  the  fits  ceased  for  a  time,  but  in  most 
instances  recurrence  followed  sooner  or  later  from  the  formation  of 
a  fresh  adherent  cicatrix.  Possibly  the  introduction  of  a  sheet  of 
sterilized  gold  or  silver  foil  between  the  brain  substance  and  the 
membranes  might  suffice  to  prevent  this  occurrence.    The  locality  of 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES      78 r 

the  lesion  has  a  considerable  influence,  according  to  Horsley,  on  the 
result,  since  the  prognosis  is  good  in  the  motor  area,  middling  in  the 
sensory  (parieto-occipital)  region,  and  bad  in  the  frontal.  The 
obvious  difficulty  of  dealing  with  epileptic  conditions  emphasizes 
the  statements  already  made  (p.  739)  as  to  the  importance  of 
dealing  with  all  depressed  fractures  of  the  skull,  simple  or  com- 
pound, slight  or  severe,  by  immediate  operation,  so  as  to  prevent, 
as  far  as  possible,  the  development  of  the  mischief.  When  there  is 
a  history  of  tubercle  or  syphilis,  or  of  both,  medicinal  treatment 
directed  to  the  absorption  of  cicatricial  tissue  should  certainly 
precede  operation. 

Traumatic  Insanity  is  sometimes  produced  by  slight  depressions  or 
lesions,  similar  in  nature  to  those  causing  epilepsy,  and  can  occa- 
sionally be  relieved  by  operation.  Certainly,  when  a  distinct  history 
of  injury  precedes  the  mental  aberration,  and  when  there  is  any 
localizing  lesion  or  symptom,  an  exploratory  operation  is  justifiable, 
and  in  a  number  of  cases  excellent  results  have  followed.  The  type 
of  insanity  is  not  constant,  but  varies  with  the  condition  and 
environment  of  the  individual. 


Hernia  Cerebri. 

By  hernia  cerebri  is  meant  a  protrusion  of  the  brain  substance 
through  an  acquired  opening  in  the  skull.  It  thus  differs  from  an 
encephalocele,  which  consists  in  the  protrusion  of  brain  substance 
through  some  congenital  defect. 

It  is  always  an  evidence  of  increased  intracranial  pressure,  and 
may  be  looked  upon  as  Nature's  safety-valve  for  the  relief  of  com 
pression.     It  is  met  with  in  two  distinct  forms: 

1.  When  a  decompression  operation  has  been  performed  for  a 
cerebral  tumour.  The  brain  substance  protrudes  through  the  open- 
ing under  the  scalp,  and  by  this  means  a  temporary  relief  of  intra- 
cranial tension  is  brought  about,  the  patient's  life  prolonged,  and 
possibly  consciousness  for  a  time  restored.  The  tumour,  however, 
continues  growing,  and  sooner  or  later  the  patient  dies  comatose, 
unless  the  tumour  is  inflammatory  and  disappears. 

2.  The  other  variety,  due  to  a  compound  depressed  or  punctured 
fracture,  is  the  result  of  infection  in  the  underlying  brain  substance, 
and  the  increased  pressure  within  the  skull  thereby  induced  leads  to 
a  protrusion  of  inflamed  and  oedematous  cerebral  tissue  through  the 
wound  in  the  dura,  which  is  usually  of  small  size.  The  tumour  is 
soft  and  dusky  in  colour,  and  pulsates  synchronously  with  the  heart, 
the  pulsations  being  often  evident  to  the  naked  eye,  and  it  usually 
increases  in  size  somewhat  rapidly.  At  first  the  mental  condition 
of  the  patient  is  unimpaired,  but  sooner  or  later  coma  follows,  if  the 
hernia  progresses,  ending  in  the  patient's  death.  To  begin  with,  the 
mass  consists  mainly  of  oedematous  granulation  tissue  covered  by 
blood-clot,  without  much  brain  substance,  but  later  on  cerebral 
tissue  itself  may  protrude.     The  condition  is  usually  fatal,  though 


782  A   MANUAL  OF  SURGERY 

recovery  is  occasionally  seen  Treatment. — Prevention  of  this 
affection  must  always  be  aimed  at  by  endeavouring  to  render  any 
wound  involving  the  meninges  aseptic  and  providing  for  drainage. 
Punctured  wounds  and  depressed  fractures  of  the  skull,  even  when 
giving  rise  to  no  urgent  symptoms,  should  always  be  operated  upon, 
since  free  relief  of  tension  may  prevent  the  formation  of  a  hernia 
cerebri,  even  should  absolute  asepsis  not  be  attained.  If,  however, 
protrusion  occurs,  it  may  be  possible  in  a  few  cases  to  apply  a  dry  dress- 
ing and  elastic  pressure,  and  thus  prevent  it  increasing  in  size;  this, 
however,  must  not  be  attempted  when  the  inflammatory  symptoms 
are  at  all  marked.  In  such  cases  it  is  of  little  use  to  slice  off  the 
tumour  and  apply  pressure,  and  possibly  the  best  treatment  that 
has  been  suggested  is  to  paint  the  projecting  mass  once  or  twice 
a  day  with  absolute  alcohol,  which  is  an  efficient  antiseptic,  and  also 
tends  b}'  its  dehydrating  power  to  diminish  the  size  of  the  hernia. 
If  such  treatment  is  successful,  the  tumour  slowly  granulates  over 
and  cicatrizes.     Traumatic  epilepsy  may,  however,  ensue. 


CHAPTER  XXVITT. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS. 

Affections  of  the  Lips. 

Hare-Lip. — By  hare-lip  is  meant  a  congenital  fissure  of  the  upper  lip, 
which  may  extend  for  a  variable  distance  through  the  soft  tissues 
alone,  or  may  also  impHcate  the  bony  alveolus  and  the  floor  of  the 


Fig.  371. — Single  Incomplete  Hare- 
Lip,  INVOLVING  MERELY  THE  TIS- 
SUES OF  THE  Lip,  and  not  ex- 
tending INTO  THE  Nose. 


Fig.  372. — Double  Hare-Lip: 
Complete  on  the  Left  Side, 
Incomplete  on  the  Right. 


A  B 

Fig.  373. — Double  Complete  Hare-Lip,  with  Displacement  Forwards 

OF  the  Central  Portion  of  the  Intermaxilla  (Os  Incisivum). 

A,  Front  view;  B,  seen  in  profile. 

nose,  and  extend  backwards  through  the  palate.  The  name  is  not 
a  good  one,  since  a  hare's  lip  is  cleft  in  a  Y-shaped  manner,  the 
fissure  being  central  below,  and  bifurcating  above  into  each  nostril. 

783 


784 


A   MANUAL  OF  SURGERY 


Varieties. — A   hare-lip   is  complete   or  incomplete,   according  to 

whether  or  not  it  extends  into  the  nostril.  It  is  termed  simple  if 
limited  to  the  soft  parts;  alveolar,  if  the  bony  alveolus  is  also  in- 
volved; complicated,  if  associated  with  a  cleft  palate.  The  defect 
may  exist  on  one  or  both  sides  of  the  middle  line;  if  unilateral  or 
single,  it  is  most  common  on  the  left  side,  in  the  proportion  of  two 
to  one;  if  double  or  bilateral,  it  is  usually,  but  not  invariably,  alveo- 
lar, and  accompanied  by  a  complete  cleft  of  the  palate.  The 
central  portions  of  the  lip  and  alveolus  (os  incisivum)  may  retain 
either  their  normal  position,  or,  as  is  more  frequently  the  case  in 


Fig.  374. — Head  of  Fcetus  of 
ABOUT  Five  Weeks,  from  Ven- 
tral Aspect  (after  His),  show- 
ing THE  Primitive  Stomod^um 
Bounded  Above  by  (A)  the  Un- 
divided Fronto-nasal  Process, 
Laterally  by  (B)  the  Maxil- 
lary, and  Below  by[(C)  the  still 
Separate  Mandibular  Pro- 
cesses. 

The   quinque-radiate   appearance   is 
well  represented. 


Fig.  375. — Head  OF  Fcetus  of  Six  TO 
Seven  Weeks,  from  the  Ventral 
Aspect.     (After  His.) 

The  mandibular  processes  (E)  have 
now  united ;  the  ocular  vesicle  (C) 
is  seen  on  either  side  towards  the 
upper  end  of  the  orbito-nasal  fissure, 
and  the  fronto-nasal  process  has 
developed  (A)  internal  and  (B)  ex- 
ternal nasal  processes  on  either  side 
of  (F)  the  still  unclosed  anterior 
nares;  (D)  maxillary  process. 


the  bilateral  type,  project  forwards  at  the  end  of  the  nose,  forming 
a  proboscis-like  appendage  (Fig.  373,  A  and  B) ;  its  base  of  support 
is  often  thin  and  elongated,  so  that  lateral  mobihty  may  be  ob- 
tained. Even  in  simple  cases  the  nose  is  deformed,  being  broad 
and  flattened,  a  condition  which  becomes  much  more  marked  when 
the  alveolus  and  floor  of  the  nose  are  widely  fissured.  Hare-lip  is 
not  uncommonly  associated  with  other  deformities — e.g.,  spina 
bifida  and  tahpes — and  it  is  frequently  transmitted  from  one 
generation  to  another.  Occasionally  a  thin  red  line,  as  of  a  cicatrix, 
is  seen  occupying  the  position  of  a  hare-lip  cleft,  and  is  probably 
due  to  a  persistence  of  the  raphe  of  union  of  the  labial  segments;  a 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


785 


slight  groove  in  the  alveolus  may  also  be  observed  at  a  corresponding 
point. 

Development- — The  bony  and  fleshy  parts  of  the  face  originate  from  the 
outgrowth  of  processes  around  the  cavity  formed  by  the  bending  forward  of 
the  primitive  cerebral  vesicle  over  the  end  of  the  notochord.  At  about  five 
weeks  after  conception  the  primitive  buccal  cavity  or  stomodaeum  has  a 
c|uinque-radiate  appearance,  due  to  the  manner  in  which  these  processes  are 
formed  (Fig.  374).  A  broad  median  lappet  (fronto-nasal  process,  A)  descends 
from  above ;  this  is  separated  by  a  fissure  on  each  side  from  the  symmetri- 
cally placed  maxillary  processes  (B),  and  these  again  below  from  the  more 
prominent  mandibular  processes  (C),  which  early  unite  across  the  middle 
line,  to  form  the  lower  jaw.  The  fronto-nasal  process  soon,  however,  changes. 
On  either  side  of  a  slight  depression  in  the  median  line  is  placed  the 
internal  nasal  process  or  globular  process  (Fig.  375,  A),  from  which  are 
produced  superficially  the  central  portion  of  the  upper  lip,  and  from  its 
deeper  aspect  the  intermaxilla,  which 
divides  into  the  two  incisive  segments, 
each  carrying  the  germ  of  an  incisor  tooth. 
Separated  from  this  by  a  hollow  (F), 
which  subsequently  forms  the  anterior 
nares,  is  the  rounded  external  nasal 
process  (B),  from  which  develop  the 
side  of  the  cheek  and  the  ala  nasi. 
External  to  this  a  fissure  (naso-orbital) 
runs  up  to,  and  even  beyond,  the  primi- 
tive eye  (C),  and  this  is  later  on  closed 
by  amalgamation  of  the  internal  and 
external  nasal  processes  on  the  inner 
side  with  the  adjacent  maxillary  process 
on  the  outer  (D),  except  in  the  deepest 
part,  which  constitutes  the  nasal  duct. 
The  integrity  of  the  upper  lip  is  obtained 
by  the  union  of  the  lower  parts  of  the 
internal  nasal  and  maxillary  processes, 
which  thus  exclude  the  external  nasal 
from  participation  in  its  free  border.  It 
is  doubtless  owing  to  this  arrangement 
that  the  sulcus  or  depression  around  the 
ala  nasi  constitutes  such  a  distinct 
and  characteristic  feature  of  the  face. 
At  the  same  time  the  deeper  parts  of 
these  nasal  processes  are   uniting   with 

one  another  and  with  the  palatal  plates,  which  grow  horizontally  inwards 
from  the  under  side  of  the  maxillary  processes,  uniting  in  a  Y-shaped  suture, 
the  point  of  junction  of  the  limbs  being  situated  at  the  anterior  palatine 
canal.  The  union  of  all  these  elements  is  taking  place  from  the  sixth  to  the 
tenth  week,  and  by  that  date  even  theuvula,  the  last  part  to  unite,  should  be 
complete. 

Ordinary  hare-hp  is  due  to  a  failure  of  union  of  the  internal  nasal  process 
with  the  structures  in  external  relation  with  it;  if  limited  to  the  soft  parts 
(simple  hare-lip),  the  cleft  runs  between  the  internal  nasal  and  maxillary 
processes;  if  complete  or  alveolar,  between  the  same  two  below  and  super- 
ficially, but  in  addition  between  the  internal  and  external  nasal  processes 
above  and  on  the  deep  side.  The  cleft  in  the  alveolus  passes  between  the 
intermaxilla  and  the  maxilla  (Fig.  376) .  The  relation  of  the  cleft  to  the  teeth 
varies  somewhat,  since  the  germ  of  the  lateral  incisor  may  be  developed  on  one 
or  other  side  of  the  suture  between  the  maxilla  and  intermaxilla,  or  may  even 
lie  between  the  segments.  Hence  the  lateral  incisor  is  sometimes  found,  on 
the  outer  side  of  the  cleft,  sometimes  on  the  inner;  moreover,  an  accessory 
incisor  is  occasionally  developed  on  the  inner  side  of  the  cleft. 

50 


Fig.  376. — Diagram  to  Repre- 
sent THE  Situation  of  the 
Cleft  in  Alveolar  Hare-Lip. 

II,  12,  Incisors;    C,  canine   tooth; 
Ml-,  M^,  first  and  second  molars. 


786  A   MANUAL  OF  SURGERY 

The  OS  incisivum,  or  projecting  portion  of  the  intermaxilla,  usually  consists 
of  two  segments  of  bone,  united  in  the  median  line,  and  in  a  child  most  fre- 
quently contains  only  the  two  milk  central  incisors  and  the  rudiments  of 
the  two  permanent  ones;  occasionally,  as  we  have  just  stated,  there  may  be 
an  extra  tooth  developed  on  one  or  both  sides  of  the  process. 

A  simple  hare-lip  does  not  interfere  seriously  with  the  infant's 
nutrition,  but  when  double,  and  especially  if  associated  with  a  cleft 
palate,  considerable  trouble  may  arise,  thus  necessitating  surgical 
treatment  as  a  life-saving  measure  at  a  very  early  date.  It  must 
also  be  remembered  that  all  movements  of  the  face — e.g.,  in  crying 
or  laughing — exaggerate  the  deformity  from  the  unbalanced  action 
of  the  divided  orbicularis  oris  and  other  muscles. 

As  to  the  period  at  which  to  operate,  it  is  better  to  allow  the  infant 
to  get  over  the  shock  of  its  entrance  into  the  world  and  become 
acclimatized  to  an  independent  existence,  whilst  at  the  same  time 
the  operation  should  be  performed  before  the  troubles  of  dentition 
begin.  From  six  weeks  to  three  months  is  perhaps  the  best  age  for 
operation — in  well-nourished  and  healthy  children  at  the  earlier 
date,  in  poorly-fed  and  weakly  children  at  the  later,  unless  the 
inanition  is  due  to  the  difficulty  of  feeding  the  infant  owing  to  the 
deformity.  Under  such  circumstances  the  operation  may  have  to 
be  undertaken  within  the  first  three  weeks. 

Operation  for  Single  Hare-Lip. — The  child  should  be  laid  on  an 
operating-table  with  its  arms  bound  to  the  body.  The  surgeon 
stands  behind  it,  the  ansesthetist  and  assistant  one  on  each  side. 
The  operation  may  be  described  in  three  stages : 

1.  The  lip  is  thoroughly  dissected  up  from  the  maxillce  and  alveoli 
b}'  cutting  through  the  reflections  of  mucous  membrane  and  the 
attachment  of  the  muscles  and  other  soft  parts.  This  is  mainly 
needed  on  the  outer  side,  and  where  there  is  much  flattening  of  the 
nose  the  ala  nasi  will  also  require  to  be  separated.  This  may  cause 
some  amount  of  bleeding,  but  sponge  pressure  easily  controls  it. 

2.  The  edges  of  the  cleft  are  then  pared.  Many  dii^erent  methods 
have  been  employed  to  accomplish  this,  but  it  is  only  necessary  to 
mention  two.  The  object  to  be  attained  is  the  union  of  the  cleft 
lip  by  means  of  a  cicatrix,  which  shall  be  as  unobtrusive  as  possible, 
whilst  the  red  margin  must  be  continuous,  and  the  section  such  that 
the  raw  surfaces  are  larger  than  are  absolutely  necessary,  so  as  to 
allow  for  subsequent  cicatricial  contraction  without  the  development 
of  a  notch.     The  methods  recommended  are  as  follows: 

(a)  The  incision  extends  from  the  apex  of  the  cleft,  or  from  within 
the  nostril,  in  a  crescentic  manner  (Fig.  377),  so  that  a  slight  angular 
projection  is  formed  to  constitute  a  prolabium.  This  is  done  on  each 
side,  and  where  the  nose  is  much  flattened,  more  tissue  is  removed 
on  the  outer  than  on  the  inner  side,  so  that  when  the  parts  are 
sutured  together  the  nostrils  become  as  nearly  as  possible  sym- 
metrical. By  this  means  the  depth  of  the  lip  is  increased  to  allow 
of  subsequent  contraction,  wh'ist  the  red  margin  can  be  made 
continuous. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


787 


(b)  Miranlt's  Operation  (Fig.  378). — The  inner  margin  and  apex  of 
the  cleft  are  pared,  so  as  to  leave  a  raw  surface;  a  flap  of  red  mar- 
ginal tissue,  as  thick  as  possible,  is  then  cut  from  the  outer  side, 
and  implanted  on  the  bevelled  raw  surface  of  the  red  margin  on 
the  inner  side,  the  upper  portions  of  the  cleft  being  also  apposed. 


Fig.  377. — Rose's  Operation  for  Single  Hare-Lip. 

On  the  left  side  the  semilunar  incisions  are  seen  extending  as  far  as  the  free 
borders  of  the  lip.  The  right-hand  figure  shows  the  parts  drawn  into 
position;  the  wide  cross  lines  represent  the  wire  sutures,  the  narrow  ones 
the  catgut  or  horsehair  stitches. 

3.  Sutures  are  now  inserted  to  maintain  the  lip  in  the  position  into 
which  it  can  be  drawn  by  the  fingers  without  tension.  Two  deep 
silver-wire  sutures  should  be  introduced,  one  just  above  the  red 
margin,  and  one  close  to  the  nose,  to  draw  into  position  and  steady 
the  nostril,  which  should  be  left  smaller  than  that  on  the  other  side. 


Fig.  378. — Mirault's  Operation  for  Hare-Lip. 

In  the  right-hand  figure  the  prolabial  flap  is  shown  ready  to  be  implanted 
on  the  prepared  inner  side. 

SO  as  to  allow  for  subsequent  dilatation,  which  is  certain  to  occur. 
Horsehair  or  catgut  stitches  are  used  to  bring  the  exact  margins 
together,  the  continuity  of  the  muco-cutaneous  line  being  accu- 
rately preserved,  and  the  cut  edges  of  the  mucous  membrane  upon 
the  deeper  aspect  being  sutured,  each  stitch,  after  it  is  tightened, 
being  used  to  elevate  and  evert  the  lip,  and  thus  assist  the  insertion 


788 


A    MANUAL  OF  SURGERY 


of  the  next.  The  wound  is  dressed  with  a  small  piece  of  gauze,  and 
secured  by  another  dry  piece  cut  in  the  shape  of  a  butterfly,  so  that 
the  narrow  body  shall  fit  over  the  lip,  and  the  wings  spread  over  the 
cheeks;  this  is  fixed  by  collodion,  and  maintained  for  some  days 
after  the  stitches  are  removed,  the  deep  ones  on  tlie  fourth  day,  and 
the  superficial  ones  about  the  eighth  or  tenth.  Careful  feeding  by 
spoon  is  necessary,  the  mother's  milk  being  drawn  off  and  given  in 
this  way  if  possible.  In  simple  cases  the  child  may  be  returned 
to  the  breast  about  the  fifth  day.  In  order  to  prevent  the  child 
from  picking  at  the  Hp  or  disturbing  the  dressing,  it  is  well  to  put  a 
sphnt  on  the  flexor  side  of  each  arm  to  control  the  elbow-joint. 

The  Treatment  of  Double  Hare-lip  may  be  discussed  under  two 
eadings,  viz.,  the  treatment  of  the  os  incisivum,  and  that  of  the 
soft  parts. 

The  OS  incisivnim  need  not  be  touched  if  it  retains  its  normal 
position,  and  the  labial  clefts  are  then  alone  dealt  with;  but  if  it 


Fig.  379. — Rose's  Operation  for  Double  Hare-Lip. 

The  central  tubercle  is  pared  in  a  V-shaped  manner,  and  the  lateral  segments 
by  curved  incisions,  extending  to  the  red  margin,  and  then  inwards. 
Only  the  apex  of  the  central  portion  is  included  in  the  completed  lip. 
The  long  cross  lines  represent  the  position  of  the  wire  stitches,  the  shorter 
ones  of  the  catgut  sutures. 

projects  forwards,  as  is  often  the  case,  it  must  be  either  removed, 
replaced,  or  reduced  in  size,  [a)  In  bad  cases  where  there  is  much 
projection  the  process  must  be  removed.  The  central  portion  of  the 
upper  lip  is  freed  from  it  by  dissection,  and  the  base  of  the  process 
divided  with  cutting-pliers;  a  small  artery  in  the  bone  will  spurt 
vigorously,  and  may  need  an  application  of  the  cautery  to  stop  it. 
The  operation  on  the  lip  is  deferred  till  ten  days  later.  A  certain 
amount  of  deformity  from  dropping  back  of  the  upper  hp  is  certain 
to  result,  but  can  be  in  measure  obviated  by  adding  a  projecting 
cheek-plate  to  that  which  carries  the  artificial  incisors,  {b)  Reposi- 
tion may  be  effected  by  several  methods,  the  best  of  which  is 
Bardeleben's,  who  incises  the  lower  border  of  the  septum,  strips  off 
the  muco-periosteum  from  either  side,  and  then  bends  or  breaks  the 
bone  back  into  position,  fixing  it  by  silver  wires,  and  uniting  the  lip 
at  once  to  form  a  sphnt  to  maintain  it  in  situ.     The  advantages 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


789 


claimed  for  reposition  are  that  the  patient  retains  his  own  central 
incisor  teeth,  and  that  the  normal  contour  of  the  jaw  and  face  is  not 
interfered  with.  Against  this  plan,  however,  must  be  placed  the 
facts  that  the  bone  rarely  becomes  firmly  united,  that  the  teeth  are 
stunted  and  erupt  obliquely  backwards  from  rotation  of  the  process, 
and  that  its  presence  prevents  the  maxillse  from  falling  together  and 
increases  the  difficulties  of  subsequently  closing  the  palatal  cleft. 
By  dividing  the  septum  parallel  to  the  plane  of  the  palate,  the 
process  can  be  slid  back,  and  its  rotation  is  thereby  avoided, 
(c)  Where,  however,  the  projection  is  not  great,  it  is  possible  to 
diminish  the  size  of  the  os  incisivum  by  gouging  away  the  teeth 
contained  within  it,  so  that  the  lip  can  be  closed  over  it. 

The  soft  parts  of  the  lip  are  dealt  with  in  much  the  same  way  as  in 
single  hare-lip.  They  are  freely  detached  from  the  maxillae,  and  the 
edges  pared,  as  shown  in  Fig.  379,  the  central  portion  being  cut  into 
a  V,  and  no  attempt  made  to  incorporate  it  into  the  free  margin  for 
fear  of  depressing  the  tip  of  the  nose,  whilst  the  lateral  segments  are 
pared  as  in  the  single  operation.  These  latter  are  now  drawn  to- 
gether and  united  in  the  middle  line  below  the  central  portion,  so 
that  a  Y-shaped  cicatrix  results.  One  of  the  deep  silver  stitches 
should  fix  the  apex  of  the  V;  the  other  should  be  inserted  just  above 
the  red  margin.  The  dressing  and  after-treatment  are  as  in  the 
single  operation.  For  a  time  the 
child  may  have  difficulty  in  breath- 
ing owing  to  the  diminution  in  the 
size  of  the  oral  aperture,  but  this 
is  obviated  by  the  nurse  drawing 
down  the  lower  lip  with  the 
fingers,  or  by  painting  it  in  a 
vertical  direction  with  collodion. 

Median  Hare-lip  may  occur  in  one  of 
two  forms ;  eittier  a  simple  cleft  exists 
in  the  middle  line  (Fig.  380),  or  there 
may  be  an  absence  of  the  intermaxilla 
and  nasal  septum,  causing  flattening 
of  the  bridge  of  the  nose,  and  a  broad 
median  defect,  flanked  by  the  maxillary 
portions  of  the  lip. 

Oblictue  Facial  Cleft  is  an  uncommon  deformity,  characterized  by  a  cleft 
or  sulcus  in  the  face,  starting  from  the  usual  situation  of  a  hare-Up  below,  but 
running  up  outside  the  nostril  to  the  inner  side  of  the  lower  Hd  (Fig.  381). 
Coloboma  of  the  iris  or  choroid  is  sometimes  associated  with  this  rare  defect. 
The  deformity  is  due  to  non-closure  of  the  naso-orbital  fissure,  and  runs  along 
the  line  of  the  nasal  duct.  It  may  be  limited  to  the  soft  parts,  or  may  involve 
the  bones,  even  lajdng  open  the  antrum. 

Macrostoma  (Fig.  382)  is  characterized  by  an  abnormal  width  of  the  mouth, 
and  is  due  to  non-union  of  the  maxillary  and  mandibular  processes.  It  may 
be  uni-  or  bi-lateral,  and  is  usually  associated  with  anomalies  of  development 
of  the  ear,  accessory  auricles  being  often  present.  As  a  rule,  a  small  papilla 
on  the  upper  and  lower  margins  will  indicate  the  true  limits  of  the  mouth, 
being  constituted  by  the  points  of  attachment  of  the  orbicularis.  The 
existence  of  these  is  of  great  importance  as  indicating  the  extent  to  which 
the  cleft  must  be  pared  in  order  to  restore  the  mouth  to  its  normal  size. 


Fig.  380. — Median  Hare-Lip. 


79° 


A   MANUAL  OF  SURGERY 


Mandibular  Clefts  are  exceedingly  rare.  They  are  due  to  non-union  of  the 
mandibular  processes  in  the  middle  line,  and  involve  either  the  soft  tissues  of 
the  lower  lip  alone,  or  may  extend  to  the  bone,  and  even  the  tongue.  Treat- 
ment is  as  for  ordinary  hare-lip. 

Microstoma  is  the  term  applied  to  a  condition  in  which  the  fusion  of  the 
parts  entering  into  the  formation  of  the  lips  progresses  to  a  greater  extent  than 
usual,  so  that  the  oral  orifice  is  contracted.  It  may  be  associated  with 
defective  development  of  the  lower  jaw.  In  the  more  severe  cases,  where  the 
mouth  is  extremely  narrowed,  a  transverse  cut  should  be  made  outwards 
on  each  side,  and  the  mucous  membrane  stitched  to  the  skin. 

Macrocheilia,  or  hypertrophy  of  the  lip,  occurs  in  three  forms: 
I.  The  congenital  variety,  a  condition  analogous  to  macroglossia, 
and  due  to  a  congenital  distension  of  the  tymphatic  spaces,  or  chronic 


Fig.     382.  —  Macrostoma 
Auricular  Appendages. 

GUSSON.) 


WITH 

(Fer- 


FiG.  381. — Oblique  Facial  Cleft, 

OR,  RATHER,  CICATRICIAL  DE- 
FORMITY ALONG  THE  LiNE 
USUALLY  TRAVERSED  BY  SUCH 

A  Cleft.     (Kraske's  Case.) 

lymphangiectasis,  accompanied  by  overgrowth  of  the  connective 
tissue.  The  lower  lip  is  most  often  involved,  and  is  firm,  thickened, 
and  everted,  causing  considerable  deformity.  The  treatment  con- 
sists in  the  removal  of  a  V-shaped  portion  from  the  centre.  2.  An 
acquired  form  occurs  in  children  and  young  people  with  a  tuber- 
culous inheritance,  constituting  the  so-called '  strumous  lip. '  Either 
lip  may  be  affected,  but  perhaps  more'Jrequently  the  upper;  the 
thickening  is  due  to  a  chronic  lymphangitis,  resulting  from  the 
absorption  of  toxic  material  from  persistent  cracks  and  fissures. 
If  these  can  be  healed,  and  the  general  health  improved,  diminution 
in  the  size  of  the  lip  soon  follows.  3.  In  adults,  macrocheiha  is 
in  almost  all  cases  due  to  tertiary  syphilis.  The  lower  lip  is  most 
often  enlarged,  and  becomes  thick  and  hard.     It  is  due  to  the  diffuse 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


791 


sclerosis  characteristic   of   tertiary  mischief.     General   treatment, 
and  not  local,  is  needed. 

Syphilitic  Affections  of  the  lip  are  not  uncommon.  A  primary 
chancre  may  be  caused  by  kissing,  or  by  smoking  an  infected  pipe, 
or  drinking  from  a  glass  with  an  infected  rim.  It  usually  presents  a 
smooth  ulcerated  surface,  dischaiging  a  small  amount  of  sero-pus, 
resting  on  a  mass  of  infiltrated  tissue  which  may  extend  over  the 
whole  lip  (Fig.  383).  The  induration  is  not  so  great  as  in  chancres 
upon  the  genital  organs,  but  the  infiltration  is  much  more  extensive. 
Enlargement  of  the  submaxillary  lymphatic  glands  occurs  very 
early,  and  the  disease  usually  runs  an  active  course.  The  treatment 
is  as  for  syphilis  elsewhere  (p.  166).  A  labial  chancre  may  closely 
resemble  epithelioma,  but  is  dis- 
tinguished from  it  by  its  rapid 
development  up  to  a  certain  point, 
by  the  early  implication  of  the 
glands,  which  soon  become  very 
large,  by  the  absence  of  typical 
cachexia,  by  the  age  of  the  patient, 
and  the  course  taken  by  the 
case,  as  well  as  by  the  local  ap- 
pearances. The  surface  is  usually 
flattened,  and  less  warty  and 
irregular  than  in  epithelioma, 
whilst  the  skin  is  more  involved 
than  the  mucous  membrane. 
Moreover,  it  is  more  common  on 
the  upper  lip,  whilst  epithelioma 
is  usually  seen  on  the  lower  (com- 
pare Figs.  383  and  384).  In  the 
secondary  stage  mucous  tubercles 
are  frequently  met  with,  involving 
the  inner  side  of  the  lip  and  the 
angle  of  the  mouth.  In  the  tertiary 
period  serpiginous  ulceration  and 
gummata  may  occur,  or  the  diffuse 
induration  described  above.  In  inherited  syphilis,  cracks  and 
mucous  tubercles  are  constantly  present,  and  may  be  so  extensive 
as  to  leave  cicatrices  radiating  from  the  mouth,  which  are  very 
characteristic  (Fig.  173). 

Cracked  Lips  (or,  as  they  are  often  called,  chapped  lips)  are  usually 
the  result  of  cold  weather,  a  central  crack  or  fissure  forming  which 
is  extremely  painful,  and  liable  to  bleed  very  readily  on  everting  or 
stretching  the  part.  The  lower  lip  is  that  generally  affected.  In 
tuberculous  children  more  than  one  may  occur,  and  by  their  per- 
sistence they  give  rise  to  a  considerable  degree  of  induration 
and  infiltration,  and  perhaps  lead  to  glandular  trouble.  All  that  is 
needed  in  the  shape  of  treatment  is  the  application  of  a  little  lanoline 
or  cold  cream,  but  if  they  persist,  it  may  be  advisable  to  touch  them 
with  nitrate  of  silver. 


Fig.  383. — Chancre  of  Upper 
Lip.    (From  a  Photograph.) 

The  enlargement  of  the  submaxil- 
lary lymphatic  glands  is  very 
evident. 


792 


A   MANUAL  OF  SURGERY 


Herpes  Labialis  is  a  condition  usually  associated  with  catarrh,  and 
not  unfrequently  with  pneumonia  or  other  fevers.  Either  lip  may 
be  affected,  and  the  herpetic  eruption  is  quite  limited  in  extent.  It 
consists  of  a  number  of  little  vesicles  situated  on  a  hypersemic  and 
painful  base ;  after  a  few  days  the  vesicles  become  transformed  into 
pustules,  and  these  in  turn  burst  and  dry  up,  the  whole  affection 
lasting  perhaps  a  week  or  ten  days.  Xo  special  treatment  is  required. 
If  the  inner  aspect  of  the  lip  is  affected,  the  epithelium  early  becomes 
sodden  and  is  shed,  so  that  the  vesicular  stage  is  much  shorter. 

Mucous  Cysts  occur  on  the  inner  side  of  the  lip  in  the  form  of 
small  rounded  swellings,  which  are  translucent  and  contain  a  glairy 

fluid.  They  are  often  due  to 
trauma,  whereby  the  opening  of 
a  mucous  gland  is  blocked.  The 
whole  cyst  wall  should  be  dis- 
sected out,  and  the  wound  closed 
by  stitches. 

Naevi  are  frequently  met  with 
in  the  lip.  If  confined  to  the 
inner  aspect  they  may  be  dis- 
sected out,  but  when  large  and 
involving  the  whole  thickness, 
they  should  be  dealt  with  by  elec- 
troh^sis. 

Warty  Growths  are  often  seen 
on  the  lower  lip,  especially  near 
the  angle,  and  may  then  simu- 
late epithelioma.  They  are  dis- 
tinguished, however,  by  the  fact 
that  ulceration  is  not  often 
present,  that  the  lymphatic 
glands  are  not  involved,  and 
that  there  is  but  little  infiltration 
of  the  base.  They  should,  how- 
ever, be  removed  as  early  as  possible,  since  malignant  disease  often 
starts  from  them. 

Epithelioma  of  the  lip  usually  occurs  in  men  of  the  working 
classes,  and  is  commonly  due  to  the  irritation  produced  by  smoking 
a  short  clay  pipe,  which  is  allowed  to  rest  on  one  or  the  other  side 
near  the  angle.  A  semicircular  notch  will  frequently  be  noticed 
in  the  teeth  of  the  upper  and  lower  jaw,  corresponding  to  the 
situation  of  the  growth  on  the  lip,  and  caused  by  the  constant 
friction  of  the  pipe-stem.  It  may  also  start  opposite  the  site  of 
some  projecting,  rough,  or  carious  tooth.  It  is  but  rarely  met  with 
in  women,  occurring  in  England  in  not  more  than  5  to  6  per  cent,  of 
the  cases,  and  probably  most  of  these  are  clay-pipe  smokers.  It 
is  certainly  more  common  amongst  country  folk,  who  use  the 
short  clay  pipe,  than  amongst  the  cigarette  and  cigar  smokers  in 
towns. 


Fig.  384.— Chronic  Epithelioma  of 
Lower  Lip.  (From  a  Photo- 
graph.) 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


793 


The  disease  may  start  as  an  induration  around  a  crack  or  fissure, 
\\'hich  gradually  extends,  forming  a  typical  malignant  ulcer ;  or  as  a 
wart-like  growth,  which  fungates  and  ulcerates;  or  as  a  chronic 
infiltration  leading  to  an  irregular  nodulated  thickening  of  the  lip, 
which  sometimes  looks  shrunken  and  feels  sclerosed  (Fig.  384). 

If  allowed  to  run  its  course  unchecked  by  treatment,  the  disease 
steadily  progresses,  forming  an  ulcerated  mass  of  greater  or  less  size, 
and  even  involves  the  jaw.  The  submental  and  submaxillary 
glands  are  early  implicated,  and  secondary  deposits  are  also  found 
in  the  glands  which  accompany  the  carotid  vessels.  Beyond  this, 
however,  the  disease  rarely  extends,  visceral  complications  being 
uncommon.  Death  is  generally  caused  by  the  secondary  growths 
in  the  neck,  which  attain  considerable  dimensions  and  then  ulcerate, 
this  stage  being  possibly  preceded  by  one  of  cystic  degeneration. 
From  these  ulcerating  surfaces  a  quantity  of  discharge  escapes, 
the  amount  varying  with  the 
septicity  or  not  of  the  wounds. 
Intense  pain  is  caused  by 
implication  of  nerves,  and 
haemorrhage  is  also  likely  to 
follow  from  erosion  of  the 
vessels  in  the  neck. 

The  Diagnosis  of  epithelioma 
is  rarely  doubtful,  but  occasion- 
ally warty  growths,  or  even  a 
primary  chancre  (p.  791),  may 
be  mistaken  for  it.  The  clinical 
history  generally  suffices  to  de- 
termine the  nature  of  the  mass, 
as   also   the   character  of  the 

base  and  the  appearance  of  the  parts;  but  in  uncertain  cases  the 
removal  of  a  small  portion  of  the  edge  under  cocaine,  and  its 
microscopic  examination,  are  required  to  set  doubts  at  rest. 

Treatment. — The  primary  growth  must  be  excised  completely,  if 
such  be  possible,  together  with  its  lymphatic  connections,  including 
the  submental  and  submaxillary  glands  and  the  deep  carotid 
glands,  whether  they  can  be  felt  enlarged  or  not.  When  once  the 
deeper  glands  in  the  neck  have  become  palpably  enlarged,  they 
often  contract  such  adhesions  as  to  render  their  extirpation  im- 
practicable. 

If  the  growth  is  limited  to  one  part  of  the  lip,  a  V-shaped  wedge 
extending  half  an  inch  beyond  it  in  all  directions  may  be  taken 
away  (Fig.  385),  and  the  wound  closed,  as  in  a  case  of  hare-lip, 
without  much  deformity  resulting.  When  it  is  more  extensive, 
considerable  ingenuity  must  be  exercised  in  order  to  make  good  the 
defect.  One  plan  that  often  gives  good  results  is  to  excise  the 
growth  by  a  somewhat  larger  V-shaped  incision,  and  then  to  extend 
the  labial  fissure  transversely  to  one  or  the  other  side,  or  to  both, 
dissecting  up  these  segments  from  the  bone;  the  flaps  can  then 


Fig.  385. — V-SHAPED  Incision  for  Re- 
moval OF  Epithelioma  of  Lip. 


794  A   MANUAL  OF  SURGERY 

usually  be  brought  together,  whilst  the  mucous  membrane  is  united 
to  the  skin  along  the  margin  of  the  new  lip. 

When  the  whole  lower  lip  requires  removal,  Syme's  operation  may 
be  performed  with  advantage.  It  consists  first  of  all  in  the  complete 
excision  of  the  diseased  lip.  Two  curved  incisions  are  then  made, 
starting  from  the  middle  line  of  the  wound,  and  extending  down- 
wards under  the  chin,  to  terminate  below  the  angles  of  the  jaw,  an 
inverted  V-shaped  portion  of  skin  between  them  remaining  fixed  to 
the  symphysis  menti  to  form  a  base  of  support  for  the  new  lip. 
The  lateral  flaps  are  now  dissected  up,  raised,  and  united  one  to  the 
other  in  the  middle  line,  so  as  to  constitute  the  new  lip,  an  inverted 
Y-shaped  cicatrix  resulting.  The  elasticity  of  the  skin  in  this 
region  allows  this  to  be  accomplished,  and  the  whole  wound  closed, 
without  leaving  any  part  to  granulate.  The  mucous  membrane 
should  be  finally  stitched  to  the  skin  over  the  upper  free  margin. 
Healing  by  first  intention  usually  follows. 

If  the  whole  of  the  upper  lip  needs  to  be  removed,  it  may  be 
restored  in  a  variety  of  ways.  Perhaps  one  of  the  best  consists  in 
making  incisions  which  skirt  the  alse  nasi  on  each  side,  and  then 
extend  outwards  into  the  cheeks  sufficiently  to  allow  the  tissues, 
when  they  have  been  freed  from  the  maxillae  by  undercutting,  to 
be  drawn  together  in  the  middle  line.  In  such  cases  care  must  be 
taken  not  to  encroach  on  Stenson's  duct. 


The  Extraction  of  Teeth. 

Although  this  operation  is  usually  undertaken  by  dentists,  yet 
surgeons  and  medical  practitioners  have  not  unfrequently  to  perform 
it,  and  not  a  little  skill  and  judgement  are  sometimes  needed  in  its 
execution.  An  anaesthetic  may  or  may  not  be  employed.  If 
merely  one  or  two  teeth  are  to  be  drawn,  gas  or  chloride  of  ethyl 
will  suffice;  but  when  a  large  number  require  extraction  at  one 
sitting,  it  is  better  to  give  ether  or  the  x\.C.E.  mixture;  chloroform 
should  never  be  administered  when  the  patient  is  in  the  sitting 
position.  The  posterior  teeth  are,  of  course,  dealt  with  first,  and 
subsequently  those  in  front.  Suitable  forceps  are  required  for  the 
various  teeth,  and  the  number  of  fangs  belonging  to  each  must  be 
kept  in  mind.  Incisor  and  canine  teeth  are  removed  by  a  com- 
bination of  traction  and  rotation;  the  bicuspids  and  molars  by 
traction  combined  with  lateral  movement,  especially  inwards. 
The  forceps,  after  being  sterilized,  should  be  pushed  well  up  under 
the  gum,  and  no  traction  made  until  a  firm  grasp  has  been  taken 
of  the  neck  of  the  tooth,  and  the  tooth  itself  loosened  by  lateral 
swaying. 

Accidents  of  various  types  happen  from  time  to  time.  The 
crown  may  break  away,  leaving  the  fangs  in  situ,  and  then  each  of 
these  must  be  sought  with  root  forceps  and  accounted  for.  In 
dealing  with  the  first  or  second  upper  molar,  it  is  quite  possible 
to  drive  a  fang  upwards  into  the  antral  cavity,  setting  up  thereby 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  795 

acute  suppuration  within  the  cavity.  Laceration  of  the  gum  is 
often  unavoidable,  and  injury  to  the  alveolar  margin  may  follow; 
but  such  accidents  as  fracture  or  dislocation  of  the  lower  jaw  are 
certainly  avoidable.  The  use  of  an  elevator  is  sometimes  desirable 
in  order  to  remove  old  roots,  but  it  is  an  instrument  that  must  be 
used  with  great  care. 

After  extraction  the  mouth  is  washed  out  with  sterilized  or  car- 
bolized  water,  and  the  bleeding  usually  ceases  without  delay.  If 
the  gum  has  been  much  torn,  it  should  be  pressed  back  into  position 
by  the  fingers,  and  when  the  mouth  is  dirty,  it  may  be  desirable  to 
touch  the  socket  over  with  tincture  of  iodine.  A  mouth-wash  of 
boric  acid  or  sanitas  is  subsequently  employed. 

Should  the  hcsmorrhage  continue,  as  in  patients  suffering  from 
purpura,  scurvy,  and  haemophilia,  the  socket  must  be  carefully 
plugged  with  a  strip  of  gauze  soaked  in  a  styptic,  such  as  adrenalin 
or  antipyrin ;  the  use  of  perchloride  of  iron  in  this  connection  is  un- 
desirable. Occasionally  the  bleeding  re-starts  after  two  or  three 
days  as  a  result  of  infection  of  the  socket  ;  it  is  then  necessary 
to  open  up  the  cavity  freely  from  the  outer  side,  cutting  away 
gum  and,  if  need  be,  bone,  so  as  to  allow  free  exit  to  discharges 
and  a  more  ready  access  for  strips  of  gauze  soaked  in  styptics  or 
antiseptics. 

AfEections  o£  the  Gums  and  Alveolar  Processes. 

Spongy  or  Inflamed  Gums  (gingivitis)  are  not  unfrequently 
caused  by  a  dirty  and  uncared-for  condition  of  the  teeth,  the  ad- 
ministration of  mercury,  or  scurvy.  They  are  characterized  by 
being  soft  and  congested,  bleeding  readily  on  pressure,  and  perhaps 
showing  signs  of  ulceration.  The  teeth  are  often  loose,  and  may  fall 
out.  All  that  is  necessary  is  the  correction  of  the  determining  cause 
and  the  use  of  an  alum  mouth- wash. 

Alveolar  Abscess  (Fig.  386)  is  almost  always  associated  with  sup- 
puration around  the  fang  of  a  carious  tooth,  the  bacteria  finding 
their  way  out  of  the  pulp  chamber  through  the  apical  foramen.  The 
alveolar  walls  become  expanded,  and  the  pus  either  finds  its  way 
over  the  edge  of  the  bone  (C,  D),  or  even  through  the  osseous  tissue 
(A),  under  the  external  periosteum.  If  limited  in  extent,  it  per- 
forates the  gum  directly,  and  is  then  known  as  a  gum-boil;  but 
occasionally  it  burrows  beneath  the  periosteum,  which  is  stripped 
from  the  bone,  and  may  thus  lead  to  an  abscess  of  larger  size,  pos- 
sibly resulting  in  necrosis  of  the  jaw.  The  formation  of  an  alveolar 
abscess  is  almost  always  associated  with  considerable  oedema  of 
the  face,  pain  of  a  serious  character,  and  when  extensive  may  give 
rise  to  marked  constitutional  disturbance.  Sometimes  graver 
comphcations  ensue;  thus,  iri  the  upper  jaw  the  antrum  may  be 
opened,  and  suppuration  in  this  cavity  follow,  whilst  in  the  lower 
the  abscess  may  travel  downwards  and  burst  externally,  either 
close  to  the  lower  margin  of  the  bone  or  in  the  neck.     A  troublesome 


796 


A   MANUAL  OF  SURGERY 


sinus  results,  which  can  only  be  cured  by  the  removal  of  the  tooth, 
and  even  then  a  depressed  and  adherent  cicatrix  ensues,  which  is 
very  unsightly.  The  most  essential  point  in  the  treatment  neces- 
sarily consists  in  the  removal  of  the  offending  tooth.  Often  this 
is  quite  sufficient,  and  possibly  the  tooth  may  come  away  with  an 
abscess  cavity  attached  to  one  of  the  fangs.  When  suppuration 
occurs  beneath  the  periosteum,  the  pain  can  at  first  be  relieved  in 
measure  by  fomentations,  but  as  soon  as  fluctuation  is  detected  a 
free  incision  should  be  made,  if  possible,  through  the  gum,  and 
the  cavity  emptied.  Possibly  it  may  be  wise  to  keep  a  small  piece 
of  stuffing  in  for  a  few  hours,  but  if  a  large  enough  opening  has  been 
made,   all  that   is  subsequently  needed  is  repeated  and  frequent 


Fig. 


386. — Diagram  of  Alveolar  Abscess,   resulting  from  Disease   of 
Molar  Tooth.     (After  the  American  System  of  Dentistry.) 

Abscess  arising  from  escape  of  septic  material  from  B,  the  pulp  chamber, 
through  the  foramen  at  apex  of  the  fang;  it  has  burrowed  directly  through 
the  alveolar  process  and  burst  through  the  gum;  C,  similar  abscess,  which 
has  tracked  down  between  the  tooth  and  the  alveolus,  and  spread  out 
beneath  the  alveolar  periosteum  at  D,  constituting  the  typical  alveolar 
abscess;  E,  cheek;  F,  antrum;  G,  nasal  cavity. 


irrigation,  preferably  with  peroxide  of  hydrogen.  When  the  skin 
is  thinned  and  the  cheek  red,  an  external  incision  is  usually  re- 
quired, and  sometimes  this  may  have  to  be  undertaken  as  a  pre- 
liminary, the  extraction  of  the  tooth  being  left  until  the  swelling 
has  somewhat  subsided.  If  a  small  sinus  persists  after  removal  of 
the  tooth,  it  must  be  opened  up,  and  any  carious  or  necrosed  bone 
taken  away.  Not  unfrequently  the  masseter  becomes  infiltrated 
and  sclerosed  when  the  lower  jaw  is  affected,  and  this  may  result 
in  fixed  closure  of  the  mouth,  demanding  operative  treatment  for 
its  cure. 

Pyorrhoea  Alveolaris  (or  Riggs'  Disease)   consists  in  an  inflam- 
matory condition  of  the  margins  of  the  gums,  accompanied  by  a 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  797 

purulent  discharge,  which  arises  from  pockets  or  pouches  which 
may  extend  a  greater  or  less  distance  along  the  roots  of  the  teeth. 
In  the  early  stages  the  gums  are  swollen  and  cedematous  to  such  an 
extent  that  they  often  hide  or  partially  cover  the  stumps  of  decayed 
teeth,  and  they  bleed  readily.  The  tongue  is  coated,  and  the 
breath  exceedingly  offensive.  In  less  severe  cases  and  in  the  later 
stages  the  tissues  of  the  gums  shrink,  and,  together  with  the  alveolar 
border,  become  atrophic ;  the  fangs  are  thereby  uncovered  and  the 
teeth  loosened,  so  that  after  a  while  a  natural  cure  may  be  estab- 
lished by  the  patient  becoming  edentulous.  The  process  is  limited 
to  a  few  teeth,  or  may  involve  many.  It  is  generally  preceded  by 
an  excessive  deposit  of  tartar,  beneath  which  bacterial  infection 
occurs,  the  inflammation  spreading  down  along  the  periodontal 
membrane,  and  perhaps  extending  to  surrounding  parts — -s.g.,  the 
maxillary  antrum.  In  most  cases,  on  making  pressure  along  the 
alveolar  margins,  a  greater  or  less  quantity  of  pus  can  be  squeezed 
out.     For  the  constitutional  results  of  this  oral  sepsis,  see  p.  84. 

Treatment  must,  in  the  first  place,  be  directed  to  the  teeth,  and 
consists  in  the  removal  of  tartar  and  the  application  of  astringents 
and  antiseptics,  preferably  peroxide  of  hydrogen,  not  only  to  the 
exposed  mucous  membiane,  but  also  into  the  pouches  and  pockets 
where  pus  collects.  In  some  cases  it  is  wise  to  destroy  the  granu- 
lation tissue  forming  the  outer  wall  of  these  pouches  by  means  of 
the  electric  cautery,  or  even  to  remove  the  teeth.  Too  much  must 
not  be  done  at  a  time,  as  the  general  symptoms  may  be  aggravated 
by  an  increased  absorption  of  toxins,  and  the  reparative  activities 
of  the  patient  may  be  very  deficient.  Goadby*  has  pointed  out 
that  in  many  of  the  worst  cases  the  resisting  power  of  the  individual, 
as  estimated  by  the  opsonic  index,  is  very  low  to  particular  organisms 
isolated  from  the  mouth,  and  recommends  the  employment  of  a 
suitable  vaccine  prepared  from  these  particular  bacteria. 

Hypertrophy  of  the  Gums  is  met  with  in  the  form  of  a  sessile  over- 
growth, sometimes  almost  cauliflower-like,  around  and  between  the 
teeth,  which  are  usually  carious;  it  occurs  most  frequently  in 
children.  In  slight  cases  the  overgrowth  may  be  destroyed  by 
the  application  of  a  crystal  of  trichloracetic  acid;  but  in  the  more 
exaggerated  types  excision  is  required. 

Dental  Cysts  are  by  no  means  uncommon,  resulting  from  the 
irritative  effects  of  dental  caries;  hence  they  follow  the  distribution 
of  that  affection,  and  are  most  frequently  seen  in  connection  with 
the  upper  first  molars  and  bicuspids.  They  develop  at  the  roots  of 
the  teeth,  causing  a  painless  regular  expansion  of  the  bone,  free  from 
inflammatory  phenomena,  unless  infected  secondarily  with  bacteria. 
After  a  time  the  centre  of  the  swelling  softens,  and,  as  the  bony  wall 
is  absorbed,  parchment -like  crackling  can  be  felt;  finally,  the  con- 
dition presents  as  a  rounded  tense  elastic  swelling,  around  the 
margins  of  which  the  remains  of  the  expanded  bone  can  be  detected. 

*  Goadby:  Erasmus  Wilson  Lecture  on  '  Pj^orrhoea  Alveolaris  '  (Lancet, 
March  9,  1907). 


798 


A   MANUAL  OF  SURGERY 


In  the  upper  jaw  they  often  encroach  on  and  project  into  the  bony 
antral  cavity,  pushing  the  mucous  membrane  in  front  of  it.  The 
tooth  which  is  the  cause  of  the  trouble  is  always  dead,  and  fre- 
quently merely  a  septic  root  is  present. 

The  catise  of  these  cysts  is  probably  the  proHferation  of  certain 
embryonic  remains  of  the  enamel  organ,  brought  about  by  the 
irritation  of  toxic  matter  which  has  escaped  from  the  pulp  cavity. 
These  foetal  residues  are  lighted  up  into  activity,  developing  into 
masses  or  columns  of  epithelial  tissue,  which  undergo  cystic  de- 
generation. Their  pathogenesis  is  practically  identical  with  that 
of  the  epithelial  odontome,  but  merely  one  cyst  develops  here  in- 
stead of  many.     The  fluid  contained  therein  is  thick  and  mucoid  in 

character,  and  broken- 
down  epithelial  cells 
and  cholesterine  are 
seen  in  it  on  micro- 
scopical examination. 

Treatment.  —  The 
cyst  must  be  laid 
freely  open  into  the 
mouth,  the  septic  tooth 
or  stump  removed, 
and  the  anterior  wall 
of  its  alveolus  cut 
away.  The  alveolus 
and  cyst  thus  laid  into 
one  cavity  are  scraped 
so  as  to  remove  all 
the  epithelial  lining, 
and  packed  with  gauze  so  as  to  ensure  healing  by  granulation. 
In  the  upper  jaw  the  utmost  gentleness  is  required  in  dealing  with 
the  deeper  wall  of  the  cyst,  as  the  septum  between  it  and  the  antral 
cavity  may  be  extremely  thin  and  entirely  devoid  of  bony  tissue. 

Epulis. — By  this  term  is  meant  a  tumour  growing  from  the 
alveolar  periosteum.  Two  varieties  are  described,  viz.,  the  simple 
and  the  myeloid. 

A  Simple  Epulis  is  usually  of  a  fibromatous  nature,  and  may  grow 
from  either  jaw,  though  more  commonly  from  the  lower.  It  is 
generally  due  to  the  irritation  of  diseased  teeth,  and  although  most 
marked  on  the  outer  aspect,  it  burrows  between  the  teeth,  and  is 
also  found  on  the  inner  side.  It  appears  as  a  red  fleshy  mass, 
smooth  or  perhaps  lobulated  (Fig.  387),  of  an  elastic  consistency, 
and  possibly  associated  with  a  little  superficial  ulceration.  It  is 
covered  with  mucous  membrane,  and  may  contain  a  few  spicules 
of  bone.  The  treatment  consists  in  removing  the  growth  together 
with  the  teeth  or  stumps  with  which  it  is  connected.  If  small,  it 
will  suffice  to  cut  away  and  scrape  the  bone  from  which  it  arises; 
but  if  large,  or  if  it  recurs  after  such  treatment,  the  portion  of  the 
alveolus  from  which  it  springs  must  also  be  excised.     This  is  best 


Fig.  3S7. — Simple  Epulis. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  799 

accomplished  by  extracting  a  tooth  on  either  side  of  the  tumour, 
and  cutting  vertically  through  each  socket  with  a  saw,  the  two  in- 
cisions being  united  below  by  a  chisel,  so  as  to  remove  a  quad- 
rangular portion  of  bone  without  interfering  with  the  continuity 
of  the  jaw. 

Myeloid  Epulis. — This  title  is  applied  to  a  myeloma  developing 
from  the  interior  of  the  alveolar  process.  It  forms  a  soft,  rapidly 
increasing  mass  of  a  dusky  purple  colour,  which  runs  on  to  ulcera- 
tion or  fungation ;  the  deeper  portions  may  contain  an  ossific  deposit. 
As  with  all  forms  of  myeloid  growth,  it  is  only  locally  malignant. 
Treatment  consists  in  free  removal  of  the  tumour  and  of  the  portion 
of  alveolus  from  which  it  arises.  In  the  upper  jaw  this  sometimes 
necessitates  excision  of  the  complete  palatal  segment  of  the  maxilla, 
but  in  the  lower  jaw  it  is  generally  possible  to  maintain  the  con- 
tinuity of  the  mandible  by  removing  merely  a  quadrilateral  portion 
in  the  same  way  as  for  a  simple  epulis. 

Epithelioma  and  Sarcoma  (round  or  spindle-celled),  arising  from 
the  gum,  are  both  met  with.  Epithelioma  in  this  situation  occa- 
sionally fungates,  but  more  often  invades  the  bony  tissues,  and  in 
the  upper  jaw  extends  upwards  to  the  antrum;  hence  it  is  sometimes 
termed  a  '  creeping  or  burrowing  epithehoma.'  The  ordinary  signs 
of  this  disease  become  evident,  lymphatic  glands  are  enlarged,  and 
typical  ulceration  of  the  gum  follows.  The  only  possible  treatment 
consists  in  free  excision  of  the  growth,  together  with  the  portion 
of  bone  affected  and  the  lymphatic  area  involved. 

Necrosis  of  the  Jaw. — Causes:  (i)  Subperiosteal  alveolar  abscess, 
connected  with  dental  caries.  (2)  Traumatism,  such  as  blows  on 
the  jaw,  with  or  without  fracture,  in  the  latter  instance  being  due  to 
infective  periostitis  or  osteo-myelitis,  owing  to  the  lesion  becoming 
compound.  The  use  of  dirty  forceps  or  elevators  in  extracting  a 
tooth  may  similarly  light  up  an  infective  inflammation,  resulting 
in  necrosis.  (3)  In  tertiary  syphihs  necrosis  also  occurs,  affecting 
most  frequently  the  palate  or  alveolar  borders.  (4)  It  results  from 
mercurial  poisoning,  but  rarely  at  the  present  day.  (5)  Phos- 
phorus necrosis  is  met  with  amongst  those  who  work  in  lucifer- 
match  factories,  but  only  when  ordinary  phosphorus  is  used;  the 
amorphous  form  is  harmless.  The  fumes  are  supposed  to  gain 
access  to  the  jaws  through  carious  teeth,  giving  rise  to  a  somewhat 
acute  inflammation,  which  terminates  in  necrosis.  A  considerable 
amount  of  new  bone  forms  beneath  the  periosteum,  and  the  seques- 
trum, which  is  curiously  gray  and  porous,  like  dirty  pumice-stone, 
is  always  slow  in  separating.  Either  jaw  may  be  affected,  but 
perhaps  the  lower  a  little  more  commonly  than  the  upper.  (6)  Ne- 
crosis may  follow  one  of  the  exanthemata  or  any  condition  of  mal- 
nutrition or  anaemia,  arising  as  an  infective  idiopathic  or  embolic 
osteo-myelitis,  and  then  probably  affecting  a  considerable  extent 
of  bony  tissue,  possibly  the  whole  mandible.  (7)  Tubercle  is 
occasionally  responsible  for  this  condition. 

The  symphysis  menti  in  children  is  occasionally  the  seat  of  a 


8oo  A   MANUAL  OF  SURGERY 

pyogenic  or  tuberculous  infection,  previous  to  the  eruption  of  the 
permanent  incisors.  An  abscess  forms,  and  caries  or  a  hmited 
necrosis  results.  In  a  case  of  this  type  an  opening  is  required  in 
the  submental  region,  through  which  the  diseased  tissue  can  be 
thoroughly  scraped  away.  Ihe  teeth  are  of  course  lost,  but  a  good 
result,  and  with  but  little  scarring,  may  be  anticipated. 

The  Clinical  Phenomena  associated  with  necrosis  of  the  jaw  are 
necessarily  much  the  same  whatever  the  cause.  The  acute  form 
commences  with  severe  pain  in  and  around  the  jaw,  followed  by 
great  swelling  of  the  face  and  difficulty  in  opening  the  mouth  or 
taking  food.  Ihe  temperature  is  raised,  and  even  rigors  may  be 
present;  the  breath  is  usually  foul.  Sooner  or  later  an  abscess 
forms,  which  may  point  either  in  the  mouth  or  on  the  face,  or  the 
pus  may  burrow  downwards  for  some  distance  into  the  neck. 
Sinuses  persist,  discharging  the  most  offensive  pus;  a  new  covering 
of  bone  sometimes  forms  in  the  lower  jaw,  enclosing  a  sequestrum, 
but  in  the  upper  this  is  rarely  noticed,  and  even  in  the  lower  it  is 
not  unusual  to  see  a  considerable  amount  of  bare  or  dead  bone 
absorbed  without  the  formation  of  an  involucrum. 

Treatment.^ — In  the  early  stage  the  cheek  should  be  fomented, 
but  as  soon  as  there  is  any  suspicion  of  pus  a  free  incision  is  made 
down  to  the  bone  inside  the  mouth  and  along  the  line  of  reflection 
of  the  mucous  membrane.  When  necrosis  is  present,  it  must  be 
treated  in  the  ordinary  way,  the  sinuses  being  flushed  out  with  an 
antiseptic  solution  three  or  four  times  a  day  until  the  sequestrum 
is  loose;  it  is  then  removed,  if  possible,  from  within  the  mouth. 
Drainage  by  means  of  an  external  opening  is  often  absolutely 
necessary.  In  the  worst  cases  necrosis  may  extend  from  the  middle 
line  of  the  mandible  to  the  temporo-maxillary  articulation;  it  is 
then  wise  to  make  an  external  incision,  and  remove  the  bone  in  toto 
after  detaching  it  by  saw  from  the  other  ramus. 

Af¥eetions  of  the  Antrum. 

Suppuration  within  the  Antrum  {empyema  of  maxillary  sinus)  fre- 
quently arises  from  disease  connected  with  the  fangs  of  the  first 
or  second  molar  or  bicuspid  teeth ;  it  not  uncommonly  results  from 
an  acute  inflammation  of  the  nasal  cavities  as  in  influenza,  and  may 
then  be  associated  with  trouble  in  the  other  accessory  nasal  sinuses, 
such  as  the  frontal  and  ethmoidal  (p.  821) ;  it  is  occasionally  lighted 
up  by  injury.  In  chronic  cases  it  is  not  unusual  to  find  the  antrum 
filled  with  soft  polypoid  granulations. 

The  Symptoms  produced  are  often  extremely  equivocal,  and  the 
condition  may  be  present  for  some  time  without  being  recognised. 

In  the  chronic  forms  all  that  is  noticed  may  be  an  intermittent  dis- 
charge of  pus  into  and  from  one  side  of  the  nose,  associated  perhaps 
with  some  pain  in  the  infra-orbital  region,  a  chronic  cough,  and 
an  irritable  throat.  The  pus  varies  considerably  in  amount  and 
character,  being  sometimes  extremely  offensive.     On  holding  the 


PLATE  V. 


Transillumination  of  the  face. 


[  To  face  page  800. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  8oi 

patient's  head  forwards,  it  can  be  demonstrated  that  there  is  an 
overflow  of  pus  into  the  nostril,  and  sometimes  when  the  patient 
rechnes  it  flows  back  into  the  pharynx.  Should  the  opening 
into  the  nose  become  blocked,  all  the  symptoms  are  aggravated, 
the  pain  becoming  more  marked  and  the  swelling  increasing.  Signs 
of  distension  of  the  antrum  may  also  be  produced  in  this  way,  and 
are  manifested  in  four  directions:  (a)  Inwards,  causing  obstruction 
to  nasal  respiration,  and  possibly  epiphora,  from  compression 
of  the  nasal  duct;  {b)  upwards,  leading  to  protrusion  of  the  eye- 
ball or  exophthalmos;  (c)  downwards,  resulting  in  depression 
of  the  side  of  the  palate,  and  possibly  irregularity  in  the  line  of 
the  teeth;  and  {d)  outwards,  giving  rise  to  a  somewhat  charac- 
teristic projection  of  the  cheek  beneath  the  malar  eminence. 
Under  these  circumstances,  a  finger  inserted  into  the  mouth, 
between  the  cheek  and  the  bone,  will  detect  a  loss  of  resistance 
in  the  anterior  wall  of  the  antrum,  and  if  the  distension  has 
lasted  long,  eggshell  crackling  may  be  noticed,  or  the  whole 
anterior  wall  may  be  absorbed  and  an  elastic  swelling  take  its 
place.  Infra-orbital  neuralgia  is  often  a  marked  feature  in  these 
cases. 

In  acute  cases  all  the  above  phenomena  may  be  present  in  an 
accentuated  degree,  accompanied  by  severe  tensive  pain  and  some 
amount  of  febrile  disturbance.  Necrosis  of  the  lining  bony  walls 
may  also  be  induced,  owing  to  the  fact  that  the  mucous  membrane 
is  closely  adherent  to  the  periosteum. 

The  Diagnosis  of  suppuration  within  the  antrum  is  not  always 
easy.  The  periodic  discharge  of  pus  from  the  nose  is  suggestive,  as 
also  the  presence  of  a  dead  or  painful  molar  or  bicuspid  tooth.  If 
a  flow  of  pus  can  be  induced  by  change  of  position  of  the  head,  it  is 
pathognomonic  of  suppuration  within  one  of  the  accessory  sinuses 
connected  with  the  nose,  probably  of  the  antrum.  If,  after  the 
nose  has  been  cleared  and  the  head  hung  down,  pus  is  seen  welling 
up  from  under  the  middle  turbinal,  the  diagnosis  is  almost  certain. 
Transillumination  of  the  antrum  may  confirm  this  opinion.  A 
suitable  electric  lamp  is  placed  within  the  mouth,  and  if  the  patient 
is  in  a  dark  room,  or  if  he  and  the  surgeon  are  under  a  photographer's 
cloth,  and  his  antra  are  normal,  the  cheeks,  lips,  and  lower  margins 
of  the  orbits  become  of  a  rosy-red  colour  (Plate  V.).  If,  how- 
ever, the  cavities  are  occupied  by  pus,  blood,  or  a  growth,  the 
parts  remain  dark.  Transillumination  does  not  answer  in  every 
individual,  and  hence  the  value  of  the  test  is  much  dimin- 
ished. The  presence  of  illumination  excludes  intra-antral  growths 
or  abscess,  but  its  absence,  unless  unilateral,  is  not  of  much 
significance.  Finally,  the  antrum  may  be  punctured  with  trocar 
and  cannula  through  the  canine  fossa,  or  through  the  inferior 
nasal  meatus,  and  an  absolute  diagnosis  obtained  by  washing 
it  out. 

The  Treatment  necessarily  varies  with  the  type  of  the  disease.  It 
must  always  be  remembered  that  the  orifice  of  the  antrum  into  the 

5^ 


8o2  A   MANUAL  OF  SURGERY 

middle  meatus  is  an  inch  above  the  antral  floor,  and  hence  the 
natural  drainage  is  very  defective  (Fig.  396). 

In  the  early  active  form  that  sometimes  follows  the  extraction  of 
a  tooth,  and  may  even  be  associated  with  the  pushing  up  of  a 
broken  fang  into  the  cavity,  it  will  probably  suffice  to  enlarge  the 
opening  in  the  alveolus  with  a  suitable  antrum  drill.  A  solid  rubber 
plug  is  introduced,  and  the  cavity  washed  out  into  the  nose  with 
sterile  salt  solution  two  or  three  times  a  day,  until  the  purulent 
discharge  ceases,  when  the  opening  may  be  allowed  to  granulate. 
The  sohd  plug  is  better  than  a  hollow  tube,  which  permits  discharge 
to  get  into  the  mouth,  and  food  or  septic  material  to  pass  up  into 
the  antrum. 

In  the  acute  post-influenzal  cases  the  cavity  may  be  washed  out 
from  the  nose,  the  inner  wall  being  punctured,  after  efficient  cocaini- 
zation,  through  the  inferior  meatus;  this  lavage  may  be  required 
at  first  daily,  but  subsequently  less  frequently,  and  in  the  intervals 
the  patients  must  be  guarded  from  cold.  Sometimes  a  change  of 
air  will  clear  up  the  trouble. 

In  the  more  chronic  cases,  intranasal  treatment  will  usually 
suffice,  but  to  be  effective  the  greater  part  of  the  inner  (nasal)  wall 
of  the  antrum  must  be  removed  so  as  to  leave  a  large  communica- 
tion through  which  the  cavity  can  be  cleansed.  Sometimes  there 
is  a  large  accumulation  of  polypoid  granulation  tissue  within  the 
antrum.,  and  to  remove  it  the  surgeon  must  make  an  additional 
opening  by  dividing  the  mucous  membrane  above  the  first  molar 
tooth  and  take  away  the  anterior  bony  wall.  Effective  curet- 
ting can  then  be  performed,  and  it  is  usually  possible  to  close  the 
buccal  opening.  Only  in  very  old-standing  neglected  cases  is  it 
necessary  to  utilize  the  old-fashioned  method  of  packing  the  antrum 
from  the  buccal  aspect  and  making  it  heal  by  granulation.  It  is 
important  in  these  cases  to  make  certain  that  the  trouble  is  limited 
to  the  antrum,  and  not  dependent  on  the  overflow  into  it  of  pus 
from  other  accessory  sinuses. 

Hydrops  Antri  is  the  terni  applied  to  a  chronic  distension  of  the 
antrum  with  a  glairy  mucoid  fluid,  somewhat  similar  in  character  to 
that  contained  in  a  ranula.  The  condition  is  painless,  and  free  from 
inflammatory  phenomena,  and  as  the  expansion  increases,  eggshell 
crackling  of  the  anterior  wall,  or  even  distinct  fluctuation,  may  be 
observed.  It  was  formerly  supposed  to  arise  from  obstruction  to  the 
aperture  into  the  nose  and  retention  of  secretion,  but  is  in  reality 
due  to  a  cystic  tumour  forming  from  the  glands  of  the  mucous 
membrane,  or  more  often  to  a  dental  cyst  (p.  797)  which  has  en- 
croached on  the  antral  cavity;  rarely  is  it  due  to  the  presence 
of  a  dentigerous  cyst  (p.  808).  The  treatment  required  is  to  open 
thoroughly  the  cyst  from  the  mouth  after  dividing  the  mucous 
membrane,  subsequently  removing  a  sufficient  portion  of  the 
anterior  wall  to  enable  it  to  be  washed  out  and  drained.  It  is 
sometimes  possible  to  remove  the  whole  lining  membrane  without 
wounding  the  mucous  membrane  of  the  antrum. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  803 

Various  Tumours  may  originate  in  the  antrum — e.g.,  mucous 
polypi,  fibromata,  odontomata,  osteomata,  sarcomata,  and  cancers. 
If  limited  to  the  cavity,  they  produce  no  definite  symptoms,  except 
when  large  enough  to  cause  expansion  of  its  walls.  Malignant 
growths,  however,  generally  pass  beyond  the  limits  of  the  antrum, 
and  lead  to  the  usual  signs  of  malignant  disease  of  the  upper  jaw. 
Treatment  consists  in  removing  simple  growths,  if  possible,  with- 
out interfering  with  the  integrity  of  the  maxilla.  This  may  be 
accomplished  by  reflecting  the  overlying  cheek,  as  in  excision  of 
the  upper  jaw.  For  malignant  tumours,  removal  of  the  complete 
upper  jaw  on  the  affected  side  is  probably  the  only  remedy. 


Tumours  of  the  Upper  Jaw. 

Many  of  the  Simple  Tumours  springing  from  the  upper  jaw  have 
been  already  described  amongst  those  involving  the  alveolar  border 
and  antrum.     Only  a  few  remain  to  be  dealt  with. 

Osteoma  occurs  either  in  the  form  of  a  tumour  composed  of 
compact  tissue,  then  usually  growing  within  the  antrum;  or  occa- 
sionally as  a  diffuse  symmetrical  overgrowth,  constituting  the  con- 
dition known  as  leontiasis  ossea.  A  few  cases  of  Chondroma  have 
also  been  reported. 

Leontiasis  ossea  is  a  disease,  fortunately  very  rare,  which,  com- 
mencing in  young  adult  life,  progresses  slowly,  but  relentlessly, 
and  may  at  length  destroy  the  patient  after  causing  a  great  amount 
of  suffering.  Nothing  is  known  as  to  its  origin.  It  affects  either 
the  cranial  or  facial  bones,  or  both,  and  consists  in  a  development 
therefrom  of  nodular  masses  of  soft  spongy  bone,  embedded  in 
which  are  areas  of  fibrous  tissue.  When  affecting  the  facial  bones, 
the  projections  may  become  very  marked,  and  give  the  patient 
a  hideously  repulsive  appearance,  with  a  more  or  less  leonine  aspect. 
As  growth  progresses,  the  new  bone  encroaches  on  the  cavities  of 
the  skull,  the  antrum,  the  orbits,  or  even  the  cranial  cavity,  and 
thus  exophthalmos,  neuralgia,  and  finally  coma  may  be  produced. 
No  satisfactory  treatment  is  known,  although  attempts  to  chisel 
away  the  masses  have  been  made. 

Malignant  Disease  of  the  Upper  Jaw  occurs  in  the  form  of  sarcoma 
or  cancer.  Sarcoma  is  perhaps  the  more  common,  and  originates 
either  from  the  anterior  wall,  from  the  cavity  of  the  antrum,  from 
the  spheno-maxillary  fossa  behind  the  bone,  or  may  extend  into  the 
maxilla  from  the  naso-pharynx.  Not  unfrequenily  these  growths 
have  a  considerable  ossific  basis,  and  this  is  sometimes  so  extensive 
as  to  obhterate  the  antral  cavity,  and  convert  the  bone  into  a  solid 
mass.  Cancer  develops  in  the  form  of  a  squamous  burrowing  epithe- 
lioma, springing  from  the  gums ;  or  as  a  columnar  or  acinous  cancer 
starting  in  the  glandular  tissue,  found  both  in  the  nasal  and  antral 
cavities.  It  is  probable  that  not  a  few  of  these  growths,  both  sar- 
coma and  carcinoma,  are  derived  from  embryonic  rests,  associated 


8o4 


A   MANUAL  OF  SURGERY 


with  the  enamel  organs  and  teeth,  and,  as  Sir  F.  S.  Eve*  points  out, 
are  in  reality  malignant  odontomata. 

The  Clinical  Features  of  both  forms  of  malignant  disease  are 
practically  identical. 

If  arising/ro;;/  the  anterior  aspect  of  the  bone,  a  tumour  is  produced 
which  projects  under  the  cheek,  the  tissues  of  which  are  invaded  by 
it;  it  extends  down  towards  the  mouth,  and  is  readily  detected 
through  the  mucous  membrane.  It  may,  however,  spread  deeply, 
and  involve  the  cavity  of  the  antrum.  It  causes  no  obstruction 
to  nasal  respiration,  and  no  epiphora  except  in  the  later  stages. 
1  .  If  it  originates  ivithin  the  antrum,  the  usual  signs  of  distension  of  that 
cavity  (p.  80 1)  are  produced,  associated  with  a  foul,  and  often  blood- 
stained, discharge  from  the  nose,  within  which  the  ulcerated  surface 

of  the  growth  may  be  seen. 
Epiphora  is  caused  by  pres- 
sure on  the  nasal  duct,  whilst 
the  growth  has  been  known 
to  burrow  upwards  along 
this  passage  and  project 
near  the  inner  canthus.  The 
passage  of  air  through  the 
nose  on  that  side  is  also 
impeded,  and  the  palate 
may  be  depressed. 

If  the  growth  commences 
behind  the  maxilla,  it  usually 
springs  from  one  of  the  walls 
of  the  spheno  -  maxillary 
fossa,  or  from  the  base  of 
the  skull,  and  is  then 
characterized  by  a  great 
tendency  to  spread  in  all 
directions.  It  may  push 
the  whole  bone  bodily  for- 
wards without  encroaching 
upon  the  antrum;  sometimes  it  finds  its  way  outwards  to  the 
pterygoid  fossa  through  the  pterygo-maxillary  fissure,  or  inwards 
to^the  nose  through  the  palatine  foramen,  or  even  up  into  the 
orbit;  whilst  more  rarely  it  spreads  down  along  the  posterior 
palatine  canal,  so  as  to  appear  at  the  postero-external  corner  of  the 
palate;  in  the  later  stages  the  antral  cavity  is  also  involved,  and 
even  the  base  of  the  skull  eroded. 

The  General  Signs  of  a  malignant  growth  of  the  superior  maxilla 
consist  in  the  appearance  of  a  tumour  which,  in  its  earlier  stages, 
may  produce  various  effects,  but  finally  is  likely  to  destroy  the  bone 
and  occupy  the  whole  of  the  maxillary  region  (Fig.  388).  It  is 
usually  accompanied  by  nasal  obstruction,  epiphora,  and  a  dis- 
charge of  blood  or  pus  from  the  nares.     Severe  pain  sometimes 

*  Sir  F.  S.  Eve,  Brit.  Med.  Journ.,  June  29,  1907, 


Fig.  388. — Osteo-Sarcoma   of^[the 
Upper  Jaw. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  805 

accompanies  the  process,  especially  affecting  the  second  division  of 
the  trigeminal.  Neighbouring  lymphatic  glands  become  enlarged, 
more  especially  in  the  carcinomata;  those  in  the  submaxillary  region 
are  first  involved,  and  afterwards  those  in  the  anterior  triangle; 
secondary  deposits  in  the  viscera  may  also  occur  somewhat  later. 
The  tumour  follows  a  typical  malignant  course,  and,  owing  to 
the  great  vascularity  of  the  parts,  its  onward  progress  is  very 
rapid. 

The  Diagnosis  of  malignant  disease  of  the  upper  jaw  from  a  simple 
tumour  or  cyst  should  be  readily  made;  the  rapidity  of  its  growth, 
the  greater  pain  and  more  abundant  discharge  from  the  nose,  the 
associated  enlargement  of  the  lymphatic  glands,  and  the  tendency 
to  spread  to  and  encroach  upon  surrounding  structures,  all  point 
to  malignant  disease.  In  some  cases,  however,  an  exploratory 
incision  is  required  to  make  certain  of  the  diagnosis.  More  fre- 
quently the  existence  of  a  tumour  at  all  is  for  some  time  entirely 
overlooked,  some  one  prominent  symptom,  such  as  neuralgia  or 
epiphora,  being  treated  without  ascertaining  the  cause.  Trans- 
illumination (p.  801)  may  assist  in  clearing  up  the  diagnosis,  as  also 
radiography,  which  would  indicate  the  presence  of  an  unerupted 
tooth  in  a  dentigerous  cyst. 

Treatment  consists  in  free  removal  of  the  growth  with  a  good 
margin  of  healthy  tissue  around  it,  together  with  the  lymphatic 
area  involved.  This  not  unfrequently  involves  excision  of  the 
superior  maxilla,  but  if  the  disease  has  spread  beyond  the  limits 
of  that  bone- — e.g.,  into  the  cheek^ — or  has  invaded  either  primarily 
or  by  extension  the  retro-maxillary  tissues,  the  advisability  of 
attempting  removal  is  very  doubtful,  since  it  involves  a  terrible 
mutilation,  and  complete  eradication  is  always  a  matter  of  uncer- 
tainty. In  these  cases,  as  in  so  many  others,  early  diagnosis  is 
all-important ;  and  inasmuch  as  this  is  now  practicable,  thanks  to 
improving  knowledge  and  experience  of  intranasal  work,  the  more 
severe  types  of  operation  are  less  frequently  required.  Wherever 
practicable,  the  alveolus  and  floor  of  the  orbit  ought  to  be  spared, 
and  if  the  case  is  recognised  sufficiently  early,  this  can  often  be 
accomplished. 

ife  Lateral  Rhinotomy  (Moure's  operation)  is  the  most  effective  and 
satisfactory  method  of  removing  growths  of  the  maxilla  or  neigh- 
bouring portions  of  the  nasal  cavity  which  do  not  encroach  on  the 
mouth  or  orbit.  The  interior  of  the  nose  is  treated  with  cocaine 
and  adrenalin;  the  patient  is  then  ansesthetized,  and  the  choana 
plugged.  Two  incisions  are  made  from  the  inner  end  of  the  eyebrow, 
one  down  to  the  nasal  orifice,  the  other  along  the  infra-orbital 
border.  The  triangular  flap  between  these  is  dissected  down  and 
outwards,  including,  if  possible,  the  periosteum,  and  the  bone  is 
thereby  exposed.  Incisions  are  then  made  through  the  bones 
with  hammer  and  chisel  as  follows:  One  between  the  nasal  bones, 
or  slightly  to  one  side;  a  second  from  the  upper  end  of  this  hori- 
zontally out  to  the  orbital  margin;  and  a  third  from  the  lower  border 


8o6 


A    MANUAL  OF  SURGERY 


of  the  nasal  aperture  upwards  and  outwards  to  the  infra-orbital 
border  close  to  the  infra-orbital  foramen.  The  portion  of  bone 
thus  marked  out,  including  a  small  section  of  the  floor  of  the  orbit, 
can  be  easily  twisted  out  of  its  bed  by  forceps,  laying  bare  the 
lachrymal  sac  and  canal.  The  amount  of  bone  removed  varies 
necessarily  with  the  case,  but  a  considerable  opening  into  the 
antrum  and  nasal  cavity  results,  and  growths  of  this  region  can  be 
readily  removed,  if  need  be  piecemeal,  without  grave  haemorrhage 
or  serious  mutilation.  The  incisions  are  subsequently  closed  by 
stitches,  and  the  resulting  deformity  is  very  slight. 

Excision  of  Superior  Maxilla  varies  somewhat  in  different  cases 
according  to  the  character  and  extent  of  the  disease. 

The  patient's  head  and  shoulders  are  well  raised,  and  anaesthesia 
is  maintained  b}^  means  of  chloroform  given  by  Junker's  apparatus. 

Prehminary  tracheotomy  is  scarcely 
necessary  or  desirable  if  good  assist- 
ance is  available.  The  proceeding  may 
be  described  in  stages  as  follows: 

Stage  I.  :  Incision  and  Reflection  of 

the  Soft  Structures  of  the  Cheek. — The 

central   incisor   tooth  of   the  affected 

side  having  been  extracted,  the  upper 

lip  is  divided  in  the  middle  line;  the 

incision  is  carried  round  the  ala  and 

along  the  side  of  the  nose,  to  a  point 

half  an  inch  below  the  inner  canthus; 

it    thence    extends    along    the    lower 

orbital   margin   to   a  point   below   its 

outer  border,  or  even  to  the  zygoma 

(Fig.  389,  A).     The  flap  thus  marked 

SAT  °^^  ^^  raised  from  the  bone,   and  re- 

'removIZ  '  of'''''^Super^or    fleeted   outwards   so    as   to   clear   the 

Maxilla;  B,  for  Removal    zygomatic  eminence,  and  the  more  im- 

oF  Lower  Jaw.  portant   vessels   secured,    as   they   are 

divided,  by  Spencer  Wells'  forceps. 
Stage  II.  :  Divison  of  the  Bony  Attachments. — The  side  of  the  nose 
is  then  freed  from  its  bony  attachments,  and  the  periosteum  stripped 
up  from  the  floor  of  the  orbit.  The  nasal  process  of  the  superior 
maxilla  is  now  cut  through  with  a  saw  (Fig.  390),  and  also  the  malar 
bone  divided  so  as  to  open  into  the  spheno-maxillary  fissure.  A  key- 
hole saw  is  next  parsed  into  the  nose,  and  the  alveolus  and  hard 
palate  divided  from  before  backwards  through  the  empty  socket 
of  the  central  incisor  tooth.  The  surgeon  then  takes  a  pair  of  long- 
handled  cutting-pliers,  and  completes  the  division  of  each  of  these 
bony  attachments.  The  cutting-pliers  must  always  be  applied 
with  the  smooth  surface  towards  the  tissues  which  are  to  be  left, 
and  the  bevelled  surface  towards  the  part  which  is  to  be  removed. 
The  section  of  the  palate  is  completed  last,  and  then  the  cutting- 
pliers  are  used  as  a  lever  to  prise  the  bone  out  of  its  bed,  the  sound 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  807 

bone  acting  as  a  fulcrum,  the  posterior  attachments  being  thus 
fractured.  The  pterygoid  processes  are  broken  through  close  to 
their  origin  from  the  sphenoid,  and  the  lateral  mass  of  the  ethmoid 
yields  along  the  inner  orbital  margin. 

Stage  III.  :  Removal  of  the  Bone  and  Tumour. — The  bone  is  now 
seized  by  lion  forceps,  one  blade  holding  the  alveolus  and  the  other 
the  infra-orbital  border;  the  mouth  is  gagged  open,  and  the  soft 
palate,  if  free  from  disease,  is  divided  from  its  attachment  to  the 
hard  by  a  transverse  incision,  and  when  all  other  connections 
to  the  soft  tissues  have  been 
severed,  the  bone  is  removed. 
Considerable  hsemorrhage  occurs 
at  this  stage  from  the  infra-orbital 

and  posterior  palatine  vessels ;  it      /  ""i  \ 

is  checked  temporarily  by  plug-    /  J  /  Jk 

ging  the  wound  firmly  with  a 
sponge,  and  subsequently  the 
chief  vessels  are  secured  by  liga- 
ture. Any  outlying  portions  of 
the  tumour  are  now  dealt  with, 
and  the  cavity  is  packed  with 
strips  of  sterile  gauze.  The  wound 
in  the  cheek  is  closed,  the  greatest 
care  being  taken  to  obtain  ac- 
curate apposition  of  the  flap, 
especially  at  the  lip  margin,  and  fig.  390.— Skull  showing  Lines  of 
dressed  with  gauze  secured  with  Section  of  the  Bone  in  Excision 
collodion.  °^  ^^^  Superior  Maxilla. 

In  the  majority  of  cases  there  On  the  right  side  of  the  skull  the  malar 
is  comparatively  little  shock,  and  bone  is  divided  into  the  spheno- 
thenatientsdoremarkablvwell—  maxillary  fissure,  as  would  be  re- 
tne  patients  ao  remarKaoiy  wen  aniv&d  for  disease  limited  to  the 

at  any  rate,  for  a  time — although,  body  of  the  bone.  If  the  tumour 
unfortunately,  recurrence  is  only  invades  the  malar  bone,  incisions 
too  likely  to  follow.  The  plug  in  as  on  the  left  side  must  be  made— 
the  nose  is  left  in  situ  for  twenty-  ^^  '^f  Sf  mSa^ bole  tt7?he 
four  hours  and  then  removed  fissure,  and  behind  through  the 
through  the  mouth,  and  the  wound  zygoma, 
irrigated    with    some    antiseptic 

solution.  The  plug  may  be  replaced,  but  can  usually  be  dispensed 
with  if  the  cavity  is  washed  out  several  times  a  day.  Healing  is 
effected  by  granulation,  and  of  course  a  large  gap  communicating 
with  the  mouth  remains.  This  can  be  subsequently  remedied  by  an 
obturator,  to  the  upper  surface  of  which  is  attached  a  plug  or  cheek- 
plate  to  prevent  falling  in  of  the  cheek,  and  to  diminish  the  cavity 
of  the  nose.  The  patient  is  fed  for  the  first  few  days  by  the  rectum, 
or  by  a  tube  passed  into  the  pharynx,  but  soon  acquires  the  knack 
of  swallowing  fluids,  especially  when  the  soft  palate  has  been  left 
intact.  The  chief  dangers  are  shock,  recurrent  haemorrhage,  and 
septic  pneumonia. 


8o8 


A   MANUAL  OF  SURGERY 


After  the  wound  has  healed  to  a  certain  extent,  the  lymphatic 
area  of  the  neck  should  be  dealt  with  as  for  cancer  of  the  tongue 
(P-843). 

Tumours  of  the  Lower  Jaw. 

These  are  similar  in  character  to  those  met  with  in  the  upper  jaw. 
Thus,  Chondroma,  Osteoma,  Fibroma,  and  the  simple  and  malignant 
forms  of  Epuhs,  have  been  already  described. 

^,"  .Dentigerous  Cysts  form  around  teeth  which  are  misplaced  so  that 
they  cannot  erupt;  though  occasionally  seen  in  the  upper  jaw,  they 

are  much  more  common  in  the  lower. 
Their  characters  and  nature  have 
been  alread}^  described  under  the  title 
of  follicular  odontomas  at  p.  215. 
They  are  met  with  in  young  people, 
and  give  rise  to  expansion  of  the  jaw 
(Fig.  391) ;  the  tumour  thus  formed  is 
at  first  hard  and  solid  to  the  touch, 
but  later  on  eggshell  crackling  and 
even  true  fluctuation  are  observed 
when  the  encasing  wall  has  become 
thin  or  absorbed.  Absence  of  one  of 
the  permanent  teeth  may  sometimes 
be  noted,  but  not  necessarily,  since 
the  corresponding  milk  tooth  is  not 
always  shed,  owing  to  the  want  of 
pressure  from  below.  Occasionally 
suppuration  within  the  cavity  may  be 
caused  by  an  extension  of  inflamma- 
tion from  the  fang  of  a  neighbouring 
tooth,  or  by  the  cyst  being  opened 
during  its  extraction,  and  a  sinus  dis- 
charging offensive  pus  will  then  form. 
The  diagnosis  from  a  myeloid  tumour 
or  from  a  dental  cyst  is  not  always 
easy.  The  long  history  and  the 
dental  irregularity  would  point  to  a 
dentigerous  cyst ;  whilst  dental  caries  would  suggest  a  dental  cyst ; 
but  the  actual  diagnosis  is  perhaps  best  made  by  radiography,  when 
the  misplaced  tooth  can  be  seen.  Treatment  consists  in  freely 
opening  the  cyst  through  the  mucous  membrane,  and  removing  a 
sufficient  portion  of  the  bony  wall  to  permit  of  the  removal  of  the 
misplaced  tooth.  The  cavity  is  left  open  and  allowed  to  heal  by 
granulation,  during  which  process  strict  attention  to  cleanliness 
must  be  observed. 

Fibro-cystic  Disease  of  the  Jaw  {epithelial  odontome,  p.  215)  has 
been  already  mentioned  as  characterized  by  the  formation  of  a 
tumour,  often  of  great  size,  which  consists  of  spaces  lined  with 
cuboidal  epithelium,  and  supposed  to  originate  from  the  enamel 


Fig.  391. — Dentigerous  Cyst, 
SHOWING  Expanded  Condi- 
tion OF  THE  Lower  Jaw, 
and  Unerupted  Tooth 
lying  Horizontally  WITHIN 
IT.  (College  of  Surgeons' 
Museum.) 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


809 


organ  (Fig.  392).  It  occurs  most  frequently  in  young  people,  and, 
as  a  rule,  runs  a  perfectly  benign  course,  although  when  of  large 
size  it  may  encroach  on  surrounding  parts  and  even  destroy  life.  The 
only  Treatment  consists  in  complete  removal  of  the  affected  portion 
of  the  jaw. 

Actinomycosis  sometimes  develops  in  connection  with  the  jaws, 
but  more  frequently  in  the  lower.  It  produces  a  large  swelling 
due  to  its  growth  within  the  bone,  which  may  closely  simulate  a 
sarcoma;  the  constant  tendency  of  this  disease  to  suppurate  and 
discharge  the  mycelial  elements  is  a  characteristic  feature.  For  the 
general  clinical  signs  and  treatment,  see  p.  192. 

Myeloma  is  met  with  in  the  lower  jaw,  not  only  in  the 
form  of  an  epulis,  but  also  occasionally  as  an  endosteal  growth, 
usually  attacking  the  central  portion  of  the  bone,  which  becomes 
expanded  by  it.  It  presents  but  slight  evidences  of  malignancy, 
and  may  be  treated  in  the  first  place  by  opening  the  outer  shell  of 


Fig.  392. — FiBRO-cYSTic  Disease  of  the  Lower  Jaw. 
(By  kind  permission  of  the  Council  of  the  Royal  College  of  Surgeons.) 

bone  through  the  mouth  and  scraping  away  the  soft  contents,  the 
cavity  thus  formed  being  swabbed  out  with  pure  carbolic  acid  and 
plugged  with  gauze.  Should  it  recur,  the  affected  portion  of  the 
bone  must  be  removed,  although,  whenever  possible,  a  bridge  of 
osseous  tissue  is  left  so  as  to  connect  the  two  segments  of  the  jaw; 
if  this  is  not  attended  to,  they  are  likely  to  fall  together,  and  lead  to 
considerable  deformity  and  discomfort.  If  the  whole  thickness  of 
the  bone  is  excised,  a  wire  frame  or  splint  should  at  once  be  intro- 
duced between  the  fragments  with  the  same  object.  It  is  replaced 
later  on  by  a  suitable  plate  carrying  artificial  teeth. 

Round  or  Spindle-Celled  Sarcoma  also  occurs,  usually  springing 
from  the  periosteum,  the  deeper  parts  undergoing  ossification 
(Fig.  393).  The  course  is  typically  malignant,  and  free  removal 
of  the  affected  portion  of  the  bone  must  be  undertaken. 

Epithelioma  invades  the  lower  jaw  as  an  extension  of  a  similar 
affection  arising  either  from  the  gum,  lips,  or  tongue.     Excision 


8io 


A   MANUAL  OF  SURGERY 


of  a  portion  of  the  bone  together  with  the  primary  disease  is  always 
required,  unless  it  has  extended  so  far  as  to  render  extirpation 
impracticable.  Removal  of  the  lymphatic  glands  of  the  neck  is 
required  at  a  later  date. 

Excision  of  the  Lower  Jaw  is  employed  in  the  treatment  of  various 
tumours  arising  from  that  bone,  as  also  sometimes  for  extensive 
necrosis.  In  the  latter  case  it  may  be  possible  to  deal  with  it  from 
the  mouth,  but  when  required  for  the  treatment  of  malignant 
disease  an  external  incision  is  absolutely  essential. 

If  the  whole  of  one  side  is  to  be  removed,  an  incision  is  made 
reaching  from  just  below  the  red  margin  of  the  lip  downwards  to  a 
point  immediatelv  below  the  symphysis,  and  thence  along  the  under 
surface  of^the  body  of  the  jaw  as  far  as  the  angle;  it  is  then  pro- 
longed upwards  along  the 
posterior    border    of    the 
vertical    ramus,    not    ex- 
tending further   than   the 
attachment  of  the  lobule 
of  the  ear,  so  as  to  avoid 
the  facial  nerve  (Fig.  389, 
B) .    When  a  large  tumour 
is   being   dealt   with,    the 
whole  thickness  of  the  lip 
should  be  divided,  and  the 
flap  thus  marked  out  dis- 
sected  off  the   bone,   and 
turned  outwards.     Where, 
however,  the  upper  portion 
of  the  lip  is  left,  the  in- 
cisions are  carried  down  to 
the  bone,  the  facial  vessels 
being  secured   above   and 
below  before  division.    The 
soft   parts  are  then  freed 
from  the  outer  aspect  of  the 
bone,  and  the  cavity  of  the 
mouth  opened.  The  central 
incisor  tooth  is  drawn,  and  the  jaw  divided  through  the  empty  socket 
with  a  saw  and  cutting-pliers  a  httle  to  the  side  of  the  middle  hne 
By  this  means  the  genial  tubercles  and  their  attached  muscles  are 
not  encroached  on,  or  the  movements  of  the  tongue  impaired.     The 
bone  is  seized  and  drawn  outwards,  and  its  internal  connections  as 
far  as  the  angle  divided.     It  is  then  firmly  depressed,   and  the 
muscular  attachments  of  the  masseter  on  the  outer  side,  and  of  the 
internal  pterygoid  on  the  inner,  cut  through,  as  also  the  inferior 
dental  nerve  and  artery.     By  still  further  depressing  the  bone,  the 
temporal  tendon  is  exposed,  and  should  be  divided  by  successive 
touches  of  the  knife,  which  is  kept  close  to  the  bone.     Finally,  the 
condyle  is  freed  after  division  of  the  external  pterygoid  muscle  and 


Fig.  393. 


-Osteo-Sarcoma    of    the 
Lower  Jaw. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  8ii 

of  the  ligaments  of  the  temporo-maxillary  articulation.  The  prox- 
imity of  the  internal  maxillary  artery  to  the  inner  aspect  of  the  neck 
of  the  bone  must  be  remembered.  After  h?emorrhage  has  been 
arrested,  the  wound  is  stitched  together  and  dressed  with  collodion 
and  gauze;  possibly  a  drainage-tube  may  be  inserted  with  ad- 
vantage for  a  few  days  through  the  floor  of  the  mouth.  Consider- 
able deformity  usually  results  from  this  operation,  owing  to  the 
remaining  half  of  the  bone  being  drawn  across  the  middle  line. 

Diseases  of  the  Temporo-Maxillary  Articulation. 

Acute  Synovitis  may  supervene  in  the  course  of  an  attack  of 
rheumatic  fever,  and  is  evidenced  by  pain  on  movement  of  the  jaw, 
and  by  tenderness  and  swelling  immediately  beneath  the  root  of  the 
zygoma,  due  to  effusion  into  and  around  the  joint.  Resolution 
generally  follows,  but  fibroid  thickening  of  the  ligaments  and  im- 
pairment of  movement  may  result. 

Acute  Arthritis  arises  from  pyaemic  infection  after  the  exanthe- 
mata, or  from  gonorrhoea,  but  may  be  caused  by  direct  extension 
of  inflammation  from  the  middle  ear,  as  in  scarlatina.  It  occurs  in 
children,  and  is  due  '  to  the  persistence  of  a  hiatus  in  that  part  of 
the  tympanic  plate  which  forms  the  floor  of  the  meatus  and  the  roof 
of  the  articulation  '  (Barker).  It  is  characterized  by  the  usual 
signs  of  a  severe  locahzed  inflammation,  with  the  formation  of 
abscesses,  and  results  commonly  in  ankylosis.  Fomentations  and 
the  antiseptic  opening  of  abscesses  constitute  the  only  early  treat- 
ment, whilst  excision  of  the  condyle  is  sometimes  required  at  a  later 
date. 

Osteo- Arthritis  is  by  no  means  a  rare  affection  of  this  joint.  It 
is  often  sjonmetrical,  and  characterized  by  an  enlargement  of  the 
condyle,  which  can  be  felt  distinctly  in  front  of  the  tragus,  especially 
on  opening  the  mouth,  when  crepitus  is  also  noticed.  The  pain  is 
worse  at  night  and  in  wet  weather,  and  the  jaw  becomes  deflected 
to  the  sound  side  if  the  disease  is  unilateral;  when  both  sides  are 
affected,  the  jaw  is  pushed  forwards,  and  the  chin  projects.  The 
articular  cartilage  undergoes  the  usual  changes,  the  inter-articular 
cartilage  disappears,  and  the  glenoid  cavity  becomes  enlarged  and 
flattened,  so  that  the  eminentia  articularis  is  relatively  less  marked, 
thus  permitting  the  external  pterygoid  muscle  to  draw  the  condyle 
forwards.  After  a  time,  considerable  difficulty  is  experienced  in 
opening  the  mouth,  even  amounting  to  ankylosis.  Ordinary 
medical  treatment  may  be  used  in  the  early  stages,  but  in  the  later 
the  condyle  of  the  jaw  should  be  excised,  a  proceeding  followed  by 
excellent  results. 

Tuberculous  Disease  may  arise  either  in  the  bone  or  synovial 
membrane,  perhaps  spreading  to  it  from  neighbouring  lymphatic 
glands.  It  runs  the  usual  course  of  the  disease,  terminating  in 
caries  of  the  condyle,  and  ankylosis  after  protracted  suppuration; 
to  prevent  this,  excision  of  the  condyle  is  indicated. 


8i2  A   MANUAL  OF  SURGERY 

Immobility  or  Closure  of  the  Jaw  may  be  caused  by  a  variety  of 
conditions: 

1.  True  ankylosis  of  tlie  temporo-maxillary  joint,  fibrous  or 
osseous,  as  the  result  of  any  of  the  diseases  mentioned  above. 

2.  Cicatricial  contraction  of  the  soft  structures  either  within  or 
without  the  mouth,  as  from  burns,  lupus,  or  extensive  operations 
in  the  pterygoid  region  upon  the  roots  of  the  fifth  nerve,  from 
cancrum  oris,  or  very  rarely  from  myositis  ossificans. 

3.  Spasm  of  the  muscles  of  the  jaw  {trismus),  due  to  reflex  irrita- 
tion, as  from  carious  teeth  or  an  unerupted  wisdom-tooth,  or  some 
other  local  lesion.  It  is  occasionally  hysterical,  and  is  one  of  the 
early  symptoms  of  tetanus. 

4.  Local  inflammatory  conditions  often  render  opening  of  the 
mouth  impossible,  both  from  the  pain  and  swelling — e.g.,  in  mumps, 
parotid  abscess,  acute  alveolar  periostitis — whilst  in  epithelioma  of 
the  jaw,  tongue,  or  fauces,  and  various  forms  of  tumour,  the  size 
and  position  of  the  growth  may  seriously  impair  the  mobility  of 
the  jaw. 

The  term  ankylosis  can  only  be  applied  to  the  conditions  men- 
tioned in  the  first  two  groups.  In  the  others  appropriate  treatment 
must  be  instituted  according  to  the  character  of  the  affection. 
Where  the  closure  of  the  jaw  is  permanent,  it  may  be  due  to  osseous 
ankylosis,  the  bony  masses  extending  not  only  between  the  articular 
surfaces,  but  also  between  the  alveoli ;  or  to  fibrous  adhesions  within 
the  joint;  or  to  extra-articular  contraction  of  the  soft  parts,  not 
only  the  skin  and  mucous  membrane  being  involved,  but  also 
frequently  the  muscles  and  deeper  structures. 

Division  of  the  neck  of  the  bone  or  excision  of  the  head  may  thus 
be  impracticable,  or,  even  if  possible,  is  useless,  since  the  muscles  of 
the  jaw  hold  the  surfaces  in  such  good  apposition  as  to  bring  about 
a  recurrence  of  bony  union,  unless  obviated  by  implanting  a  flap  of 
the  temporal  muscle  or  a  vulcanite  plate  between  the  bony  surfaces. 
Division  of  the  intra-  or  extra-buccal  cicatrices  is  usually  unsatis- 
factory, owing  to  their  rapid  re-formation.  The  best  treatment  in 
most  cases  is  either  removal  of  the  vertical  ramus  of  the  jaw  down 
to  the  level  of  the  alveolus,  or  the  plan  suggested  by  Esmarch,  viz., 
excision  of  a  wedge  of  bone,  with  its  apex  towards  the  alveolar 
border,  from  the  neighbourhood  of  the  angle,  and  the  establishment 
of  an  artificial  joint  at  that  spot.  The  incision  should  be  made 
below  and  behind  the  angle  down  to  the  bone,  from  which  the 
periosteum  is  stripped  up,  and  division  is  accomplished  by  means 
of  the  saw. 

Excision  of  the  Condyle  of  the  Jaw  is  not  always  a  simple  opera- 
tion, since  the  space  at  the  surgeon's  disposal  is  limited  by  the 
zygoma  above,  the  facial  nerve  below,  the  parotid  gland  in  front, 
and  the  external  ear  behind.  The  best  incision  is  a  curvilinear  one, 
commencing  over  the  middle  of  the  zygoma,  and  passing  downwards 
in  front  of  the  tragus.  It  should  merely  divide  the  skin  and  sub- 
cutaneous tissue,  and  the  flap  thus  marked  out  is  turned  forwards. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  813 

A  transverse  incision  is  now  made  through  the  deep  fascia  im- 
mediately below  the  posterior  extremity  of  the  zygoma,  extending 
down  to  the  neck  of  the  bone,  which  is  cleared  by  a  raspatory  and 
divided  by  cutting-pliers;  the  condyle  is  then  grasped  by  necrosis 
forceps,  and  twisted  out.  But  little  bleeding  occurs,  and  the  wound 
heals  by  first  intention,  except  along  the  track  of  the  drainage-tube, 
which  should  always  be  employed. 

Internal  Derangement  of  the  temporo-maxillary  joint  (locking 
or  clicking  jaw)  is  not  a  very  uncommon  affection,  resulting  from 
laxity  of  the  interarticular  cartilage,  which  gets  folded  up  and 
caught  between  the  condyle  and  the  eminentia  articularis  when  the 
mouth  is  opened.  The  effect  is  a  temporary  painful  fixation  or 
locking  of  the  jaw,  which  is  usually  set  free  by  lateral  movements. 
At  other  times  there  is  marked  clicking  or  creaking  of  the  jaw 
when  the  mouth  is  opened.  In  bad  cases  treatment  consists  in  ex- 
cising or  stitching  down  the  loose  cartilage^ — preferably  the  former — 
through  an  incision  made  as  for  excision  ;  in  the  milder  cases 
nothing  can  be  done  except  to  assist  the  removal  by  blistering  of 
the  synovial  effusion  which  may  be  present. 


CHAPTER  XXIX. 

AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX. 

Depression  or  Flattening  of  the  Bridge  of  the  Nose  is  either  a  result 
of  traumatism,  such  as  a  fracture  of  the  nasal  bones  (p.  493),  or  may 
follow  defective  growth  of  the  ethmo-vomerine  septum,  due  to 
disease  either  of  syphilitic  or  tuberculous  origin  early  in  life,  whilst 
it  may  also  be  due  to  tertiary  syphihs.  If  caused  by  injury,  and 
dealt  with  promptly,  it  may  be  remedied;  but  when  once  acquired, 
and  especially  if  the  consequence  of  disease,  treatment  is  much  less 
satisfactory.  Several  cases  have  been  recorded,  however,  in  which 
bone-grafting  has  been  successful.  An  incision  is  made  down  the 
middle  line  of  the  nose,  the  soft  parts  are  reflected  on  either  side, 
and,  after  making  a  comfortable  bed  for  it,  the  bone-graft  is  in- 
troduced, and  kept  in  position  partly  by  sutures,  but  mainly  by 
closing  up  the  wound  in  the  soft  tissues.  In  one  case  the  patient's 
own  fourth  metatarsal  bone  was  utilized  with  success,  whilst 
platinum,  gold,  or  celluloid  frames  have  also  been  employed  in  the 
same  way. 

The  subcutaneous  injection  of  paraffin  has  been  utilized  in  many  of 
the  worst  cases  with  advantage.  At  first  a  paraffin  was  employed 
which  melts  at  110°  F. ;  this,  however,  caused  a  good  deal  of  irrita- 
tion, and  its  exact  limitation  to  the  desired  area  was  difficult.  At 
the  present  time  a  cold  paraffin  is  utilized,  being  expressed  little  by 
little  from  a  powerful  syringe  (Mahu's),  and  the  tissues  are  built 
up  into  shape  exactly  as  is  desired.  The  paraffin  is  supposed  to 
remain  permanently  as  an  infiltration  of  the  tissues,  but  further 
experience  is  required  to  make  sure  that  this  is  the  case. 

Expansion  of  the  Bridge  of  the  Nose  is  always  the  outcome  of  some 
long-continued  intranasal  pressure,  especially  from  the  growth  of 
polypi.  It  rarely  follows  the  development  of  mucous  polypi,  except 
when  they  are  very  large  and  chronic,  but  it  is  not  an  uncommon 
accompaniment  of  the  fibrous  or  fibro-sarcomatous  variety.  The 
bridge  is  flattened  and  bulged  out  on  either  side,  giving  the  face  an 
appearance  justifying  the  name  '  frog-nose  '  which  has  been  applied 
to  it. 

Congenital  swellings  at  the  root  of  the  nose  are  not  very  un- 

814 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  815 

common,  and  may  be  either  a  meningocele  (p.  725),  or  a  dermoid 
cyst  which  may  have  a  deep  connection  between  the  nasal  bones 
with  the  cerebral  membranes.  It  is  often  advisable  to  leave  them 
alone  until  adult  life,  since  their  intracranial  connections  may  be 
shut  off  as  the  child  grows  up. 

It  is  impossible  to  discuss  all  the  different  affections  of  the  skin  ot 
the  nose.  Many  of  them  are  associated  with  the  sebaceous  glands, 
which  in  this  region  are  very  large  and  abundant.  Thus,  acne  is 
commonly  met  with,  arising  from  an  inflammation  of  the  glands 
after  obstruction  to  their  ducts.  It  is  especially  frequent  in  drinkers 
and  dyspeptics,  women  addicted  to  tea-drinking  often  suffermg 
severely.  When  the  superficial  capillaries  become  markedly 
dilated  and  the  face  readily  flushes  on  the  imbibition  of  hot 
or  stimulating  fluids,  the  term  rosacea  is  attached  to  it,  whilst  if 
acne  pustules  are  also  present,  it  is  known  as  acne  rosacea. 
Sometimes  the  spots  become  much  en- 
larged, and  there  is  a  considerable 
amount  of  infiltration  of  the  base,  a 
condition  described  as  acne  hypertrophi- 
cum.  In  the  most  exaggerated  stage 
the  sebaceous  glands  become  over- 
grown and  form  large  protuberant 
nodular  masses  projecting  from  the  end 
of  the  nose,  and  covered  with  red 
greasy  skin,  in  which  the  dilated  orifices 
of  the  glands  are  very  evident,  and 
with  dilated  capillaries  coursing  freely 
over  them.  This  condition  is  generally 
known  as  lipoma  nasi,  rhinophyma, 
or  hammer-nose  (Fig.  394) .  The  Treat-  pj(,_ 
ment  of  simple  acne  consists  in  cor- 
recting the  dyspepsia,  and  limiting  the 

amount  of,  or  interdicting  entirely,  alcohol  or  tea.  Capsules  of 
ichthyol  (3  to  10  minims)  may  also  be  administered  thrice  daily, 
and  soothing  appHcations  should  be  used  locally,  such  as  a  lotion 
consisting  of  calamine,  oxide  of  zinc,  and  precipitated  sulphur, 
held  in  suspension  with  glycerine  and  lime  water.  Dilated  and 
unsightly  capillaries  may  be  dealt  with  by  puncturing  them  with 
the  galvano-cautery  or  an  electrolytic  needle.  Rhinophyma 
requires  operative  proceedings;  the  protuberant  mass  should  be 
freely  dissected  away  from  the  cartilages,  and  the  raw^  surface 
covered  by  Thiersch  grafts  or  allowed  to  granulate. 

Partial  or  Total  Destruction  of  the  Nose  may  result  from  trau- 
matism,  but  usually  from  some  chronic  inflammatory  or  malignant 
growth,  such  as  lupus,  tertiary  syphilis,  or  rodent  ulcer.  Epithe- 
lioma sometimes  attacks  it,  and  requires  total  removal  of  the  nose 
for  its  cure.  In  any  of  these  conditions  the  resulting  deformity  is 
so  repulsive  that  the  surgeon  is  certain  to  be  asked  to  undertake 
some  proceeding  to  remedy  it.     Indian  surgeons  have  had  a  good 


394.  —  Rhinophyma.^or 
Hammer-Nose, 


8i6 


A   MANUAL  OF  SURGERY 


deal  of  experience  in  this  direction,  since  in  that  country  cutting 
off  the  nose  is  often  resorted  to  as  a  means  of  avenging  some  real  or 
fancied  wrong.  Various  plastic  operations  have  been  devised, 
wliich,  however,  we  can  only  indicate  briefly  here,  referring  students 
to  larger  works  of  operative  surgery  for  fuller  details. 

The  chief  methods  of  Rhinoplasty  are  as  follows : 

1.  The  so-called  Indian  method  *  consists  in  the  formation  of  a  nose  from  a 
fiap  of  skin  obtained  from  the  forehead.  The  ffap  (Fig.  395)  is  more  or  less 
pyriform,  with  the  pedicle  so  placed  as  to  contain  one  of  the  frontal  arteries 

and  the  supratrochlear  nerve.  Necessarily  its 
exact  shape  and  size  vary  with  the  character 
of  the  defect  and  with  the  type  of  nose  desired. 
Keegan,  who  has  done  some  excellent  work  in 
this  direction,  advises  that  the  skin  covering 
the  nasal  bones,  as  high  as  the  level  where  the 
bridge  of  spectacles  would  rest,  should  first  be 
turned  down  in  two  flaps,  using  their  attach- 
ment to  the  nasal  mucosa  as  a  hinge,  so  that 
the  cutaneous  surface  shall  look  inwards  and 
the  raw  surface  outwards.  Over  these  the 
forehead  flap  is  placed,  and  there  should  be 
sufficient  tissue  in  the  nasal  flaps  to  enable  their 
free  ends  to  be  stitched  below  to  the  forehead 
flap  on  either  side  of  the  columna,  thus  com- 
pleting the  anterior  nares.  The  columna  itself 
IS  formed  by  the  free  end  of  the  forehead  flap. 
Drainage-tubes  are  inserted  through  the  an- 
terior nares  and  kept  in  position  for  ten  to 
fourteen  days.  The  lateral  margins  of  the  flap 
are  carefully  sutured  to  the  freshened  edges  of 
the  defect.  When  the  union  of  the  lower  por- 
tion is  sufficiently  firm,  the  nose  is  made  more 
shapely  by  partially  dividing  the  twisted 
pedicle,  but  if  possible  the  integrity  of  the  fron- 
tal artery  should  still  be  retamed.  The  wound 
in  the  forehead  is  drawn  together  as  far  as 
possible  b}'  sutures,  and  healing  promoted  later 
by  skin-grafting. 

2.  In  the  Tagliacozzian  or  Italian  operation  (so  called  from  Tagliacozzi,  the 
surgeon  who  first  proposed  it)  a  flap  of  skin  is  taken  from  the  arm.  The 
pedicle  must  always  be  broad,  and  is  left  attached  to  the  upper  part  of  the 
inner  aspect  of  the  arm;  it  must  be  so  placed  that  it  can  be  brought  into 
apposition  with  the  nasal  defect  without  tension,  the  fore-arm  and  hand  being 
fixed  by  a  suitable  apparatus  above  the  head,  and  retained  there  until  good 
union  has  been  accomplished,  when  the  pedicle  is  gradually  divided.  Abso- 
lute fixation  of  the  arm  is  an  essential,  and  as  this  may  need  to  be  maintained 
for  two  or  three  weeks,  the  patient  needs  a  considerable  amount  of  pluck 
and  perseverance.  When  the  pedicle  has  been  detached,  subsequent  plastic 
measures  are  required  to  mould  the  new  tissue  to  the  shape  of  the  nose. 

3.  The  cheeks  have  also  been  made  use  of  in  what  is  known  as  the  French 
method  to  supply  material  for  the  nose,  flaps  being  dissected  up  from  either 
side,  and  united  in  the  middle  line. 

4.  The  above  operations  have  the  great  objection  that  the  new  nose  only 
consists  of  soft  tissues,  and  hence  it  is  very  likely  to  shrivel  up  and  contract,  so 
that  all  that  is  finally  obtained  is  a  covering  for  the  defect,  which  is  often  quite 
flush  with  the  surface.     To  obviate  this,  and  to  secure  a  bony  basis  for  the 

*  For  full  details  of  this  plan  we  would  refer  to  Keegan's  '  Rhinoplastic 
Operations.'     Bailliere,  Tindall  and  Cox,  1900. 


Fig.  395. — Indian  Method 
OF  Rhinoplasty,  show- 
ing THE  Shape  and  Posi- 
tion OF  THE  Forehead 
Flap. 

The  points  A  and  B  are 
brought  down  to  A'  and 
B'  when  the  flap  is  twisted 
into  position. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX        817 

nose,  attempts  have  been  made  to  utilize  a  fmger  for  the  purpose,  and  Mr. 
Astley  Bloxam  has  had  one  or  more  successful  cases.  The  terminal  phalanx 
is  removed,  the  soft  parts  split  down  the  middle  line  on  the  palmar  aspect, 
and  the  divided  segments  united  by  suture  to  the  margins  of  the  nasal  defect. 
When  union  is  secured,  the  amputation  of  the  finger  is  completed. 

Naturally,  where  only  a  portion  of  the  nose  is  destroyed,  partial  operations 
can  be  devised  to  meet  the  requirements  of  the  case. 

It  must  be  admitted,  however,  that  the  nose  produced  artificially 
by  any  of  these  methods  is  rarely  satisfactory,  and  has  a  consider- 
able tendency  to  shrink.  Indeed,  it  is  probable  that  in  the  majority 
of  cases  patients  are  better  off  with  an  artificial  nose  made  of  vul- 
canite or  some  such  material  and  suitably  coloured,  and  held  on  by 
a  spectacle  frame  or  some  adhesive  substance. 

Examination  of  the  Nasal  Fossae  and  Naso-Pharynx.— In  order  to  under- 
stand fully  the  diseases  of  the  nose,  it  is  essential  that  the  mterior  of  the 
organ  be  efficiently  examined,  and  to  do  this  three  chief  methods  are 
employed. 

I.  Anterior  rhinoscopy  consists  in  the  illumination  of  the  front  of  the  nasal 
cavity  through  the  anterior  nares.  A  good  light  is  required,  such  as  that 
derived  from  an  electric  head-lamp,  and  some  form  of  nasal  speculum.  Per- 
haps Thudichum's  speculum  is  one  of  the  best ;  it  consists  of  two  unf enestrated 
blades,  connected  by  a  U-shaped  spring,  which  is  held  in  the  hand  whilst 
the  blades  are  inserted  into  the  nostril,  the  nasal  vibrissas  being  thus  held  aside ; 
the  ring  and  index  fingers  are  placed  one  on  each  limb,  so  as  to  regulate  the 
amount  of  tension,  and  prevent  painful  overstretching.  By  this  or  similar 
means  one  is  enabled  to  see  the  anterior  part  of  the  nasal  fossae,  including  the 
inferior  turbinal  and  the  erectile  tissue  at  its  anterior  extremity.  The  amount 
of  distension  of  the  latter  limits  the  view  of  other  structures ;  if  greatly  swollen, 
it  feels  soft  and  even  fluctuating,  but  collapses  entirely  on  the  apphcation  of 
a  5  per  cent,  solution  of  cocaine,  allowing  the  free  convex  border  of  the  middle 
turbinal  to  come  into  view,  as  also  the  cleft  or  olfactory  fissure  between  it 
and  the  septum.  The  septum  can  also  be  examined,  frequently  showing 
deviations  from  the  middle  hne,  and  thickenings  or  spurs  of  bone  or  cartilage 
which  run  in  an  antero-posterior  or  vertical  direction.  A  certain  amount  of 
erectile  tissue  is  also  present  on  the  septum. 

The  introduction  of  a  sterihzed  probe  under  the  guidance  of  the  eye  is  of 
the  greatest  value  in  examining  the  nose.  It  not  only  serves  to  distinguish 
the  different  qualities  of  growth  that  can  be  seen,  but  will  also  give  information 
concerning  regions  beyond  the  surgeon's  eye. 

2  By  posterior  rhinoscopy  is  meant  an  examination  of  the  posterior  nares 
by  a  mirror  placed  behind  the  uvula  and  soft  palate.  It  is  by  no  means  easy 
to  accomplish,  and  requires  some  dexterity  and  practice.  The  tongue  should 
be  depressed  and  a  small  mirror,  previously  warmed  to  prevent  condensation 
of  moisture  is  then  passed  behind  the  uvula,  without  touching  it  or  the 
posterior  wall  of  the  pharynx,  and  by  shifting  its  angle  and  position  a  view 
should  be  obtained  of  the  structures  exposed  posteriorly.  If  not  successful, 
and  it  is  absolutely  necessary  to  obtain  a  view,  the  fauces  should  be  cocainized 
and  the  velum  held  up  by  some  form  of  palate  retractor,  such  as  White  s. 
The  posterior  nares  (or  choanse)  are  seen,  separated  by  the  vertical  posterior 
free  margin  of  the  septum,  and  within  each  cavity  the  rounded  ends  of  the 
turbinals  with  the  meatuses  intervening.  The  inferior  meatus  often  looks 
very  small  owing  to  the  prominence  of  the  velum  palati,  whilst  the  middle 
meatus  may  be  encroached  on  by  tumefaction  of  the  erectile  tissue  at  the  back 
of  the  inferior  spongy  bone.  Outside  the  choanse  are  seen  the  yellowish 
openings  of  the  Eustachian  tubes,  and  above  and  between  them  Luschka  s 
tonsil,  a  raised  collection  of  lymphoid  tissue  in  the  roof  of  the  pharynx  is 
occasionally  observed.  "  •       1      j- 

3.  Palpation  of  the  Posterior  Nares  with  the  index  finger,  previously  dis- 


8i8  A  MANUAL  OF  SURGERY 

infected,  will,  however,  give  better  results  in  the  majority  of  cases  to  those 
who  are  not  specially  practised  in  the  above  method.  The  index  finger  is 
j)asscd  behind  the  uvula  and  velum,  and  the  narcs  can  then  be  well  explored, 
and  the  existence  of  adenoids  or  other  growths  determined. 

Spurs  and  Deviations  of  the  Nasal  Septum. — By  the  term  spur  is 
meant  a  cartilaginous  or  bony  ridge  or  thickening  of  the  septum, 
which  runs  in  a  more  or  less  transverse  direction,  and  is  of  congenital 
origin.  A  deviation  is  a  bending  of  the  septum  from  the  middle  line, 
leading  to  inequality  of  the  nasal  fosscC ;  the  cartilaginous  septum  is 
mainly  involved,  and  the  condition  is  sometimes  of  traumatic  origin. 
The  two  conditions  are  not  unfrequently  combined,  and  when  they 
are  not  the  outcome  of  an  injury,  a  high-arched  palate  is  usually 
present.  They  give  rise  to  unilateral  nasal  obstruction,  associated 
with  a  chronic  rhinitis  on  the  patulous  side.  Attacks  of  paroxysmal 
sneezing  of  the  hay-fever  type,  and  possibly  asthma,  may  result 
from  these  defects.  External  deformity  in  the  shape  of  nasal 
as3-mmetry  is  visible  in  most  of  the  cases  of  deviated  septum.  Spurs 
may  be  removed  by  a  special  knife  or  spokeshave,  if  cartilaginous, 
and  by  a  suitable  saw- — e.g.,  Bosworth's — if  bony.  Most  of  these 
operations,  however,  have  been  displaced  b}'  stibmucous  resection 
of  the  septum.  It  is  performed  under  a  local  or  general  ansesthetic, 
and  the  results  are  excellent.  The  mucous  membrane  is  stripped 
up  on  the  convex  side,  and  the  w^hole  thickness  of  the  cartilage 
removed;  the  two  layers  of  mucous  membrane  are  placed  in  contact, 
and  by  their  union  constitute  a  median  septum. 

Foreign  Bodies  are  rarely  impacted  in  the  nasal  passages  except  in 
children,  in  whom  the  condition  is  not  uncommon.  Any  unilateral 
purulent  discharge  from  a  child's  nose  should  suggest  the  likelihood 
of  such  an  occurrence,  peas,  beads,  or  buttons  being  the  substances 
usually  introduced.  A  certain  amount  of  unilateral  obstruction  to 
nasal  respiration  is  caused  thereb}-,  followed  by  a  catarrhal  or  even 
suppurative  rhinitis,  and  in  old-standing  cases  a  rhinolith  or  nasal 
calculus  may  be  caused  by  the  deposit  of  inspissated  mucus  upon 
the  outer  surface  of  a  foreign  body.  Removal  is  best  effected  by 
thoroughly  cocainizing  the  affected  side  so  as  to  reduce  the  con- 
gestion and  swelling  of  the  mucous  membrane,  and  then  seizing  the 
foreign  body  by  suitable  forceps,  a  hook,  or  a  snare.  This  should 
never  be  attempted  without  the  assistance  of  frontal  illumination 
and  a  rhinoscope.  Necessarily,  all  instruments  used  for  this  pur- 
pose should  be  thoroughly  sterilized.  After  the  removal,  the  nostrils 
are  carefully  washed  out  for  a  few  days  with  a  weak  alkaline  anti- 
septic lotion,  such  as  salt  and  water  to  which  a  little  sanitas  has  been 
added.  1  he  old-fashioned  plan  of  attempting  removal  by  syringing 
is  most  unsatisfactory,  and,  indeed,  dangerous,  and  should  be  totally 
discaided. 

Acute  Rhinitis.— Several  distinct  varieties  of  this  affection  are 
described. 

I.  The  Catarrhal  form  is  extremely  common,  constituting  what  is 
popularly  kno\\n  as  a  '  cold  in  the  head.'     It  is  not  only  due  to  ex- 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX         819 

posure  to  cold,  but  may  be  caused  by  irritating  gases,  dust,  and  the 
pollen  of  plants  (hay-fever) .  Not  only  is  the  nasal  mucosa  involved, 
but  the  inliammation  often  extends  to  the  frontal  or  maxillary 
sinuses,  causing  brow-ache  and  face-ache,  whilst  if  it  spreads  to 
the  mucous  lining  of  the  Eustachian  tube,  temporary  deafness  may 
ensue.  In  infants  great  dyspnoea  often  results  owing  to  the  ex- 
treme narrowness  of  the  nasal  passages,  and  this  may  be  so  marked 
as  to  interfere  for  a  time  with  breast-feeding.  Apart  from  the  usual 
domestic  remedies  directed  to  increasing  the  action  of  the  bowels, 
kidneys,  and  skin,  considerable  rehef  can  often  be  obtained  by 
washing  out  the  nasal  cavities  three  or  four  times  a  day  with  a  weak 
warm  alkaHne  lotion  containing  borax,  or  by  spraying  the  interior 
of  the  nose  with  menthol  dissolved  in  paroleine  by  means  of  a  suit- 
able atomizer. 

2.  A  Suppurative  form  arises  not  unfrequently  as  a  result  of  acute 
suppuration  in  one  of  the  accessory  sinuses  (acute  empyema),  and 
then  treatment  must  be  directed  mainly  to  the  sinus.  Occasionally 
it  is  due  to  gonorrhoeal  infection  either  in  adults  or  infants,  but 
perhaps  more  commonly  in  the  latter.  The  discharge  is  abundant, 
and  causes  much  obstruction  to  nasal  respiration,  whilst  ulceration 
is  likely  to  occur.  The  passages  must  be  well  cleansed  with  a 
solution  of  boric  acid  several  times  daily,  and  the  interior  sprayed 
or  painted  with  a  weak  solution  of  nitrate  of  silver  (gr.  5  to  i  ounce) 
once  every  day  as  long  as  the  suppuration  continues. 

3.  True  diphtheria  also  occurs  in  the  nasal  fossae,  usually  as  a 
complication  of  the  same  disease  elsewhere,  and  requiring  a  similar 
form  of  treatment  (p.  134)- 

Chronic  Rhinitis  occurs  in  many  distinct  types,  of  which  we  can 
merelv  give  a  bare  outline. 

I.  Chronic  Hypertrophic  Rhinitis,  one  of  the  most  common 
forms,  is  characterized  by  engorgement  of  the  erectile  tissue  cover- 
ing the  inferior  turbinated  bone,  causing  obstruction  to  nasal 
respiration  and  an  abundant  discharge  of  muco-pus.  It  usually 
occurs  in  patients  with  prominent  noses,  where  the  passages  are 
narrow,  and  may  be  lighted  up  by  some  slight  local  irritant,  suchas 
a  sudden  change  of  temperature.  The  anterior  end  of  the  inferior 
turbinal  is  swollen,  red,  and  rounded,  the  mucous  covering  being 
oedematous,  and  the  mass  feehng,  on  touching  it  with  a  probe,  like 
a  sac  full  of  fluid.  The  local  application  of  a  5  per  cent,  solution 
of  cocaine  causes  its  complete,  though  temporary,  collapse  in  a  few 
moments.  If  it  is  allowed  to  persist,  hypertrophy  of  the  mucous 
membrane  follows,  and  in  the  most  marked  types  a  projecting 
papillomatous-like  mass,  almost  resembling  a  polypus,  results. 
It  is,  however,  merely  an  inflammatory  hyperplasia,  arid  not  a  new 
gro^vth;  true  papillomata  are  extremely  rare  in  this  situation. 
The  posterior  end  of  the  bone  may  be  similarly  affected,  and  the 
mucous  covering  of  the  middle  turbinal  may  participate  in  the 
same  process.  A  certain  amount  of  pharymgitis  or  laryngo-tracheitis 
may  also  be  present.     Treatment.— In  the  early  stages  aU  that  is 


820  A   MANUAL  OF  SURGERY 

required  is  to  wash  out  the  nasal  cavity  night  and  morning  with 
some  simple  nose  lotion,  such  as  borax  or  bicarbonate  of  soda 
(5  grains  to  i  ounce).  This  may  be  accomplished  either  by  sniffing 
the  solution  from  the  palm  of  the  hand,  or  by  using  some  form  of 
nasal  irrigator  or  douche;  Basdon's  douche  is  perhaps  the  best  for 
this  purpose.  If  such  is  insufficient  to  give  relief,  or  if  collapse  is 
not  produced  by  cocaine,  the  surface  may  be  swabbed  over  with 
some  diluted  caustic  {e.g.,  chromic  acid,  5  grains  to  i  ounce), 
or,  better  still,  a  point  of  galvano-cautery  at  a  red  heat  may  be  run 
along  the  length  of  the  bone.  In  the  later  stages  removal  of  the 
hypertrophied  excrescences  by  the  cold-wire  snare,  or  by  the 
galvano-ecraseur,  is  required. 

2.  Chronic  Rhinitis  Sicca  is  associated  with  collapse  of  the  erectile 
tissue,  and  there  is  but  little  discharge,  since  the  exudation  dries 
within  the  nasal  cavities  and  forms  inspissated  crusts  or  scabs 
which  are  often  difficult  to  remove.  The  nasal  fossae  are  in  this  case 
more  patulous  than  usual,  and  a  dry  pharyngitis  and  chronic 
laryngitis  are  often  present.  Both  nostrils  may  be  involved,  but 
occasionally  the  affection  results  from  deviations  of,  or  spurs  on, 
the  septum,  and  then  is  unilateral,  the  discharge  coming  from  that 
side  which  is  most  patulous,  whilst  the  narrowed  side  remains 
healthy.  When  symmetrical,  the  disease  is  rather  due  to  constitu- 
tional than  to  local  causes,  occurring  in  weakly,  anaemic  women,  and 
is  to  be  treated  by  general  rather  than  local  measures.  In  the 
unilateral  form,  the  deviation  or  spur  must  be  remedied.  In  this 
way  the  inspired  air  is  made  to  pass  more  freely  along  the  narrowed 
healthy  side,  and  the  other  nostril  is  dealt  with  by  the  use  of  weak 
alkaline  lotions.  It  may  also  be  advisable  to  plug  the  dilated  side 
with  cotton-wool  for  some  time  daily,  so  as  to  enforce  respiration 
through  the  other  nostril.  Treatment  is  always  likely  to  be  pro- 
longed, and  it  is  possible  that  a  daily  alkaline  nose  lotion  may  be 
needed  permanently.  Stimulating  applications  are  never  borne 
well,  and  hence  should  rarely  be  ordered. 

3.  Chronic  Atrophic  Rhinitis  (Ozaena)  is  characterized  by  an  ex- 
ceedingly offensive  muco-purulent  discharge  from  the  nostrils.  It 
must  be  carefully  distinguished  from  such  conditions  as  tuber- 
culous or  syphilitic  disease  of  the  turbinated  bones  or  of  the  septum, 
suppuration  in  the  accessory  sinuses,  the  impaction  of  foreign  bodies, 
or  the  ulceration  of  malignant  growths,  in  which  an  offensive  dis- 
charge also  occurs. 

True  ozsena  is  usually  met  with  in  young  females,  and  may  some- 
times originate  from  traumatism,  or  after  one  of  the  exanthemata. 
The  nose  is  almost  always  wide  and  roomy ;  the  lips  are  often  thick 
and  everted,  and  the  mouth  is  usually  held  open  owing  to  the  im- 
pediment to  nasal  respiration  caused  by  inspissated  mucus.  The 
foetor  of  the  breath  due  to  the  decomposition  of  this  discharge  is 
the  special  feature  that  calls  attention  to  the  complaint;  it  is 
peculiarly  searching  and  objectionable,  but  the  patient  fortunately 
is  not  cognizant  of  it.     There  is  not  much  discharge,  but  at  varying 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX         821 

periods  large  crusts  come  away,  giving  relief  both  to  the  nasal 
respiration  and  to  the  f  re  tor.  Both  nostrils  are  usually  involved. 
The  disease  lasts  for  many  years,  but  in  time  tends  to  improve,  and 
gradually  to  disappear. 

On  examination,  the  narcs  are  found  to  be  unusually  patulous, 
and  the  vibrissae  are  scanty.  The  mucous  membrane  over  the 
turbinated  bones  is  dry,  collapsed,  and  pale,  so  that  after  clearing 
away  all  the  dried  mucus  and  scabs,  it  is  often  possible  to  see  the 
posterior  pharyngeal  wall,  and  even  the  orifices  of  the  Eustachian 
tubes.  The  pharyngeal  wall  is  also  dry,  and  may  be  coated  with  a 
film  of  inspissated  mucus.  No  ulceration  is  present,  although  the 
removal  of  the  crusts  may  be  associated  with  a  slight  amount  of 
bleeding  owing  to  their  close  attachment  to  the  mucous  membrane. 
The  examination  of  a  case  of  suspected  ozsena  should  also  include 
the  accessory  cavities  of  the  nose,  since  many  cases  in  which  crust- 
formation  is  a  prominent  symptom  are  really  due  to  an  empyema  of 
one  or  more  of  the  sinuses. 

Treatment.- — The  first  essential  is  to  keep  the  nose  clean  and  free 
from  putrefying  masses  of  dried  secretion.  This  must  be  accom- 
plished by  irrigating  the  cavity  once  or  twice  daily  with  a  warm 
weak  solution  of  common  salt  to  which  a  little  sanitas  has  been 
added.  At  first  it  is  well  for  the  surgeon  to  see  to  this  himself,  but 
after  a  while  the  patient  or  her  friends  can  be  entrusted  with  the 
task.  Every  portion  of  scab  ought  to  be  removed  daily,  and  the 
surface  lubricated  with  some  such  application  as  a  spray  of  menthol 
and  paroleine  (10  grains  to  i  ounce).  The  nose  should  then  be 
partially  plugged  with  a  tampon  of  cotton-wool,  especially  along 
the  lower  meatus,  and  if  thought  desirable  the  wool  may  be  medi- 
cated with  some  antiseptic.  By  this  means  a  flow  of  mucus  from 
the  membrane  is  determined,  and  the  discharge  is  thus  rendered 
more  fluid,  and  inspissation  prevented.  A  similar  end  may  also  be 
obtained  by  plugging  the  nostril  partially  with  a  rubber  tube,  so  as 
to  diminish  its  size.  The  general  health  must  be  attended  to,  and 
patience  and  perseverance  will  generally  be  crowned  with  success. 
Operative  measures  are  scarcely  ever  required  in  this  disease, 
although  they  have  frequently  been  resorted  to  most  unnecessarily. 

Disease  of  the  Accessory  Sinuses  of  the  Nose  is  a  frequent  accom- 
paniment of  either  the  acute  or  chronic  nasal  affections  just  passed 
under  review,  or  it  may  arise  from  more  localized  lesions — e.g., 
antral  trouble  from  affections  of  the  teeth,  or  frontal  sinus  mischief 
from  traumatism.  Perhaps  the  most  common  cause  is  a  sharp 
influenzal  attack,  which  may  lead  to  an  involvement  of  the  nasal 
fossae  and  all  the  sinuses  (the  so-called  pan-sinusitis) ;  this  is  toler- 
ably amenable  to  treatment  in  the  early  stages,  but  if  neglected, 
may  become  chronic,  and  then  serious  trouble  may  result.  Pyogenic 
infection  of  the  nasal  fossae  from  the  introduction  of  dirty  instru- 
ments by  careless  or  meddlesome  surgeons  may  also  be  responsible 
for  this  condition.  The  obvious  outcome  is  the  persistent  discharge 
of  offensive  purulent  material  from  the  nose,  which  is  often  wrongly 


822  A   MANUAL  OF  SURGERY 

termed  ozsena;  to  this  may  be  added  special  features  according  to 
the  particular  sinuses  which  arc  mainly  affected. 

It  must  be  remembered  tliat  the  outlet  of  most  of  the  sinuses 
(Fig.  396)  is  badly  placed  for  drainage  purposes,  especially  the 
maxillary  antrum,  the  opening  to  wliich  is  near  the  roof  rather  than 
the  floor.  Even  in  the  case  of  the  frontal  sinus,  the  outlet,  which 
is  well  situated  for  drainage,  is  a  long  narrow  passage  easily  blocked 
by  oedematous  swelling  of  the  mucous  lining.  When  once  su])pura- 
tion  has  commenced  among  the  sinuses,  it  is  likely  to  spread  from 
one  to  another  owing  to  the  close  proximity  of  the  various  orifices; 
thus,  pus  escaping  from  the  infundibuhmi  is  almost  certain  to  find 
its  way  into  the  antrum  or  ethmoidal  sinuses,  especially'  if  the  escape 
of  the  discharge  is  hindered  by  the  presence  of  granulation  tissue. 

In  the  more  acute  cases  which  follow  influenza  or  cold,  the  antrum 
and  frontal  sinus  are  most  frequently  involved.  Readers  are  referred 
back  to  what  has  already  been  written  on  these  subjects  (pp.  742 
and  801),  with  the  emphatic  reminder  that  careful  treatment  during 
the  early  stages  may  prevent  the  affection  becoming  chronic  and  save 
the  patient  from  much  suffering  and  danger.  The  nose  should  be 
carefully  irrigated  with  warm  saline  solution  night  and  morning, 
and  the  antrum  washed  out  after  puncturing  its  inner  wall. 

In  chronic  cases  the  discharge  will  be  found  to  come  from  one  or 
both  sides  of  the  nose,  and  the  patient  will  complain  of  feeling  stuffed 
up;  breathing  will  be  mainly  oral,  and  the  breath  is  likely  to  become 
offensive.  On  examining  the  interior  of  the  nose,  even  after  cleans- 
ing it,  the  cavity  is  not  found  to  be  patent  as  in  ozaena,  but  is  blocked 
up  with  polypoid  masses  of  granulation  tissue,  which  project  mainl}^ 
from  the  middle  meatus;  they  are  often  covered  with  a  half-dried 
scab,  and  pus  can  be  seen  to  exude  from  it  when  pressed  upon;  this 
usually  comes  from  the  antrum  or  frontal  sinus,  a  mass  of  granula- 
tion tissue  developing  both  above  and  below  the  entrance.  A  probe 
passed  into  the  mass  always  impinges  on  dead  or  carious  bone, 
which  is  probably  a  part  of  the  middle  turbinal. 

The  special  features  of  diseases  of  the  frontal  sinus  and  antrum  of 
Highmore  have  been  already  indicated,  and  their  peculiar  dangers 
and  methods  of  treatment  discussed. 

The  ethmoidal  cells  lie  along  the  inner  wall  of  the  orbit,  and 
should  they  become  distended  with  mucus  or  pus,  may  bulge  into 
the  orbital  cavity  on  the  inner  side  and  even  displace  the  eyeball 
outwards.  The  sphenoidal  sinus  lies  at  the  back  of  the  nose 
(Fig.  396,  S),  and  the  discharge  escapes  downwards  into  the  naso- 
pharynx. Suppuration  therein  causes  deep-seated  pain  in  the  back 
of  the  orbit  and  nose,  and,  unless  relieved,  may  determine  infective 
comphcations  about  the  base  of  the  skull — e.g.,  basal  meningitis, 
thrombosis  of  the  cavernous  sinus,  or  affections  of  the  nerves  to  the 
eye  and  orbit  in  the  neighbourhood  of  the  sphenoidal  fissure. 

Treatment,  except  in  the  simpler  cases,  should  always  be  handed 

over  to  a  rhinological  expert,  as  operative  measures  of  a  serious 

haracter  may  have  to  be  undertaken.     The  essential  element  is 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX         823 

drainage  of  the  affected  cavities,  together  with  removal  of  the  pro- 
tuberant granulation  tissue  and  diseased  bone  which  hinder  the 
exit  of  the  discharge.  It  may  be  desirable  for  a  few  days  to  treat 
the  patient  merely  by  irrigation  of  the  nasal  fossae,  and  of  such 
sinuses  as  are  readily  accessible,  e.g.,  the  antrum  and  frontal  sinus; 
but  further  and  more  effective  treatment  must  not  be  long  delayed. 
In  many  cases  the  Hning  membranes  of  these  cavities  will  be 
thickened  and  transformed  into  polypoid  masses,  and  hence  the  more 
extensive  of  the  procedures  mentioned  at  pp.  743  and  813  are  hkely 
to  be  required  for  the  frontal  sinus  and  antrum.     For  suppuration 


m-/ 


-ET 


PiG_  396.— Outer  Wall  of  Nasal  Fossa,  indicating  the  Position  of  the 

Accessory  Sinuses  and  of  their  Orifices. 
F  Probe  passed  from  frontal  sinus  down  the  infundibulum  to  middle  meatus; 
'  AE,  anterior  ethmoidal  cells ;  PE,  orifices  of  posterior  ethmoidal  m  superior 
meatus  shown  by  removal  of  a  portion  of  the  superior  turbmal;  S,  sphe- 
noidal sinus  with  probe  in  its  orifice;  MA,  orifice  of  maxillary  antrum 
shown  by  cutting  away  part  of  the  middle  turbinal;  ND,  orifice  of  nasal 
duct  under  cover  of  the  inferior  turbinal,  part  of  which  has  been  removed ; 
ET,  pharyngeal  opening  of  Eustachian  tube. 

of  the  ethmoidal  sinuses  it  may  sufdce  to  remove  the  anterior  por- 
tion of  the  middle  turbinal  and  to  break  down  the  inner  wall  of  the  - 
cells,  so  as  to  lay  the  cavities  into  the  nose ;  but  when  the  surrounding 
bone  has  become  diseased,  it  may  be  desirable  to  open  into  them 
from  the  orbit  by  prolonging  backwards  the  incision  for  exposing 
the  frontal  sinus.  The  sphenoidal  sinus  can,  of  course,  only  be 
dealt  with  from  its  nasal  aspect,  and  an  opening  has  to  be  carefully 
made  into  its  anterior  wall,  which  is  picked  away  by  punch  forceps. 
Syphilitic  Disease  of  the  nasal  fossae  is  generally  tertiary  m  type, 
and  consists  in  a  diffuse  gumniatous  affection  of  the  septum  and 


824 


A  MANUAL  OF  SURGERY 


tiirbinals,  with  resultant  suppuration,  and  either  caries  or  necrosis. 
Ihc  condition  is  usually  a  very  offensive  one,  but  the  accessory 
sinuses  are  not  specially  liable  to  involvement.  Treatment  is  of  the 
usual  antisyphilitic  type,  including  the  injection  of  salvarsan, 
and  perhaps  the  use  of  iodides  and  mercury.  Locally,  the  nose 
niust  be  ke]:)t  clean  by  irrigation,  and  diseased  bone  removed.  It 
is  probable  that  if  the  septum  is  seriously  affected,  the  bridge  of 
the  nose  will  become  depressed. 

Nasal  Polypi.- — Two  fomis  of  nasal  polypus  are  described,  viz., 
the  simple  or  mucous  polyp,  and  the  fibrous  or  fibro-sarcomatous. 
Other  malignant  tumours  occur  in  the  nasal  fossae,  to  which,  how- 
ever, the  term  polypus  can  scarcely  be  extended;  they  mainly 
originate  from  the  superior  maxilla. 

The  Mucous  Polypus  consists  of  a  soft  gelatinous  mass,  which 
on   microscopic  examination  much  resembles  myxomatous  tissue, 

covered  by  cihated  columnar 
epithehum,  and  supplied  freely 
with  bloodvessels.  Polypi  are 
inflammatory  in  origin,  con- 
sisting merely  of  oedematous 
hypertrophic  tissue,  mainly 
dependent  on  a  chronic  osteitis 
of  the  underlying  turbinated 
bone.  They  are  often  associ- 
ated with  suppuration  of  the 
adjacent  sinuses,  especially 
the  ethmoidal,  but  the  pus 
production  may  be  secondary 
and  not  causative.  Polypi  are 
usually  situated  on  the  middle 
and  superior  turbinals;  they 
rarely  start  from  the  roof  of 
the  nasal  fossas,  occasionally 
in  the  sinuses,  or  at  the  orifices 
leading  into  them;  they  hardly  ever  involve  the  septum  or  inferior 
turbinal.  Polypi  are  generally  multiple  (Fig.  397),  a  large  one 
projecting  downwards  and  forwards  towards  the  anterior  nares,  and 
covering  or  hiding  a  series  of  smaller  ones,  which  readily  spring 
into  prominence  when  that  in  front  is  removed.  They  are  usually 
attached  by  a  small  pedicle,  and  when  developing  in  the  nasal 
fossa  are  pyriform  and  laterally  compressed.  When  of  large  size, 
they  may  protrude  through  the  nostrils,  and  then  the  epithelium 
covering  the  anterior  portion  becomes  squamous,  and  the  mass 
firmer  in  texture  and  papillomatous  in  appearance.  Sometimes 
they  project  backwards  into  the  pharynx,  and  are  more  distinctly 
globular  and  usually  single. 

The  main  Symptom  arising  from  nasal  polypi  is  obstruction  to 
the  passage  of  air  along  one  or  both  sides  of  the  nose.  This  is 
always  of  gradual  onset,  and  invariably  worse  in  wet  weather,  on 


'V 


Fig.   397.^Mucous     Polypi    of    Nose, 

SPRINGING  FROM  THE  BaCK  AND    FrONT 

'  OF  THE  Middle  Turbinated  Bone. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX        825 

account  of  the  hygroscopic  property  of  mucoid  tissue.  There  is 
often  a  thin,  watery  discharge  from  the  nose,  which  may  perhaps  be 
blood-stained.  The  patient  is  unable  to  blow  the  nose,  and  his 
articulation  becomes  nasal  in  quality.  On  rhinoscopic  examination 
one  finds  a  grayish  semi-translucent  glistening  mass  occupying  the 
nostril,  and  attempts  to  blow  the  nose  render  this  more  obvious. 
Its  pedunculated  nature  can  be  easily  demonstrated  by  passing  a 
probe  around  it.  When  of  large  size,  some  flattening  or  expansion 
of  the  bridge  of  the  nose  may  be  caused  thereby,  and  possibly 
epiphora  from  pressure  on  the  opening  of  the  nasal  duct. 

The  Diagnosis  should  present  no  difficulty  to  one  who  knows  how 
to  employ  the  nasal  speculum.  Abscess,  a  spur,  or  a  deviation  of 
the  septum,  though  causing  unilateral  obstruction,  can  be  recog- 
nised by  the  exercise  of  a  very  small  amount  of  intelhgence. 
(Edematous  masses  of  granulation  tissue,  associated  with  tuber- 
culous or  syphihtic  disease  of  the  bones,  are  recognised  by  involving 
usually  the  septum  as  well  as  the  turbinals,  by  the  absence  of  super- 
ficial epithelium,  and  by  not  being  distinctly  pedunculated ;  carious 
bone  can  often  be  felt  by  a  probe  through  the  granulation  tissue. 
From  hypertrophy  of  the  mucous  membrane  over  the  inferior 
turbinated  bone,  a  polypus  is  known  by  the  fact  that  it  scarcely 
ever  springs  from  this  region,  whilst  the  former  condition  is 
sessile  and  red,  and  shrinks  considerably  on  the  application  of 
cocaine. 

The  Treatment  of  mucous  polypi  consists  in  their  removal  either 
by  the  snare  or  the  curette. 

The  snare  is  specially  indicated  if  there  is  a  single  polypus  hanging 
down  the  naso-pharynx,  or  if  the  polypi  are  few  in  number.  The 
patient  is  seated  in  a  chair,  and  the  surgeon  sits  or  stands  m  front 
of  him.  The  nasal  cavities  are  well  sprayed  with  a  solution  of 
eucaine  or  cocaine  (5  per  cent.)  and  adrenalin  (5  per  cent.),  and  the 
situation  of  the  pedicle  ascertained  by  inspection  and  by  the  use 
of  a  probe.  The  snare  is  then  introduced,  and  the  loop  passed  round 
the  base  of  the  pedicle  and  gradually  tightened  until  it  has  cut 
through.  The  same  process  is  repeated  to  the  smaller  tumours 
until  the  nostril  is  clear.  A  certain  amount  of  hemorrhage  may 
result,  and  to  check  this  the  nostrils  should  be  plugged  with  a  strip 
of  sterilized  gauze,  but  this  should  never  be  left  unchanged  longer 
than  twenty-four  hours.  The  plug  is  then  removed,  and  the  base 
of  the  growth  carefully  examined  and  cauterized  with  the  galvano- 
cautery  by  the  aid  of  a  nasal  speculum  so  as  to  prevent  recurrence. 
The  patient  should  be  again  examined  after  a  short  interval,  so  that 
any  smaller  polypi  which^have  commenced  to  develop  may  be 
suitably  treated. 

Where  many  polypi  exist,  or  if  recurrence  has  occurred  after  the 
removal  by  the  snare,  the  nostril  must  be  effectively  curetted,  a.nd 
the  polypi  and  underlying  bone  removed  as  a  stage  in  the  operation 
for  the  cure  of  the  underlying  sinus  trouble. 

A  Fibrous  Polypus  is  the  term  applied  to  a  fibroma,  which  sooner 


826  A   MANUAL  OF  SURGERY 

or  later  becomes  sarcomatous,  springing  from  the  base  of  the  skull, 
especially  from  the  basi-sphenoid  or  basi-occipital.  It  is  at  first 
distinctly  pedunculated,  and  is  usually  firm,  smooth,  and  fleshy  in 
character;  when  of  large  size,  it  may  be  lobulated.  The  early 
symptoms  are  almost  limited  to  those  of  obstruction  to  nasal 
respiration,  but  to  this  is  not  unfrequently  added  severe  epistaxis, 
owing  to  the  vascularity  of  the  capsule  and  of  the  overlying  mucous 
membrane.  As  it  increases  in  size,  ulceration  occurs,  leading  to  a 
foetid  sanious  discharge,  and  the  growth  rarely  remains  limited  to 
the  nasal  fossae.  If  pushing  forwards,  it  may  lead  to  expansion  of 
the  bridge  of  the  nose  and  separation  of  the  eyes,  which  may  even 
be  made  to  diverge;  but  if  backwards,  it  may  depress  the  velum, 
and  hang  downwards  as  a  naso-pharyngeal  tumour.  In  other  cases 
it  may  force  its  way  into  the  orbit  or  any  of  the  other  surrounding 
cavities,  or  may  even  erode  the  base  of  the  skull,  or  encroach  upon 
the  cranium.  It  is  rare  for  any  of  these  latter  manifestations  to 
occur  until  after  the  tumour  has  taken  on  a  distinctly  sarcomatous 
type. 

The  disease  usually  attacks  young  people,  and  mainly  those  in 
the  second  decade  of  life.  It  progresses  with  considerable  rapidity, 
and  the  fatal  issue  may  be  due  to  haemorrhage,  asphyxia,  or  cerebral 
complications. 

Treatment. — When  the  gro\\i;h  is  small  and  polypoid,  it  can  some- 
times be  dealt  with  from  the  anterior  nares  by  means  of  a  galvano- 
ecraseur.  The  wire  loop  is  inserted  from  the  front,  and  hitched  over 
the  tumour,  so  as  to  encircle  its  base,  by  the  assistance  of  the  right 
index  finger  passed  behind  the  velum.  The  pedicle  must  be  divided 
as  near  the  skull  as  possible,  and  even  then  recurrence  is  almost 
certain  to  follow.  Nelaton's  operation,  or  one  of  the  other  methods 
described  below  (p.  827),  will  in  some  instances  assist  the  surgeon 
to  reach  the  base  of  the  skull  and  deal  with  the  tumour.  In  the 
more  severe  cases,  where  the  growth  has  become  diffuse,  it  is  very 
doubtful  whether  much  good  can  be  done  by  operation,  since  the 
base  of  the  skull  is  sure  to  be  gravely  affected. 

Other  forms  of  Malignant  Disease  of  the  Nose  are  met  with,  and 
may  originate  in  any  part  of  the  nasal  fossae.  Squamous  epithelioma 
is  that  which  occurs  most  frequently;  the  S3-mptoms  consist  in  the 
presence  of  a  blood-stained  discharge,  and  a  certain  amount  of 
respiratory^  obstruction,  together  with  pain  and  cachexia.  The 
lymphatic  glands  at  the  angle  of  the  jaw  are  early  enlarged,  and  the 
course  of  the  disease  is  usually  rapid,  owing  to  the  great  vascu- 
larity of  the  part.  It  is  sometimes  possible  to  deal  with  these 
patients  by  operative  measures,  which  must  be  varied  accord- 
ing to  the  requirements  of  the  case.  Radium  may  perhaps  be  of 
service. 

Sarcoma  may  also  commence  in  the  nose  itself,  quite  apart  from 
that  which  originates  in  the  superior  maxilla.  It  gives  rise  to  the 
usual  signs  of  an  intranasal  growth,  and  may  occasionally  be  dealt 
with  in  a  satisfactory  manner  by  local  means,  such  as  curetting  and 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX         827 

the  application  of  caustics.  Not  a  few  cases  are  on  record  in  which 
such  treatment  has  proved  efficacious  in  curing  the  disease,  although 
one  would  now  raise  the  question  as  to  whether  these  tumours  were 
sarcomatous  at  all,  and  not  endotheliomata. 

The  operations  which  have  been  devised  Joy  dealing  with  disease  of  the  nose 
and  naso-pharynx  are  so  numerous  and  comphcated  that  it  is  impossible  for 
us  to  mention  more  than  a  few  of  the  most  useful  and  important. 

(rt)  In  many  cases  of  intranasal  disease  considerable  assistance  can  be 
derived  by  opening  up  the  anterior  nares,  especially  when  one  is  operating  for 
caries  or  necrosis  of  the  turbinated  bones.  It  may  suffice  merely  to  divide 
one  ala  nasi  and  the  attachments  of  the  cartilages  to  the  maxilla;  but  where 
both  sides  are  involved  Rouge's  operation  is  advisable.  This  consists  in  the 
detachment  of  the  mask  of  the  face  from  the  maxilla  by  everting  the  upper 
Up  and  incising  the  mucous  membrane  and  subjacent  tissues  until  the  nasal 
cavities  are  opened.  The  septum  nasi  is  divided  by  cutting-pUers,  and  the 
nasal  cartilages  are  completely  separated.  The  soft  tissues  of  the  face  can 
then  be  retracted  upwards,  and  the  nasal  fossae  fully  exposed.  The  bleedmg 
is  always  considerable,  and  the  space  gained  in  children  is  but  slight.  When 
the  operation  is  completed,  the  mask  of  the  face  is  allowed  to  fall  back  again 
into  position,  union  occurring  without  difficulty,  although  no  sutures  are 
employed. 

When  the  upper  and  anterior  portion  of  the  nasal  cavity  is  to  be  dealt  with, 
lateral  rhinotomy,  as  described  above  (p.  805),  or  some  modification  of  it, 
may  be  employed  with  advantage.  , 

When  the  septum  alone  is  involved  in  malignant  disease,  it  is  possible  to 
deal  with  it  by  an  operation,  which  consists  in  sphtting  the  upper  lip  m  the 
middle  line,  and  carrying  the  incision  round  the  ala  nasi  on  each  side  so  that 
the  lower  portion  of  the  nose  can  be  turned  upwards  after  dividing  the  septum. 
A  wedge-shaped  portion  is  then  removed  from  the  front  of  the  palate  after 
detaching  the  muco-periosteum  from  its  buccal  aspect.  An  excellent  approach 
is  thus  obtained  into  the  nasal  cavity,  and  the  entire  septum  can  m  this  way 
be  removed  without  difficulty.  The  parts  can  be  afterwards  brought  together 
quite  naturally,  and  the  deformity  is  very  shght.  A  patient  on  whom  this 
operation  was  performed  for  undoubted  epithelioma  of  the  septum  reported 
himself  at  hospital  eight  years  later ;  he  was  quite  free  from  recurrence,  and 
apart  from  a  sunken  bridge  to  his  nose,  there  was  no  deformity. 

[b)  When  the  disease  is  located  further  back,  originating  rather  m  the  naso- 
pharynx than  in  the  nose  itself,  the  palatine  route  may  be  used  with  advantage. 
Perhaps  the  best  of  the  several  suggested  operations  is  that  of  NSlaton.  Ihis 
consists  in  a  median  section  of  the  velum  and  of  the  mucous  membrane  cover- 
ing the  posterior  half  of  the  hard  palate.  A  transverse  incision  is  then  made 
on  either  side  of  the  anterior  extremity  of  this,  and  two  muco-penosteal 
flaps  are  reflected,  exposing  a  quadilateral  area  of  bone  which  is  removed  by 
chisel  and  mallet.  If  need  be,  part  of  the  vomer  is  also  taken  away,  and  thus 
the  naso-pharynx  is  opened  sufficiently  to  allow  of  the  removal  of  the  polypus 
or  growth.  The  reflected  segments  of  the  palate  are  subsequently  sutured 
together. 

Adenoids.— It  has  been  already  mentioned  that  the  naso-pharynx 
is  the  seat  of  a  large  amount  of  lymphoid  tissue,  similar  to  that  met 
with  in  the  tonsil,  which  may  either  be  distributed  widely  over  the 
whole  mucous  membrane,  or  be  gathered  into  a  special  mass  on  the 
roof,  known  as  the  pharyngeal  or  Luschka's  tonsil.  Adenoids 
consist  in  a  hyperplasia  of  this  tissue,  exactly  analogous  to  the 
chronic  hypertrophic  form  of  tonsillitis,  with  which,  indeed,  it  is 
often  associated.  They  usually  occur  in  the  form  of  broad,  cushion- 
like  masses  springing  mainly  from  the  roof  or  posterior  walls,  or 


828 


A   MANUAL  OF  SURGERY 


occasionally  as  pedunculated  tumours  hanging  down  into  the 
posterior  nares.  The  tumours  are  extremely  soft  and  vascular, 
bleeding  very  readily.  The  surface  is  often  plicated,  and  in  the 
recesses  or  folds  between  the  different  portions  of  the  mass  bacteria 
lodge  and  give  rise  to  various  inflammatory  troubles,  both  locally 
and  in  neighbouring  lymphatic  glands.  Not  uncommonly  isolated 
masses  similar  in  structure  to  the  above  are  also  to  be  seen  on  the 
posterior  wall  of  the  pharynx,  and  a  certain  amount  of  chronic  rhinitis 
and  laryngitis  may  be  associated.  The  condition  is  rarely  seen  in 
others  than   children,   and  especially  those  living  in  the  smoky 

atmosphere  of  large  towns.  If 
untreated,  they  usually  atrophy 
in  time,  but  not  before  much 
harm  may  have  been  done  to 
the  individual. 

The  Symptoms  are  mainly  due 
to  obstruction  to  nasal  respira- 
tion. The  mouth  is  generally 
held  half  open,  so  as  to  allow 
the  child  to  breathe  through  it, 
thereby  exposing  the  upper 
central  incisors  (Fig.  398) ;  from 
a  similar  cause  he  snores  during 
sleep,  and  usually  wakes  with 
the  mouth  and  tongue  dry.  The 
nostrils  are  drawn  in,  and  the 
nose  is  thin  and  pinched,  the 
whole  facies  being  very  charac- 
teristic; the  children  often  look 
sleepy  and  half  silly,  and,  in- 
deed, may  be  very  backward  in 
their  studies.  Not  uncommonly 
there  is  a  certain  amount  of 
semi-purulent  discharge  from 
the  nose,  or  it  may  be  hawked 
up  from  the  pharynx,  perhaps 
mixed  with  blood.  Acute  or 
chronic  otitis  media  often  results 
from  extension  of  the  catarrhal 
condition  to  the  mucous  lining  of  the  Eustachian  tubes,  and  deafness 
may  be  thereby  induced;  both  taste  and  smell  are  sometimes  im- 
paired. The  palate  becomes  high  and  arched,  owing  to  the  defective 
intranasal  air  pressure,  and  as  the  patient  grows  up,  the  incisor  teeth 
may  project  forwards,  giving  a  curious  rabbit-like  expression  to  the 
face.  The  cervical  glands  are  sympathetically  enlarged,  and  often 
the  seat  of  tuberculous  disease.  In  bad  cases  which  have  been 
allowed  to  persist  throughout  adolescence  the  thorax  becomes 
flattened  owing  to  the  inability'of  the  child  to  take  a  really  deep  in- 
spiration, the  ribs  are  drawn  in,  and  the  spine  is  kyphotic  (Fig.  399)- 


Fig.  398. — Adenoid  Facies.  (From 
A  Photograph  kindly  lent  by 
Sir  St.  Clair  Thomson.) 

This  illustration  shows  well  the  sleepy 
look,  the  pinched,  nostrils,  the  open 
mouth  and  projecting  upper  central 
incisors,  so  characteristic  of  this 
condition. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX 


829 


Physical  Examination  consists  in  posterior  rhinoscopy,  by  means 
of  wliich  the  growths  can  be  seen,  or  in  palpation  of  the  posterior 
nares,  a  process  more  suitable  to  children,  who  rarely  have  sufihcient 
control  to  permit  of  the  former.  On  passing  the  finger  behind  the 
velum,  the  naso-pharynx  is  found  to  be  occupied  by  a  soft  mass  of 
tissue  which  readily  bleeds,  and  more 
or  less  obstructs  the  openings  of  the 
posterior  nares. 

Treatment  consists  in  the  great 
majority  of  cases  in  removal  of  the 
adenoids  by  operation.  In  mild  cases, 
however,  much  may  be  done  by  enforcing 
respiratory  exercises  with  the  mouth 
shut;  and  in  young  adults  attention  to 
the  general  health,  combined  with  irri- 
gation of  the  nose  with  salt  and  water, 
and  perhaps  the  local  application  of  a 
weak  solution  of  nitrate  of  silver  (5  grains 
to  I  ounce)  to  the  naso-pharynx,  may 
suffice  to  bring  about  improvement. 

Operation. — As  a  general  rule  the 
child  should  be  anaesthetized  with  gas, 
chloroform,  or  chloride  of  ethyl,  and  the 
head  may  be  allowed  to  hang  backwards 
over  the  end  of  the  table.  If  enlarged 
tonsils  co-exist,  these  should  be  dealt  with 
in  the  first  place.  Gottstein's  curette, 
or  some  modification  of  it,  is  then  intro- 
duced behind  the  soft  palate,  the  velum 
being  drawn  forwards  by  the  left  index 
finger.  It  is  pressed  upwards  so  that  its 
free  convex  edge  impinges  on  the  upper 
part  of  the  posterior  border  of  the  nasal 
septum.  It  is  then  swept  backwards 
and  downwards  over  the  pharyngeal 
wall,  so  as  to  shave  away  the  chief  por- 
tion of  the  projecting  mass  of  adenoids. 
Possibly  the  application  of  a  second 
smaller  curette  may  be  required  to  deal 
with  outlying  lateral  portions  of  the  mass ; 
and  finally  the  adenoid  tissue  about  the  orifices  of  the  Eustachian 
tubes  and  any  remaining  tags  are  removed  by  the  use  of  Lowenberg's 
forceps  or  the  finger-nail.  Of  course,  there  is  considerable  bleeding, 
but  this  quickly  stops  of  itself ;  as  soon  as  the  operation  is  over,  the 
child  should  be  turned  over  and  held  face  downwards,  so  as  to  allow 
the  blood  to  run  out  of  the  mouth  and  nose,  whilst  the  face  and  fore- 
head are  sponged  with  ice-cold  water  to  check  the  hcemorrhage. 
The  patient  is  kept  indoors  for  a  few  days,  and  only  fluid  food 
allowed.     No  local  after-treatment  is  required  as  a  rule,  but  the 


Fig.  399. — -Lateral  View 
OF  A  Child  with  Neg- 
lected Adenoids.  (From 
A  Photograph  lent  by 
Sir  St.  Clair  Thomson.) 

This  is  the  same  child  whose 
face  appears  in  Fig.  398. 
It  will  be  seen  that  the 
chest  is  shallow  and  re- 
tracted, and  the  spine 
kjrphotic.  The  arms  are 
small,  but  the  legs  are 
well  developed. 


830  A   MANUAL  OF  SURGERY 

tliroat  may  be  gargled  or  the  nose  washed  out  with  weak  salt  and 
water.     Nose-breathing  exercises  should  be  subsequently  instituted. 

Epistaxis,  or  bleeding  from  the  nose,  may  arise  from  a  variety  of 
causes,  including  traumatism,  directed  either  to  the  mucous  mem- 
branes or  the  bones,  or  from  the  presence  of  ulceration  or  tumours. 
Some  of  these  local  causes  are  very  evident,  if  only  they  are  care- 
fully looked  for  with  a  rhinoscope  and  frontal  mirror.  One  of  the 
commonest  lesions  is  a  small  abrasion  or  ulcer  of  the  septum,  due  to 
detaching  by  the  linger  a  scab  or  dried  crust  of  mucus  which  causes 
irritation  within  the  nostril ;  each  time  the  nose  is  '  picked  '  in  this 
way,  bleeding  recurs.  Another  frequent  source  of  epistaxis  is  the 
rupture  of  a  varicose  vein  in  the  mucous  membrane  of  the  septum ; 
varix  occurs  not  unusually  in  plethoric  individuals,  and  sneezing  or 
blowing  the  nose  violently  may  lead  to  an  attack.  Foreign  bodies 
may  cause  haemorrhage,  as  also  ulceration  of  an  angioma  on  the 
septum.  It  frequently  occurs  in  young  people  about  puberty  in 
consequence  of  local  disturbance  in  the  vascular  arrangement  of 
the  parts;  again,  cerebral  congestion  may  induce  it,  owing  to  the 
communication  by  means  of  emissary  veins  between  the  interior  of 
the  skull  and  the  venous  plexuses  in  the  nose ;  excessive  changes  in 
the  atmospheric  pressure,  as  in  mountaineering,  may  lead  to  epis- 
taxis, whilst  in  abnormal  states  of  the  blood  it  may  be  associated 
with  haemorrhage  elsewhere,  as  in  haemophilia,  purpura,  and  scurvy. 
It  is  sometimes  an  evidence  of  chronic  Bright's  disease,  and  may  be 
one  of  the  first  symptoms  to  call  attention  to  its  existence;  it  may 
follow  cardiac  or  pulmonary  disease,  resulting  in  cerebral  congestion, 
and  may  be  a  prominent  symptom  in  enteric  fever.  One  or  both 
nostrils  may  be  the  seat  of  the  bleeding,  and  it  may  be  so  excessive 
as  even  to  threaten  life. 

Treatment.' — It  must  not  be  forgotten  that,  in  the  majority  of 
cases,  there  is  some  local  cause  of  epistaxis  which  can  be  found  and 
treated  directly- — a  fact  which  once  more  emphasizes  the  necessity 
for  gaining  a  mastery  over  the  use  of  the  rhinoscope.  The  bleeding 
is  generally  unilateral,  and  in  nine  out  of  ten  cases  the  source  is 
within  easy  reach  of  the  anterior  nares,  and  hence  in  many  instances 
all  that  is  required  is  to  grasp  the  nostrils  hrmly,  and  thus  allow  the 
blood  to  collect  within,  and  give  it  an  opportunity  of  clotting.  At 
the  same  time,  the  patient  should  sit  up,  and  cold  be  applied  to  the 
root  of  the  nose,  or  to  the  nape  of  the  neck.  If  on  examination  the 
bleeding-point  is  detected,  whether  it  be  a  varicose  vein  or  an  ulcer- 
ated surface,  the  haemorrhage  can  almost  at  once  be  stayed  by 
applying  a  pointed  galvano-cautery,  or  by  sealing  the  spot  with  a 
swab  soaked  in  a  solution  of  chromic  acid  (5  per  cent.)  or  adrenalin. 
Faihng  these  measures,  the  nostrils  may  need  to  be  plugged,  but  such 
a  proceeding  ought  to  be  seldom  required.  It  may  suffice  merely  to 
pack  the  anterior  nares  with  long  strips  of  sterile  lint  or  gauze  soaked 
in  adrenalin,  or  a  sterilized  rubber  finger-stall  may  be  introduced 
and  filled  with  wool.  If  this  does  not  suffice,  the  posterior  nares 
must  also  be  plugged.     For  this  purpose  Bellocq's  sound  is  usually 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX        831 

employed  in  order  to  pass  a  thread  round  the  base  of  the  palate,  and 
out  of  both  nose  and  mouth  ;  but  where  it  is  not  obtainable,  a 
suitably  curved  pair  of  laryngeal  forceps  or  a  rubber  catheter  may  be 
used  instead.  To  the  lower  end  of  this  thread  a  pledget  of  sterilized 
lint  or  gauze  about  i-|  inches  by  i  inch  in  size  is  attached,  and  this, 
guided  by  the  finger  round  the  soft  palate,  is  drawn  tightly  forwards 
into  the  posterior  nares.  It  is  a  good  plan  to  have  two  threads 
coming  forwards  out  of  the  nose,  and  these  may  be  tied  firmly 
around  a  pad  of  lint  placed  over  the  side  of  the  nostril,  thereby 
occluding  the  anterior  nares  and  completely  blocking  the  nasal 
cavity,  back  and  front.  The  loose  end  of  the  thread  emerging  from 
the  mouth  is  fixed  to  the  cheek  by  a  strip  of  adhesive  plaster.  The 
plug  is  retained  for  twelve  hours,  and  then  removed,  and  the  nasal 
fossse  irrigated  with  a  weak  warm  alkaline  antiseptic  lotion  in  order 
to  prevent  infection. 


CHAPTER  XXX. 

AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS. 

Stomatitis,  or  inflammation  of  the  mucous  membrane  of  the  mouth, 
is  by  no  means  uncommon,  especiahy  in  children. 

1.  Catarrhal  Stomatitis  results  from  mechanical  irritants,  such  as 
roughened  teeth,  from  irritating  chemicals,  or  from  septic  inflamma- 
tion following  operations  which  involve  the  mouth.  It  also  arises 
in  the  course  of  fevers,  and  in  conditions  of  debility  such  as  follow 
measles  and  other  exanthemata  in  children;  or  is  associated  with 
disturbances  in  the  alimentary  canal,  as  from  improper  feeding, 
dyspepsia,  etc.  The  mucous  membrane  becomes  hyperaemic  and 
swollen,  usually  in  small  localized  patches,  which  may  gradually 
spread  and  become  confluent,  involving  nearly  the  whole  of  the  oral 
cavity.  The  exudation  of  mucus  is  increased,  and  becomes  viscid 
and  turbid,  whilst  the  epithelium,  at  first  white  and  sodden,  is  after 
a  while  rubbed  off,  leaving  superficial  erosions  or  distinct  ulcers, 
which  are  very  painful.  Ihe  treatment  consists  in  the  removal  of 
all  sources  of  irritation,  and  the  administration  of  drugs  to  correct 
intestinal  derangements.  Antiseptic  mouth-washes  should  also  be 
employed,  such  as  sanitas  (i  in  20),  boro-glyceride  (i  in  20),  chlorate 
of  potash,  Condy's  fluid,  or  peroxide  of  hydrogen. 

2.  Aphthous  Stomatitis  occurs  in  badly-fed  children  in  the  form 
of  small  whitish  spots  on  a  hypersemic  base,  which  run  together  and 
produce  ulceration.  Attention  must  be  directed  to  the  general  con- 
dition, and  a  little  borax  and  honey  or  a  solution  of  boro-glyceride 
(i  in  20)  applied  locally.  Thrush  is  due  to  the  presence  of  a  para- 
sitic fungus,  the  Oidinm  albicans,  and  occurs  in  patches  somewhat 
resembhng  curdled  milk  in  appearance.  In  history  and  treatment 
it  resembles  the  aphthous  variety.  In  both  these  types  there  is 
often  considerable  enlargement  of  the  lymphatic  glands,  which, 
however,  frequently  subside  without  suppuration  when  the  cause  is 
cured. 

3.  Gangrenous  Stomatitis,  or  cancrum  oris,  has  been  already 
described  (p.  123).  A  similar  condition  occurs  in  elderly  debili- 
tated people,  especially  if  suffering  from  albuminuria  or  diabetes, 
and  the  possessors  of  foul  teeth.  Treatment  must  be  of  a  similar 
character. 

832 


AFFECTIONS  OF  THE  MOUTH,  THRO  A  T,  AND  (ESOPHAGUS     833 

4.  Mercurial  Stomatitis  may  arise  during  the  administration  of  a 
course  of  mercury,  or  occasionally  from  a  single  dose  in  persons  who 
are  sensitive  to  its  action.  It  is  increased  in  severity  if  the  mouth 
and  teeth  are  dirty,  or  if  the  patient  smokes  to  excess.  The  gums 
are  swollen  and  tender,  bleed  on  pressure,  and  are  very  painful, 
especially  when  biting,  or  drinking  hot  fluids.  The  teeth  may 
become  loose  and  fall  out,  whilst  the  alveolar  borders  may  be  laid 
bare  and  necrose.  The  tongue  is  sometimes  swollen  and  inflamed; 
salivation  is  a  marked  symptom,  and  the  breath  becomes  very 
offensive.  Treatment. — Either  leave  off  the  mercury,  or  at  any  rate 
reduce  the  dose  considerably,  and  administer  saline  purgatives. 
Chlorate  of  potash,  combined  with  alum,  dilute  hydrochloric  acid, 
or  tincture  of  myrrh,  may  be  useful  locally. 

5.  For  Syphilitic  Stomatitis,  see  p.  159. 

The  buccal  mucous  membrane  is  also  involved  in  the  course  of 
other  diseases,  e.g.,  diphtheria,  scarlet  fever,  and  erysipelas,  but 
special  descriptions  are  not  needed  here. 

Affections  of  the  Tongue. 

Congenital  Abnormalities. — {a)  The  tongue  has  been  completely 
or  partially  absent.  (6)  One  half  of  the  tongue  is  defective  in  size 
[hemiatrophy) .  (c)  Tongue-tie  is  said  to  be  present  when  the  f raenum 
is  shorter  than  usual,  causing  the  tip  to  be  depressed  and  fixed  in 
the  floor  of  the  mouth  so  that  it  cannot  be  protruded.  Sucking 
becomes  difficult  in  such  a  condition,  and  when  it  is  allowed  to  per- 
sist, there  is  often  a  lisp  in  the  speech.  Treatment  is  only  needed 
in  the  severer  forms,  and  consists  in  raising  the  tongue  with  the 
index  and  middle  fingers  placed  one  on  either  side,  and  snipping  the 
frsenum,  thus  put  on  the  stretch,  across  its  centre  with  a  pair  of 
blunt-pointed  scissors  directed  downwards,  [d)  The  tongue  may 
be  adherent  to  the  floor  of  the  mouth,  being  hound  down  by  folds  of 
mucous  membrane  [ankyloglossia) .  This  may  also  exist  as  an 
acquired  condition  due  to  cicatricial  contraction  after  ulceration. 
In  congenital  cases  the  adhesions  are  but  slight,  and  the  organ  can 
be  readily  freed;  in  the  acquired  condition  this  cannot  always  be 
accomplished,  (e)  The  frsenum  and  tongue  are  occasionally  too 
long,  allowing  of  increased  mobility,  and  even  fatal  results  have 
occurred  from  the  organ  rolling  backwards  and  impeding  respira- 
tion. (/)  The  tongue  may  be  cleft,  presenting  a  bifid  appearance; 
this  may  be  complete  or  partial,  and  is  usually  associated  with  a 
congenital  fissure  through  the  lower  lip  and  mandible,  (g)  Macro- 
glossia  (or  large  tongue),  although  sometimes  acquired,  is  usually  a 
congenital  deformity.  The  organ  is  enlarged  in  all  directions,  and 
protrudes  from  the  mouth,  so  that  the  teeth  indent  it,  and  cause 
ulceration  and  considerable  interference  with  the  venous  return. 
It  thus  becomes  purplish  and  dry  from  exposure,  the  mucous  mem- 
brane looking  almost  like  skin,  although  saliva  dribbles  freely  from 
beneath  it.     In  old-standing  cases  the  teeth  are  displaced  outwards 

5j 


834  A   MANUAL  OF  SURGERY 

and  the  jaws  defomicd,  so  that,  even  if  the  tongue  is  reduced  to  its 
normal  size  by  treatment,  it  may  be  impossible  to  close  the  mouth. 
Pathologically,  it  is  due  to  diffuse  overgrowth  of  the  connective 
tissue,  secondary  to  lymphatic  obstruction  and  dilatation.  Re- 
current attacks  of  lymphangitis  add  to  the  trouble,  the  tongue 
gradually  increasing  in  size,  and  the  disease  has  been  known  to 
terminate  in  the  development  of  a  lympho-sarcoma.  The  treatment 
consists  in  excision  of  a  V-shaped  portion,  suturing  the  raw  surfaces 
subsequently  with  catgut. 

Wounds  of  the  tongue  are  usually  caused  by  the  teeth,  especially 
during  an  epileptic  seizure,  or  in  children  as  a  result  of  falls  with  the 
tongue  out.  There  is  often  brisk  haemorrhage  for  a  few  moments, 
which  soon  ceases,  though  blood  may  be  extravasated  into  its  sub- 
stance, and  cause  considerable  swelling.  In  simple  cases  the  wound 
should  be  examined  and  purified,  and  the  mouth  constantly  cleansed 
with  mild  antiseptic  lotions;  a  few  points  of  suture  may  also  be 
inserted  if  necessary,  but  the  wound  must  not  be  entirely  closed,  or 
tension  from  infection  will  result.  When  smart  arterial  bleeding  is 
present,  the  mouth  must  be  opened,  the  tongue  pulled  forwards,  and 
the  wounded  vessel  sought  for  and  tied.  Failing  this,  the  lingual 
artery  may  be  tied  in  the  neck,  or  even  the  external  carotid. 

Acute  Superficial  Glossitis  occurs  as  part  of  a  general  stomatitis, 
and  needs  no  special  notice. 

Acute  Parenchymatous  Glossitis,  or  acute  inflammation  of  the 
tongue,  may  arise  from  penetrating  and,  of  necessity,  infected 
wounds,  or  from  the  bites  or  stings  of  insects,  or  may  be  associated 
with  acute  stomatitis  in  the  course  of  fevers,  but  is  most  commonly 
due  to  the  injudicious  administration  of  mercury.  The  condition 
may  be  limited  to  one  half  of  the  organ,  but  when  arising  from 
general  causes  is  bilateral.  The  tongue  becomes  painful,  swells  up 
rapidly  so  as  to  fill  the  mouth,  and  even  protrudes  beyond  the  teeth, 
the  pressure  of  which  leads  to  superficial  ulceration.  The  salivary 
glands  are  enlarged  and  painful,  and  salivation  is  a  marked  feature 
in  the  case.  Speech,  swallowing,  and  even  respiration  are  much 
interfered  with,  and  there  may  be  considerable  febrile  disturbance. 
The  case,  if  treated  with  care,  usually  ends  in  resolution ;  but  diffuse 
or  localized  suppuration  may  ensue,  as  well  as  the  most  urgent 
dyspnoea,  arising  either  from  oedema  glottidis  or  from  the  pressure 
of  the  enlarged  organ.  Treatment  consists  in  stopping  the  mercury, 
or  removing  any  evident  cause,  and  in  the  administration  of  saline 
purgatives  with  chlorate  of  potash.  Leeches  may  be  applied  be- 
neath the  angles  of  the  jaw,  but  in  bad  cases  a  free  incision  into  the 
dorsum  should  be  made  on  either  side  of  the  median  line  to  give  exit 
to  the  effused  fluids  and  blood.  The  most  rapid  relief  to  the  symp- 
toms is  thereby  obtained,  although  the  organ  may  remain  enlarged 
for  some  time.  If  asphyxia  is  threatening,  high  tracheotomy  or 
laryngotomy  is  required. 

Abscess  of  the  tongue  may  result  from  the  acute  process  described 
above,  but  is  more  usually  of  a  chronic  nature,  and  situated  at  the 


A  FFECTIONS  OF  THE  MO  U  TH.  THRO  A  T.  A  ND  CESOPHA  G  US     835 

anterior  part  of  the  organ.  It  is  generally  due  to  the  admission  of 
micro-organisms  through  some  superficial  lesion  which  has  quickly 
healed.  It  presents  as  a  tense  swelling,  fluctuation  in  which  may  be 
masked  by  the  amount  of  inflammator\-  thickening  which  surrounds 
it.     A  free  incision  both  settles  the  diagnosis  and  cures  the  case. 

Sublingual  Abscess,  when  acute,  is  due  to  infection  of  the  sub- 
mucous tissue,  as  bv  puncture  with  a  fishbone,  or  starts  in  a  folhcle 
of  the  sublingual  or  in  a  submucous  gland.  A  puffy  sweUing  forms 
beneath  the  tongue,  which,  if  not  opened  early,  may  lead  to  an 
extension  downwards  of  the  mischief  into  the  submental  region. 
The  tongue  becomes  swollen  and  turgid  from  pressure  upon  the  veins, 
whilst  (Edematous  laryngitis  mav  also  be  induced.  Considerable 
constitutional  disturbance  generally  accompanie.-  this  process.  _  A 
median  incision  through  the  mucous  membrane,  and  the  insertion 
and  opening  of  a  pair  of  dressing  forceps,  is  the  safest  and  best  method 
of  treatment,  the  ca\-itv  being  subsequently  washed  out  and  drained. 
The  more  diffuse  form  of  subUngual  abscess  is  usually  associated 
\\-ith  submaxillary  cellulitis  (p.  89). 

Chronic  Superficial  Glossitis  is  an  interesting  and  important  disease, 
which  may  be  associated  with  a  similar  condition  of  the  mucous 
membrane  lining  the  interior  of  the  cheeks  and  hps.  It  is  most 
commonly  due  to  syphiHs,  occurring  as  a  tertiary  phenomenon,  but 
may  arise  from  excessive  smoking,  ragged  and  rough  teeth,  or  spirit- 
drinking,  chronic  d\-spepsia,  perhaps  of  a  gouty  nature,  being  also 
present  in  many  cases.  It  is  very  liable  to  be  followed  by  epithe- 
lioma. Barker  stating  that  out  of  no  cases  he  carefully  investigated 
cancer  occurred  in  43.  .  . 

For  purposes  of  description  it  is  useful  to  divide  the  disease  into 
the  f  ollo\nng  five  stages,  although  it  must  be  clearly  understood  that 
they  are  artificial,  and  several  of  them  mav  be  present  m  different 
parts  of  the  same  tongue,  (i.)  The  papiUs  become  enlarged  and 
sw^oUen,  leading  to  the  appearance  of  red  hypersemic  patches,  which 
cannot  be  recognised  for  certain  unless  the  tongue  is  thoroughly 
dried  \nth  a  handkerchief,  towel,  or  piece  of  clean  blotting-paper, 
which  must  not  be  carelessly  dabbed  over  the  organ,  but  should 
be  firmly  pressed  down  so  as  to  absorb  aU  the  moisture.  (11.)  Over- 
gro\\-th  of  epithelium  follows,  and  as  it  increases  m  thickness,  it 
becomes  opaque  and  hornv  (Plate  VI.,  Fig.  i),  so  that  the  red  patches 
are  replaced  bv  white  ones,  leading  to  the  appearance  which  has  been 
designated  Leucoplakia.  Sometimes  the  papiUffi  become  much  en- 
larged, and  stand  out  definitely  and  separately  from  the  organ ;  or 
the  whole  surface  may  be  covered  \nth  dense  white  patches.  To 
this  condition  the  term  IcJithvosis  has  been  appHed.  (ni.)  Later  on, 
the  excess  of  epithelium  is  shed,  leaving  red  smooth  patches  m  which 
the  papillce  are  atrophied,  or  have  entirely  disappeared.  If  this 
occurs  over  the  greater  part  of  the  organ,  the  glazed  red  tongue  so 
characteristic  of  tertiary  syphilis  is  produced.  If,  however,  this 
process  only  occurs  in  smaUer  areas  intermixed  with  portions 
covered  \ritii  white  epithehum,  a  patchy  appearance  of  the  tongue 


836  A   MANUAL  OF  SURGERY 

results,  wrongly  termed  Psoriasis  linguce.  (iv.)  At  varying  periods 
of  the  disease,  sometimes  earlier,  sometimes  later,  the  organ  be- 
comes ulcerated,  cracked,  or  fissured  in  a  somewhat  characteristic 
manner.  A  median  fissure  is  usually  seen  running  down  the  middle, 
and  from  this  furrows  extend  transversely,  dividing  the  surface  into 
rectangular  compartments.  These  fissures  are  not  always  due  to 
the  cicatrization  of  cracks,  as  when  opened  out  healthy  papillae  are 
seen  at  the  base,  and  no  sign  of  superficial  scarring.  They  are,  then, 
evidently  the  result  of  the  contraction  of  deep  sclerosed  tissue  in  the 
substance  of  the  organ.  Superficial  ulceration  often  occurs,  apart 
from  these  fissures,  being  probably  due  to  some  local  irritation,  or  to 
smoking;  the  atrophic  condition  of  the  mucous  membrane  explains 
the  great  liability  to  this  occurrence,  (v.)  Still  later,  epithelioma 
may  develop,  and  usually  in  connection  with  one  of  the  cracks,  or 
of  the  cicatrices  arising  therefrom.  It  is  often  somewhat  slow  in  its 
progress,  owing  to  the  amount  of  sclerosis  induced  by  the  preceding 
inflammation. 

The  typical  smoker's  patch  is  a  red  irritable  area  on  the  front  of  the 
tongue,  from  which  papillae  are  often  absent,  and  perhaps  covered 
.  with  a  yellowish-white  crust.  Sometimes  the  epithelium  is  heaped 
up  here  into  a  well-marked  leucoplakic  spot. 

All  these  stages  of  the  disease  are  accompanied  with  much  dis- 
comfort, the  tongue  being  sometimes  so  tender  that  the  patient  can- 
not drink  hot  fluids  or  take  condiments  or  stimulants  without  pain. 
The  speech,  too,  is  interfered  with,  becoming  thick  and  indistinct. 
The  course  of  the  case  varies  considerably,  and  the  affection  may 
settle  down  after  a  time,  and  cause  but  little  discomfort,  so  long  as 
the  patient  conforms  to  the  restrictions  as  to  diet,  etc.,  which  are 
essential.  If,  however,  he  is  careless  or  refuses  to  obey  orders,  the 
trouble  may  progress,  and  epithelioma  develop. 

The  Treatment  of  the  case  is  usually  a  matter  of  some  difficulty. 
All  sources  of  irritation  are  excluded  from  the  mouth  as  a  first  pre- 
caution. Thus,  smoking  or  chewing  tobacco  must  be  rigidly  pro- 
hibited. Spirit-drinking  and  all  acid  wines  which  cause  pain  should 
be  forbidden,  dilute  whisky  and  water  being  perhaps  the  best 
stimulant.  The  teeth  must  be  well  brushed  night  and  morning,  and 
all  stumps  and  rough  excrescences  removed;  definite  pyorrhoea 
must  be  carefully  treated.  Gaps  between  the  teeth  should  be  filled 
by  artificial  teeth  fitted  to  a  smooth  plate.  Condiments,  such  as 
mustard,  spices,  curry,  and  cheese,  are  excluded  from  the  dietary, 
and  only  simple  unirritating  ingesta  allowed.  The  mouth  is  washed 
out  frequently  with  an  alkaline  lotion — e.g.,  bicarbonate  of  soda 
{20  grains  to  I  ounce),  or  borax  (10  grains  to  i  ounce) — especially  after 
meals,  so  as  to  exclude  all  risk  of  acid  fermentation  in  the  debris 
of  food.  Cracks  and  sores  may  be  treated  by  painting  the  surface 
with  a  solution  of  chromic  acid  (grs.  v.  ad  ,5i.)  or  of  perchloride  of 
mercury  (grs.  ii.  ad  ,3i.),  but  it  is  better  to  excise  them  completely, 
as  also  any  wart-like  formations.  Solid  nitrate  of  silver  should  parti- 
cularly be  avoided,  as  its  use  is  likely  to  predispose  to  epithelioma. 


AFFECTIONS  OF  THE  MOUTH.  THROAT.  AND  (ESOPHAGUS     837 

General  antisyphilitic  remedies  are  employed  where  necessary, 
even  including  salvarsan;  the  digestion  is  attended  to,  and  if  the 
new  formation  of  epithelium  is  excessive,  arsenic  may  be  adminis- 
tered. 

On  the  appearance  of  definite  epithelioma  suitable  operative 
measures  must  be  instituted. 

Ulceration  of  the  tongue  arises  from  a  variety  of  causes,  and  occurs 
in  many  different  forms.  Ihus,  dental  or  traumatic  ulcers,  due  to 
the  irritation  of  rough  and  carious  teeth,  are  generally  seen  at  the 
margins  of  the  organ.  Dyspeptic  ulcers  are  associated  with  gastric 
disturbances ;  they  are  usually  located  on  the  middle  of  the  dorsum, 
and  are  often  very  painful.  It  is  sufficient  to  touch  them  with  lunar 
caustic  after  dealing  with  the  cause.  Tuberculous  ulcers  are  not 
common,  and  are  nearly  always  secondary  to  pulmonary  or  laryngeal 
phthisis,  the  organ  being  infected  by  the  sputum.  They  commence 
in  the  form  of  a  submucous  abscess,  which  bursts  and  leaves  a  small 
painful  sore,  rarely  situated  on  the  posterior  part  of  the  organ,  but 
chiefly  at  the  sides  or  on  the  dorsum  near  the  tip.  Secondary 
abscesses  form  around  and  coalesce  with  the  original  ulcer.  Treat- 
ment is  chiefly  needed  on  account  of  the  pain  and  discomfort  caused 
by  them;  it  consists  in  their  complete  excision,  or  in  cocainizing  and 
scraping  the  sores,  touching  the  base  with  pure  carbolic  acid,  and 
dressing  with  iodoform.  Applications  of  cocaine  may  also  be  made 
before  meals,  as  a  palliative  measure  where  radical  treatment  is  not 
undertaken  on  account  of  the  extent  of  the  piilmonary  mischief. 
Lupus  also  attacks  the  tongue,  but  is  very  uncommon,  and  almost 
invariably  secondary  to  a  similar  affection  of  the  skin  of  the  face. 
In  a  case  under  our  care  it  appeared  in  the  form  of  an  irregular 
granulating  surface  surrounded  by  nodulated  cicatricial  tissue  of  an 
exceedingly  dense  character.  The  progress  was  very  slow,  owing 
to  the  amount  of  sclerosis  present.  Treatment  consists  in  the  appli- 
cation of  the  X  rays  or  of  radium;  but  in  some  cases  it  may  be 
advisable  to  undertake  a  preliminary  course  of  treatment  by  scrap- 
ing and  cauterization.  Syphilitic  and  cancerous  ulcerations  are 
described  below. 

Syphilitic  Disease  of  the  tongue  occurs  in  a  variety  of  different 
forms.  A  primary  sore  presents  a  characteristic  indolent  and  inac- 
tive surface,  usually  near  the  tip,  with  subjacent  infiltration,  and 
much  chronic  enlargement  of  the  submental  lymphatic  glands, 
which,  however,  do  not  generally  suppurate.  In  the  secondary 
stage  mucous  tubercles,  fissures,  and  ulcers  form,  and  usually  on 
the  sides  or  near  the  tip.  Occasionally  one  meets  with  a  broad 
wart-like  condyloma  on  the  dorsum,  which  may  be  associated  with 
longitudinal  fissures;  it  is  sometimes  termed  '  Hutchinson's  wart.' 
In  the  tertiary  period  chronic  superficial  glossitis  may  develop,  as 
also  diffuse  infiltration  of  the  organ,  or  gummata. 

Gumma  of  the  tongue  is  not  uncommon,  occurring  usually  in 
patients  under  forty  years  of  age,  as  a  late  tertiary  phenomenon. 
It  starts  as  a  localized  submucous  or  intramuscular  infiltration  near 


838  A   MANUAL  OF  SURGERY 

the  median  line,  and  generally  towards  the  middle  or  posterior  part 
(Fig.  400).  The  swelling  is  at  first  hard  and  firm,  but  later  on 
becomes  soft  and  fluctuating,  and  in  time  the  overlying  mucous 
membrane,  which  was  unaffected,  yields,  and  gives  exit  to  the 
characteristic  contents.  The  ulcer  thus  produced  is  oval  or  round 
in  shape,  and  deeply  excavated,  the  base  being  constituted  by  a 
slough.  There  is  but  httle  induration  either  of  the  base  or  edges, 
and  neither  the  floor  of  the  mouth  nor  the  base  of  the  tongue  is 
involved,  so  that  the  organ  can  be  freely  protruded,  whilst  degluti- 
tion and  articulation  are  scarcely  interfered  with.  The  patient 
complains  of  little  pain,  and  the  submaxillary  glands  are  only 
affected  either  as  part  of  a  general  enlargement  throughout  the 
body,  or  from  the  local  irritation.  The  progress  is  slow,  and  the 
effect  of  antisyphilitic  treatment  very  decided,  the  gumma  being 
absorbed,  or  the  ulcer,  if  present,  healing  readily,  but  leaving  a 

localized  area  of  sclerosis  or  a  deep 
cicatrix,  from  which  malignant  disease 
may  subsequently  originate.  In  some 
cases  a  diffuse  infiltration  of  the  organ 
occurs,  leading  to  a  generalized  sclerosis 
rather  than  to  a  localized  gumma.  The 
treatment  consists  in  the  administration 
of  iodides  with  or  without  mercury,  whilst 
t\x  >  ''  -^^^Z  ^^^  mouth  is  kept  clean  with  a  simple 
1     ^-.--^  "^1;^^^*         mouth-wash. 

Innocent  Tumours  are  not  frequent  in 

-^  ^  ^  the  tongue,  papilloma,  cysts,  lipoma,  and 

Fig.  400.— Gumma  of  Right  •   ,  °-       \^J      ,  •    r  •  i.:        „„^    ^^ 

Side  of  Tongue.     (From    "^^i  being  the  chief  varieties,  and  re- 

Wax  Model  in   College    quiring  no  special  description. 

OF  Surgeons'  Museum.)  Dermoid    Cysts    also    form    within    or 

under  the  tongue,  occupying  the  middle 
line,  projecting  either  into  the  floor  of  the  mouth  or  beneath 
the  chin.  They  are  due  to  non-obliteration  of  the  upper  end 
of  the  thyro-glossal  duct  (p.  886).  The  contents  are  of  the  usual 
sebaceous  type.  Such  tumours  should  rarely  be  dealt  with  from  the 
mouth,  as  they  extend  deeply,  and  need  to  be  carefully  dissected 
out.  A  free  incision  should  be  made  beneath  the  chin,  and  the 
whole  cyst  removed  unopened. 

Cancer  of  the  Tongue  occurs  in  the  form  of  squamous  epithelioma, 
and  is  both  a  frequent  and  a  very  fatal  variety  of  this  disease.  It  is 
usually  met  with  in  men,  and  may  arise  as  a  result  of  the  irritation 
caused  by  excessive  smoking,  especially  when  neglected,  rough,  and 
carious  teeth  are  present.  An  underlying  strain  of  syphilis  is  also 
frequently  present  in  these  cases. 

Its  mode  of  onset  varies  somewhat  according  to  the  situation: 
[a]  It  arises  most  commonly  as  an  ulcer  at  the  margin  of  the  organ, 
towards  the  junction  of  the  middle  and  posterior  thirds,  and  is  then 
generally  due  to  the  irritation  caused  by  ragged  and  irregular  bicus- 
pid or  molar  teeth  (Plate  \T.,  Fig.  i) ;  [h)  it  may  start  in  a  crack, 


PLATE  VT. 


Fig.  I. — Epithelioma  of  Tongue,  secondary  to  chronic  superficial^  glossitis.  The 
tongue  was  a  characteristic  one,  showing  heaping  up  of  the  epithelium,  which  was 
white  and  sodden  (ichthyosis),  as  well  as  cracks  and  fissures  in  the  middle  line,  due 
partly  to  chronic  interstitial  glossitis  ;  the  epithelioma  developed  late  in  the  case 
on  the  left  side  opposite  a  diseased  and  dirty  tooth. 


/>•,.-.  5.— Epithelioma  of  Tongue  of  a  hypertrophic  papillomatous  type. 

\To  face  page 'i>l%. 


AFFECTIONS  OF  THE  MOUTH,  THROAT.  AND  (ESOPHAGUS     839 

fissure,  or  cicatrix  on  the  dorsum,  as  a  result  of  chronic  superficial 
glossitis,  or  of  a  preceding  gumma;  (c)  it  may  commence  as  a  wart- 
like growth  (Fig.  2),  the  base  of  which  becomes  infiltrated,  the  tumour 
invading  the  muscular  substance,  and  spreading  to  the  root  of  the 
tongue;  [d)  it  may  originate  as  a  submucous  infiltration,  starting  as 
an  ingrowth  from  the  mucous  membrane,  without  much  external 
manifestation  of  its  presence;  {e)  it  may  first  be  noticed  as  an 
irregular  ulcer  in  the  floor  of  the  mouth;  or  (/)  it  may  spread  into 
the  tongue  from  surrounding  parts,  such  as  the  tonsil  or  larynx. 

In  whatever  way  it  starts,  the  same  features  are  soon  manifested, 
viz.,  a  new  growth  is  noticed,  hard  in  consistence,  indefinite  in  its 
extent,  which  ma}-  or  may  not  be  painful  from  the  first,  and  which 
ulcerates  superficially,  exposing  a  more  or  less  crateriform  cavity, 
with  a  gray,  sloughy,  foul  surface,  readily  bleeding  when  touched, 
and  discharging  a  foul  secretion,  which  causes  extreme  foetor  of  the 
breath.  The  ulcer  is  surrounded  by  an  indurated'  mass,  which 
gradually  shelves  off  into  the  neighbouring  healthy  structures,  or  may 
be  abruptly  limited.  Profuse  salivation  is  produced  by  the  irritation 
of  the  branches  of  the  third  division  of  the  trigeminal,  and  all  the 
movements  of  the  tongue  are  painful  and  limited  on  account  of  the 
infiltration  of  the  base,  so  that  both  swallowing  and  speech  are 
difficult,  the  patient  allowing  the  saliva  to  dribble  out  of  his  mouth. 
The  pain  is  often  severe,  and  usually  extends  along  many  of  the 
branches  of  the  fifth  nerve,  especially  to  the  ear,  so  that  sleep  be- 
comes impossible,  and  the  patient's  condition  steadily  and  rapidly 
deteriorates. 

The  submental,  submaxillary  and  subparotid  glands  early  become 
involved  in  the  disease  according  to  the  position  of  the  primary 
growth;  thus,  cancer  of  the  tip  of  the  tongue  usually  affects  the 
submental  glands ;  if  situated  further  back,  the  submaxillary  glands 
are  involved ;  whilst  in  the  region  of  the  pillars  of  the  fauces  the  sub- 
parotid  glands  are  first  attacked.  Ultimately  the  disease  spreads  to 
the  deep  glands  lying  along  the  main  vessels,  a  gland  lying  over  the 
bifurcation  of  the  common  carotid  artery  being  early  enlarged. 
These  glands,  if  not  removed,  soon  attain  considerable  dimensions, 
and  become  stony  hard  and  fixed  to  surrounding  structures,  especi- 
ally the  carotid  sheath.  If  the  disease  is  strictly  limited  to  one  half 
of  the  tongue,  the  lymphatic  glands  on  the  other  side  of  the  neck  are 
seldom  affected  except  in  the  last  stages ;  but  if  the  disease  extends 
towards  the  centre  of  the  organ,  the  glands  on  both  sides  are  often 
equally  involved.  These  secondary  growths  are  very  frequently 
cystic  in  character,  from  the  degeneration  of  the  masses  of  epithe- 
lium fonned  within  them;  after  a  time  they  approach  the  surface 
and  burst,  leaving  ragged  malignant  ulcers  in  the  neck.  The  lower 
jaw  itself  is  often  invaded  in  the  later  stages  of  the  disease. 

The  occurrence  of  the  typical  cachexia  is  determined  not  only  by 
the  pain  and  consequent  sleeplessness,  but  also  by  the  inability  to 
take  sufficient  nourishment,  the  absorption  of  products  of  putre- 
faction  swallowed  with  the  saliva,   the  excessive  salivation,   the 


S4'5  A   MAl^UAL  OF  SUliGERY 

occasional  lucmorrliages,  and  the  extent  of  the  secondary  growths. 
The  patient  rarely  lives,  apart  from  treatment,  for  more  than  twelve 
months  after  the  disease  has  been  first  noticed.  Death  is  due  to 
exhaustion,  haemorrhage,  or  septic  pneumonia. 

Diagnosis. — When  a  case  is  met  with  where  the  ulcer  is  situated 
at  the  side  or  base  of  the  tongue  in  a  patient  over  forty-live  years  of 
age,  with  the  typical  enlargement  of  the  glands,  profuse  salivation, 
and  impaired  movements,  there  can  be  little  doubt  as  to  the  diag- 
nosis. But  when  it  is  seen  in  the  early  stage,  as  an  inliltration  of  a 
syphilitic  fissure  or  cicatrix,  or  as  a  small  wart,  it  may  be  difficult 
to  determine  whether  or  not  malignant  disease  is  present.  The  early 
enlargement  of  the  glands,  the  amount  and  character  of  pain,  the 
fixity  of  the  organ,  and  the  inliltration  of  the  base  of  the  ulcer,  are 
important  guiding  marks;  but  in  doubtful  cases  a  small  portion  of 
the  edge  of  the  growth  and  of  the  adjacent  parts  should  be  excised 
under  cocaine,  and  subjected  to  careful  microscopic  examination, 
and  thus  its  nature  ascertained.  Moreover,  the  fact  of  improvement 
after  the  administration  of  steadily  increasing  doses  of  iodide  of 
potassium,  does  not  absolutely  disprove  the  existence  of  cancer,  as 
the  two  conditions  so  often  co-exist. 

Treatment.- — The  only  hope  of  curing  the  patient  lies  in  thorough 
.  and  earh'  removal  of  the  growth,  which  it  sliould  be  remembered  has 
probably  extended  much  further  than  one  expects.  The  excision 
must  include  not  only  the  tumour,  but  also  a  wide  area  of  tissue 
around  it,  so  as  to  get  well  beyond  the  zone  of  infiltration;  not  only 
the  lymphatic  glands,  which  are  obviously  enlarged,  but  also  the 
whole  lymphatic  area,  extending  practically  from  the  base  of  the 
skull  to  the  episternal  notch.  It  is  obviously  desirable  to  undertake 
such  extensive  operative  proceedings  in  two  stages,  if  possible,  deal- 
ing first  with  the  tumour  in  the  mouth,  and  subsequently  with  the 
glands.  When  the  base  of  the  organ  is  free  from  infiltration,  and 
the  disease  appears  to  be  separated  from  the  glandular  area  by  a 
sufficient  margin  of  healthy  tissue,  the  operation  in  two  stages  may 
be  undertaken ;  and  the  fact  that  recurrence  is  rarely  noted  in  the 
portion  of  the  organ  that  intervenes  between  the  two  operative  areas 
indicates  that  such  a  practice,  though  not  ideal,  is  justifiable.  The 
mouth  is  often  in  a  very  dirty  state,  and  the  danger  of  infection  after 
making  an  extensive  dissection  of  the  main  vessels  of  the  neck  is  not 
slight.  On  the  other  hand,  when  there  is  considerable  infiltration 
of  the  deeper  parts  of  the  tongue  with  extensive  glandular  mischief, 
it  may  be  impossible  to  find  a  sufficient  margin  of  healthy  tissue  to 
justify  the  division  into  two  stages;  and  then  the  patient  must  run 
the  risks  associated  with  the  removal  of  tongue  and  glands  at  one 
time. 

In  all  cases  great  care  must  be  taken  in  the  preparation  of  the 
patient  so  as  to  minimize  the  risk  of  infective  mischief.     Suitable 
antiseptic  mouth-washes  are  employed  for  some  days;  dirty  roots 
and  stumps  are  removed,  and  the  remaining  teeth  carefully  cleansed.    ' 
Possibly,    if  time  permit,  a  culture  might  be  made  of  the  chief 


AFFECTIONS  OF  THE  MOUTH.  THROA T.  AND  (ESOPHAGUS     841 

organisms  in  the  mouth,  and  a  vaccine  procured,  which  may  help  to 
guard  the  patient  from  post-operative  infection.  It  is  wise  also  to 
keep  him  indoors  for  a  few  days  beforehand  so  as  to  protect  him 
from  risks  of  cold  and  bronchitis. 

The  actual  operative  details  differ  somewhat  according  to  the 
extent  and  situation  of  the  disease,  but  most  of  the  operations  for 
removing  the  growth  are  a  modification  of  the  intrabuccal  method 
suggested  by  Whitehead. 

If  the  tip  only  is  involved,  it  can  be  removed  by  a  V-shaped 
incision,  made  after  steadying  the  tongue  with  a  deep  suture.  The 
small  ranine  artery  will  spurt  on  each  side,  but  is  easily  secured, 
and  the  gap  closed  by  sutures. 

When  the  disease  involves  one  side  of  the  tongae  and  is  not  very 
extensive,  and  does  not  spread  deeply  into  the  base,  it  will  suffice  to 
remove  the  anterior  half  or  two-thirds  of  the  affected  side  as  a  first 
stage  without  touching  the  glands.  The  patient  having  been 
anesthetized,  the  mouth  is  opened  with  an  efficient  gag,  and  anaes- 
thesia is  maintained  by  giving  chloroform  through  a  Junker's 
apparatus,  or  ether  by  intratracheal  insufflation.  A  good  assis- 
tant is  necessary  in  order  to  prevent  blood  entering  the  larynx, 
small  swabs  or  pieces  of  sponge  held  in  smooth-nosed,  long-handled 
forceps  or  suitable  sponge-holders  being  used  to  clear  the  pharynx. 
A  coarse  silk  thread  is  passed  through  each  half  of  the  tongue  to 
draw  it  forwards  and  steady  it.  The  tongue,  being  drawn  out  of 
the  mouth  by  these  loops  of  silk,  is  carefully  divided  by  blunt-ended 
straight  scissors  down  the  middle  line  into  two  segments,  which  are 
readilv  separated  from  one  another  by  the  finger,  the  scissors  merely 
dividing  the  mucous  membrane.  The  base  of  the  organ  is  freed  by 
cutting  through  the  mucous  membrane  close  to  the  alveolus,  and 
then  along  the  middle  line  of  the  floor  of  the  mouth,  so  that  the 
subhngual  salivary  gland  can  be  also  taken  away — a  most  necessary 
step.  The  mucous  fining  of  the  dorsum  is  now  divided  transversely 
behind  the  growth,  and  the  muscular  structure  of  the  organ  slowly 
snipped  through  with  scissors.  During  this  process,  by  the  aid  of 
the  finger  or  a  director,  the  vessels  can  be  seen  and  secured  before 
division.  Removal  of  the  diseased  half  with  the  subhngual  gland 
is  thus  easily  accomphshed  by  making  the  incisions  meet,  and 
dividing  the  "^ intervening  tissues.  Bleeding-points  are  picked  up 
and  secured  as  they  appear.  It  is  often  possible  and  advisable  to 
expedite  heahng  by  closing  the  wound  in  the  tongue  partially  or 
entirelv,  either  bv  stitching  the  mucous  membrane  of  the  dorsum 
to  that  of  the  base,  or,  better,  by  twisting  the  half  tongue  on  itself 
and  stitching  the  tip  to  the  back  of  the  organ.  The  patient  will 
probably  be  sufficiently  recovered  from  this  operation  to  enable  the 
surgeon'to  deal  with  the  glands  in  a  week  or  ten  days  (p.  843). 

If  both  sides  of  the  tongue  are  involved,  but  the  disease  has  not 
extended  deeply  into  the  base,  it  is  not  difficult  to  effect  removal  by 
a  modification  of  the  same  procedure.  The  mouth  is  gagged  open, 
and  two  silk  sHngs  are  inserted,  one  through  the  anterior  portion,  and 


842  A   MANUAL  OF  SURGERY 

the  other  just  in  front  of  the  epiglottis.  The  mucous  membrane  of 
the  floor  of  the  mouth  is  then  incised  on  either  side,  and  the  muscles 
attached  to  the  genial  tubercles  divided.  By  this  means  the  tongue 
is  considerably  loosened  and  can  be  drawn  well  up  out  of  tlie  mouth, 
so  as  to  enable  the  section  to  be  made  across  it  with  scissors  at  the 
desired  level.  The  main  vessels  can  generally  be  seen  and  secured 
before  division,  and  the  amount  of  bleeding  is  not  excessive.  It 
is  often  possible  to  draw  forward  the  stump  of  the  tongue  and 
secure  the  mucous  membrane  anteriorly,  so  as  to  diminish  the  size 
of  the  raw  area  in  the  mouth. 

If  the  disease  extends  more  deeply  into  the  substance  of  the 
tongue,  so  that  the  whole  organ  has  to  be  removed,  it  is  wise  to 
employ  a  preliminary  division  of  the  lower  jaw,  as  originally  sug- 
gested by  Syme,  and  more  lately  recommended  and  practised  by 
Kocher.*  An  incision  is  made  in  the  middle  line  dividing  the 
lower  lip,  extending  downwards  to  the  hyoid  bone.  The  mandible  is 
sawn  through  in  the  middle,  and  the  two  halves  separated  widely. 
As  much  of  the  tongue  as  is  considered  necessary  can  be  easily 
removed  by  the  scissors.  After  affecting  hccmostasis,  a  silk  thread 
or  silver  wire  is  passed  through  the  stump  of  the  tongue  and  epi- 
glottis in  order  to  control  it  and  prevent  interference  with  respiration ; 
the  halves  of  the  jaw  are  wired  together  and  the  superficial  wound 
closed.  It  is  possible  that  a  preliminary  tracheotomy  may  be  useful 
in  these  cases,  but  it  is  not  essential. 

When  the  tongue,  or  a  portion  of  it,  has  to  be  removed  with  the 
glands  en  bloc,  the  lateral  extrabuccal  method,  known  as  Kocher's 
operation,  is  perhaps  the  best.  A  preliminary  tracheotomy  is  usually 
associated  with  it.  An  incision  is  made,  commencing  close  to  the 
lobule  of  the  ear,  running  down  along  the  anterior  border  of  the 
sterno-mastoid  to  the  great  cornu  of  the  hyoid  bone,  and  thence 
forwards  nearly  to  the  middle  line,  and  upwards  to  the  symphysis. 
This  flap  of  skin  and  subcutaneous  tissue  is  dissected  up,  and  stitched 
to  the  cheek  out  of  harm's  way.  All  the  lymphatic  glands  in  the 
region — the  submental,  submaxillary,  and  those  lying  over  the 
carotid — are  now  removed,  as  well  as  the  submaxillary  salivary 
gland,  the  lingual  and  facial  arteries  being  tied  close  to  the  carotid. 
If  necessary,  the  incision  is  enlarged  downwards  along  the  anterior 
border  of  the  sterno-mastoid  in  order  to  permit  of  more  thorough 
removal  of  the  glands.  Any  diseased  portion  of  the  jaw  is  isolated 
by  saw-cuts  in  front  and  behind,  and  removed.  Where  only  half  the 
tongue  is  to  be  removed,  it  is  now  split  down  the  middle  line  with 
scissors,  and  the  mucous  membrane  in  the  floor  and  side  of  the 
mouth  divided  so  as  to  leave  that  side  of  the  tongue  attached  merely 
by  the  muscular  structures.  If  the  whole  organ  is  to  be  removed,  it 
is  unnecessary  to  divide  it  in  the  middle  hue.  By  detaching  the 
mylo-hyoid  from  the  bone  a  communication  is  made  between  the 

*  '  Kocher's  Textbook  of  Operative  Surgery.'  Translated  from  the  fourth 
German  edition  by  Harold  J.  Stiles,  M.B.,  F.R.C.S.  London:  Adam  and 
Charles  Black,  191 1 5 


AFFECTIONS  OF  THE  MOUTH.  THROAT,  AND  (ESOPHAGUS     843 

outside  wound  and  the  mouth,  and  the  tongue  is  then  drawn  through 
this  Literal  opening,  and  can  be  removed  as  far  back  as  the  epiglottis 
behind  and  the  hj^oid  bone  below,  the  whole  floor  of  the  mouth  being 
effectually  dealt  with  in  this  way.  The  wound  in  the  neck  is  closed 
by  buried  and  superficial  sutures,  a  drainage-tube  being  inserted  for 
a  few  days. 

The  After-Treatment  is  much  the  same  in  all  cases.  The  raw 
surface  may  be  painted  with  Whitehead's  varnish  (which  consists  of 
Friar's  balsam,  but  with  the  rectified  spirit  replaced  by  a  saturated 
solution  of  iodoform  in  ether) ;  the  all-essential  thing,  however,  is  to 
keep  the  cavity  well  irrigated  with  antiseptic  lotions,  such  as  weak 
solutions  of  boric  acid,  boroglyceride  (i  in  20),  sanitas  or  lysoform. 
The  patient  must  be  closely  watched  for  the  first  forty-eight  hours,  to 
see  that  his  respiration  is  not  obstructed  by  the  stump  of  the  tongue 
falling  backwards;  but  at  the  end  of  that  time  this  danger  will  be  at 
an  end,  and  the  silk  or  silver  wire  may  be  removed.  It  is  not 
desirable  to  keep  him  in  bed  more  than  two  or  three  days.  The 
patient  is  fed  per  rectum  for  twenty-four  hours,  but  afterwards  a 
tube  attached  to  the  spout  of  a  feeder  is  introduced  into  the  pharynx 
or  oesophagus.  In  the  simpler  cases  he  is  able  to  swallow  freely 
and  without  difficulty  in  the  course  of  a  day  or  two,  and  even  in 
the  worst  cases  he  can  feed  himself  with  a  long  tube  passed  into  the 
pharynx  in  five  or  six  days.  The  chief  dangers  of  the  operation  arise 
from  septic  contamination,  resulting  in  secondary  haemorrhage  or 
septic  pneumonia;  and  these  are  best  avoided  by  careful  and 
thorough  preparation  of  the  patient. 

The  removal  of  a  part,  or  even  the  whole,  of  the  tongue  is  not  such 
a  mutilation  physiologically  as  one  might  expect  at  first.  Degluti- 
tion is  interfered  with  for  a  time,  but  the  power  is  soon  regained,  and 
even  articulation  may  be  in  great  measure  restored. 

The  operation  for  removing  the  glandular  area  in  connection  with 
cancer  of  the  tongue  is  a  formidable  proceeding,  as  its  scope  must 
extend  from  the  mastoid  process  to  the  episternal  notch.  If  the 
disease  has  involved  both  sides  of  the  tongue,  both  sides  of  the  neck 
must  be  cleared,  and  even  when  the  disease  has  only  apparently 
affected  one  side  of  the  tongue,  the  glands  on  both  sides  of  the  neck 
may  be  involved.  The  incision  should  extend  along  the  anterior 
border  of  the  sterno-mastoid  throughout  its  whole  length,  and  a 
second  incision  meets  it  extending  from  the  chin  to  just  below  the 
great  cornu  of  the  hyoid  bone.  The  flaps  thus  marked  out  are  dis- 
sected up  and  turned  forwards,  the  platysma  being  included  in  them. 
The  submental  and  submaxillary  regions  are  cleared  of  their  loose 
cellular  tissue,  including  all  lymphatic  glands  and  the  submaxillary 
salivary  gland  (except  the  deep  process  and  duct) ,  which  are  turned 
back  towards  the  main  vessels.  The  internal  jugular  vein  is  then 
laid  bare  and  all  the  lymphatic  glands  lying  upon  it  are  dissected 
upwards  from  below  or  downwards  from  above.  All  the  cellular 
tissue  of  the  anterior  triangle  is  cleared  away  in  one  piece  with  the 
glands,  extending  from  that  which  lies  under  cover  of  the  omohyoid 


844  A   MANUAL  OF  SURGERY 

below  to  those  which  are  phiced  beneath  the  posterior  belly  oi  the 
digastric  and  lower  edge  of  the  parotid  above.  The  facial  and 
lingual  arteries  will  have  to  be  secured  back  and  front ;  the  external 
jugular  vein  will  be  sacrificed,  and  if  need  be  the  interned  should  also 
be  taken  away;  but  the  facial  and  spinal  accessory  nerves  must  be 
spared.  Careful  deep  suturing  will  minimize  the  deformity,  but  it 
will  be  necessary  to  drain  the  lower  part  of  the  wound,  and  if  the 
parotid  has  been  encroached  on  a  tube  must  also  be  inserted  above. 

Affections  of  Salivary  Glands. 

Inflammation  of  the  Parotid  Gland  is  met  with  in  several  different 
forms. 

1.  Epidemic  Parotitis  (Mumps)  is  an  acute  specific  disease  usually 
seen  in  children,  and  highly  infectious  or  contagious  in  character. 
The  period  of  incubation  is  about  three  weeks,  and  the  attack 
itself  consists  in  a  slight  febrile  disturbance,  associated  with 
swelling  of  one  or  both  parotid  glands;  one  gland  is  attacked  first, 
becoming  enlarged  and  tender,  whilst  the  other  side  is  similarly 
affected  in  a  day  or  two.  Mastication  becomes  difficult,  owing  to 
the  tension  of  the  parts.  The  swelling,  which  lasts  for  about  a  week 
and  then  gradually  subsides,  extends  below  and  in  front  of  the  ear, 
and  the  socia  parotidis  can  be  distinctly  felt  lying  over  the  masseter  ; 
the  submaxillary,  sublingual,  and  neighbouring  lymphatic  glands  are 
sometimes,  but  not  frequently,  enlarged.  Suppuration  is  rare,  but 
in  adults  metastatic  inflammation  of  the  testis,  mamma,  or  ovary  is 
not  uncommon.  This  complication  is  generally  unilateral,  and  thus, 
although  atrophy  of  the  testis  commonly  follows  orchitis,  sterility 
is  not  produced.  Treatment.- — Keep  the  patient  warm  and  quiet,  and 
administer  salines.  In  the  later  stages  friction  with  stimulating 
liniments  will  hasten  resolution.  After  the  acute  attack,  the  gland 
may  remain  enlarged  for  some  time. 

2.  A  Simple  Parotitis  occasionally  results  from  exposure  to  cold 
or  from  injury,  whilst  the  presence  of  a  calculus  in  the  duct  leads  to 
a  chronic  sclerosing  inflammation.  The  s>Tnptoms  consist  of  pain 
and  swelling,  together  with  a  certain  amount  of  constitutional  dis- 
turbance. An  extremely  interesting  phenomenon  is  the  parotitis 
which  follows  injuries  or  diseases  of  the  abdominal  or  pelvic  viscera. 
This  condition  is  not  very  unusual,  and  was  fomierly  attributed  to 
pyaemia,  but  is  now  considered  to  be  due  to  infection  spreading  up 
from  the  mouth,  owing  to  a  dirty  state  of  the  teeth  induced  by 
prolonged  rectal  feeding.  In  confirmation  of  this  view  is  the  fact 
that  it  has  been  seen  in  not  a  few  cases  of  gastric  ulcer,  where  the 
patient  had  been  fed  per  rectum  for  some  time.  Treatment  in  these 
simple  cases  consists  in  the  application  of  fomentations,  perhaps 
medicated  with  belladonna. 

3.  Suppurative  Parotitis  is  a  much  more  serious  condition.  It  may 
extend  from  the  mouth  along  Stenson's  duct,  or  supervene  in  the 
course  of  pyaemia,  or  as  a  sequela  of  some  of  the  exanthemata — e.g., 


A  FFECTIONS  OF  THE  MO  UTII.  THRO  A  T,  A  ND  OISOPHA  G  US     845 

scarlet  or  typhoid  fevers.  The  gland  becomes  much  enlarged,  with 
congestion  and  oedema  of  the  overlying  skin,  and,  owing  to  the  ten- 
sion of  the  fascia,  exceedingly  painful.  For  the  same  reason,  pus 
cannot  readily  find  its  way  to  the  surface,  and  hence  is  likely  to 
burrow  in  various  directions — e.g.,  amongst  the  muscles  of  the  neck, 
or  even  upwards  and  inwards  towards  the  base  of  the  skull,  or  to 
the  cavity  of  the  mouth,  finding  its  way  over  the  border  of  the 
superior  constrictor  (the  so-called  '  sinus  of  Morgagni  ').  The  con- 
stitutional symptoms  from  toxic  absorption  are  usually  very  severe. 
Owing  to  the  fact  that  large  veins  and  arteries  pass  through  the 
parotid  gland,  pysemic  symptoms  are  not  unhkely  to  supervene,  and 
the  prognosis  is  therefore  somewhat  serious. 

Diagnosis. — Inflammation  of  the  lymphatic  glands  lying  on  the 
outer  surface  of  the  parotid  closely  simulates  the  above  affections, 
but  is  distinguished  from  them  by  the  fact  that  they  are  more 
superficial,  and  that  the  socia  parotidis  is  not  enlarged 

Treatment. — In  the  early  stages  fomentations  are  employed,  but 
as  soon  as  there  is  any  indication  that  suppuration  has  occurred,  a 
free  incision  must  be  made,  and  the  pus  let  out.  Every  precaution 
should  be  taken  to  prevent  mischief  to  the  facial  nerve,  and  Hilton's 
method  of  operating  may  be  advantageously  employed;  but  in  the 
more  severe  cases  where  the  patient's  life  is  threatened  and  the  pus 
is  burrowing  in  all  directions,  the  knife  must  be  used  freely,  regard- 
less of  anatomical  considerations. 

Inflammation  of  the  submaxillary  and  sublingual  glands  may  arise 
in  an  exactly  similar  way,  but  no  special  description  is  called 
for.  _  Occasionally,  however,  the  process  extends  beyond  the  sub- 
maxillary glands  to  the  neighbouring  tissues,  giving  rise  to  what  has 
already  been  described  as  submaxillary  cellulitis,  or  Ludwig's  an- 
gina (p.  89). 

Ranula  is  a  cystic  swelHng  of  the  floor  of  the  mouth,  containing 
a  glairy  mucoid  fluid,  and  sometimes  due  to  obstruction  and  disten- 
sion of  one  of  the  sublingual  ducts  (or  ducts  of  Rivini) .  A  similar 
condition  has  been  caused  in  rare  cases  by  a  blocking  of  Wharton's 
duct,  but  this  has  generally  been  found  to  run  along  the  outer  surface 
of  the  cyst.  The  tumour  may  be  as  large  as  a  walnut  or  pigeon's 
egg,  and  is  unilateral.  The  Treatment  consists  in  removing  a  good- 
sized  piece  of  the  wall,  so  that  the  cavity  may  be  obliterated  by  a 
process  of  granulation,  or  if  that  should  fail,  the  whole  cavity  must 
be  dissected  out. 

Obstruction  to  the  Flow  of  Saliva  results  from  various  causes,  such 
as  cicatricial  contraction  in  the  neighbourhood  of  the  entrance  of  the 
duct  into  the  mouth,  or  from  the  presence  in  the  duct  of  a  salivary 
calculus,  consisting  of  phosphate  and  carbonate  of  lime,  and  usually 
fusiform  in  shape.  Calculus  formation  only  occurs  in  connection 
with  the  submaxillary  and  sublingual  glands,  since  the  saliva  secreted 
by  them  is  thick  and  mucoid,  whereas  parotid  saliva  is  limpid  in 
character. 

The  chief  Symptom  of  such  obstruction  is  a  painful  enlargement 


846  A  MANUAL  OF  SURGERY 

of  the  gland  during  and  after  meals,  which  slowly  passes  away  as 
the  saliva  finds  its  way  past  the  block;  if  it  persists  for  long,  the 
gland  becomes  chronically  enlarged,  and  its  interstitial  tissue  in- 
creased in  bulk,  whilst  a  certain  amount  of  peri  -  adenitis  also 
follows.  When  a  calculus  is  present,  there  is  usually  a  consider- 
able discharge  of  offensive  muco-pus  into  the  mouth.  Where  the 
obstruction  is  complete,  a  cyst  may  form,  and  if  this  is  opened, 
or  finds  its  way  to  the  exterior  and  bursts,  a  salivary  fistula  results. 

Treatment. ^In  cases  of  simple  obstruction  an  attempt  must  be 
made  to  restore  the  natural  exit,  or  to  make  an  artificial  one.  If  a 
calculus  is  present,  it  can  usually  be  seen  or  felt  at  intervals  project- 
ing from  the  entrance  of  the  duct ;  in  such  a  case  the  duct  must  be 
incised  from  the  mouth,  and  the  stone  removed.  Where,  however, 
it  is  located  in  the  substance  of  the  submaxillary,  total  removal  of 
the  gland  ma\-  be  necessary. 

Salivary  Fistula  occurs  almost  solely  in  connection  with  the  parotid 
gland.  It  arises  from  penetrating  wounds  of  the  cheek  dividing 
Stenson's  duct,  or  more  frequently  it  follows  operations  in  its  neigh- 
bourhood. It  is  a  very  troublesome  condition,  both  for  the  surgeon 
who  is  called  upon  to  treat  it,  and  for  the  patient  who  suffers  from 
the  inconvenience  of  saliva  flowing  down  the  cheek,  the  amount 
being,  of  course,  increased  at  meal-times.  Stenson's  duct  extends 
forsvards  from  the  socia  parotidis  across  the  masseter  muscle  for  a 
distance  of  about  2  inches,  and  then  turns  abruptly  inwards  to  pierce 
the  buccinator,  and  enter  the  mouth  opposite  the  second  upper 
molar  tooth.  The  buccal  and  masseteric  portions  are  almost  at 
right  angles,  the  latter  being  represented  by  a  line  drawn  from  the 
lobule  of  the  ear  to  a  point  midwa^^  between  the  ala  nasi  and  the 
angle  of  the  mouth.  The  diameter  of  the  duct  is  about  |  inch,  its 
narrowest  portion  being  at  the  orifice. 

Treatment.^ — If  the  buccal  portion  is  involved,  a  cure  is  often 
attained  by  slitting  up  the  duct  within  the  mouth;  but  when  the 
masseteric  portion  is  wounded,  and  especially  if  near  the  socia 
parotidis,  treatment  becomes  more  difficult.  The  following  plan 
is  often  successful:  A  fine  probe  is  passed  along  the  duct  from  the 
mouth  as  far  as  the  lesion;  it  is  then  grasped  by  forceps  inserted 
through  the  external  aperture,  and  drawn  out  on  to  the  cheek,  a  pro- 
ceeding sometimes  facilitated  by  slightly  enlarging  the  wound.  A 
double  thread  of  silk  is  now  tied  to  the  end  of  the  probe,  and  drawn 
through  the  thickness  of  the  cheek,  along  the  buccal  portion  of  the 
duct,  and  out  of  the  external  wound.  A  fine  drainage-tube  is  then 
carried  along  the  same  track,  and  left  so  as  to  project  both  externally 
and  internally.  A  silk  thread  is  attached  to  each  end  of  the  tube, 
and  these  are  knotted  together  round  the  angle  of  the  mouth.  By 
this  means  a  passage  is  re-established  into  the  mouth,  and  as  soon  as 
it  becomes  easier  for  the  saliva  to  travel  along  this  than  along  the 
external  wound,  the  fistula  will  close.  At  the  end  of  a  few  days  the 
outer  half  of  the  tube  is  removed,  and  only  a  silk  thread  allowed  to 
occupy  the  outer  portion  of  the  fistula,  which  gradually  contracts  so 


AFFECTIONS  OF  THE  MOUTH,  THROAT.  AND  (ESOPHAGUS     847 


that  more  and  more  of  the  saliva  finds  its  way  into  the  mouth.  The 
silk  thread  and  tube  are  then  finally  removed,  and  if  the  opening  in 
the  mouth  is  kept  patent,  the  external  wound  soon  heals.  In  those 
cases  where  the  buccal  portion  of  the  duct  is  completely  obliterated 
or  obstructed  so  that  a  probe  cannot  be  passed,  a  trocar  and  cannula 
are  inserted  through  the  external  wound  and  cheek  into  the  mouth; 
a  silk  thread  is  insinuated  through  the  cannula,  and  a  tube  drawn  into 
position,  as  in  the  former  case.  The  subsequent  treatment  is  the 
same  as  that  indicated  above. 

Tumours  of  the  Parotid  Gland  are  of  considerable  interest,  and 
may  be  simple  or  malignant. 

{a)  The  Simple  parotid  tumour  is  usually  an  endothelioma,  in 
which,  however,  fibrous  and  adenoid  tissue  may  occur.  It  usually 
commences  near  the  surface  in  the  endothelium  lining  the  blood- 
vessels and  lymph  spaces,  and,  owing 
to  a  colloid  or  mucoid  degeneration 
of  the  interstitial  tissue,  may  simu- 
late a  chondroma  or  myxoma.  The 
tumour  feels  hard,  firm,  and  nodular, 
but  areas  of  softening  may  be  in- 
terspersed amongst  the  harder  por- 
tions. The  mass  is  situated  between 
the  jaw  and  the  sterno-mastoid, 
accessory  processes  also  extending 
over  the  masseter  in  the  region  of  the 
socia,  and  later  on  burrowing  deeply 
between  the  mastoid  bone  and  the 
styloid  process,  and  beneath  the 
ramus  of  the  jaw  (Fig.  401).  In 
the  early  stages  the  tumour  is  freely 
moveable  on  the  deeper  parts,  as 
is  also  the  skin  over  it,  but  subse- 
quently the  mass  becomes  fixed 
and  adherent.  The  growth  is  usually  slow,  and  at  first  quite  pain- 
less, and  there  is  no  tendency  to  invade  lymphatic  glands  or  produce 
cachexia.  Mastication  is  impaired  in  the  later  stages,  but  otherwise 
the  subjective  symptoms  are  of  but  slight  importance,  owing  to  the 
fact  that  the  growth  is  superficial  to  the  gland,  and  to  the  more 
important  vessels  and  nerves.  If  allowed  to  persist,  the  growth 
will  finally  take  on  malignant  characters.  True  adenoma  or  fibroma 
of  the  parotid  gland  is  occasionally  observed. 

[h)  Malignant  tumours  of  the  parotid  (Fig.  402)  occur  in  the  form 
of  endothelioma,  sarcoma,  or  carcinoma,  and  are  not  unfrequently 
grafted  on  to  a  simple  tumour,  the  change  of  type  being  marked  by 
increased  rapidity  of  growth  and  greater  pain.  The  mass  becomes 
more  fixed,  and  signs  of  pressure  upon  the  vessels  and  nerves 
develop;  the  facial  nerve  is  very  likely  to  be  imphcated,  leading 
to  paralysis  of  the  face.  Moreover,  the  skin  becomes  hyperaemic 
and  often  adherent  to  the  tumour,  and  finally  ulceration  9,nd  even 


Fig.  401. — Parotid  Tumour. 
(Fergusson.) 


A   MANUAL  OF  SURGERY 


fungation  may  obtain.  Secondary  deposits  occur  in  the  neigh- 
bouring lymphatic  glands  or  in  the  viscera,  and  the  patient  soon 
passes  into  a  state  of  malignant  cachexia.  Carcinomatous  tumours 
are  less  common  than  the  sarcomata,  but  run  a  similar  course. 
The  growth  is  an  adenoid  cancer,  not  unfrequently  of  the  soft  or 
encephaloid  type,  and  neighbouring  lymphatic  glands  are  early 
invaded. 

The  Diagnosis  of  simple  parotid  tumours  from  malignant  growths 
is  a  matter  of  the  greatest  importance  from  a  prognostic  point  of 
view,  since  simple  tumours  are  usually  encapsuled,  and  their  removal, 
except  when  large  or  deeply  placed,  is  not  a  matter  of  special  diffi- 
culty; malignant  disease  is  more  diffuse,  rendering  extirpation  of 
the  "mass  almost  impracticable.  The  distinction  between  the  two 
forms  is  made  by  a  consideration  of  the  signs  and  symptoms  con- 
sidered above,  attention  being 
directed  to  the  rate  of  growth, 
the  condition  of  the  skin  and 
surrounding  parts,  the  mobility 
or  not  of  the  neoplasm,  and  the 
general  aspect  of  the  patient, 
whilst  associated  paralysis  of 
the  facial  nerve  is  almost  always 
characteristic  of  malignancy. 
The  lymphatic  glands  lying  on 
the  surface  of  the  parotid,  when 
invaded  by  tubercle  or  by 
epithelioma  secondary  to  some 
intrabuccal  growth,  may  closely 
simulate  a  true  parotid  tumour, 
but  are  recognised  by  their 
more  superficial  position. 

The  Treatment  is  often  a 
matter  of  some  difficulty,  owing 
to  the  important  character  of 
the  surrounding  tissues.  Removal  should  only  be  attempted  if  the 
skin  is  not  extensively  involved,  if  the  growth  is  moveable  on  the 
deeper  parts,  and  if  there  is  no  evidence  of  secondary'  deposits. 
Even  simple  tumours  become  irremoveable  after  a  time  on  account 
of  their  deep  connections  and  change  of  type,  whilst  it  is  seldom 
justifiable  to  touch  malignant  growths  on  account  of  their  early 
and  wide  local  dissemination.  Simple  parotid  tumours  are  dealt 
with  by  turning  forwards  or  upwards  a  flap  of  skin  and  subcu- 
taneous tissue,  so  as  to  expose  completely  the  capsule  and  enable 
the  dissection  of  the  growth  to  be  made  with  as  little  danger 
to  the  facial  nerve  as  possible.  It  is  generally  placed  beneath  the 
growth,  but  occasionally  runs  superficial  to  it,  or  in  its  substance. 
The  tumour  is  often  enucleated  without  much  difficulty,  but  the 
surgeon  must  make  certain  that  no  deeper  processes  are  left,  or  re- 
currence will  inevitably  follow.     The  haemorrhage  from  the  trans- 


FlG. 


402.  —  Malignant     Tumour     of 
THE  Parotid  Gland. 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     849 


verse  facial  and  other  arteries  is  free,  but  easily  restrained.  There 
is  no  need  to  remove  redundant  skin  in  these  cases,  as  it  quickly 
contracts. 

In  dealing  with  early  malignant  disease  excision  of  the  whole  parotid 
gland  may  be  occasionally  required.  It  is  accomplished  through  a 
vertical  incision,  or  if  the  skin  is  involved  by  two  crescentic  ones. 
The  gland  is  then  gradually  freed  from  its  connections,  care  being 
taken,  if  possible,  to  keep  outside  its  capsule.  It  is  best  to  deal 
with  the  lower  part  first,  securing  with  double  ligatures  the  external 
carotid  artery  and  temporo-facial 
vein.  The  mass  is  then  drawn  up- 
wards and  forwards,  and  its  deep 
connections  severed.  The  facial 
nerve  is,  of  course,  divided,  and  the 
patient  must  be  warned  before  the 
operation  of  the  necessarily  result- 
ing facial  palsy.  Recurrence  is 
almost  certain  to  follow.  Removal 
of  the  angle  of  the  jaw  as  a  pre- 
liminary step  has  been  recommended, 
since  considerable  space  is  gained 
thereby,  and  a  better  access  to  the 
field  of  operation. 

Tumours  o£  the  Submaxillary 
Gland  are  very  similar  in  nature 
to  those  of  the  parotid.  Simple 
tumours  are  represented  by  endo- 
theliomata,  resembling  cartilaginous 
or  myxomatous  growths,  according 
to  whether  they  are  hard  or  soft  (Fig.  403).  Sarcoma  and  car- 
cinoma are  also  met  with;  if  seen  in  the  early  stages  they  are 
easily  removed. 


Fig.  403.— 

MOUR. 


-Submaxillary  Tu- 

(TlLLMANNS.) 


Affections  of  the  Palate. 

Cleft  Palate.— By  cleft  palate  is  meant  a  congenital  defect  of  the 
roof  of  the  mouth,  whereby  the  structures  entering  into  its  formation 
do  not  unite  in  the  middle  line,  thus  allowing  an  abnormal  com- 
munication to  exist  between  the  nose  and  mouth.  The  term  does 
not  include  losses  of  substance,  resulting  from  injury,  syphilis,  or 
lupus.  The  mildest  cases  consist  merely  of  a  bifid  uvula,  perhaps 
not  involving  the  palate  at  all ;  the  next  degree  of  severity  affects 
the  velum  alone  (Fig.  404,  A) ;  more  or  less  of  the  hard  palate  may 
also  be  implicated,  the  cleft  reaching  as  far  forwards  as  the  site 
of  the  anterior  palatine  canal  (B) ;  whilst  the  severest  type 
of  the  deformity  extends  in  addition  through  the  alveolus  and  upper 
lip  on  one  or  both  sides,  the  os  incisivum  being  in  the  latter 
case  displaced  forwards,  perhaps  on  the  tip  of  the  nose  (C). 
The  union  of  the  palatal  segments  takes  place  from  before  back- 

54 


850 


A   MANUAL  OF  SURGERY 


wards,  so  that  it  is  very  unusual  to  find  the  alveolar  portion  of  the 
palate  affected  apart  from  the  rest. 

On  looking  carefully  at  a  cleft  palate,  the  defect  usually  appears  to 
be  mesial,  but  occasionally  it  seems  as  if  a  unilateral  or  bilateral 
fissure  existed.  To  understand  such  an  occurrence  it  must  be 
remembered  that  three  anatomical  elements  unite  in  the  middle  line 
of  the  roof  of  the  mouth,  viz.,  the  two  palatal  processes  growing  in 
horizontally  from  the  maxillai,  one  on  each  side,  and  tlic  ethmo- 
vcmerine  septum  projecting  vertically  downwards  from  the  under 
surface  of  the  fronto-nasal  process  and  base  of  the  skull.  All  these 
should  join  together  about  the  ninth  or  tenth  week  of  intra-uterine 
life.  If,  however,  the  palatal  processes  fail  to  reach  the  middle  line, 
a  median  defect  appears  (Fig.  405,  A),  unless  the  ethmo-vomerine 
septum  is   so  hypertrophied  as  to  project   between  them,  when 


Fig.  404. — Various  Forms  of  Cleft  Palate:  A,  Involving  merely  the 
Velum;  B,  traversing  the  Hard  Palate  as  Far  Forwards  as  the 
Anterior  Palatine  Canal;  and  C,  being  complicated  with  a  Double 
Hare-Lip. 

the  appearance  of  a  double  cleft  is  produced  (B).  When  only 
one  division  of  the  palate  unites  with  the  septum,  an  apparently 
unilateral  cleft  results;  most  commonly  the  defect  is  on  the  left 
side,  the  vomer  being  attached  to  the  right  free  edge,  a  left-sided 
alveolar  hare-lip  also  complicating  the  case  (C).  In  these  cases  the 
septum  often  slopes  off  so  as  to  appear  to  be  continuous  with  the 
palatal  segment. 

The  width  of  the  cleft  and  the  slope  of  the  segments  varies  greatly 
in  different  cases.  The  wider  the  cleft,  the  more  unfavourable  it  is 
for  treatment  by  operative  means ;  and  this  is  one  of  the  arguments 
used  in  favour  of  the  removal  of  the  intermaxilla  in  cases  of  double 
hare-lip,  so  as  to  allow  of  the  approximation  of  the  two  maxillae. 
As  to  the  slope  of  the  segments,  the  more  vertical  they  are,  the 
more  favourable  for  operation,  since  the  flaps  of  muco-periosteum 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     851 

easily  meet  in  the  middle  line.  When  the  palate  is  more  horizontal, 
and  like  a  Norman  rather  than  a  Gothic  arch,  the  flaps  are  shorter, 
and  greater  lateral  displacement  is  necessary  to  bring  their  edges 
into  a])position;  this  involves  much  more  traction  on  the  stitches, 
and  hence  less  satisfactory  results. 

1  he  effect  of  such  a  deformity  upon  the  infant,  from  a  physiological 
point  of  view,  is  very  serious.  The  process  of  nutrition  is  consider- 
ably impaired,  owing  to  the  fact  that  the  power  of  suction  is  lost, 
and  fluids  taken  into  the  mouth  are  apt  to  escape  through  the  nostrils 
instead  of  being  swallowed.  Consequently  these  children  must  be 
carefully  spoon-fed  with  the  head  thrown  well  back.  Articulation 
becomes  very  indistinct,  so  that  it  is  often  impossible  to  understand 
what  is  said,  the  voice  having  a  peculiar  and  characteristic  intona- 
tion. All  the  letters  known  as  explosives,  whether  dentals,  labials, 
or  gutturals,  requiring  a  certain  amount  of  air  pressure  within  the 


ABC 
Fig.  405. — Diagram  to  Show  the  Modifications  of  Cleft  Palate. 

a,  Ethmo- vomerine  septum;  b,  palatal  segments;  c,  tongue;  d,  cavity  of  the 
I  nose;  e,  buccal  cavity. 

mouth  for  their  due  pronunciation,  are  difficult  to  produce,  par- 
ticularly b,  d,  p,  t,  g,  f,  etc.  Moreover,  the  exposure  of  the  nasal 
mucous  membrane  to  the  air  is  so  much  greater  than  usual  that  it 
is  liable  to  chronic  rhinitis  sicca  (p.  820).  Both  taste  and  smell 
are  much  diminished,  partly  from  the  unhealthy  state  of  the  mucous 
membrane,  and  also  from  the  absence  of  an  opposing  surface  against 
which  the  food  can  be  tiiturated  by  the  tongue. 

Treatment.- — Considerable  divergence  of  opinion  exists  as  to  the 
period  at  which  operation  should  be  undertaken  for  dealing  with 
this  defect,  and  also  as  to  the  best  method  to  be  employed.  Some 
surgeons  advocate  its  performance  at  as  early  a  date  as  possible, 
even  within  a  few  weeks  of  birth;  but,  whilst  admitting  that  in  some 
hands  this  seems  to  have  met  with  a  certain  degree  of  success,  the 
plan  does  not  seem  generally  applicable.  The  parts  are  very  small; 
the  tissues  are  very  delicate  and  friable.  The  operation  is  therefore 
increasingly  difficult,  and  the  child  is  incapable  of  standing  much 
shock  or  loss  of  blood.     On  the  other  hand,  operation  should  not 


852  A   MANUAL  OF  SURGERY 

be  deferred  too  long;  bad  habits  of  articulation  will  be  contracted, 
and  subsequent  physiological  success,  as  gauged  by  the  quality  of 
the  speech,  is  much  less  likely  to  follow.  On  the  whole,  we  see  no 
reason  to  modify  the  opinion  expressed  from  the  start  in  this  text- 
book, that  the  best  period  for  operation  is  between  the  second  and 
third  years,  when  a  child  can  be  easily  kept  under  control.  It  is 
most  important  that  the  general  health  be  good,  and  the  mouth  and 
throat  free  from  local  disease  or  inflammation.  To  guard  against 
accidents,  it  is  well  to  make  a  routine  practice  of  keeping  a  child 
indoors  under  observ-ation  for  a  few  days  before  operating,  and  for 
choice  the  spring  or  summer  should  be  selected.  Enlarged  tonsils 
are  usually  removed  before  operation,  but  a  pad  of  pharyngeal 
adenoids  may  sometimes  be  left  with  advantage,  as  they  assist 
subsequently  in  closing  the  nasal  cavity. 

The  object  of  operative  treatment  is  to  close  the  gap  in  the  hard 
palate  by  the  union  of  flaps  of  muco-periosteum  or  by  compressing  the 
maxillae;  it  is  also  desirable  that  the  velum  palati  should  not  only 
be  continuous,  but  mobile.  Of  the  various  methods  that  have  been 
suggested  to  attain  these  ends,  only  three  need  be  noted. 

Brophy's  operation  is  one  which  aims  at  closing  the  palate  by  draw- 
ing together  the  bony  maxillse.  The  child  is  anaesthetized;  the 
margins  of  the  cleft  are  pared,  even  down  to  the  bone,  and  stout 
silver  sutures,  two  or  three  in  number,  are  carried  through  the 
maxillae  from  side  to  side,  just  above  the  palate.  The  ends  of  the 
silver  wire  are  passed  through  holes  in  lead  plates,  and  drawn 
tightly  together  by  twisting.  The  maxillae  are  forced  together  by 
digital  pressure  so  as  to  approximate  the  margins  of  the  palate,  and 
the  wires  are  tightened  as  much  as  necessary.  The  soft  palate  is 
subsequently  closed  by  sutures.  The  wires  are  kept  in  place  for 
three  or  four  weeks  and  then  removed  This  operation  is  not 
desirable  after  the  age  of  six  months,  and  should  be  performed 
before  the  treatment  of  the  associated  hare-lip.  It  has  been  but 
little  used  in  this  country,  and  its  advantages  are  doubtful. 

Lane's  method  of  treatment  is  applicable  to  young  children  within 
a  few  weeks  of  birth.  It  is  in  reality  an  elaboration  of  the  method 
suggested  by  the  late  Mr.  Davies  CoUey.  It  consists  in  raising 
suitably  shaped  flaps  of  muco-periosteum  from  either  side  of  the 
palate,  in  such  a  manner  that  when  turned  over  they  can  be  sutured 
one  to  the  other,  and  form  a  complete  barrier  between  the  mouth 
and  the  nose.  Text-books  on  operative  surgery  must  be  consulted 
for  exact  details  of  this  procedure,  which  will  have  to  be  modified 
according  to  the  requirements  of  each  particular  case,  but  the 
accompanying  diagrams  (Figs.  406  to  410)  will  sufficiently  suggest 
the  character  of  the  operation.  It  will  be  noted  that  the  muco- 
periosteum  is  detached  on  one  side  from  the  bony  palate,  and  allowed 
to  hang  down,  whilst  a  small  flap  consisting  only  of  mucous  mem- 
brane is  raised  from  the  back  of  the  soft  palate.  On  the  other  side 
a  similar,  but  rather  more  extensive  flap,  encroaching  on  the  alveolus, 
is  raised  from  without  inwards,  and  turned  over,  the  free  margin 


Fig.  406  indicates  the  treatment 
of  the  left  side  of  the  palate. 
At  A  and  B  small  incisions  are 
made,  through  which  the  com- 
plete  muco-periosteum  of  the 
hard  palate  is  separated  from 
the  bone.  The  dotted  hnes 
from  CD  indicate  the  outlines 
of  a  flap  of  mucous  membrane 
to  be  raised  from  the  upper 
nasal  surface  of  the  velum; 
a  smaller  flap  is  raised  from 
the  margin  of  the  hard  palate. 

Fig.  407  shows  the  incision  (EF 
GH)  needed  on  the  right 
side,  and  shows  the  muco- 
periosteal  flap  in  process  of 
being  raised. 


*    exposed 


Figs.   408  and  409. — Palatal  Flaps  Dissected  up  and  Ready 
FOR  Suturing. 


Fig.   ^10.  —  Palatal    Flaps    Over- 
lapped AND  Sutured  Together 


The  lower  figure  shows  the  completed 
palate  in  section,  M  representing 
the  flap  from  the  right  side,  over- 
lapped by  and  united  to  L,  the 
muco-periosteum  of  the  left  side. 


Figs.  406-410. 

LANE'S  OPERATION  FOR 
CLEFT  PALATE. 


853 


854 


A   MANUAL  OF  SURGERY 


of  the  cleft  acting  as  a  hinge.  The  raw  surfaces  of  these  two  flaps 
are  approximated  by  a  double  row  of  suitable  stitches,  and  if  they 
unite  an  effective  barrier  is  produced,  constituting  a  new  palate. 
It  will  be  noted  that  a  considerable  area  has  to  be  left  bare,  to  be 
healed  by  granulation,  and  some  amount  of  interference  with  the 
subsequent  development  of  the  teeth  may  be  anticipated.  It  is 
very  doubtful  whether  the  final  results  are  any  more  satisfactory 
than  those  gained  by  Langenbeck's  operation,  and  certainly  a  good 
many  failures  and  a  certain  percentage  of  deaths  have  been  re- 
corded. 

Langenheck' $  operation  of  uranoplasty  is  usually  undertaken  be- 
tween the  age  of  two  and  three  years,  and  in  practised  hands  gives 
admirable  results.  It  consists  in  the  detachment  of  muco-periosteal 
flaps  from  either  side,  and  the  careful  approximation  of  their  pared 


Fig.  411. — Diagrams  to  indicate  Extent   of  Incisions  in  Urano 

PLASTY. 

The  thick  black  lines  show  the  primary  incision;  the  thick  dotted  lines,  the 
extension  backwards  of  the  same  to  relieve  lateral  tension ;  the  thin  dotted 
lines  indicate  approximately  the  position  of  the  free  border  of  the  bony 
palate.  The  right-hand  figure  shows  the  position  of  the  sutures,  and  the 
condition  of  the  parts  at  the  close  of  the  operation. 

edges  one  to  the  other.  In  a  case  involving  both  the  hard  and  soft 
palates  there  is  no  reason  why  the  whole  cleft  should  not  be  dealt 
with  at  one  sitting ;  and  there  are  but  few  cases  where  the  gap  is  so 
wide  that  it  cannot  be  closed  by  this  means,  at  any  rate  posteriorly. 
Occasionally  the  anterior  portion  of  the  cleft  has  to  be  left  open, 
especially  if  the  premaxilla  has  been  removed;  but  this  really  is 
not  an  important  matter,  as  an  obturator,  carrying  the  necessary 
artificial  teeth,  can  always  be  applied.  Where  the  soft  palate, 
with  or  without  the  posterior  part  of  the  hard  palate,  is  alone  in- 
volved, Langenbeck's  operation  gives  admirable  results. 

Operation. — Anaesthesia  is  induced  in  the  ordinary  way  by 
chloroform  dropped  upon  a  suitable  mask  or  given  by  Junker's 
apparatus.  The  greatest  care  must  be  taken  not  to  drop  chloro- 
form into  the  mouth  nor  to  direct  the  stream  of  chloroform  vapour 
against  the  edges  of  the  cleft.    The  mouth  is  efficiently  gagged 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     855 

open,  and  preferably  by  a  unilateral  instrument  which  can  easily 
be  slipped  in  and  out  of  place. 

Stacc  I.  :  Incision  and  Detachment  of  Muco-periosteal  Flaps. — 
The  knife  should  be  inserted  close  to  the  last  molar  tooth  and  about 
half  an  inch  from  the  alveolar  margin,  and  carried  forwards  parallel  to 
the  teeth  to  a  spot  just  anterior  to  the  apex  of  the  cleft;  or,  if  the 
alveolus  is  involved,  the  incision  should  stop  behind  the  lateral  in- 
cisor to  preserve  the  vascular  supply  of  theiront  of  the  flap  (Fig.  411) . 
The  muco-periosteum  is  divided  down  to  the  bone,  and  by  the  use 
of  a  suitable  raspatory  the  soft  structures  of  the  palate  are  stripped 
up  towards  the  middle  line,  until  the  point  of  the  instrument  is  seen 
protruding  into  the  cleft.  Great  care  is  needed  to  ensure  its  total 
detachment  from  the  back  of  the  bony  palate,  and  yet  not  to  damage 
it  at  this,  its  weakest  part.  This  must  be  thoroughly  carried  out  on 
both  sides.     Copious  bleeding  always  accompanies  this  stage  of  the 


Fig.  412.  Fig.  413.  Fig.  414. 

Figs.  412-414. — Diagrams  to  illustrate  the  Loop  Method  of  Passing 

Stitches  in  the  Operation  for  Cleft  Palate. 

The  needles  and  silk  thread  are,  for  purposes  of  illustration,  represented  much 
thicker  than  would  be  really  employed. 

operation,  and  the  head  should  be  turned  on  one  side  and  lowered, 
and  the  pharynx  kept  clear  by  careful  sponging. 

Stage  II. :  Paring  the  Edges  of  the  Cleft.— This  is  accomplished  by 
grasping  the  base  of  the  uvula  with  a  suitable  pair  of  angular  catch- 
forceps.  Thus  steadied  and  held,  a  thin  paring  can  be  removed,  m 
one  piece,  if  possible,  on  the  side  seized,  and  the  same  process 
repeated  on  the  other.  The  paring  of  the  edges  is  purposely  deferred 
until  after  the  muco-periosteal  flaps  have  been  detached,  because  the 
freshened  edges  do  not  thus  get  bruised  by  the  frequent  use  of  the 
sponge ;  moreover,  the  bevel  at  which  the  edges  should  be  pared  can 
be  more  accurately  estimated  when  the  flaps  have  been  loosened. 

Stage  III.  :  Passage  and  Tightening  of  Sutures.— The  simplest  plan 
to  adopt  is  that  known  as  the  '  loop  method  '  of  Sir  W.  Fergusson, 
and  it  is  carried  out  as  follows :  A  long-handled  palate  needle  with  a 
suitable  curve,  and  threaded  with  about  18  inches  of  fine  white  silk, 
is  passed  through  the  muco-periosteal  flap  from  below  upwards,  and 
at  a  spot  about  2  or  3  mm.  from  the  margin  (Fig.  412,  A).  This 
loop  projecting  from  the  cleft  (Fig.  412,  B)  is  now  grasped  with 


856  A   MANUAL  OF  SURGERY 

smooth-nosed  forceps,  and  drawn  out  of  the  mouth,  whilst  the 
needle  is  withdrawn.  A  similar  loop  is  inserted  through  the  opposite 
side  of  the  cleft  at  an  exactly  corresponding  point,  so  that  there  are 
now  two  loops  emerging  from  behind  through  the  cleft  (Fig.  412, 
C,  D).  One  of  these  is  loosely  threaded  through  the  other  (Fig.  413, 
E),  and  the  latter  gently  withdrawn,  carrying  with  it  the  loop-end 
of  the  former  (Fig.  413,  F),  through  which  a  suitable  length  of  fine 
well-annealed  silver  wire  can  be  drawn  into  position  (Fig.  414,  G,  H), 
and  tightened  to  the  requisite  degree  by  a  wire-twister,  so  that 
the  pared  edges  are  exactly  apposed.  Ihis  process  is  commenced 
anteriorly  and  carried  backwards  until  the  base  of  the  uvula  is 
reached,  the  stitches  being  inserted  about  half  a  centimetre  apart. 
Finalh',  the  uvula  is  stitched  with  silk  inserted  by  means  of  a  double- 
curved  needle ;  silver  wire  would  irritate  the  back  of  the  tongue  too 
much  and  cause  vomiting. 

Some  surgeons  prefer  to  introduce  the  wire  by  means  of  a  specially 
constructed  hollow  needle  with  a  double  curve,  through  which  the 
wire  is  protruded  by  unwinding  a  drum  in  the  handle.  This  is  passed 
through  both  flaps,  commencing  at  the  uvula,  and  working  forwards, 
tying  each  stitch  as  it  is  inserted. 

Stage  IV.- — It  is  now  only  necessary  to  take  steps  for  the  relief  of  all 
lateral  tension,  a  most  important  and  essential  proceeding.  The  best 
way  to  accomplish  this  is  to  prolong  backwards  through  the  soft 
palate  the  lateral  incisions  already  made  so  as  thoroughly  to  divide 
the  levator  palati  (see  the  thick  dotted  lines  in  Fig.  411).  Occa- 
sionally the  anterior  and  posterior  pillars  of  the  fauces,  containing 
respectively  the  palato-glossi  and  palato  -pharyngei  muscles,  will  also 
need  to  be  snipped  across. 

The  child  should  be  put  to  bed  with  the  head  low,  so  that  any 
accumulation  of  blood  or  mucus  may  gravitate  easily  into  the 
pharynx.  The  mouth  can  be  washed  out  with  a  weak  solution  of 
sanitas,  although  some  surgeons  prefer  not  to  disturb  the  parts  for 
three  or  four  days.  No  nourishment  should  be  given  for  the  first 
four  or  five  hours,  and  but  very  sparingly  for  the  first  twenty-four. 
Milk  and  water,  given  by  a  spoon  or  from  a  feeder,  will  form  the 
staple  article  of  diet.  By  about  the  fifth  day  soft  food,  such  as  soaked 
bread  and  custard  pudding,  may  be  safely  permitted.  The  patients 
are  generally  allowed  up  on  the  sixth  day.  The  silver  stitches  may 
be  left  in  for  ten  days  or  a  fortnight  without  doing  any  harm.  Should 
an}'  signs  of  inflammation  occur,  the  palate  should  be  sprayed  over 
with  a  solution  of  peroxide  of  hydrogen. 

In  dealing  with  clefts  of  the  soft  palate  alone,  a  modification  of  the 
above  operation  may  be  performed  called  staphylorrhaphy.  The  edges 
are  first  pared,  lateral  incisions  are  then  made  to  divide  the  levatores 
palati.  and  the  stitches  finally  passed  and  tied. 

Results.— It  is  possible  that  in  most  cases  articulation  will  be,  if 
anything,  impaired  as  the  immediate  result  of  the  operation,  since 
the  mechanism  which  the  patient  ordinarily  employs  is  thrown  out 
of  gear;  subsequent  education  at  the  hands  of  a  voice-trainer  is  abso- 


A  FFECTIONS  OF  THE  MO  UTH,  THRO  A  T,  A  ND  CESOPHA  GUS     857 

lutely  essential  in  order  to  correct  this.  Even  then  the  unpleasant 
articulation  occasionally  persists,  owing  to  the  patient  being  unable 
to  draw  up  the  velum  so  as  to  close  the  posterior  nares ;  this  is  due 
to  a  reduction  of  the  depth  of  the  soft  palate  owing  to  the  traction 
required  to  close  the  cleft.  In  spite  of  this,  however,  the  operation 
is  most  beneficial  in  that  it  shuts  off  the  nose  from  the  mouth, 
prevents  the  dropping  of  mucus,  improves  the  sense  of  taste,  and 
adds  greatly  to  the  general  comfort  of  the  patient. 

Mechanical  Treatment  of  clefts  in  the  palate  by  means  of  obturators  or 
artificial  vela  is  still  advocated  by  some  surgeons  and  dentists  in  preference 
to  any  operative  interference.  An  obturator  consists  of  an  adjustable  plate 
or  plug  fitted  to  and  closing  an  aperture  in  the  hard  palate.  It  may  be  used 
with  advantage  in  perforations  due  to  traumatism  or  syphilis,  and  in  aper- 
tures left  after  operations  in  which  portions  of  the  palate  are  removed,  such 
as  excision  of  the  superior  maxilla.  In  cases  of  double  hare-lip  and  cleft 
palate,  where  the  os  incisivum  has  been  extirpated,  an  aperture  is  often  left 
anteriorly  which  cannot  be  satisfactorily  closed  except  by  an  obturator, 
which  also  serves  to  carry  the  necessary  artificial  incisors,  and  may  have  cheek- 
plates  attached  to  push  forwards  the  upper  lip.  For  whatever  purpose  an 
obturator  is  needed,  it  should  never  take  the  form  of  a  closely-fitting  plug, 
which,  by  its  constant  pressure  and  irritation,  causes  the  aperture  to  become 
enlarged,  but  always  that  of  a  plate,  either  of  thin  vulcanite  or  gold,  which 
can  be  fixed  to  the  teeth,  and  maintained  in  position  by  suction.  It  is  some- 
times found,  however,  that  the  addition  of  an  intranasal  projection  to  the 
upper  surface  of  the  plate  improves  the  articulation  by  diminishing  the  size 
of  the  nasal  cavity.  An  artificial  velum  consists  of  a  plate  obturator,  to  which 
is  attached  posteriorly  a  moveable  segment  to  take  the  place  of  the  normal 
velum.  Such  consists  either  of  a  hinged  metal  plate,  resting  on  the  nasal 
side  of  the  segments  of  the  soft  palate,  and  moved  by  them,  or  of  a  thin  india- 
rubber  bag  filled  with  air,  sewn  to  the  back  of  the  obturator.  They  are 
complicated  and  difficult  to  keep  in  order,  and  as  a  general  rule  the  results  of 
operative  interference  are  superior. 

Ulceration  of  the  Palate  occurs  in  a  variety  of  forms,  e.g.,  [a)  simple, 
as  an  accompaniment  of  general  stomatitis :  (6)  syphilitic,  which  may 
involve  either  the  hard  or  soft  palate;  if  superficial,  it  is  usually  a 
late  secondary  phenomenon ;  if  deep,  it  involves  the  bones,  and  often 
leads  to  necrosis,  and  is  then  due  to  tertiary  mischief:  (c)  lupoid,  a 
somewhat  uncommon  condition,  which  may  result  in  great  destruc- 
tion of  tissue ;  it  is  usually  seen  in  children,  and  often  associated  with 
a  similar  disease  of  the  nose,  from  which,  indeed,  it  may  have  spread : 
{d)  tuberculous,  due  to  the  breaking  down  of  a  tuberculous  abscess 
under  the  periosteum,  and  then  complicated  with  caries  of  the  bony 
palate:  {e)  malignant,  usually  resulting  from  the  growth  of  epithe- 
lioma, either  starting  primarily  in  the  palatal  mucous  membrane,  or 
extending  to  it  from  the  tongue,  tonsil,  or  upper  jaw. 

Acquired  Perforations  of  the  Palate,  though  occasionally  caused  by 
traumatism  or  lupus,  are  in  almost  all  cases  due  to  tertiary  syphilis. 
The  ethmo-vomerine  septum  is  often  involved  in  the  destructive 
process,  giving  rise  to  a  most  offensive  discharge  from  the  nose.  If 
.  the  soft  palate  is  alone  affected,  the  velum  may  become  fixed  by 
cicatricial  adhesions  to  the  back  of  the  pharynx,  and  pharyngeal 
stenosis,  or  considerable  loss  of  substance  of  the  velum,  results.  A 
nasal  intonation  of  the  voice  is  always  caused  by  any  condition  which 


858  A   MANUAL   OF  SURGERY 

interferes  with  the  closure  of  the  naso-pharynx  by  the  vehim  during 
articulation.  The  treatment  of  these  conditions  sliould  foUow  the 
usual  antisyphilitic  course.  Perforations  arc  best  remedied  by  the 
use  of  plate  obturators.  We  have  seen  out-patients  make  efificient 
obturators  out  of  a  piece  of  sheet  indiarubber  maintained  in  situ  by 
suction,  or  of  two  pieces  stitched  together  in  the  middle,  one  piece 
passing  above  and  the  other  below  the  opening.  Occasionally  when 
the  aperture  is  small,  the  local  disease  soundly  cured,  and  the  general 
health  good,  an  attempt  may  be  made  to  close  it  by  stripping  up 
muco-pcriosteal  flaps,  paring  the  edges  and  suturing  them  together. 
The  results  are,  however,  seldom  satisfactory. 

Any  of  the  ordinary  forms  of  inflammation  of  bone  may  be  met 
with  in  the  hard  palate.  Necrosis  is  usually  due  to  tertiary  syphilis, 
or  may  accompany  acute  subperiosteal  suppuration,  extending  from 
an  alveolar  abscess.  In  either  case  the  surgeon  must  wait  till  the 
sequestrum  is  loose,  and  then  it  may  be  removed.  Caries  is  generally 
due  to  syphilis  or  tubercle. 

The  following  tumours  occur  on  the  hard  palate.  Simple  epulis 
(p.  798)  may  extend  from  the  alveolus,  or  an  identical  condition  may 
start  in  the  middle  line.  An  adenoma  of  the  palatal  glands  is  occa- 
sionally met  with.  It  presents  as  a  smooth  or  papillated  tumour, 
somewhat  resembling  epithelioma,  but  distinguished  from  it  by  its 
slower  rate  of  growth,  and  the  absence  of  ulceration,  pain,  or 
glandular  enlargement.  An  operation  limited  to  the  soft  parts  is 
probably  all  that  is  necessary.  Sarcoma  may  be  primary,  and  is  then 
often  myxo-sarcomatous  in  type,  or  secondary.  In  the  former  case 
it  simulates  rather  closely  a  diffuse  alveolar  abscess,  but  is  recognised 
by  its  slower  growth,  less  pain,  absence  of  inflammation,  and,  if  need 
be,  by  the  results  of  an  exploratory  puncture.  Epithelioma  also 
occurs,  but  is  uncommon.  Treatment  for  the  two  latter  conditions, 
if  limited  to  the  palate,  would  consist  in  partial  removal  of  the 
affected  superior  maxilla. 

Elongation  of  the  Uvula  is  frequently  the  result  of  a  chronic  re- 
laxed throat.  At  first  it  merely  lasts  for  a  time,  and  by  the  use  of 
astringents  disappears;  but  later  on  the  elongation  becomes  chronic, 
and  causes  great  irritation  of  the  back  of  the  tongue  and  fauces,  re- 
sulting in  a  troublesome  throat-cough  and  even  vomiting.  Under 
such  circumstances  it  should  be  removed.  After  well  cocainizing  the 
part,  it  is  grasped  by  a  pair  of  hook-forceps,  which  seize  not  only  the 
mucous  membrane,  but  also  the  muscular  structures  beneath,  and  a 
sufficient  amount  is  then  removed  by  snipping  it  across  near  the  base 
with  a  pair  of  blunt-ended  scissors,  leaving  about  a  third  of  an  inch  of 
the  organ  behind. 

Affections  of  the  Tonsils. 

Acute  Tonsillitis  results  either  from  cold  or  from  the  inhalation  of 
impure  air,  or  of  sewer-gas.  It  is  often  seen  amongst  the  residents 
in  hospitals  (hospital  throat),  and  may  precede  an  attack  of  acute 
rheumatism.     Three  varieties  are  described: 


AFFECTIONS  OF  THE  MOUTH.  THROAT.  AND  (ESOPHAGUS     859 

(a)  Acute  superficial  tonsillitis,  which  consists  of  a  shght  superficial 
inflammation/the  result  of  cold,  etc.,  in  which  the  tonsil  participates 
with  the  pharynx  and  velum.  There  is  but  little  swelhng  of  the  part, 
which  however,  becomes  red  and  painful,  rendering  swallowing 
difficult.  Ordinary  anti-catarrhal  remedies  are  necessary,  and  a 
chlorate  of  potash  gargle. 

(h)  Acute  follicular  tonsillitis  is  characterized  by  a  general  enlarge- 
ment of  the  organ,  which  is  dusky  red  in  colour  and  pam  ul,  causing 
obstruction  to  both  breathing  and  swallowing,  the  tonsils,  perhaps, 
almost  meeting  in  the  middle  line.  There  is  a  good  deal  of  yellow 
patchy  exudation  from  the  foUicles.  which  may  coagulate  on  the 
surface  and  form  a  false  membrane,  somewhat  hke  that  of  diph- 
theria. The  temperature  is  high ;  the  glands  below  the  angle  of  the 
iaw  become  enlarged  and  tender,  and  may  suppurate;  the  tongue 
is  covered  with  a  thick,  whitish  fur,  and  the  bowels  are  confined. 
Such  a  condition  is  often  due  to  streptococci,  and  may  herald  m  an 

attack  of  septicaemia.  .        .  x    •  a  +i^v, 

(c)  Acute  suppurative  tonsillitis,  or  quinsy,  is  an  acute  inflammation 
of  the  tonsil,  with  suppuration  within  and  around  it  {peritonsillar 
abscess) .  Both  sides  are  affected,  but  the  suppuration  is  often  uni- 
lateral or  if  bilateral,  one  tonsil  is  affected  before  the  other,  pus 
usually  takes  three  to  seven  days  to  form,  /he  swelling  is  great, 
so  that  breathing  and  swallowing  are  ahke  difficult,  the  tempera- 
ture is  high,  pain  is  severe,  and  the  cervical  glands  are  consider 
ably  enlarged  (Edema  of  the  glottis  ^^V  'ff''}^:,  J^^^Z 
symptoms  are  much  the  same  as  in  the  above.  Left  to.  itself  the 
abscess  sooner  or  later  bursts  and  gives  the  patient  immediate 

"^^^The  Diagnosis  must  be  made  from  scarlet  fever  by  the  absence  of 
the  characteristic  rash  and  red  tongue  of  the  latter  condition,  and  by 
the  redness  being  more  dusky  and  less  diffuse  in  tonsihitis.  From 
erysipelas  of  the  fauces,  it  is  known  by  the  redness  Jemg  more  con- 
centrated, the  oedema  less  marked  and  more  hmited,  by  the  glands 
at  the  angle  of  the  jaw  being  less  enlarged,  and  bj  the  absence  of  any 
external  manifestation  of  the  disease.  From  diphtheria  the  folhc- 
ular  variety  is  recognised  by  the  want  of  adhesion  of  the  false  mem- 
branl  to  the  subjacent  parts,  it  being  readily  detached  by  a  camel  s- 
hair  brush,  and   by  the  absence  of  the  Klebs-Loffler  bacillus  on 

'""TieatmenUholM  always  be  commenced  by  a  good  calomel  purge 
which  may  be  followed  by  the  administration  either  of  sahcy  ate  of 
Toda  (20  grains,  thrice  daily),  or  of  chlorate  of  potash  and  sulphate 
of  magnelia,  to  which  a  few  drops  of  tincture  of  aconite  may  be 
added  if  the  constitutional  symptoms  are  severe^  The  patient  wi  1 
experiencemuch  relief  by  inhahng  the  steam  from  hot  water  (150  F, 
in  which  a  little  creasote  or  carbolic  acid  is  dissolved,  or  the  tonsils 
mav  be  scarified.  Suppuration  is  dealt  with  by  a  free  incision,  the 
S  enterTng  at  a  spot  on  the  line  drawn  from  the  base  of  the  uvula 
to  the  last  molar  tooth,  and  nearer  the  inner  than  the  outer  end 


86o 


A   MANUAL  OF  SURGERY 


(Fig.  415,  X),  as  recommended  by  Sir  St.  Clair  Thomson.  Hot 
flannels  or  fomentations  may  be  applied  to  the  neck  and  throat,  and 
plenty  of  fluid  nourishment  administered.  This  is  followed  as  soon 
as  possible  by  iron,  bark,  and  other  tonics.  The  fact  that  quinsy 
is  very  liable  to  recur  suggests  that  during  the  quiescent  interval 
after  an  attack  the  tonsils  should  be  removed. 
'.  Chronic  Tonsillitis  appears  in  two  distinct  forms: 
'  J  {a)  Chronic  inflammatory  tonsillitis  occurs  in  children  whose  tonsils, 
after  one  acute  attack,  remain  enlarged,  painful,  congested,  and  very 
liable  to  recurrence,  which  often  runs  on  to  suppuration  and  ulcera- 
s  ,  tion.     After  a  time  the 

tonsils  shrink  back 
and  atrophy,  becoming 
hard  and  fibroid. 

(b)  Chronic  hyper- 
trophic tonsillitis  is  met 
with  in  weakly  chil- 
dren predisposed  to 
tubercle,  and  is  usually 
associated  with  the 
presence  of  adenoids 
in  the  naso-pharynx. 
The  tonsils  are  en- 
larged, pale  in  colour, 
and  firm  in  consist- 
ence; the  orifices  of 
the  crypts  are  often 
patent,  and  in  them 
are  seen  plugs  of  mu- 
cous secretion,  which 
may  become  infiltrated 
with  lime  salts,  form- 
ing concretions  (ton- 
silloliths), or  may  de- 
velopinto cysts.  Some- 
times the  tonsils  pro- 
ject inwards,  and  may 
meet  in  the  middle 
line  beneath  the  uvula,  causing  obstruction  both  to  swallowing 
and  respiration;  sometimes  they  are  buried  and  lie  under  cover 
of  the  anterior  pillar  of  the  fauces,  but  their  enlargement  may  be 
recognised  by  pressing  inwards  from  the  neck.  The  patient 
usually  breathes  with  the  mouth  open,  owing  to  the  concurrent 
naso-pharyngeal  obstruction,  and  from  the  same  cause  speaks 
thickly,  as  if  he  had  some  loose  body  in  the  mouth,  and  necessarily 
snores  during  sleep.  Hearing  is  often  interfered  with  from  the 
mucous  lining  of  the  Eustachian  tube  becoming  thickened  and 
inflamed.  Recurrent  attacks  of  inflammation  occur  from  time  to 
time,  with  or  without  suppuration. 


Fig.  415. — Diagram  to  indicate  the  Situation 
TO  Open  a  Peritonsillar  Abscess — viz.,  on 
A  Line  drawn  from  the  Base  of  the  Uvula 
to  the  Last  Molar  Tooth,  but  Nearer  the 
Uvula.     (After  Sir  St.  Clair  Thomson.) 


AFFECTIONS  OF  THE  MOUTH,  THROAT.  AND  CESOPHAGUS     861 

The  Treatment  of  these  cases  consists  in  first  attending  to  con- 
stitutional weakness  by  removal  of  the  patient  to  fresh  or  seaside  air, 
and  by  the  administration  of  iron  and  cod-liver  oil;  at  the  same  time 
the  throat  should  be  painted  twice  a  day  with  glycerine  of  tannic  acid, 
or  with  equal  parts  of  glycerine  and  tinct.  fern  perchloridi.     i^aihng 
this,  the  tonsils  should  be  removed,  and  for  choice  by  enucleation. 
Tonsillotomy  may  be  undertaken  in  the  following  ways: 
(a)  By  the  guillotine.     The  fauces  having  been  carefully  and  re- 
peatedly brushed  or  sprayed  with  a  5  per  cent,  solution  of  cocaine, 
the  mouth  is  opened  and  one  of  the  many  forms  of  tonsil  guillotine 
introduced;  Mackenzie's  spade  guillotine  is  as  good  as  any.     ine 
ring  of  the  instrument  is  passed  over  the  projecting  organ,  external 
pressure  behind  the  angle  of  the  jaw  assisting  in  this  manauvre. 
By  the  pressure  of  the  thumb  the  projecting  mass  is  cut  off  by  tne 
sharp  blade.     In  dealing  with  the  right  side,  unless  the  surgeon  is 
ambidextrous,  he  had  better  stand  behind  the  patient  s  head,  look- 
ing over  into  the  mouth.  .   ,        , 
(h)  By  the  bistoury.     The  tonsil  is  seized  at  its  lowest  point  and 
drawn  well  inwards  by  means  of  hooked  forceps,  and  the  projecting 
mass  removed  by  a  straight  blunt-ended  bistoury,  the  base  of  the 
blade  being  guarded,  if  preferred,  by  a  piece  of  plaster  wrapped  round 
it      The  incision  should  be  made  from  below  upwards,  and  the  edge 
of   the  knife   kept   rather  in  than   out,  so  as  to  avoid  all  nsk  ot 
wounding  the  internal  carotid,  which  is  in  close  contiguity  to  the 
outer  surface  of  the  gland.     Care  must  be  taken  to  include  the  lowest 
portion  of  the  tonsil,  which  often  hangs  down  into  the  pharynx, 
and  is  liable  to  be  left  behind.     This  method  is  not  frequently  em- 
ployed at  the  present  day.                                            n  ^       -i  t.^ 
(c)  In  children  the  hypertrophic  type  of  enlarged  tonsil  may  be 
enucleated  without  much  difficulty  by  dividing  the  mucous  rnenibrane 
in  front  of  it,  and  shelling  it  out  of  its  bed,  the  posterior  reflection  ot 
mucous  membrane  being  subsequently  divided  by  bistoury,  scissors 

or  guillotine.  -f  „„^„ 

The  h£emorrhage,  though  brisk  for  the  moment,  soon  ceases  if  care 
is  taken  not  to  cut  too  deeply,  or  encroach  upon  the  surrounding 
mucous  membrane.     Should  the  bleeding  continue,  it  can  generally 
be  arrested  by  douching  the  face  with  iced  water,  or  by  the  local 
pressure  of  wool  pledgets  soaked  in  iced  boric  acid  lotion,  or  in 
adrenahn.     Occasionally  a  bleeding  vessel  can  be  seen  and  secured 
by  ligature ;  but  in  bad  cases  of  persistent  or  recurrent  bleeding  it  may 
be  necessary  to  stitch  the  anterior  and  posterior  pillars  of  the  fauces 
together  over  a  gauze  plug  which  is  retained  for  twenty-four  hours. 
Serious  bleeding  is  more  hkely  to  occur  in  adults  than  m  children. 
Syphilitic  Disease  of  the  Tonsil  is  met  with  m  various  stages,     i  ne 
l^rimayy  chancre  is  seen  occasionally,  arising  in  one  case  we  know  ot 
through  infection  from  a  stick  of  caustic  which  had  been  previously 
used  to  cauterize  a  syphilitic  ulcer  and  insufficiently  cleaned  before 
being  apphed  to  the  tonsil,  the  surface  of  which  was  abraded,     i  he 
glandular  enlargement  in  the  neck  is  very  marked  m  such  cases,  and 


862  A  MANUAL  OF  SURGERY 

the  course  of  the  disease  as  a  rule  severe.  Secondary  ulcers  of  the 
'  snail-track  '  type  [plaques  muqueuses)  are  common  in  this  region, 
being  usually  symmetrical.  In  the  tertiary  period  a  diffuse  gumma- 
tous infiltration  occurs,  involving  also  the  palate  and  fauces  (p.  864) 
and  leading  to  phar^-ngeal  stenosis. 

Tumours  of  the  Tonsil  are  almost  always  malignant  in  type,  but  are 
not  very  common.  Epithelioma  occurs  as  a  firm  indurated  infiltra- 
tion, rapidly  spreading  to  adjacent  parts,  and  involving  the  lym- 
phatic glands.  It  generally  starts  either  in  the  root  of  the  tongue 
or  in  the  pillars  of  the  fauces,  and  presents  a  ragged  ulcerated  surface 
with  a  hard  margin  and  sloughing  base.  It  is  not  always  very 
painful,  and  notice  may  first  be  called  to  it  by  the  enlargement  of 
the  glands  in  the  neck.  It  runs  a  rapidly  fatal  course,  if  left  to 
itself.  Lymphosarcoma  of  the  tonsil  arises  in  the  organ  itself;  it 
presents  a  smooth,  dusky  red  appearance,  the  mucous  membrane 
being  stretched  over  it,  and  feels  soft  and  almost  fluctuating.  In 
the  early  stages  it  may  be  freely  moveable,  but  ere  long  it  infil- 
trates surrounding  structures,  and  affects  the  neighbouring  lymphatic 
glands.  Round-celled  sarcoma  also  attacks  the  tonsil  as  a  primary 
growth,  and  is  less  limited  and  defined  than  the  former.  In  all  these 
varieties  the  growth  extends  into  the  pharynx,  impeding  deglutition 
and  respiration,  and  ulceration  with  or  without  serious  haemorrhages 
may  ensue;  indeed,  the  latter  complication  is  a  frequent  cause  of  the 
fatal  result. 

Extirpation  of  Malignant  Tumours  of  the  tonsil  is  often  imprac- 
ticable from  the  extent  of  the  disease  and  the  early  implication  of 
the  surrounding  structures,  although  it  has  now  been  shown  that 
they  are  more  amenable  to  treatment  than  was  formerly  thought  to 
be  the  case.  The  disease  may  be  dealt  with  in  two  ways:  [a)  From 
the  mouth  in  the  case  of  the  loosely  encapsuled  and  freely  moveable 
lympho-sarcomata.  The  capsule  is  divided  preferably  by  a  galvano- 
cautery,  and  the  growth  shelled  out  sometimes  with  the  utmost 
ease,  and  with  very  little  haemorrhage.  Recurrence  in  the  lym- 
phatic glands  is,  however,  almost  certain  to  follow,  [h)  From  the 
neck.  This  is  the  only  plan  of  any  value  in  dealing  with  an  epithe- 
lioma, and  it  is  seldom  available,  owing  to  the  extent  of  the  mis- 
chief when  the  patient  is  first  seen.  An  incision  is  made  along  the 
anterior  border  of  the  sterno-mastoid,  and  a  careful  dissection  con- 
ducted down  to  the  pharyngeal  wall,  removing  all  lymphatic  glands 
which  are  enlarged  or  suspicious,  and  securing  the  external  carotid 
or  its  anterior  branches.  The  mass  is  then  isolated  from  the  sur- 
rounding structures  and  removed.  It  is  sometimes  necessary  to 
make  an  incision  from  the  angle  of  the  mouth  backwards  through 
the  cheek,  or  to  remove  a  portion  of  the  mandible.  It  is  very 
questionable  whether  extensive  proceedings  such  as  these  are  ever 
justifiable.  The  immediate  mortality  is  high,  and  the  ultimate 
freedom  from  recurrence  very  small.  The  majority  of  cases  demand 
merely  palliative  treatment,  including  gastrostomy  to  permit  of  the 
administration  of  food,  and  tracheotomy. 


AFFECTIONS  OF  THE  MOUTH.  THROAT,  AND  (ESOPHAGUS     863 

Affections  of  the  Pharynx. 

Acute  Pharyngitis  is  usually  associated  with  a  similar  inflamma- 
tory condition  of  the  velum  palati,  nasal  mucous  membrane,  and 
tonsils,  and  results  from  exposure  to  cold,  from  absorption  of  sewer- 
gas,  and  from  general  diseases  of  the  exanthematous  type — e.g., 
scarlet  fever  and  diphtheria.  It  is  characterized  by  redness,  pain, 
and  swelling  of  the  mucous  membrane,  which  becomes  covered 
with  mucus  or  muco-pus.  An  irritable  cough,  with  perhaps  sneez- 
ing, interference  with  nasal  respiration,  and  great  pain  on  swallow- 
ing, are  produced  by  this  condition,  and  if  it  spreads  to  the  Eusta- 
chian tube  temporary  deafness  is  induced.  Ulceration  of  the  velum 
and  fauces  occasionally  follows. 

The  Treatment  consists  in  attending  to  the  general  condition, 
especially  if  of  exanthematous  origin,  and  when  due  to  catarrh,  in 
administering  antiphlogistic  remedies  [e.g.,  purgatives,  sudorifics, 
and  diuretics)  and  soothing  local  applications  {e.g.,  ice  to  suck, 
chlorate  of  potash  gargle,  etc.).  Great  rehef  is  often  given  by 
inhahng  steam  from  water  at  150°  F.  to  which  a  httle  Friar's  balsam 
has  been  added. 

Chronic  Pharyngitis  is  commonly  met  with  in  clergymen  and  public 
speakers  who  are  called  upon  to  exert  their  voices  for  any  length  of 
time,  in  costers  and  street-hawkers  who  shout  their  wares,  and  in 
drinkers  and  smokers.  It  may  commence  as  a  chronic  inflammation, 
or  may  follow  an  acute  attack.  The  mucous  membrane  is  more  or 
less  red  and  infiltrated,  with  vessels  coursing  over  it,  and  there  is 
often  a  good  deal  of  muco-purulent  discharge.  If  the  buccal  side  of 
the  velum  palati  is  affected,  there  is  usually  much  less  secretion  than 
from  the  pharyngeal  aspect,  where  a  considerable  amount  of  dark 
green  viscid  material  may  collect  and  cling  to  the  pharyngeal  wall, 
constituting  scabs,  which  may  decompose  and  cause  the  breath  to  be 
somewhat  offensive.     Two  main  varieties  are  described: 

1.  Chronic  follicular  pharyngitis,  in  which  the  lymphoid  follicles 
scattered  throughout  the  mucous  membrane  become  enlarged.  This 
is  specially  evident  upon  the  soft  palate,  but  is  often  greater  in 
amount  upon  the  upper  wall  and  sides  of  the  pharynx,  where  there 
is  a  mass  of  lymphoid  tissue,  sometimes  known  as  the  pharyngeal  or 
Luschka's  tonsil  (vide  Adenoids,  p.  827) .  The  uvula  may  be  also 
elongated  and  hypertrophic  in  this  condition. 

2.  Chronic  atrophic  pharyngitis  is  generally  associated  with  the 
atrophic  form  of  rhinitis  sicca  (p.  820),  and  possibly  with  chronic 
laryngitis.  The  mucous  membrane  is  smooth,  dry,  and  glazed,  and 
the  exudation  forms  adherent  scabs.  The  throat  feels  dry  and  irri- 
table, and  the  voice  is  often  husky. 

The  Treatment  of  chronic  pharyngitis  varies  with  the  condition 
and  character  of  the  affection.  In  many  cases  the  nasal  trouble  is 
the  more  urgent,  and  if  it  is  treated  effectively  the  pharynx  improves 
rapidly.  In  simple  relaxed  throats  all  sources  of  irritation — such  as 
sm.oking,  spirits  and  condiments — must  be  avoided,  the  bowels  and 


864  ^   MANUAL  OF  SURGERY 

digestion  attended  to,  and  astringent  sprays,  gargles,  or  applications 
made  use  of.  The  most  useful  reagents  are  the  glycerine  of  tannic 
acid,  and  equal  parts  of  glycerine  and  tinct.  ferri  perchloridi,  whilst 
chloride  of  ammonium  inhalations  are  sometimes  valuable,  as  also 
sprays  of  menthol  dissolved  in  paroleine,  or  lozenges  containing 
menthol  and  liquorice.  When  the  inflammation  is  of  the  follicular 
type,  it  may  be  further  necessary  to  destroy  the  follicles  with  the 
galvano-cautery  after  cocainizing  the  surface ;  enlarged  and  varicose 
vessels  may  be  divided  in  the  same  way. 

Syphilitic  Affections  of  the  Pharynx  may  be  met  with  in  the 
secondary  or  tertiary  stages.  In  the  former  they  are  of  a  superficial 
character,  such  as  mucous  tubercles,  snail-track  ulcers,  etc.;  in  the 
latter  they  appear  in  the  shape  of  a  diffuse  gummatoiis  infiltration, 
which  is  often  of  considerable  consequence,  both  at  the  time  and 
subsequently.  It  manifests  itself  as  a  widespread  nodular  thicken- 
ing of  the  mucous  membrane,  especially  in  the  neighbourhood  of  the 
fauces  and  soft  palate,  which  rapidly  runs  on  to  ulceration,  and  may 
impede  both  respiration  and  deglutition.  The  administration  of 
salvarsan,  or  of  mercury  and  iodide  of  potassium  usually  causes  a 
rapid  improvement,  but  the  subsequent  cicatrization  may  bind  down 
the  velum,  and  lead  to  pharyngeal  stenosis  of  such  a  character  as  to 
constitute  a  fibro-cicatricial  septmn,  with  an  opening  through  it 
perhaps  only  large  enough  to  allow  a  small  bougie  to  pass.  For 
such  a  condition  much  may  be  done;  the  opening  may  be  more  or 
less  dilated  by  careful  division  of  some  of  the  bands  and  the  passage 
of  bougies;  and  the  soft  palate  can  be  set  free  from  the  dorsum  of 
the  tongue.  Of  course,  there  is  a  great  tendency  for  the  opening 
to  contract  again,  and  treatment  by  bougies  must  be  persisted  in. 

A  localized  gumma  may  form  in  the  submucous  tissue,  not  unfre- 
quently  involving  the  posterior  pharyngeal  wall,  and  running  its 
ordinary  course  with  or  without  ulceration. 

Tumours  of  the  pharynx  are  rarely  primary.  They  may  extend 
into  it,  however,  from  surrounding  parts — e.g.,  naso-pharyngeal 
polypi  arising  from  the  base  of  the  skull,  or  retro -pharyngeal  growths 
from  the  spine. 

Epithelioma  either  involves  the  pharynx  primarily,  or  spreads  to 
it  from  adjacent  parts,  such  as  the  tongue  or  tonsil.  The  usual  type 
of  tumour  develops  with  some  amount  of  ulceration;  lymphatic 
glands  become  secondarily  affected,  and  the  tumour  gradually  in- 
vades surrounding  tissues,  although  it  is  interesting  to  note  that  for 
some  time  it  is  limited  to  the  mucous  membrane,  extending  super- 
ficially over  it,  but  not  involving  the  underlying  pharyngeal  muscles. 
Death  results  from  haemorrhage  due  to  ulceration  into  large  vessels, 
from  interference  with  swallowing  or  breathing,  from  pressure  on 
important  nerves,  or  from  general  dissemination. 

Treatment. — It  is  only  within  the  last  decade  that  any  attempt  has 
been  made  to  deal  with  these  cases ;  even  now  the  mortality  is  very 
high,  and  statistics  prove  that  if  the  operation  involves  removal  of 
portions  of  the  upper  or  lower  jaw,  a  fatal  issue  is  likely  to  follow. 


AFFECTIONS  OF  THE  MOUTH.  THROAT.  AND  (ESOPHAGUS    865 

The  same  precautions  as  to  cleansing  the  teeth,  etc.,  must  be  taken 
as  in  dealing  with  naso-pharyngeal  or  buccal  growths.  As  a  general 
rule,  an  incision  along  the  anterior  border  of  the  sterno -mastoid  is  the 
best  to  employ,  although  occasionally  a  second  may  be  required,  split- 
ting the  cheek  towards  the  angle  of  the  jaw.  The  external  carotid  is 
tied,  all  glands  are  removed,  and  then  the  growth  is  extirpated, 
partly  from  without,  partly  from  within.  It  is  always  advisable  to 
perform  a  preliminary  tracheotomy,  and  feeding  must  be  undertaken 
for  some  days  by  means  of  a  stomach-tube.  Transhyoid  pharyn- 
gotomy  is  a  useful  means  of  approach  in  some  of  these  cases  (p.  907). 

Betro-pharyngeal  Abscess  is  acute  or  chronic  in  its  course.  The 
acute  form  results  from  infection  through  the  mucous  membrane,  as 
by  fishbones,  etc. ;  or  arises  from  an  inflammation  of  the  lymphatic 
glands  which  are  found  in  this  situation  in  children,  but  atrophy  in 
adults,  and  derive  their  lymph  from  the  interior  of  the  nose  and  naso- 
pharynx. The  pus  is  situated  between  the  pharyngeal  wall  and  the 
pre- vertebral  fascia,  and  is  therefore  tolerably  superficial.  The 
chronic  variety  generally  follows  tuberculous  caries  of  the  spine,  or 
disease  of  the  bones  at  the  base  of  the  skull,  and  the  pus  is  placed 
behind  the  pre-vertebral  fascia.  Whether  acute  or  chronic,  the 
abscess  forms  a  tense  elastic  swelling,  situated  behind  the  posterior 
pharyngeal  wall ;  in  the  former  case  it  is  associated  with  high  fever, 
and  locally  much  redness  and  inflammatory  oedema,  which  may 
even  extend  to  the  glottis,  and  cause  dyspnoea ;  in  the  latter,  where 
the  affection  is  chronic,  there  is  less  local  inflammatory  reaction,  but 
signs  of  cervical  spinal  disease  are  present.  The  abscess  may  burst 
into  the  pharynx,  or  may  burrow  outwards  on  either  side,  being 
guided  by  the  pre-vertebral  fascia,  and  point  either  in  front  of  or 
behind  the  sterno -mastoid. 

Treatment  should  never  be  delayed,  from  fear  of  the  supervention 
of  oedema  of  the  glottis.  The  chronic  abscess  should  always  be 
opened  from  the  neck,  as  then  an  aseptic  course  can  be  maintained, 
and  there  is  no  fear  that  the  pus  will  enter  the  air-passages.  If 
pointing  in  front  of  the  sterno -mastoid,  the  abscess  is  opened  in  that 
situation ;  but  otherwise  an  incision  should  be  made  along  the  pos- 
terior border  of  the  muscle,  which  must  be  drawn  forwards,  and  the 
transverse  processes  of  the  cervical  vertebrae  defined.  Possibly  the 
abscess  will  be  opened  by  the  necessary  manipulation  of  the  wound ; 
if  not,  the  index  finger  of  the  left  hand  should  be  placed  against 
the  abscess  wall  in  the  mouth  to  guard  it  from  injury,  and  a  pair  of 
sinus  forceps  thrust  into  it  in  front  of  the  vertebrse  by  the  right 
hand.  A  drainage-tube  is  then  inserted,  and  the  case  runs  an 
ordinary  aseptic  course. 

The  great  majority  of  cases  of  acute  abscess,  however,  may  be 
opened  from  the  mouth  without  much  fear.  The  child  is  placwi  on 
its  back  with  its  head  hanging  far  back ;  a  gag  is  introduced,  and  a 
guarded  knife  inserted  through  the  mucous  membrane  into  the 
swelling  at  its  most  prominent  point.  Careful  swabbing  should 
avoid  any  danger  of  pulmonary  trouble. 

55 


866  A   MANUAL  OF  SURGERY 

Affections  of  the  (Esophagus. 

The  cesophagns  reaches  from  the  lower  extremity  of  the  pharynx  to  the 
cardiac  orifice  of  the  stomach,  a  distance  of  about  lo  inches;  it  corresponds 
above  to  the  lower  border  of  the  cricoid  cartilage,  and  below  approximately 
to  the  lower  end  of  the  sternum.  The  distance  from  the  central  incisor 
teeth  to  the  stomach  is  about  i6  inches.  The  tube  is  not  quite  in  the 
middle  line,  but  inclines  to  the  left  as  it  passes  through  the  posterior  medias- 
tinum. The  pericardium  is  in  relationship  with  the  oesophagus  in  front, 
and  the  pleura  on  each  side.  Its  narrowest  portions  are  its  upper  end,  in 
the  centre  about  12  inches  from  the  teeth  where  the  left  bronchus  crosses  it, 
and  at  the  cardiac  extremity.  The  pneumogastric  nerves  are  also  in  immediate 
relationship  with  it. 

The  Methods  of  Examination  of  the  oesophagus  are  threefold : 

1.  By  the  introduction  of  a  bougie  it  is  possible  to  detect  the  existence  of 
a  stricture  and  its  situation.  Before  undertaking  this,  it  is  essential  to  make 
sure  that  there  is  no  aneurism  of  the  aorta  by  the  use  of  radiography  or  by 
auscultating  the  left  vertebral  curve.  To  pass  an  oesophageal  bougie,  the 
surgeon  stands  in  front  and  slightly  to  the  right  of  the  patient,  who  is  seated 
with  the  head  held  forward;  if  thrown  backwards,  the  larynx  is  pressed  against 
the  spine,  and  the  difficulty  of  introducing  the  instrument  is  increased.  The 
bougie,  which  bj^  preference  should  have  a  conical  end,  is  warmed  and  smeared 
with  glycerine  or  melted  butter,  and,  having  been  suitably  curved,  it  is 
guided  by  the  surgeon's  left  index  finger  over  the  base  of  the  tongue  and 
epiglottis  into  the  oesophagus.  This  stage  usually  causes  a  certain  amount 
of  discomfort  and  retching  on  the  part  of  the  patient.  Once  past  the  entrance 
to  the  larynx,  the  bougie  is  pushed  steadily  onwards,  and  if  there  is  no 
stricture,  the  point  enters  the  stomach  about  16  inches  from  the  teeth. 
Formerly  this  was  the  only  method  of  examination  available  for  the  lower 
part  of  the  tube.  It  was  possible  to  palpate  in  an  indefinite  way  the  upper 
part  of  the  tube,  and  auscultation  of  the  vertebral  curve  whilst  the  patient 
swallowed,  was  sometimes  resorted  to;  but  obviously  these  methods  are  very 
inexact. 

2.  The  use  of  the  oesophagoscope  has  transformed  the  surgery  of  this 
organ.  The  instrument  is  practically  the  same  as  that  introduced  by  Killian 
for  examination  of  the  bronchi  (p.  900),  and  its  method  of  use  is  very  similar. 
It  is  advisable  to  administer  a  preliminary  injection  of  morphia  and  atropin 
not  only  to  dull  the  patient's  sensitiveness,  but  also  to  check  the  salivary 
secretion.  The  mouth  and  pharjmx  are  thoroughly  cocainized,  and  then, 
with  the  patient  either  sitting  or  lying  on  his  back,  it  is  possible  to  introduce 
the  instrument  and  gently  to  insinuate  it  down  the  tube.  By  this  means 
foreign  bodies,  growths,  strictures,  etc.,  can  be  seen,  and  direct  treatment 
controlled  by  vision  can  then  be  adopted. 

3.  Radiography  is  also  of  assistance  in  the  examination  of  the  oesophagus. 
Metallic  foreign  bodies  can  be  seen  and  accurately  located;  and  by  the  use  of 
a  bismuth  meal  it  is  possible  to  determine  the  situation  of  a  stricture,  and  the 
amount  of  distension  of  the  oesophagus  above  it. 

Malformations  of  the  oesophagus  are  congenital  or  acquired. 

A  Congenital  communication  may  exist  between  the  oesophagus 
and  trachea,  either  in  the  form  of  a  small  fistula,  or  the  upper  end  of 
the  oesophagus  ends  blindly,  whilst  the  lower  end  opens  into  the 
trachea  near  its  bifurcation.  Life  is  impossible  under  such  con- 
ditions, and  the  children  die  shortly  after  birth.  Congenital  stricture 
may  also  be  met  with  near  the  cardiac  orifice,  resulting  in  general 
distension  and  dilatation  of  the  oesophagus  [cesophagoccele).  The 
Acquired  malformations  consist  in  the  dev^elopment  of  the  so-called 
Diverticula.     Two  forms  have  been  described  by  Zenker ;  [a)  Pressure 


AFFECTIONS  OF  THE  MOUTH.  THROAT,  AND  CESOPHAGUS     867 

Diverticula,  which  are  the  more  common,  and  seem  to  be  associated 
with  some  congenital  weakness  of  the  wall,  probably  connected  with 
the  branchial  clefts.  They  vary  much  in  size,  perhaps  becoming  as 
large  as  a  child's  head,  and  rarely  come  under  observation  before  the 
age  of  thirty.  They  usually  spring  from  the  posterior  wall,  close  to 
the  junction  of  the  pharynx  and  oesophagus,  constituting  what  is 
sometimes  known  as  a  *  pharyngocoele  ' ;  the  cavity  extends  down- 
wards between  the  oesophagus  and  vertebral  column.  The  symp- 
toms are  due  to  distension  of  the  cavity  with  food  which  stagnates 
and  putrehes,  forming  a  swelling  in  the  neck  which  can  be  emptied 
by  pressure;  the  difficulty  of  obtaining  sufficient  food  gradually 
leads  to  emaciation.  When  a  bougie  is  used,  it  generally  passes  into 
the  diverticulum,  and  hence  its  onward  course  is  arrested;  by  careful 
manipulation  it  may  be  kept  on  the  sound  wall,  and  so  slipped  past 
the  orifice  into  the  stomach.  The  administration  of  a  small  bismuth 
meal  and  subsequent  radiography  will  probably  make  clear  the 
diagnosis.  Treatment,  where  possible,  consists  in  exposing  the 
diverticulum  in  the  neck,  through  a  lateral  incision  in  front  of  the 
sterno-mastoid,  removing  it,  and  stitching  up  the  opening  in  the 
pharyngeal  or  oesophageal  wall.  (6)  Traction  Diverticula  are  much 
rarer;  they  usually  occur  on  the  anterior  wall,  near  the  bifurcation 
of  the  trachea,  and  are  due  to  cicatricial  traction  from  without,  as 
by  an  inflamed  bronchial  gland.  They  are  always  of  small  size, 
often  multiple,  and  cause  no  symptoms,  unless  a  foreign  body  lodges 
in  them,  when  ulceration  and  perforation  may  lead  to  suppurative 
mediastinitis  and  death.  They  cannot  be  recognised  ante  mortem, 
except,  perhaps,  by  direct  oesophagoscopy. 

Foreign  Bodies  not  unfrequently  lodge  in  the  oesophagus,  especi- 
ally in  children  and  lunatics.  Portions  of  food,  coins,  fishbones, 
pins,  plates  of  false  teeth,  etc.,  are  the  substances  usually  met  with. 
The  patient  complains  that  something  has  lodged  in  the  gullet, 
causing  a  feeling  of  pain  and  distension,  whilst  swallowing  is  painful 
or  impossible,  and  respiration  may  be  more  or  less  hampered.  Large 
bodies  are  often  impacted  at  the  entrance  to  the  gullet,  and  then 
cause  sudden  death  from  dyspnoea ;  if  the  obstruction  is  not  so  great 
and  remains  unrelieved,  oedema  of  the  glottis  may  supervene.  Im- 
paction lower  down  is  likely  to  be  followed  by  ulceration,  perfora- 
tion, and  death,  either  from  haemorrhage  owing  to  one  of  the  large 
vessels  being  opened,  or  from  suppurative  cellulitis.  In  the  case  of 
a  metallic  body,  diagnosis  both  as  to  its  presence  and  situation  can 
be  made  by  radiography,  and  attempts  at  removal  undertaken  with 
the  assistance  of  the  radiographic  screen.  By  means  of  the  oeso- 
phagoscope  it  is  possible  to  see  the  foreign  body  and  sometimes  to 
remove  it. 

The  Treatment  varies  much  according  to  the  nature,  size,  and 
situation  of  the  obstructing  body.  If  small  and  incapable  of  being 
detected  by  a  sound — e.g.,  a  fishbone — it  is  best  removed  by  an 
expanding  probang  (Fig.  416),  being  caught  in  the  loops  of  thick 
horsehair  forming  part  of  the  apparatus.     If  a  coin  or  smaU  hard 


868  A  MANUAL  OF  SURGERY 

substance  is  impacted,  it  may  be  removed  by  oesophageal  forceps,  or 
by  a  coin-catcher.  If  it  is  impossible  to  draw  it  up,  it  may  some- 
times be  pushed  down  into  the  stomach.  A  large  bolus  of  food  may 
be  removed  by  forceps  from  the  upper  part  of  the  (esophagus,  and 
large  foreign  bodies- — e.g.,  plates  of  teeth- — may  be  similarly  ex- 
tracted, perhaps  with  the  help  of  the  resophagoscope,  though  great 
care  must  be  taken  not  to  tear  the  mucous  membrane. 

If  firmly  impacted  in  the  upper  part,  cesophagotomy  may  be  per- 
formed. An  incision,  4  inches  long,  is  made  along  the  anterior 
border  of  the  sterno-mastoid,  preferably  on  the  left  side,  because 
the  oesophagus  naturally  curves  that  way.  The  surgeon  carefully 
finds  his  way  between  the  carotid  sheath  on  the  outer  side  and  the 
larynx  and  trachea  on  the  inner,  avoiding  the  thyroid  vessels  and 
nerves.  The  projection  of  the  foreign  body  will  indicate  the  situa- 
tion of  the  tube,  and  this  is  incised  and  the  obstruction  dealt  with. 
The  oesophageal  wound  may  then  be  closed  by  sutures  which  do  not 
include  the  mucous  membrane,  whilst  the  external  wound  is  either 
packed  with  gauze  plugs  or  drained.     When  the  foreign  body  is 

located  in  the  upper  part  of 
the  thoracic  portion  of  the 
cesophagus,  the  tube  is 
opened  as  low  as  possible  by 
cutting  down  on  the  point 
of  a  bougie  passed  from  the 

^  ^     „  T^  mouth,  and  then  it  is  often 

Fig.  416. — Expanding  Probang  for  the  .,   '  .^  ■     ^     -^ 

Removal  of  Foreign  Bodies  from  the     possiDle  to  extricate  it. 

CEsopHAGus.  When    impacted    in    the 

It  is  introduced  closed  as  at  A,  and  opened     thorax  and  removal  by  one 

as  at  B  on  withdrawal.  of  the  suggested  methods  IS 

impossible,  it  has  been  pro- 
posed to  open  the  oesophagus  from  behind  in  the  posterior  medias- 
tinum, after  excising  the  necks  of  one  or  more  ribs ;  but  a  successful 
case  has  not  }'et  been  published. 

When  the  foreign  body  is  fixed  near  the  cardiac  orifice,  and  cannot 
be  moved  either  up  or  down,  the  stomach  may  be  opened,  the  fingers 
or  even  the  hand  inserted  into  it,  the  cardiac  orifice  dilated,  and 
the  obstruction  removed. 

When  once  the  foreign  body  has  passed  into  the  stomach,  purga- 
tives and  emetics  should  be  avoided,  and  if  not  of  large  size  and 
irregular  shape,  the  case  is  left  to  Nature,  the  treatment  being  merely 
expectant.  The  patient  is  kept  quiet,  and  fed  on  pultaceous  food — 
such  as  brown  bread,  porridge,  etc. — and  the  course  of  the  foreign 
body  watched  by  radiography.  Should  it  be  large  and  its  course 
be  arrested  at  any  particular  point,  and  especially  if  inflammatory 
symptoms  occur,  a  laparotomy  for  its  removal  must  be  promptly 
undertaken. 
Jlnflammation  oi  the  oesophagus,  with  or  without  ulceration,  is 
caused  by  swallowing  corrosives  or  irritants,  and,  in  a  more  localized 
form,  by  the  impaction  of  foreign  bodies.     The  symptoms  are  pain 


B 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS     869 

and  difficulty  in  deglutition,  and  the  treatment  consists  in  the  re- 
striction of  the  diet  to  liquids,  whilst  in  bad  cases  rectal  feeding  may 
be  necessary.  Chronic  catarrh,  followed  by  stenosis,  may  result  from 
the  continual  drinking  of  raw  spirits. 

Varix  of  the  veins  in  the  lower  portion  of  the  oesophagus  is  occa- 
sionally met  with  as  the  result  of  pressure  on  the  portal  vein,  or  from 
cirrhosis  of  the  liver.  This  is  due  to  the  fact  that  these  branches 
open  into  the  gastric  division  of  the  portal  system,  passing  through 
the  oesophageal  opening  in  the  diaphragm.  Haematemesis  may 
result,  and  has  even  proved  fatal. 

Spasm  of  the  (Esophagus,  or  hysterical  stricture,  arises  in  neurotic 
young  women,  usually  under  twenty-five  years  of  age,  and,  although 
sometimes  independent  of  organic  lesion,  is  often  associated  with 
some  shght  abrasion  or  ulceration  of  the  mucous  membrane,  perhaps 
originated  by  the  impaction  at  an  earher  date  of  a  fishbone.  The 
symptoms  complained  of  are  difficulty  in  swallowing,  and  a  sensation 
as  of  a  ball  arising  in  the  throat  {globus  hystericus),  due  to  a  spas- 
modic action  of  the  pharyngeal  constrictor  muscles.  At  times,  when 
the  patient's  attention  is  diverted,  deglutition  occurs  quite  normally. 
The  best  course  of  treatment  is  anti-neurotic  in  character  {e.g.,  cold 
douches  to  the  spine,  massage,  the  administration  of  purgatives, 
valerian,  etc.),  whilst  the  passage  of  a  full-sized  oesophageal  bougie 
is  useful. 

Organic  Stricture  of  the  (Esophagus  occurs  in  two  forms — the 
fibrous  and  the  malignant : 

1.  Fibrous  Stricture  of  the  (Esophagus  is  usually  located  near  its 
commencement,  just  behind  the  cricoid  cartilage,  and  is  most  fre- 
quently caused  by  the  swallowing  of  corrosives,  and  the  cicatrization 
of  the  wounds  caused  thereby;  it  also  results  from  syphilitic  disease. 
At  the  cardiac  orifice  it  may  arise  from  the  healing  and  contraction 
of  a  gastric  ulcer.  The  main  symptom  produced  is  a  gradually  in- 
creasing difficulty  in  the  swallowing,  firstly  of  solids,  but  finally  even 
of  fluids.  If  the  obstruction  is  placed  at  the  upper  end  of  the  tube, 
food  is  returned  immediately;  but  if  lower  down,  the  oesophagus 
may  become  dilated,  and  in  this  pouch  or  oesophagocoele  the  food 
collects  for  a  time,  and  then  returns  unchanged.  There  is  but  little 
pain  in  this  form  of  stricture,  although  the  patient  is  usually  able 
to  indicate  the  level  of  the  obstruction.  As  the  case  progresses,  he 
becomes  steadily  emaciated  from  sheer  starvation,  and  may  even 
die  from  this  cause. 

2.  Malignant  Stricture  of  the  (Esophagus  is  usually  epitheliomatous 
in  type,  occurring  in  subjects  over  forty  years  of  age,  and  situated 
either  at  the  junction  of  the  pharynx  and  oesophagus,  i.e.,  behind  the 
cricoid  cartilage  (Fig.  417),  or  in  the  middle  of  the  tube,  where  it  is 
crossed  by  the  left  bronchus,  or  at  the  cardiac  orifice  of  the  stomach; 
in  the  latter  site,  columnar  carcinoma  is  the  form  usually  found. 
The  growth  involves  the  whole  circumference  of  the  tube,  and  sooner 
or  later  ulcerates,  perhaps  perforating  the  trachea,  pleural  cavity,  or 
one  of  the  large  vessels.     Secondary  deposits  occur  in  the  lymphatic 


Syo 


A"! MANUAL  OF  SURGE RY 


glands,  either  of  the  neck  or  posterior  mediastinum,  visceral  compH- 
cations  being  uncommon.  The  symptoms  are  similar  in  character  to 
those  of  fibrous  stenosis  detailed  above,  but  in  addition  the  vomited 
materials  may  contain  blood,  and  there  is  a  good  deal  of  cough  and 

pain,  referred  usuaUy  to  the  site  of 
the  disease.  Should  the  growth  be 
at  the  upper  end  of  the  tube,  a 
tumour  may  be  distinctly  felt,  placed 
deeply  in  the  neck  and  more  marked 
on  the  left  side ;  in  the  earlier  stages 
nothing  can  be  felt  externally,  al- 
though the  side-to-side  movements 
of  the  larynx  may  be  impeded. 
Perforation  of  the  trachea  leads  to 
the  entrance  of  food  into  the  air- 
passages,  and  rapidly  results  in  septic 
pneumonia  and  death.  When  the 
upper  part  of  the  gullet  is  affected, 
the  growth  may  spread  to  the  back 
of  the  larynx,  and  cause  hoarseness 
and  even  aphonia.  Occasionally  the 
pneumogastric  nerves  may  ba  in- 
volved in  the  mass,  leading  to  inter- 
ference with  the  action  of  the  heart, 
whilst  implication  of  the  recurrent 
laryngeal  nerves  causes  constant 
cough  and  uni-  or  bilateral  paralysis 
of  the  larynx. 

The  Diagnosis  of  (esophageal 
stricture  can  be  made  by  the  ad- 
ministration of  a  bismuth  meal  and 
radiography,  or  by  examining  the 
condition  of  the  tube  with  an  oesophageal  bougie.  The  greatest 
care  must  be  taken,  especially  in  suspected  malignant  disease,  as 
it  is  not  difficult  to  perforate  the  walls  and  open  up  the  medias- 
tinal tissues,  causing  thereby  a  fatal  cellulitis.  A  cancerous 
stricture  sometimes  feels  rough  and  is  painful ;  a  simple  stricture  is 
smooth,  regular,  and  almost  painless.  It  is  by  no  means  easy  to 
distinguish  the  two  forms  by  the  bougie  alone,  and  the  history  of 
the  case  and  the  general  condition  of  the  patient  will  need  to  be 
investigated  thoroughly;  a  hacking  cough  with  no  special  pulmonary 
symptoms  is  always  a  bad  and  suggestive  sign.  The  use  of  the 
oesophagoscope  in  skilful  hands  will  enable  the  upper  surface  of  the 
stricture  to  be  seen,  and  an  absolute  diagnosis  effected. 

Treatment  of  Fibrous  Stricture  of  the  CEsophagus.^ — [a)  Dilatation 
of  the  stricture  by  means  of  gradually  increasing  bougies;  for  this 
purpose  it  is  better  to  use  conical  rather  than  blunt-ended  instru- 
ments. The  use  of  the  oesophagoscope  facilitates  this  procedure. 
An  interval  of  some  days  should  elapse  between  the  attempts  at 


Fig.  417. — Cancerous 

OF   THE   QiSOPHAGUS. 

'  Surgery.') 


Growth 
(Treves' 


AFFECTIONS  OF  THE  MOUTH.  THROAT.  AND  (ESOPHAGUS     871 

dilatation,  and  during  this  period  the  patient  should  be  given  as 
much  food  as  he  can  take  in  the  shape  of  strong  broths,  minced 
meat,  raw  eggs,  etc.,  or,  if  need  be,  rectal  alimentation  must  be 
resorted  to.  {b)  If  it  is  impossible  to  dilate,  or  if  the  stricture 
recurs,  a  tine  rubber  tube  can  usually  be  passed  through  the  stric- 
ture by  the  assistance  of  the  cesophagoscope,  and  is  maintained 
there  for  a  time.  The  upper  end  is  drawn  out  of  the  mouth  and  fixed 
to  the  ear.  Feeding  is  thereby  rendered  easy,  and  the  presence  of 
the  tube  for  a  time  gradually  determines  dilatation  of  the  stricture, 
(c)  When  the  contraction  is  at  the  pharyngeal  extremity,  it  may  be 
possible  to  divide,  and  subsequently  dilate,  the  stricture  by  the  aid 
of  the  cesophagoscope.  {d)  If  the  cardiac  orifice  of  the  stomach  is 
contracted,  the  stomach  may  be  opened  as  in  gastrotomy,  and  the 
fingers  used  to  dilate  the  stricture  (retrograde  dilatation) .  [e)  Where 
these  proceedings  are  not  possible,  or,  if  tried,  have  failed,  the 
stomach  may  be  opened  and  division  of  the  stricture  by  Abbe's 
stnng  sai&  attempted.  The  patient  is  made  to  swallow  one  end  of 
a  piece  of  string,  or  a  small  shot  may  be  clamped  on  a  piece  of  fine 
silk,  and  allowed  to  find  its  way  into  the  stomach.  When  this 
viscus  is  opened,  the  free  end  is  secured  and  by  this  means  a  coarse 
silk  thread  is  carried  through  the  obstruction;  by  up-and-down 
sawing  movements  the  stricture  can  be  thereby  divided,  enabling 
the  surgeon  to  introduce  bougies.  Excellent  results  have  been 
reported  from  such  practice.  (/)  Gastrostomy  (p.  1005)  is  the  final 
resource.  Occasionally  when  the  oesophagus  has  by  this  means 
been  kept  at  rest  for  some  time,  the  stricture  will  yield,  and 
dilatation  by  bougies  becomes  practicable.  In  such  a  case  the 
opening  in  the  stomach  may  be  allowed  to  close. 

Treatment  of  Malignant  Disease  of  the  (Esophagus.— Dilatation 
by  bougies  even  with  the  assistance  of  the  cesophagoscope,  should 
not  be  employed  as  a  routine  practice,  for  fear  of  increasing  the 
ulceration,  causing  severe  haemorrhage,  or  perforating  the  walls  of 
the  tube.  It  may,  however,  be  used  very  carefully  so  as  to  enable 
a  tube  to  be  passed  through  the  stricture  for  feeding  purposes. 
Symond's  method  of  ttibage  may  be  utilized  in  malignant  disease, 
the  patients  often  bearing  the  inserted  tube  well,  even  when  the 
cardiac  orifice  is  involved,  the  lower  end  then  projecting  into  the 
cavity  of  the  stomach.  Radium  has  been  employed,  but  is  of  little 
real  value,  for  although  the  primary  growth  may  be  improved,  the 
patient  dies  of  secondary  deposits  which  cannot  be  affected  by  its 
influence.  Hence,  gastrostomy  is  likely  to  be  required  sooner  or  later 
in  not  a  few  of  the  cases. 

By  the  term  Dysphagia  is  meant  a  condition  in  which  swallowing  is  painful 
or  difficult.     The  Causes  are  very  numerous,  and  may  be  arranged  as  follows: 

1.  Pharyngeal — e.g.,  acute  or 'chronic  inflammation,  whether  simple,  scar- 
latinal, diphtheritic,  etc.;  ulceration  of  syphihtic  or  malignant  origin;  stenosis 
as  a  result  of  ulceration;  paralysis  {e.g.,  labio-glosso-laryngeal  or  bulbar) 
or  spasm;  impaction  of  foreign  bodies;  naso-pharyngeal  pol}^)!  projectmg 
behind  the  velu  m;  retro-pharyngeal  abscess  or  tumour,  etc. 

2.  Laryngeal — e.g.,  acute  or  chronic  laryngitis;  tiiberculous,  syphilitic,  or 
malignant  disease. 


872  A  MANUAL  OF  SURGERY 

3.  (Esophageal — e.g.,  acute  or  chronic  inflammation,  impaction  oi  foreign 
bodies,  the  presence  of  diverticula,  cesophagospasm,  and  simple  or  maUgnant 
stricture. 

4.  Extrinsic. — In  the  neck  :  goitre,  enlarged  glands,  aneurisms,  etc.  In  the 
thorax  :  mediastinal  growths  or  glands,  aneurisms  of  the  aorta  and  large 
vessels,  tumours  growing  from  the  vertebral  bodies,  pericardial  effusion,  and 
displacement  backwards  of  the  sternal  end  of  the  clavicle. 

To  investigate  a  case  of  dysphagia,  note:  (i)  The  method  of  onset,  whether 
acute  or  chronic — if  the  former,  it  is  probably  due  to  a  foreign  body;  (2)  the 
condition  of  the  phar^Tix  as  seen  from  the  mouth  and  on  digital  exploration ; 

(3)  the  condition  of  the  neck  as  seen  and  felt  from  without,  whether  or  not 
a  tumour  is  to  be  felt  behind  the  cricoid,  or  whether  a  goitre  or  aneurism  exists  ; 

(4)  the  character  of  the  voice,  as  indicative  or  not  of  laryngeal  mischief — if 
the  voice  is  husky,  a  laryngoscopic  examination  must  be  made;  (5)  the  chest 
must  be  carefully  examined  for  aneurisms,  etc.;  (6)  the  oesophagus  is  examined 
by  bougies  or  the  oesophagoscope.  If  the  obstruction  is  in  the  oesophagus, 
the  patient's  age  and  general  condition  will  give  prima  facie  evidence  as  to 
whether  or  not  it  is  due  to  malignant  disease;  but  it  must  not  be  forgotten 
that  the  stenosis  per  se  causes  some  of  the  loss  of  flesh  and  of  weight.  The 
presence  of  blood  and  offensive  mucus  on  the  bougie  or  on  the  material 
vomited,  and  the  existence  of  enlarged  glands  in  the  neck,  will  also  assist  in 
establishing  a  diagnosis. 


CHAPTER  XXXI. 
AFFECTIONS  OF  THE  EAR. 

The  Examination  of  the  Ear  is  carried  out  by  inspecting  the  membrana 
Lmpfm  tTrouTa  speculum  by  means  of  light  reflected  from  a  frontal  mirror ; 
bv  testin-  the%ower  of  hearing;  and  by  ascertaining  whether  or  not  the 
Eustachran  tubers  permeable,  and  the  effect  on  the  hearing  of  inflation  through 

^^'i  ""vrsuaf  inspection  by  means  of  a  speculum  and  frontal  mirror  In  in- 
trodudnrthe  speculum  the  auricle  is  held  between  the  third  and  fourth 
Inters  oi  the  operator  (the  left  hand  being  used  for  the  right  ear,  and  vice 
...?:  and  draw^n  backwards,  upwards,  and  outwards  so  as  to  ^ J--ght«n  t^^^^ 
rartilaeinous  portion  of  the  meatus.  The  speculum  held  by  the  operator  . 
Sumrandfi?sT  finger  is  then  gently  .inserted  and  held  m  position.  The 
reflected  light  illuminates  the  tympanic  membrane,  unless  the  presence  ot 
wax  epitheUal  debris,  or  pus  obstructs  the  view,  when  they  must  be  removed 
brcot?on-wool  mops  or  by  syringing.     The  following  points  are  to  be  noted 


Fig.  418. — Eustachian  Catheter. 

in  the  normal  membrana  tympani  (Fig.  419):  The  projection  of  the  short 
process  and  handle  of  the  malleus  which  runs  from  the  centre  upwards  and 
Forwards;  behind  this  the  processus  gracilis  of  the  .incus  and  the  tendon  of 
the  stapedius-  and  at  the  upper  border  Shrapnell  s  membrane  (i-ig.  421  j • 
The  motility  of  tSe  membrane  should  be  considered,  as  also  its  colour,  whilst 
pathSoScaliy  the  presence  of  perforations,  polypi,  or  adhesions,  should  be 

''°?'The  Investigation  of  the  Hearing  is  usually  carried  out  by  testing  the 
greati^dSce  ft  wh^^^^^  patient  can  hear  the  ordinary  conversational 

foice  or  the  tick  of  a  watch;  the  whispered  voice  is  also  ^^„^°iP°X*.  ^^f^J^^^ 
The  cause  and  location  of  deafness  is  ascertained  by  Rinnes  Tuning-*  OfK 
Test  To  perform  it  a  tuning-fork  of  about  five  hundred  and  twelve  vibra- 
fions  is  placed  in  contact  with  the  mastoid  process,  and  retamed  there  until 
the  natient  can  hear  it  no  longer.  If  now  it  is  placed  opposite  the  external 
auditorv  meatus  Se  sound  shSuld  again  be  heard  if  the  middle  ear  is  normal, 
but  Snofbrnoted  if  disease  is  pfesent.  Weber's  Test  consists  m  p  acing 
a  vibrating  tuning-fork  in  the  middle  line  of  the  forehead.  In  cases  01  pure 
L^dL  e?r^iseasf ,  the  sound  will  be  noticed  more  in  the  affected  ear  than 

on  the  healthy  side. 

873 


874 


A  MANUAL  OF  SURGERY 


3.  Inflation  of  the  Tympanic  Cavity  is  required  both  as  a  test  of  the  permc- 
abihty  ol  the  Iv.islai  hum  tube  and  also  as  a  means  of  treatment  in  various 
conditions.      1  lie  methods  of  eftecting  it  are  as  follows: 

Valsalva's  Method  consists  in  closing  the  lips,  holding  the  nose,  and  expiring 
forcibly;  the  air  is  thereby  driven  up  the  Eustachian  tubes  if  they  are  patent. 

In  Politzer's  Method  an  indiarubber  bag  with  a  teat-like  end  is  introduced 
into  one  nostril  so  as  to  occupy  it  completely.  The  other  nostril  is  closed  by 
the  surgeon's  linger.     The  patient  is  instructed  to  take  a  sip  of  water  and  to 


Fig.   419. 


Fig.  420. 


Fig.  421.  Fig.  422. 

Figs.  419-422. — Appearance  of  the  Membrane  in  Various  Circumstances 

ON  Examination  through  a  Speculum. 

By  permission,  from  Mr.  Albert  A.  Gray's  '  Diseases  of  the  Ear.'     London: 
Baillidre,  Tindall  and  Cox.) 
Fig.  419. — Normal  membrane  (right  side). 
Fig.  420. — Perforation  below  and  in  front  of  head  of  malleus  (left  ear)  m 

acute  otitis  suppurativa. 
Fig.  421. — Perforation   through  Shrapnell's  membrane  in  chronic  otor- 

rhoea. 
Fig.  422. — Polypi  protruding  through  perforation  in  membrane. 

hold  it  in  the  mouth  with  closed  lips  until  told  to  swallow.  As  he  swallows, 
the  bag  is  forcibly  compressed,  and  air  is  thereby  driven  up  the  tubes.  An 
auscultating  tube  may  pass  from  the  patient's  meatus  to  the  surgeon's  ear, 
and  various  sounds,  whistling,  bubbling,  etc.,  may  be  detected,  according 
to  the  character  of  the  lesion. 


AFFECTIONS  OF  THE  EAR 


875 


The  Eustachian  Catheter  (Fig.  4x8)  can  be  Passed  mto  tl.c  E-^tachian^ube 
and   the  degree  o£  inflation  more  ^f  urate  ycont^lled.      ine 
carelnlly  steriHzed,  is  passed  with  the  beak  downwards  along  tne 
meatus  of  the  nose  until  the.postenor  pharyngeal  wains  le^  ^^ 

l-Si:^  -  SySS,^S^iS^S;StL  ^Srl^S  S.e  Eustachian 
tube  '  (Lambert  Lack). 

The  External  Ear  is  the  site  of  various  affections  ^^^^^^^^  ^^^^ 
under  the  observation  of  the  general  surgeon.  1  ^^f'^^h^  Pmna  may 
be  congenitally  absent,  and  even  the  external  meatus  c.osed^a  mal 
formation  often  associated  with  macrostoma.  Nothing  can  be  done 
for  this  want  of  development,  and  the  surgeon  must  nevei  be  tempted 
to  try  and  dig  out  the  concealed  membrana  tympam.  More  tre 
quently  accessory  auricles  are  present   con-  — 

sisting  merely  of  fibro-cartilage  covered  with 
fat  and  skin.  Large  and  prominent  ears 
constitute  a  very  unsightly  deformity,  tor 
which  operative  interference  is  occasionally 
required.     The  size  may  be  diminished  by 

removing  a  V-shaped  portion  from  the  upper 

part  •  the  prominence,  by  excising  a  portion 

of  skin  and  cartilage  through  an  incision  on 

the   posterior    aspect.      The    wounds   thus 

produced  are   accurately  sutured  together, 

and  considerable  improvement  in  the  appear- 
ance   results.      Hsematoma    of    the   ear   is 

usually  due  to  injury,  but  is  occasionally 

idiopathic  in  origin,  especially  amongst  the 

insane.     The   auricle   becomes  swollen  and 

enlarged,  and  of  a  bluish-red  colour  in  trau- 
matic cases  (Fig.  423) ;  unless  Ihe  swelling 

is  punctured  and  the  blood  let  out,  consider-  ^,,,^^    l^oUs 

able  deformity  will  result  from  its  org^^^^^^^^^^-^.^^ff.'^^^^As^^are 
and  other  inflammatory  affections,  as  also  sebaceous  cysts,  are 
met  with  in  the   external  ear  and  pmna,  but  call  for  no  special 

"'plugs  o£  wax  (cerumen),  which  become  dark  and  indurated  not 
unfrequently  block  the  rneatus  leading  to  more  or  less  compMe 
deafness;  this  may  come  on  suddenly  after  b^^hing  owing  to  the 
Dluff  rapidly  swelling  up.  If  they  encroach  on  the  membrana 
rJ^'paTsubjective  fym^toms  of  giddiness,  vomiting  and  rush.ng 
noises  in  the  ear  may  also  be  caused.  On  examination  with  an  ear 
spTcuC  th^pres J^  is  readily  detected,  ^re^^^jl^^^^^^^^ 
washing  them  away,  after  previously  so  tenmg  w^th  oil  or  glycenne^ 
A  laree  svringe  with  a  fine  nozzle  should  be  used,  and  a  stream  01 
warXX^^iected  along  the  roof  of  the  --t-'  ^  1^^^^^^^^^^^^ 
softened  masses  of  wax  are  washed  away,  ^o^^^^^n  bodies  in  the 
meatus,  such  as  buttons  or  beads,  are  similarly  removed,  if  possible, 


Fig. 


423. HiEMATOMA 

AURIS. 


876  A    MANUAL  OF  SURGERY 

by  syringing;  if  this  fails,  a  fine  pair  of  forceps  is  employed  for  the 
purpose,  but  it  must  be  remembered  that  behind  the  foreign  body  lie 
delicate  structures,  which  can  readily  be  harmed  by  the  exhibition 
of  impatience  or  force.  Where  all  other  plans  fail,  the  auricle  may 
be  turned  forwards  and  the  meatus  opened  from  behind.  Exostoses 
are  occasionally  met  with  springing  from  the  bony  walls  of  the 
meatus;  they  give  rise  to  deafness  by  obstructing  the  passage,  and 
may  be  removed  by  the  dental  drill. 

AfEections  of  the  Middle  Ear. 

Traumatic  Rupture  of  the  Tympanic  Membrane  is  due  to  direct  or 
indirect  violence;  the  former  includes  the  introduction  of  foreign 
bodies,  or  the  ill  -  advised  efforts  of  friends  or  even  of  medical 
practitioners  to  remove  the  same;  the  latter  causes  rupture  of  the 
membrane  by  the  sudden  compression  of  the  air  in  the  external 
meatus — e.g.,  by  boxing  the  ear,  loud  noises  as  from  explosions 
or  big-gun  practice,  or  from  diving.  The  lesion  also  occurs  not 
uncommonly  in  fractures  of  the  middle  fossa  of  the  skull.  The 
patient  complains  of  pain  and  deafness,  and  blood  escapes  from  the 
meatus,  but  not  to  any  great  extent.  On  inflating  the  drum- 
chamber,  as  by  Valsalva's  or  Politzer's  methods,  air  can  be  heard  to 
escape  tlirough  the  opening,  perhaps  with  a  whistling  sound.  As  a 
general  rule,  these  cases  do  well,  the  wound  cicatrizing,  and  the 
hearing  being  fully  restored;  but  the  surgeon  must  at  first  give  a 
guarded  opinion,  as  there  may  be  some  deeper  lesion  which  does  not 
immediately  become  apparent.  The  greatest  care  must  be  taken  to 
sterilize  the  meatus,  although  it  is  not  wise  to  use  a  syringe  for  the 
purpose;  the  meatus  is  filled  with  i  in  20  carbolic  lotion,  which  is 
allowed  to  soak  m ;  by  this  means  infection  of  the  tympanic  cavity 
with  pyogenic  organisms  may  be  prevented  A  strip  of  gauze  is 
then  gently  inserted  into  the  meatus,  and  an  external  dressing 
applied. 

Otitis  Media.- — Inflammation  of  the  middle  ear  is  an  exceedingly 
common  affection,  and  constitutes  the  great  bulk  of  all  ear  diseases. 
It  must  be  remembered  that  the  tympanic  cavity  is  lined  by  a 
mucous  membrane  which  is  in  direct  communication  through  the 
Eustachian  tube  with  that  of  the  naso-pharynx ;  and  hence  the 
cause  is  almost  invariably  an  extension  of  inflammation  along  the 
Eustachian  tube,  and  the  organisms  usually  present  are  the  pneu- 
mococcus  or  ordinary  pyogenic  cocci.  The  inflammation  may  be 
catarrhal  or  suppurative,  acute  or  chronic.  We  can  here  only  refer 
very  briefly  to  that  most  commonly  associated  with  surgical  lesions. 
Acute  Inflammation  of  the  Middle  Ear  is  very  common  in  children, 
being  secondary  to  lesions  of  the  naso-pharynx,  such  as  an  ordinary 
cold,  adenoids,  scarlatina,  measles,  etc.  It  is  ushered  in  by  severe 
pain  in  the  ear  (earache)  of  a  boring,  persistent  character,  together 
with  deafness  and  perhaps  some  degree  of  fever.  The  pain  increases 
as  the  secretion  accumulates,  and  if  the  Eustachian  tube  becomes 
closed  in  consequence  of  the  inflammatory  hypersemia  of  its  lining 


AFFECTIONS  OF  THE  EAR  877 

wall,  the  tympanic  membrane  bulges  outwards  into  the  meatus  and 

finally  ruptures  (Fig.  420),  the  pain  being  at  once  reheved.  The 
discharge  is  mucous,  or  purulent  fromthe  first ;  in  the  former  mstance, 
if  infection  from  the  meatus  is  guarded  against,  the  inflammation 
may  subside,  the  perforation  heal,  and  no  ill  result  follow.  In  many 
instances,  however,  especially  when  the  child  is  suffermg  from 
measles,  or  if  his  resisting  powers  to  microbic  invasion  are  low, 
pyogenic  infection  follows,  and  the  catarrhal  otitis  media  is  trans- 
formed into  a  suppurative  lesion,  which  may  persist  as  a  chronic 
otorrhcea  for  a  lengthy  period,  and  may  lead  to  the  most  serious 
results.  .     , 

It  is  therefore  obvious  that  the  greatest  care  should  be  taken  m  the 
Treatment  of  all  cases  of  acute  otitis  media.  In  the  first  place,  the 
possibility  of  infection  from  the  external  meatus  must  be  guarded 
against  by  thoroughly  purifying  it ;  the  external  ear  is  well  washed 
with  soap  and  water,  and  the  meatus  is  filled  with  i  m  20  carbolic 
lotion,  which  is  aUowed  to  soak  in  and  act  for  some  minutes.  An 
antiseptic  dressing  is  then  placed  within  and  over  it.  The  child  is 
kept  in  a  warm  room,  and  his  general  condition  attended  to  by  suit- 
able diet,  diaphoretic  medicine,  and  a  smart  purge.  In  mild  cases  a 
blister  behind  the  ear  will  often  act  beneficially,  whilst  m  more  acute 
ones  leeches  may  be  applied.  Solution  of  cocaine  or  drops  of  lauda- 
num instilled  into  the  meatus  may  relieve  pain,  and  in  adults  it  may 
be  possible  to  cocainize  the  orifice  of  the  Eustachian  tube  in  the 
pharynx,  thereby  relieving  the  hypersemia  and  opening  up  the  tube, 
and  thus  giving  an  exit  to  the  retained  discharge.  Pain  is  often 
relieved  by  fomenting  the  ear  or  by  the  appHcation  of  dry  heat,  as 
in  the  form  of  a  hot-water  bottle  or  a  baked  bran-bag.  _ 

When  the  membrane  is  seen  (by  speculum)  to  be  bulging,  it  is  wise 
to  incise  it,  as  a  clean  cut  often  heals  better  than  the  ragged  perfora- 
tion made  by  Nature.  Local  or  general  ansesthcsia  is  required,  and 
the  incision  is  usually  made  just  behind  and  slightly  above  the 
handle  of  the  malleus  downwards  and  backwards.  An  antiseptic 
dressing  is  left  in  and  over  the  meatus  until  healing  has  occurred. 

Chronic  Otorrhcea,  as  already  explained,  is  a  common  sequence  ot 
an  acute  attack,  which  may  have  been  purulent  from  the  first,  or 
may  have  been  the  result  of  a  pyogenic  infection  from  without  of  a 
simple  catarrhal  otitis  media.  The  membrane  is  perforated,  and  the 
discharge  varies  in  amount  and  character.  In  uncomplicated  cases, 
treatment  consists  in:  (i)  Improvement  of  the  general  health,  as  by 
the  administration  of  tonics,  residence  in  fresh  country  air,  and 
avoidance  of  chills.  (2)  The  naso-pharyngeal  condition  must  be 
attended  to,  so  as  to  ensure  a  patulous  condition  of  the  Eustachian 
tube,  by  which  discharges  may  escape.  Gargles  may  be  ordered 
and  adenoids  and  enlarged  tonsils  may  require  removal.  (3)  ine 
middle  ear  must  be  kept  free  from  any  accumulation  of  discharge 
which  might  undergo  decomposition.  When  the  discharge  is  abun- 
dant, external  syringing  with  sterilized  salt  solution  or  weak  boric 
acid  solution  is  needed,  and  the  tympanic  cavity  is  inflated  from  tne 
Eustachian  tube  by  Valsalva's  method,  PoHtzer's  bag,  or  even  the 


878  A   MANUAL  OF  SURGERY 

Eustachian  catheter,  once  or  twice  a  day.  If  the  discharge  is  offen- 
sive, or  difficult  to  dislodge,  peroxide  of  hydrogen  (10  volume 
strength)  will  be  found  useful.  If  the  discharge  is  slight,  the  meatus 
may  be  packed  with  boric  acid  powder,  and  syringing  avoided. 
Not  unfrequently,  however,  a  persistent  discharge  from  the  ear  is 
due  to  some  of  the  complications  mentioned  below,  and  further 
operative  treatment  may  be  required. 

The  Surgical  Complications  of  Chronic  Otorrhoea  are  often  serious, 
and  call  for  prompt  treatment ;  they  may  be  classified  under  three 
headings- — the  extracranial,  the  cranial,  and  the  intracranial. 

The  extracranial  complications  of  otorrhoea  are  comparatively 
unimportant.  ((/)  Eczema  of  the  meatus  is  frequently  seen,  and 
merely  needs  the  parts  to  be  kept  dry  and  clean,  and  possibly  a  Httle 
boric  acid  powder  insufflated:  it  readily  disappears  when  the  dis- 
charge ceases,  but  is  not  unfrequently  associated  with  enlargement 
of  the  cervical  glands,  which  may  suppurate  or  become  tuberculous. 
(h)  Boils  arise  from  infection  of  the  sebaceous  glands  in  the  meatus 
with  pyogenic  cocci  from  the  discharge,  and  are  exceedingly  painful 
owing  to  the  denseness  of  the  tissues  involved.  They  should  be 
fomented,  and  opened  when  pus  has  formed,  (c)  Inflammation 
may  occasionally  spread  from  the  meatus  to  the  tympanic  plate  of 
the  temporal  bone,  leading  to  subperiosteal  abscess  and  necrosis; 
or  it  may  extend  into  the  temporo-maxillary  articulation,  giving 
rise  to  suppurative  arthritis  anddisorganizationof  that  joint  (p.  811). 

The  cranial  complications  of  otitis  media  are  often  of  a  grave 
nature,  and  may  produce  deafness,  or  even  endanger  life. 

{a)  The  ossicles  become  ankylosed,  or  may  die  and  be  cast  off  in 
the  discharge,  the  hearing  being  impaired  in  either  case,  but  not 
necessarily  destroyed. 

{b)  The  inflammation  may  extend  from  the  lining  membrane  of 
the  tympanum  to  the  bony  walls  surrounding  it,  giving  rise  to  a 
limited  caries  or  necrosis  of  the  temporal  bone.  This  may  be  as- 
sociated with  suppuration  within  the  skull,  and  any  of  the  intra- 
cranial complications  mentioned  below.  The  roof  of  the  tympanic 
cavity  {iegmen  tympani),  which  is  very  thin,  is  especially  liable  to  be 
affected  in  this  way.  If  diseased  bone  can  be  felt  through  the 
external  auditory  meatus  with  a  probe,  an  attempt  should  be  made 
to  remove  it ;  if  this  is  impossible,  the  part  must  be  kept  clean  by 
the  injection  of  mild  antiseptics,  retention  of  discharges  being  pre- 
vented by  the  regular  use  of  Politzer's  bag. 

(c)  Polypi  may  also  develop,  consisting  essentially  of  granulation 
tissue  protruding  through  the  opening  in  the  membrane  (Fig.  422) 
thereby  hindering  the  escape  of  the  discharge.  Ihey  should  be 
removed  by  the  snare  or  curette,  and  the  base  touched  with  a  satu- 
rated solution  of  chromic  acid;  the  part  is  subsequently  syringed 
with  a  weak  carbolic  solution  and  dressed  antiseptically. 

[d]  Facial  Paralysis  not  uncommonly  arises  from  sclerosis  and 
thickening  of  the  bony  tissue  surrounding  the  aqueductus  Fallopii, 
causing  pressure  on  the  facial  nerve  in  the  canal.  It  must  be  re- 
membered that  the  bony  canal  lies  immediately  behind  the  tympanic 


AFFECTIONS  OF  THE  EAR  879 

cavity,  and  to  the  inner  side  of  the  passage  from  the  attic  to  the 
mastoid  antrum  [aditus  ad  antrum).  For  symptoms  and  treatment, 
see  p.  384. 

[e)  Involvement  of  the  Internal  Ear  or  Labyrinthitis  results  from 
the  spread  of  the  infection  inwards,  either  through  the  wall  of  the  ex- 
ternal semicircular  canal,  or  through  the  fenestrum  rotundum  or 
ovale;  in  the  former  case  the  posterior  or  vestibular  portion  is 
involved,  in  the  latter  the  cochlea.  Invasion  of  the  semicircular 
canals  is  usually  evidenced  by  vertigo,  a  tendency  to  fall  towards  the 
affected  side,  nystagmus  and  vomiting;  pain  and  fever  are  present 
in  the  more  acute  forms.  Involvement  of  the  cochlea  is  generally 
a  later  manifestation,  and  results  in  tinnitus  and  absolute  deafness. 
Infection  of  the  meninges  sometimes  arises  by  spread  of  inflammation 
along  the  internal  auditory  meatus. 

(/)  Inflammation  may  also  extend  into  the  mastoid  cells,  giving 
rise  to  the  condition  known  as  mastoiditis.     The  mastoid  process  is 
a  triangular  mass  of  bone,  which  is  practically  undeveloped  until  the 
age  of  puberty.     Before  that  period  a  single  cell  relatively  of  large 
size  communicates  with  the  posterior  portion  of  the  tympanic  cavity 
and  represents  the  antrum;  it  is  comparatively  superficial,  being 
immediately  under  cover  of  the  squamous  flake  of  bone,  and  is  in 
reality  petro-squamosal  rather  than  mastoid  in  origin.    After  puberty 
the  whole  bone  may  become  hollowed  out  into  a  series  of  spongy 
cells,  lined  with  mucous  membrane,  which  open  into  the  floor  of  the 
antrum;  or  it  may  develop  but  few  cells,  and  remain  more  or  less 
solid.     These  cells  lie  below  and  superficial  to  the  antrum,  which  is 
therefore  more  deeply  placed  in  the  adult  than  in  the  child.     The 
communication  with  the  tympanic  cavity,  which  in  a  child  is  widely 
open,  becomes  encroached  on  in  the  adult,  and  narrowed  to  the  small 
track  known  as  the  aditus  ad  antrum.     When  the  inflammation  in 
otitis  media  becomes  purulent  and  extends  into  the  antrum,  severe 
local  and  general  symptoms  are  likely  to  result.     The  patient  com- 
plains of  intense  pain  in  the  ear,  with  tenderness  on  pressure,  and 
perhaps  redness  and  oedema  over  the  mastoid  process.     The  dis- 
charge from  the  ear  often  ceases  for  a  time  at  the  commencement 
of  these  symptoms,  but  reappears  later  on.     As  the  case  progresses, 
febrile  symptoms  of  an  intermittent  type,  and  even  rigors,  may 
supervene,  whilst  the  patient  becomes  drowsy,  or  may  be  irritable 
and  restless.     An  abscess  may  form  under  the  periosteum  covering 
the  mastoid  process,  with  or  without  caries  or  necrosis  of  the  outer 
table  of  the  bone;    in  children,  where  this  bony  lamella  is  thin,  it  is 
not  unfrequently  absorbed,  and  on  incising  the  abscess  protuberant 
masses  of  granulations,  springing  from  the  interior  of  the  bone,  may 
be  seen.     When  such  an  abscess  has  developed,  the  auricle  is 
characteristically  displaced  downwards  and  outwards.     Not  unfre- 
quently the  suppuration  extends  through  the  bone  cells  and  may 
encroach  on  the  inner  aspect  rather  than  the  outer,  and  hence  is 
likely  to  lay  bare  the  dura  mater  and  expose  the  lateral  sinus ;  in  such 
circumstances  intracranial  complications  are  probable  (Fig.  369). 
Occasionally  a  few  thin-walled  cells  occupy  the  tip  of  the  mastoid; 


88o 


A   MANUAL  OF  SURGERY 


and  these,  if  involved,  may  perforate  downwards,  and  thus  an  ab- 
scess may  form  under  cover  of  the  sterno-mastoid,  and  track  into  the 
neck;  this  is  known  as  Bezold's  perforation  (Fig.  369,  F).  At  times 
the  trouble  is  of  a  more  chronic  type,  and  is  then  associated  with 
the  more  solid  form  of  mastoid  process.  Sometimes  it  is  tuberculous 
in  nature,  the  cells  being  choked  up  with  lymph  and  inflammatory 
material  of  a  cheesy  nature,  whilst  the  bone  itself  becomes  thickened 
and  condensed.  The  process  feels  distinctly  enlarged,  and  is  the 
seat  of  a  good  deal  of  deep-seated  pain  of  an  aching  character,  and 
worse  at  night. 

When  the  discharge  is  inspissated  and  mixed  with  epithelial  cells 
and  cholesterine,  so  as  to  form  flaky  masses  like  the  layers  of  an 
onion,  the  condition  is  known  as  cholesteatoma.  It  k  often  the  cause 
of  great  distension  of  the  antrum,  which  in  one  case  operated  on 
measured  quite   i|   inches  across.     The  symptoms,   at   first  of  a 


Fig.  424. — Incision  for 
[  Mastoid  Operations. 


Fig.  425. — Site  for  Drilling 
Bone  in  Order  to  Open  the 
Mastoid  Antrum. 


It  is  often  well  to  apply  a  chisel  over  the  desired  area  so  as  to  include  a  triangle, 
the  centre  of  which  corresponds  to  the  apex  of  the  so-called  supra-meatal 
triangle.  As  soon  as  the  outer  layers  of  the  bone  have  been  removed  by 
the  chisel,  the  gouge  is  used  to  reach  the  deeper  parts. 

chronic  type,  are  likely  to  be  followed  sooner  or  later  by  an  acute 
attack  of  suppurative  inflammation. 

Treatment. — In  the  early  acute  stage  belladonna  fomentations  may 
be  employed,  and  the  patient  kept  quietly  in  bed,  whilst  the  diet  is 
regulated  and  a  suitable  purgative  administered;  accumulated  dis- 
charge is  removed  from  the  tympanum  by  the  use  of  Politzer's  bag. 
Two  or  three  leeches  may  also  be  applied  over  the  mastoid  process, 
and  relief  to  the  pain  thus  obtained,  though  it  is  often  only  of  a 
temporary  character.  It  is  most  important  not  to  rely  upon  such 
palhative  measures  for  too  long,  but  if  the  symptoms  are  well 
marked,  the  mastoid  antrum  must  he  laid  open  and  its  contents 
evacuated  without  interfering  with  the  tympanic  structures  which 
in  acute  cases  are  capable  of  effective  repair  [Schwartzes  operation). 
A  curved  incision  is  made  immediately  behind  the  ear,  which  is 
drawn  well  forwards  (Fig.  424),  and  a  gouge  or  burr  worked  by  a 
surgical  engine,  applied  on  a  level  with  the  roof  of  the  external 


AFFECTIONS  OF  THE  EAR 


881 


auditory  meatus,  and  about  h  inch  behind  its  centre  (Fig.  425).  A 
small  dmiple  in  the  bone  can  often  be  felt  at  the  required  spot, 
which  can  also  be  found  by  taking  the  point  of  junction  of  two  hues 
drawn  as  tangents  to  the  roof  and  posterior  wall  of  the  bony  meatus 
respectively  (Fig.  370,  C) .  The  direction  taken  by  the  gouge  should 
be  slightly  downwards,  forwards,  and  inwards,  and  a  useful  guide 
will  be  found  in  a  probe  , 

passed  down  the  external 
auditory  meatus,  the  bor- 
ing being  made  exactly 
parallel  to  this.  In  an 
adult  the  mastoid  antrum 
is  reached  about  three- 
fifths  of  an  inch  from  the 
surface  of  the  bone.  The 
surgeon  recognises  that 
he  has  opened  the  cavity 
by  the  probe,  or  by  the 
loss  of  resistance  and 
escape  of  offensive  pus. 
The  opening  is  enlarged 
by  the  use  of  the  gouge 
and  spoons,  so  as  to  ex- 
pose all  the  affected  bj.ie 
cells  and  remove  all 
diseased  bone,  and  the 
cavity  is  then  syringed 
out.  The  wound  is 
packed  with  sterile  gauze 
and  should  be  syringed  daily.  A  Bezold's  perforation  must  be 
enlarged,  and  possibly  an  incision  in  the  neck  may  be  prevented,  if 
the  case  is  treated  early. 

In  the  more  chronic  cases,  where  tympanic  complications  are 
present,  a  more  extensive  proceeding  known  as  Stacke's  operation  is 
usually  required.  In  it  the  auricle  is  detached  posteriorly  from  the 
bony  margins  of  the  meatus,  and  then  the  antrum  is  opened  and  the 
whole  of  the  osseous  tissue  intervening  between  it  and  the  meatus 
and  tympanic  cavity  in  front  is  gouged  away.  A  metal  guide  is 
passed  from  the  opening  in  the  antrum  into  the  attic  along  the 
aditus,  and  all  the  bone  superficial  to  the  guide  may  be  safely 
removed.  The  facial  nerve  and  superior  semicircular  canal  lie 
behind,  and  are  protected  by  the  guide.  The  remains  of  the  mem- 
brane and  the  ossicles  are  then  removed,  and  the  cavity  curetted 
(Fig.  426) .  The  deep  portion  of  the  posterior  wall  of  the  cartilagin- 
ous meatus  is  incised  longitudinally  and  the  margins  of  the  aperture 
stitched  to  the  posterior  edge  of  the  wound,  the  meatus  thus  leading 
to  the  whole  of  the  opening  in  the  bone,  which  can  in  this  way  be 
syringed  out  and  cleansed  more  effi,ciently. 

The  intracranial  complications  of  otorrhcea  are  subcranial  abscess, 

56 


Fig.  426.^Stacke's  Operation  completed. 

The  antrum  (A)  has  been  thoroughly  opened 
up,  and  the  bridge  of  bone  covering  the 
aditus  removed,  thus  bringing  the  antrum 
into  free  communication  with  the  tympanic 
cavity  (B),  which  is  curetted  and  the 
ossicles  removed . 


882  A   MANUAL  OF  SURGERY 

localized  or  diffuse  meningitis,  thrombosis  of  the  lateral  sinus,  and 
abscess  in  the  cerebrum  or  cerebellum. 

{a)  Subcranial  Abscess.^ — For  general  phenomena  connected  with 
this  condition,  see  p.  764.  Accumulations  of  pus  occur  most  com- 
monly along  the  summit  of  the  petrous  portion  of  the  temporal  bone 
(Fig.  369,  B),  and  in  the  sulcus  in  which  the  lateral  sinus  is  lodged. 
The  patient  complains  of  pain  and  headache,  which  increase  for  a 
time  and  are  then  followed  by  drowsiness,  which  may  pass  into 
coma.  The  temperature  is  raised,  but  rigors,  even  if  present  at  first, 
are  b}-  no  means  a  constant  feature  of  the  case.  The  pulse  is  of  the 
usual  febrile  type,  viz.,  quick,  full,  and  bounding.  There  is  no  pain 
in  the  neck  along  the  course  of  the  jugular  vein,  but  retraction  of 
the  head  occurs  if  basal  meningitis  is  present,  and  vomiting  is  a 
marked  S3-mptom.  Optic  neuritis  ma}'  be  observed  in  consequence 
of  the  inflammation  extending  to  the  membranes  at  the  base  of  the 
brain.  There  may  be  some  tenderness  on  pressure  over  the  temporal 
region,  and  possibly  oedema.  In  some  cases  the  pus  finds  its  way 
outwards  along  the  mastoid  emissary  vein,  or  through  the  suture 
between  the  occipital  and  temporal  bones. 

The  Diagnosis  from  cerebral  abscess  is  sometimes  a  matter  of  con- 
siderable difficulty.  1  he  sj^mptoms,  however,  set  in  somewhat  more 
acutely,  whilst  the  temperature  is  raised,  and  the  signs  of  irritation 
of  the  membranes,  such  as  retraction  of  the  neck,  all  suggest  that 
the  lesion  is  extradural,  and  not  cerebral  in  origin.  The  pulse  is 
fast,  and  not  slow,  and  focal  symptoms  are  less  likely  to  develop. 

Ihe  Treatment  consists  in  trephining  above  and  behind  the  meatus, 
so  as  to  escape  the  lateral  sinus,  and  in  much  the  same  situation  as 
for  a  temporo-sphenoidal  abscess  {q.v.).  The  pus  is  washed  out, 
and  a  drainage-tube  inserted  for  a  few  daj-s. 

[b)  Meningitis  ma}'  be  localized  or  diffuse.  The  former  often 
accompanies  some  other  condition,  and  is  in  itself  of  little  moment. 
It  may  produce  fixed  headache,  but,  if  non-suppurative,  usually  dis- 
appears when  the  originating  disease  has  been  cured.  The  diffuse 
variety  is  generalh'  infective  in  nature,  and  secondary  to  some  sup- 
purative affection  in  the  neighbourhood,  or  to  thrombosis  of  the  lateral 
sinus.  (For  symptoms,  see  p.  766) .  Occasionally  a  simple  serous  effu- 
sion occurs  within  the  meninges,  leading  to  increased  pressure  and 
consequent  drowsiness,  but  disappearing  entirely  when  the  cause  has 
been  removed,  or  the  excess  of  fluid  withdrawn  by  lumbar  puncture. 

(c)  Thrombosis  of  the  Lateral  Sinus  arises  from  direct  extension  of 
the  inflammatory  process  from  the  middle  ear  through  the  mastoid 
bone  (Fig.  369,  E),  or  it  may  be  set  up  by  an  infective  thrombosis 
of  the  mastoid  emissary  vein  spreading  to  the  sinus.  A  clot  forms 
within  it,  which,  gradually  increasing  in  size,  leads  finally  to  occlu- 
sion of  its  lumen.  Infection  with  pyogenic  organisms  determines 
disintegration  of  the  clot;  infected  emboli  are  detached,  and  thus 
pysemic  symptoms  originated.  In  well-marked  cases  the  thronibus 
extends  as  far  back  as  the  Torcular  Herophili,  and  downwards  along 
the  jugular  vein. 

Ihe  most  marked  Symptom  of  the  case  is  the  sudden  appearance 


AFFECTIONS  OF  THE  EAR  883 

of  a  high  temperature,  which  is  usually  remittent,  and  associated 
with  rigors,  vomiting,  and  localized  pain  in  the  head,  perhaps  most 
marked  over  the  point  of  emergence  of  the  emissary  vein  at  the 
posterior  border  of  the  mastoid  process.  The  pulse  is  rapid,  feeble, 
and  easily  compressible,  and  in  the  later  stages  the  patient  is  drowsy 
and  dull,  probably  from  serous  exudation  within  the  meninges.  The 
discharge  from  the  ear,  which  may  have  been  previously  offensive, 
usually  ceases.  Optic  neuritis  may  or  may  not  exist,  being  often 
preceded  by  photophobia.  If  the  thrombus  extends  into  the  neck, 
a  firm,  tender,  elongated  swelling  is  felt  in  the  region  of  the  jugular 
vein,  and,  owing  to  the  interference  with  the  venous  circulation,  the 
face 'often  becomes  dusky.  The  cervical  lymphatic  glands  become 
enlarged,  and  stiffness  of  the  muscles  at  the  back  of  the  neck  is  an 
evidence  of  associated  basal  meningitis,  as  is  also  the  optic  neuritis. 
Suppuration  may  occur  outside  the  sinus,  or  around  the  vein  in  the 
neck,  which  becomes  swollen,  red,  and  oedematous. 

In  well-marked  cases  the  Diagnosis  is  easily  made,  but  m  the  early 
stages,  and  especially  in  children,  it  is  often  a  matter  of  some 
difficulty.  The  abrupt  onset,  the  oscillating  temperature,  the  re- 
current rigors,  the  pain  in  the  neck,  and  the  deep  tenderness  on 
pressure  over  the  course  of  the  lateral  sinus  or  jugular  vein,  are  the 
most  trustworthy  signs  of  this  affection. 

Treatment.— A  radical  mastoid  operation  is  usually  undertaken 
first,  and  by  extending  its  scope  backwards  the  sinus  can  be  exposed. 
Apart  from  this,  the  sinus  is  laid  bare  by  applying  a  trephine  at  a 
spot  about  1  inch  above  Reid's  base-Hne,  and  about  i  inch  behind 
the  centre  of  the  external  auditory  meatus  (Fig.  370,  A  or  B).  A 
puncture  with  a  fine  needle  readily  determines  whether  the  smus 
contains  fluid  blood  or  thrombus.  If  it  is  thrombosed,  there  is  often 
some  evidence  of  inflammation  or  pus  around  it,  between  the  dura 
mater  and  the  bone.  Having  thus  verified  the  diagnosis,  an  incision 
is  made  along  the  anterior  border  of  the  sterno-mastoid,  through 
which  the  jugular  vein  is  tied  at  a  spot  below  the  lowest  point  of  the 
thrombus,  so  as  to  prevent  the  escape  of  any  more  emboli  into  the 
general  circulation.  In  old-standing  cases  this  may  involve  exposing 
the  vein  in  the  lowest  part  of  the  neck,  and  placing  the  ligature  close 
to  the  innominate.  Ihe  lateral  sinus  is  now  freely  incised,  and  the 
infected  thrombus  partly  scraped,  partly  washed  away,  the  opening 
in  the  bone  being  increased  in  size,  if  necessary.  It  is  desirable,  but 
not  essential  in  the  simpler  cases,  to  remove  completely  the  lower 
part  of  the  thrombus;  if  such  is  attempted,  the  jugular  must  be 
opened  above  the  ligature,  and  the  clot  syringed  or  scraped  away. 
Bleeding  occurs  from  the  posterior  part  of  the  upper  opening  as  soon 
as  all  the  coagulum  is  removed,  but  is  easily  controlled  by  plugging 
the  sinus  with  a  small  piece  of  aseptic  gauze.  The  wound  in  the  neck 
should  be  lightly  packed  and  not  closed,  since  infection  and  suppura- 
tion are  almost  certain  to  follow.  The  upper  wound  is  also  packed 
in  the  same  way,  and  allowed  to  granulate. 

[d]  Abscess  in  the  cerebrum  or  cerebellum,  a  comphcation  not 
unfrequently  met  with,  has  been  already  discussed  (p.  769). 


CHAPTER  XXXII. 

SURGERY  OF  THE  NECK. 

Affections  connected  with  the  Branchial  Clefts. — In  the  second  or 
third  week  of  intra-uterine  life  a  series  of  branchial  arches  form  in  the 
human  embryo  as  in  other  mammalia,  constituting  the  foundation 
from  which  the  future  structures  of  the  neck  are  developed.  In  the 
majority  of  mammals  five  such  post-oral  arches  occur,  separated 
from  one  another  by  the  so-called  branchial  clefts;  but  in  man  the 
fourth  and  fifth  are  amalgamated.  They  project  from  the  side  of  the 
primitive  spinal  column,  and  consist  of  mesoblast  lined  on  either  side 
by  epithelium.  They  unite  across  the  median  line  at  an  early  date, 
and  also  one  with  another,  thereby  leading  to  a  large  extent  to  the 
obliteration  of  the  clefts.  Occasionally,  however,  this  union  is 
imperfect,  and  sundry  malformations  result. 

It  must  be  remembered  that  the  mandible  and  the  processus 
gracilis  of  the  malleus  arise  from  the  first  arch;  the  Eustachian  tube, 
tympanic  cavity,  external  auditory  meatus,  and  Glaserian  fissure 
from  a  normally  unobliterated  portion  of  the  first  cleft ;  the  styloid 
process,  stylo-hyoid  ligament,  and  lesser  cornu  of  the  hyoid  bone 
from  the  second  arch ;  the  body  and  great  cornu  of  the  hyoid  bone 
from  the  third  arch;  and  the  rest  of  the  cervical  tissues  from  the 
remaining  arch ;  whilst  the  second,  third,  and  fourth  clefts  are,  under 
ordinary  circumstances,  totally  obliterated. 

Branchial  Fistulse  are  due  to  imperfect  closure  of  the  branchial 
clefts.  They  consist  of  narrow  sinuous  tracks  extending  inwards 
from  the  skin,  and  perhaps  communicating,  but  not  necessarily  so, 
with  the  pharynx.  The  external  opening  is  usually  situated  along 
the  anterior  border  of  the  sterno-mastoid,  and  most  commonly  near 
its  lower  end,  close  to  the  episternal  notch,  the  fistula  then  arising 
from  the  lowest  cleft.  They  are  lined  with  epithelium,  and  secrete  a 
glairy  or  mucoid  fluid.  They  are  not  uncommonly  associated  with 
other  abnormalities,  such  as  macrostoma,  absence  of  the  pinna,  or 
accessory  auricles  situated  either  near  the  orifice  of  the  fistula  or  close 
to  the  ear.  In  the  majority  of  cases  they  may  be  disregarded,  but  if 
troublesome  should  be  laid  open  and  the  lining  membrane  either 
dissected  away  or  destroyed  with  the  galvano-cautery. 


SURGERY  OF  THE  NECK  885 

Branchial  Cysts  arise  from  incomplete  closure  of  a  branchial  cleft, 
the  unoblitcratcd  portion  becoming  distended  with  secretion.    They 
usually  appear  in  adolescents,  often  between  the  ages  of  ten  and 
twenty,  and  are  frequently  attributed  to  a  blow,  which,  it  may  be 
presumed,  brings  into  activity  structures  which  would  otherwise  have 
remained    passive.     They    grow    slowly    and    painlessly,    fornimg 
rounded  swellings,   often  rather  soft,  with  more  or  less  distinct 
fluctuation,  according  to  the  depth  at  which  they  are  situated;  their 
contents,  if  near  the  cutaneous  end  of  the  cleft,  are  sebaceous  in 
character,  similar  to,  but  more  fluid  than,  that  found  in  dermoid 
cysts  (viz.,  flattened  epithelial  cells,  cholesterine  plates,  and  fatty 
granules) .     If  placed  nearer  to  the  pharynx  they  are  occupied  by  a 
glairy  mucoid  fluid.     They  are  usually  lined  with  squamous  epithe- 
lium, but  a  few  cases  have  been  recorded  in  which  the  cells  were 
columnar,    and  even   ciliated,    in   character.     The   most   common 
situation  is  in  the  third  cleft,  the  cyst  then  lying  between  the  thyroid 
cartilage  and  the  anterior  border  of  the  sterno-mastoid,  in  relation 
with  the  great  wing  of  the  hyoid  bone ;  when  of  large  size,  they  may 
extend  beneath  that  muscle,  displacing  it  outwards.     More  rarely  a 
cyst  arises  from  the  second  cleft,  being  then  located  in  the  upper 
third  of  the  neck,  and  spreading  up  towards  the  styloid  process ; 
it  may  even  reach  from  the  mastoid  process  to  the  hyoid  bone, 
running  parallel  to  the  posterior  border  of  the  jaw,  and  fluctuation 
may  be  detected  through  the  mouth.  Treatment  consists  in  extirpa- 
tion when  the  condition  has  attained  sufficient  size  to  be  troublesome. 
Branchial  Carcinoma.— Considerable  doubt  has  been  expressed  as 
to  whether  it  is  possible  for  carcinoma  to  originate  in  the  un- 
obliterated  remains  of  the  branchial  clefts,  cases  which  might  have 
been  considered  of  this  nature  being  ascribed  to  developments  of 
epithelioma  in  the  deep  lymphatic  glands  which  have  undergone 
cystic  degeneration,  and  secondary  to  some  undiscovered  or  aborted 
lesion  in  the  pharynx  or  larynx.     The  balance  of  evidence  is,  how- 
ever, in  favour  of  the  fact  that  carcinoma  can  start  in  this  way,  giving 
rise  to  what  has  been  described  as  a  malignant  cyst  of  the  neck.     It  is 
characterized  by  the  formation  of  a  tumour  placed  deeply  beneath 
the  sterno-mastoid,  indefinite  in  outline,  and  of  firm  consistence. 
Considerable  pain  is  experienced,   and  lymphatic  glands  become 
secondarily  enlarged.     The  disease  runs  its  ordinary  course,  but  may 
destroy  life  through  haemorrhage  from  the  main  vessels,  which  are 
invaded  by  the  tumour.     The  cyst  sometimes  gives  way  into  the 
pharynx,  and  a  malignant  ulcer  of  the  pharyngeal  wall  is  thus  in- 
duced.    Pathologically,  the  condition  is  an  epithelioma.     Treatment 
is  usually  impracticable  owing  to  the  deep  connections  of  the  growth. 
Various  other  congenital  conditions  may  be  met  with  in  the  neck. 
Congenital  induration  of  the  sterno-mastoid  in  all  probability  arises 
from  injury  during  parturition,  and  usually  occurs  in  head  presenta- 
tions, probably  from  bruising  of  the  side  of  the  neck  against  the 
under  surface  of  the  symphysis ;  it  is  said  to  be  more  common  on  the 
left  side  than  on  the  right.     In  cases  that  have  been  examined  micro- 


886 


A   MANUAL  OF  SURGERY 


scopically,  the  indurated  mass  has  been  found  to  consist  of  fibrous 
tissue.  It  disappears  spontaneously  after  a  time,  but  may  lead  to 
torticollis  at  a  later  date.  The  congenital  form  of  torticollis  (p.  432), 
cysts  in  connection  with  the  thyro-glossal  duct,  and  cystic  hygroma, 
may  also  be  mentioned. 


Cysts  of  the  Neck. 

I.  Cysts  o£  Congenital  Origin. — {a)  Dermoids  occur  here  as  in  any 
other   region    where    congenital   remains   are   found.     As    already 

mentioned,  they  may  develop  later- 
ally from  the  branchial  clefts,  but 
may  also  be  found  in  the  middle 
line,  or  in  connection  with  the 
thyro-glossal  duct,  [b)  The  thyro- 
glossal  duct  (Fig.  427)  consists  of 
a  tubular  outgrowth  from  the  em- 
bryonic pharynx  passing  down- 
wards behind  the  body  of  the  hyoid 
bone  in  front  of  the  larynx  and 
trachea  as  far  as  the  isthmus  of 
the  thyroid  gland,  which  is  sub- 
sequently developed  from  it,  and 
unites  with  the  lateral  lobes,  which 
in  turn  spring  from  the  deeper 
parts  of  the  branchial  arches.  The 
upper  end  of  this  duct  is  situated 
at  the  foramen  caecum  of  the  tongue, 
and  thence  traverses  the  substance 
of  that  organ  between  the  genio- 
hyo-glossi  muscles  to  reach  the 
hyoid  bone ;  the  lower  end  is  repre- 
Median  Section  of  rented  by  the  pyramid  of  the  thy- 
roid  isthmus.  The  whole  of  this 
tube  disappears  under  ordinary 
circumstances;  if,  however,  the 
upper  part  remains  unobliterated, 
a  dermoid  cyst  may  originate  from 
it,  placed  either  in  the  substance 
of  the  tongue  or  immediately  below 
it  (p.  838).  If  the  lower  portion 
A  small  dermoid  cyst  in  the  centre  remains  patent,  a  cyst  develops 
of  the  tongue  is  also  represented.      containing  mucoid  or  glairy   fluid, 

which,  however,  is  not  present  at 
birth.  If  it  bursts  spontaneously,  or  is  opened,  a  so-called  median 
cervical  fistula  results,  which  requires  the  same  treatment  as  a 
branchial  fistula,  viz.,  incision,  and  complete  removal  or  destruction 
of  the  epithelial  lining.  Accessory  thyroid  growths  of  an  adenom- 
atous nature  mayjdevelop  from^any  part  of  the  duct,  but  especially 
from  the  lower  end;  they  are  quite  innocent  in  nature,  and  unless 


Fig.  427 

Tongue,  Larynx,  and  Trachea, 
SHOWING  Thyro-glossal  Duct 
Extending  from  the  Foramen 
C^cuM  OF  the  Tongue  Down- 
wards Behind  the  Hyoid  Bone, 
and  in  Front  of  the  Trachea 
TO  the  Isthmus  of  the  Thyroid 
Body  (Semi  -  diagrammatic, 
FROM  College  of  Surgeons' 
Museum.) 


SURGERY  OF  THE  NECK  887 

troublesome  may  be  left  alone,  (c)  Cystic  hygroma  is  sometimes 
congenital,  but  may  also  be  acquired.  It  consists  of  a  multilocular 
swelling,  the  spaces  composing  it  being  due  to  dilatation  of  lymphatic 
spaces,  and  filled  with  lymph.  The  tumour  is  often  of  considerable 
size,  with  a  sinuous,  irregular  outline,  and  may  produce  great 
deformity  and  marked  pressure  effects.  The  skin  over  it  may  be 
occupied  by  dilated  capillaries  or  lymphatics.  Unless  extending  to 
inaccessible  parts,  such  as  the  superior  mediastinum,  it  should  be 
dealt  with  by  excision  (p.  359). 

2.  Acquired  Cysts  of  the  Neck  are  of  the  following  types:  {a) 
Sebaceous  cysts  develop  in  the  skin  as  elsewhere,  but  need  no  separate 
notice,  [b]  Bursal  cysts  are  stated  to  occur  in  connection  with  the 
larynx  and  hyoid  bone.  There  is  usually  a  bursa  over  a  prominent 
pomum  Adami,  and  this  may  become  enlarged  and  distended  with 
fluid.  A  bursa  is  also  stated  to  exist  between  the  back  of  the  hyoid 
bone  and  the  thyroid  cartilage,  which  might  easily  be  mistaken  for 
one  of  thyro-glossal  origin.  In  doubtful  cases  a  microscopical  ex- 
amination of  the  lining  wall  will  quickly  settle  the  diagnosis,  since  if 
it  is  bursal  in  origin  it  is  lined  with  endothelium,  whilst  if  it  is  thyro- 
glossal  it  is  lined  with  epithelium.  In  the  former  case  incision  and 
drainage  usually  suffice  to  bring  about  a  cure,  although  excision  is 
preferable;  in  the  latter  case  the  lining  wall  must  be  entirely  re- 
moved, (c)  Unilocular  serous  cysts  are  sometimes  met  with  in  the 
lower  part  of  the  posterior  triangle,  constituting  the  condition  known 
as  '  hydrocele  of  the  neck.'  They  contain  serous  fluid,  with  perhaps 
an  admixture  of  blood.  Their  origin  has  not  been  defined  with  any 
certainty,  but  they  are  probably  due  to  a  dilatation  of  the  lymph 
spaces,  and  are  best  treated  by  excision,  {d)  True  hydatid  cysts  also 
occur  in  this  region  (p.  233) .  [e]  Blood  cysts  have  been  found  in  close 
connection  with  the  large  vessels  of  the  neck.  They  are  possibly  due 
to  the  dilatation  of  a  vein,  and  may  communicate  or  not  with  some 
vascular  channel,  such  as  the  jugular,  being  then  partly  emptied  on 
pressure.  Where  no  communication  with  a  venous  trunk  exists,  the 
lining  membrane  is  intensely  vascular.  If  .their  vascular  origin  is 
recognised,  they  should  be  left  alone  unless  causing  urgent  symp- 
toms. If,  however,  a  blood  cyst  is  opened  by  mistake,  the  supplying 
vessels  must  be  secured,  if  possible,  and,  failing  that,  the  cavity  must 
be  packed  with  gauze  soaked  in  adrenalin.  (/)  Cysts  are  also  occa- 
sionally met  with  in  connection  with  the  salivary  glands  and  the 
thyroid  body,  (g)  Malignant  cysts  arise,  as  already  mentioned,  from 
the  remains  of  the  branchial  clefts,  or  from  a  degeneration  of  epithe- 
liomatous  lymphatic  glands.  They  are  often  of  large  size,  and  their 
removal  is  impracticable  owing  to  the  adhesions  which  they  contract 
to  the  deeper  structures. 

Cut  Throat. 

Injuries  of  the  neck  are  commonly  met  with  in  cases  of  attempted 
homicide  or  suicide,  and  vary  much  in  severity  according  to  the 
extent  and  position  of  the  wound.     A  right-handed  suicide  usually 


888  A   MANUAL  OF  SURGERY 

cuts  his  throat  from  left  to  right,  and  therefore  the  incision  is  bold 
and  clean  on  the  left  side,  tailing  off  towards  the  right;  in  a  left- 
handed  suicide  the  incision  runs  in  the  opposite  direction.  A  homi- 
cidal cut  throat  varies  in  its  direction  according  to  whether  it  is  done 
from  behind  or  in  front,  and  also  with  the  hand  employed.  If  the 
front  of  the  neck  is  mainly  involved,  the  air-passages  are  laid  open, 
and  the  patient's  life,  though  much  endangered,  is  not  necessarily 
destroyed.  If,  however,  the  wound  chiefly  affects  the  side,  the  great 
vessels  and  nerves  may  be  divided,  and  death  from  hemorrhage  is 
very  liable  to  ensue,  'f  he  course  and  treatment  of  the  latter  class  of 
case  require  no  particular  notice,  since  the  general  principles  relating 
to  all  wounds  must  be  adhered  to.  Where,  however,  the  air- 
passages  have  been  opened,  special  complications  arise,  requiring 
suitably  modified  treatment. 

Wounds  involving  the  Air-passages,  the  result  of  cut  throat,  may 
be  situated  at  four  different  levels:  [a)  above  the  hyoid  bone,  en- 
croaching on  the  base  of  the  tongue;  (b)  through  the  thyro-hyoid 
space,  the  most  common  situation ;  (c)  in  the  larynx ;  and  {d)  opening 
or  dividing  the  trachea. 

The  immediate  effects  of  such  lesions  are  due  to  shock,  hsemor- 
rhage,  asphyxia,  or  the  entrance  of  air  into  veins.  When  above  the 
hyoid  bone,  the  root  of  the  tongue  and  submaxillary  region  are  in- 
volved, and  haemorrhage  from  the  lingual  or  facial  arteries  or  their 
branches  follows ;  if  the  wound  extends  far  enough,  the  main  vessels 
are  divided,  and  death  results.  In  the  less  severe  cases  the  patient 
runs  considerable  risk  of  being  suffocated  by  the  epiglottis  and  base 
of  the  tongue  falling  back  over  the  larynx.  Much  difficulty  will  be 
subsequently  experienced  in  feeding  the  patient,  owing  to  impair- 
ment of  the  movements  of  the  tongue.  When  the  thyro-hyoid  space 
is  opened,  the  facial  and  lingual  arteries  are  again  in  danger,  as  also 
the  upper  part  of  the  superior  thyroid.  The  base  of  the  epiglottis  is 
divided,  and  portions  of  mucous  membrane  around  the  entrance  of 
the  larynx  may  be  detached,  and  cause  obstruction  to  respiration. 
Blood  may  also  trickle  down  the  larynx  into  the  trachea,  and  lead  to 
asphyxia.  Wounds  of  the  larynx  are  usually  transverse,  and  not 
very  extensive,  owing  to  the  resistance  offered  to  the  knife  by  the 
cartilage.  The  thyroid  body  may  be  wounded  and  bleed  freely, 
otherwise  there  is  iDut  little  haemorrhage.  Blood  may  find  its  way 
into  the  trachea  or  lungs,  and  asphyxiate  the  patient.  When  the 
trachea  is  involved,  the  common  carotid  and  inferior  thyroid  vessels 
are  very  liable  to  be  wounded,  giving  rise  to  severe,  if  not  fatal, 
haemorrhage.  Asphyxia  may  be  brought  about  by  displacement  of 
the  severed  portions  of  the  tube,  or  from  the  entrance  of  blood  into 
the  air-passages,  whilst  air  may  also  be  sucked  into  opened  veins. 
The  recurrent  laryngeal  nerve  may  be  divided,  causing  paralysis  of 
the  larynx. 

The  secondary  effects  following  cut  throat  are  mainly  inflammatory 
in  origin,  (a)  The  wound  is  likely  to  become  infected,  giving  rise  to 
a  cellulitis  which  may  spread  down  to  the  mediastinum,  or  to  oedema 


SURGERY  OF  THE  NECK  889 

of  the  glottis.  Secondary  haemorrhage  also  arises  from  this  cause, 
and  even  general  pyaemia,  [h)  Inflammation  of  the  air-passages, 
tracheitis,  bronchitis,  or  broncho-pneumonia,  frequently  follows, 
partly  as  a  result  of  the  entrance  of  cold  air,  partly  from  the  admis- 
sion of  septic  material,  such  as  food,  decomposing  blood-clot,  or 
discharges.  The  patient  may  become  cyanosed  from  these  causes, 
and  in  consequence  of  the  partial  asphyxia  the  sensibility  of  the 
mucous  membrane  of  the  glottis  is  diminished,  allowing  of  the 
passage  into  it  of  food  which  appears  at  the  mouth  of  the  wound ;  in 
some  cases  this  may  have  arisen  from  division  of  the  superior 
laryngeal  nerve,  but  the  depth  at  which  this  structure  is  situated  in 
the  neck  makes  it  difficult  to  conceive  how  it  could  be  divided  with- 
out injury  to  the  main  vessels,  (c)  Surgical  emphysema,  or  the 
entrance  of  the  atmospheric  air  into  the  cellular  tissue,  may  also 
follow  a  wound  of  the  air-passages.  It  is  not  limited  to  the  neck,  but 
extends  to  the  trunk,  being  recognised  by  the  puffy  distension  of  the 
part,  and  by  a  soft  crackling  crepitus  elicited  on  pressure.  It  is  of 
no  great  consequence,  and  usually  disappears  in  a  few  days. 

The  Treatment  consists  in  securing  all  bleeding-points,  if  possible, 
but  occasionally  they  are  placed  so  deeply  that  it  is  necessary  to  tie 
the  external  carotid;  general  oozing  from  the  surface  must  be 
attended  to,  for  fear  of  blood  being  sucked  into  the  air-passages. 
Every  effort  should  be  made  to  render  the  wound  aseptic,  and  if 
there  is  a  reasonable  prospect  that  this  has  been  attained,  it  may  be 
closed  by  sutures  in  the  ordinary  way.  Where,  however,  asepsis  is 
doubtful ,  only  the  ends  of  the  incision  should  be  drawn  together,  the 
central  portion  being  left  open. 

The  treatment  of  the  air-passages  varies  with  the  site  of  the  lesion. 
If  the  trachea  has  been  roughly  divided,  the  portions  should  be 
steadied  by  a  stitch  on  either  side,  and  a  tracheotomy-tube  inserted 
— at  any  rate,  for  a  few  days ;  when  cleanly  cut,  total  closure  without 
the  use  of  a  tube  can  be  safely  permitted.  When  the  wound  involves 
the  larynx,  it  is  desirable  to  close  the  opening  at  once,  since  the 
larynx  does  not  readily  tolerate  the  presence  of  a  tube;  if  necessary, 
it  is  better  to  perform  a  high  tracheotomy.  When  the  wound  in- 
volves the  thyro-hyoid  space,  or  is  situated  above  the  hyoid  bone,  it 
is  quite  safe  in  many  cases  to  close  the  wound  layer  by  layer  after 
carefully  disinfecting  it.  The  mucous  membrane  is  first  dealt  with 
by  stitches  which  do  not  penetrate  its  whole  thickness,  and  then  a 
more  thorough  purification  can  be  undertaken;  if  the  epiglottis  is 
divided,  it  must  be  accurately  sutured.  If  there  is  any  doubt  as  to 
the  advisability  of  this  proceeding,  a  high  tracheotomy  is  first  per- 
formed, and  then  the  wound  closed  as  far  as  possible. 

In  every  instance  the  head  should  be  flexed  on  the  chest,  and  in 
suicidal  cases  a  careful  watch  maintained  to  prevent  the  patient 
tearing  the  wound  open.  Loss  of  blood  is  dealt  with  by  the  infusion 
of  saline  solution,  and  the  patient's  general  condition  attended  to. 
Feeding  should  always  be  undertaken  through  a  tube  passed  into  the 
oesophagus,  whether  that  structure  is  wounded  or  not,  and  this 


Sgo  A   MANUAL  OF  SURGERY 

should  be  continued  until  the  patient's  natural  powers  of  swallowing 
are  restored. 

The  following  Sequelae  occasionally  result  from  a  cut  throat: 
{a)  An  aerial  fistula  is  a  persistent  abnormal  communication  between 
the  air-passages  and  the  external  air,  and  occurs  most  often  in  the 
thyro-hyoid  space,  the  skin  and  mucous  membrane  becoming  con- 
tinuous one  with  the  other  around  the  margins  of  the  opening.  In 
some  cases  it  may  be  closed ;  but  if  laryngeal  stenosis  or  adhesions  are 
present,  it  must  be  left  alone  for  a  time  until  these  conditions  have 
been  treated.  The  operation  consists  in  separating  the  skin  from 
the  mucous  membrane,  and  in  order  to  accomplish  this,  the  external 
wound  must  be  enlarged  vertically.  The  edges  of  the  mucous  mem- 
brane are  then  pared,  and  stitched  together  horizontcdly.  The 
external  wound  is  either  closed  vertically,  or  left  partially  open  and 
packed,  [h]  Laryngeal  or  tracheal  stenosis,  due  to  the  cicatrization  of 
wounds  in  these  regions,  may  be  remedied  by  wearing  an  O'Dwyer's 
tube  (p.  916)  for  a  time,  or  may  necessitate  the  constant  use  of  a 
tracheotomy-tube,  (c)  A  phonia  may  arise  from  division  of  the  recur- 
rent laryngeal  nerve,  and  is  then  usually  persistent,  {d)  (Esophageal 
or  pharyngeal  fistulcB  may  also  in  rare  instances  complicate  the  heal- 
ing of  an  extensive  wound  in  the  throat,  but  tend  to  close  of  them- 
selves, and  require  no  special  treatment. 

Diseases  of  the  Thyroid  Body. 

Goitre. — Enlargement  of  the  thyroid  body,  or,  as  it  is  termed, 
bronchocele  or  goitre,  is  a  condition  frequently  seen  in  this  country, 
and  is  of  general,  and  not  merely  local,  importance,  since  the  thyroid 
body  exercises  considerable  influence  over  metabolism  and  nutrition. 
Total  absence  or  removal  of  the  gland  or  its  complete  degeneration 
leads  to  accumulation  of  mucin  in  the  body,  producing  myxoedema 
in  adults,  and  cretinism  in  children ;  whilst  the  excessive  absorption 
of  normal  or  vitiated  thyroid  secretion  is  probably  responsible  for 
Graves'  disease,  and  possibly  to  some  forms  of  skeletal  trouble. 

The  Causes  of  bronchocele  are  still  enshrouded  in  a  good  deal  of 
uncertainty.  It  occurs  endemically  in  this  and  many  other  countries , 
being  especially  frequent  in  mountainous  districts.  At  home  the 
favourite  sites  are  the  hilly  parts  of  Derbyshire  and  Gloucestershire 
(where  it  is  known,  in  fact,  as  Derbyshire  neck) ;  it  is  exceedingly 
common  in  Switzerland  and  the  valleys  of  Northern  Italy,  but  also 
occurs  frequently  in  relation  with  the  Himalayas,  Pyrenees,  Andes, 
etc.  Epidemics  have  also  been  known  to  occur,  but  rarely  except  in 
goitrous  regions.  There  can  be  little  doubt  that  the  disease  is  due 
to  the  presence  in  the  drinking-water  of  some  living  contagion,  which 
probably  develops  in  the  intestinal  canal  and  produces  a  peculiar 
toxaemia.  Major  McCarrison  in  his  Milroy  Lectures*  has  elaborated 
this  thesis  in  a  most  convincing  manner,  and  related  at  length  his 
observations  and  experiments  in  connection  therewith.  Working 
with  the  goitrogenous  waters  of  certain  springs,  he  was  able  to  pro- 
*  Lancet,  1913,  January  18  et  seq. 


SURGERY  OF  THE  NECK  891 

duce  the  affection  in  animals  (rats  and  goats)  and  in  healthy  men ;  if 
filtered  effectively,  the  water  had  no  result ;  the  scrapings  of  the  filter, 
however,  if  administered,  produced  goitre.  These  results  coincide 
with  the  experimental  findings  of  other  workers  in  this  field  in 
Switzerland  and  elsewhere.  Thus  Wilms  and  Sazuli  (Heidelberg) 
found  that  rats  fed  on  cooked  rice  mixed  with  rat  fseces,  or  injected 
subcutaneously  with  rat  fasces,  developed  moderate  goitres,  whereas 
all  other  t\'pes  of  abnormal  and  vitiated  feeding  had  no  result. 
jMixing  the  contaminated  food  with  KI  or  th^'roidin  gave  a  negative 
result.  The  goitre  itself  is  probably  alwa\-s  sterile  and  free  from 
micro-organisms;  the  intestinal  habitat  of  the  germs  is  rather  pre- 
smned  than  proven  from  the  results  of  the  emplo\'ment  of  intestinal 
antiseptics  and  of  vaccines  of  intestinal  bacteria,  but  there  can  be 
little  doubt  as  to  the  value  of  these  suggestions. 

Other  contributory  causes  may  assist  in  this  development — -e.g., 
want  of  sunshine  and  air,  as  in  the  case  of  those  who  live  in  valleys 
into  which  the  air  does  not  readil}'  penetrate,  or  in  the  underground 
kitchens  and  cellars  of  large  towns,  defective  sanitary  conditions,  and 
the  habit  of  carrying  weights  upon  the  head.  The  ordinar}-  t\'pe  of 
goitre  seen  in  this  country  is  much  more  common  in  women  than  in 
men ;  it  is  not  hereditary  to  an}-  great  extent,  and  is  not  influenced  by 
intermarriage;  but  it  maj^  be  congenital,  and  then  is  associated  mth 
skeletal  changes,  defective  gro^\i;h,  and  intellectual  weakness,  con- 
stituting the  condition  known  as  cretinism. 

Varieties  and  Clinical  Features. — Four  chief  forms  of  goitre  are 
described,  \-iz. :  The  parenchymatous  or  simple,  the  cystic,  the  fibro- 
adenomatous,  and  the  exophthalmic;  but  the  th\Toid  body  may 
become  enlarged  in  other  ways,  giving  rise  to  the  conditions  known 
as  malignant  goitre  and  acute  goitre,  whilst  acute  inflammation  is 
sometimes  seen. 

General  Features. — In  all  these  cases  the  thyroid  body  is  the  site 
of  a  swelling  involving  its  whole  substance,  or  one  or  other  of  its 
lobes,  or  possibh*  the  isthmus  alone.  Its  consistence  varies  with  the 
nature  of  the  gro\\-th,  but  it  always  moves  with  the  larynx  on  deglu- 
tition. In  every  form  there  is  probably  a  certain  amount  of  anaemia, 
whilst  some  of  the  symptoms  characteristic  of  the  exophthalmic 
variety  are  often  produced  even  in  simple  cases,  possibly  from  the 
excessive  absorption  of  thyroid  secretion.  Pressure  on  surrounding 
structures  leads  to  dyspnoea  or  d\'sphagia,  and  cerebral  symptoms 
may  arise  from  interference  with  the  main  vessels,  which  are  dis- 
placed outwards.  The  trachea  is  especiaUy  liable  to  changes  of 
situation  and  shape  from  its  compression ;  it  is  usually  flattened  from 
side  to  side  [scabbard  trachea),  and  is  sometimes  pushed  an  inch  or 
more  from  the  middle  line.  Atrophy  of  the  cartilaginous  rings  may 
also  be  induced,  and  if  this  results  from  the  pressure  of  a  cyst  or 
adenoma  of  the  isthmus,  severe  dyspnoea  may  be  caused  thereby. 
If,  as  sometimes  happens,  the  goitre  develops  downwards,  pushing 
behind  the  sternum  (^retrosternal  goitre),  the  trachea  is  likel}'  to  be 
compressed  from  before  backwards,  and  respiration  may  then  be 


892 


A   MANUAL  OF  SURGERY 


accompanied  by  stridor,  but  with  no  aphonia.  Pressure  on  the 
recurrent  lar^^ngeal  nerve  Jeads  to  harshness  or  loss  of  voice,  and  to 
spasmodic  attacks  of  dyspnoea,  which  may  even  prove  fatal.  It 
must  be  clearly  understood,  however,  that  the  effects  produced  by  a 
goitre  are  not  necessarily  proportionate  to  its  size;  some  of  the 
smaller  growths  at  times  produce  severe  symptoms. 

Simple  or  Parenchymatous  Goitre  (Fig.  428)  consists  of  a  diffuse 
overgrowth  of  the  whole  thyroid  body,  the  parts  retaining  to  a  great 
extent  their  usual  proportions.  The  enlargement  is  due  partly  to  an 
overgrowth  of  the  glandular  tissue,  but  also  to  an  accumulation  of 
colloid  material  within  the  vesicles;  a  normal  amount  of  fibrous 
stroma  is  usually  present.     The  whole  gland  is  generally  involved, 


Fig.  428. — Front  and  Lateral  \ie\v  ok  a  Parenchymatous  Goitre. 
The  right  lobe  had  been  removed  by  a  former  operation. 

but  possibly  one  lobe  is  larger  than  the  other.  It  is  soft  and  elastic 
to  the  touch,  quite  painless,  and  there  may  be  some  amount  of  lobu- 
lation. Not  uncommonly  it  is  associated  with  a  cystic  development 
or  new  formation  of  an  adenomatous  type.  When  the  interstitial 
tissue  is  abnormally  abundant,  as  often  occurs  in  the  later  stages,  the 
tumour  feels  harder  than  usual,  and  is  more  definitely  lobulated.  It 
ii  then  termed  a.  fibrous  goitre,  and  if  the  sclerosis  is  very  marked, 
myxoedema  may  supervene. 

The  Fibro-adenomatous  Goitre  (Figs.  429  and  430)  consists  in  the 
development  of  one  or  more  encapsuled  adenomatous  nodules  in  the 
substance  of  the  thyroid  body,  which  is  itself  often  concurrently 
enlarged.  These  nodules  may  occupy  one  or  other  lobe,  or,  when 
multiple,  be  scattered  through  the  substance  of  the  organ ;  occasion- 
ally they  develop  in  the  isthmus  alone.     If  situated  near  the  surface 


SURGERY  OF  THE  NECK 


893 


their  limitation  and  free  mobility  in  the  gland  can  be  easily  detected; 
but  when  placed  deeply,  their  special  features  cannot  be  recogmsecL 
Two  varieties  have  been  described:  [a)  The  foetal  m  which  the 
growth  is  solid  and  homogeneous,  consisting  of  closely  apposed 
ah-eoli  in  which  there  is  no  coUoid  development,  and  identical  in 
structure  with  embryonic  thyroid  tissue.  Such  growths  are  usually 
seen  in  young  people;  they  are  seldom  very  large,  but  frequently 
rather  vascular,  ih)  The  more  ordinary  type  of  adenoma  resembles 
ordinary  adult  thyroid  tissue  more  closely,  and  shows  a  considerable 
tendency  to  cyst  "formation.     It  is  impossible  to  draw  an  exact  line 


Fig    429.— Fcetal  Adenoma  of  Right  Lobe  of  Thyroid  Body  in  a  Woman 
AGED  Twenty-five  Years. 

(From  photograph  kindly  lent  by  Mr.  James  Berry.) 

of  separation  between  this  latter  condition  and  the  simple  hyper- 
trophy, which  is  often  of  a  diffuse  adenomatous  nature. 

Cystic  Goitre  (Cysto-adenoma)  arises  from  the  dilatation  into  cysts 
of  alveolar  spaces  in  the  normal  gland  tissue  or  m  a  localized 
adenoma,  the  interalveolar  w^alls  being  absorbed.  They  may  be 
single  or  multiple,  and  contain  either  a  thin  fluid  or  a  thick  grumous 
colloid  material,  somewhat  like  furniture  pohsh.  Intracystic 
growths  of  a  papillary  nature  are  not  unfrequent.  The  hnmg  mem- 
brane of  these  cysts  is  epithehal  in  nature,  the  individual  cells  being 
cuboidal  when  the  cyst  is  small,  and  flattened  out  or  even  squamous 
when  large.  It  is  sometimes  intensely  vascular,  and  haemorrhage 
into  the  cyst  is  by  no  means  uncommon,  causing  the  contents  to  be 
brown  or  blood-stained.  .     . 

Secondary  changes  occur  in  any  of  these  varieties,  chiefly  affecting 
the  interstitial  tissue,  which  may  develop  into  cartilage  or  bone,  or 


894 


A   MANUAL  OF  SURGERY 


may  calcify,  but  only  in  very  chronic  cases.  Haemorrhage  into  the 
alveolar  spaces  or  cysts  is  not  uncommon ;  acute  infective  inflamma- 
tion may  also  involve  the  mass,  and  malignant  disease,  usually  of  a 
cancerous  nature,  sometimes  supervenes. 

As  a  rare  complication  may  be  mentioned  general  dissemination,* 
gi\-ing  rise  to  secondary  growths,  which  are  usually  found  in  the  short 
and  flat  bones,  especially  the  cranium  and  vertebrie,  but  occasionally 
in  the  viscera.  Their  texture  is  usually  identical  with  normal  thyroid 
tissue,  but  may  be  more  cellular  and  of  a  cancerous  type,  and  may  be 
sufficiently  vascular  to  pulsate.     They  produce  local  symptoms  of 


Fig. 


430- 


-Multiple  Fibro-adenomatous  Goitre.  (King's  College 
Hospital  Museum.) 


varying  gravity.     The  thyroid  may  be  apparently  normal  or  the 
site  of  a  simple  goitre. 

The  Treatment  of  the  three  preceding  forms  of  goitre  may  be  con- 
sidered together,  as  they  are  very  different  in  nature  to  those  which 
follow.  In  the  early  stages  palliative  measures  can  be  employed, 
consisting  in  the  use  of  soft  or  distilled  water,  the  improvement  of 
the  general  health,  and  the  correction  of  errors  in  the  personal  and 
sanitary  hygiene.  Change  of  air  to  the  seaside  is  often  advisable, 
whilst  iron  and  iodides  may  be  administered  internally,  and  iodine 
paint  applied  locally,  or  driven  in  by  cataphoresis  (p.  54).  In  India 
cures  are  often  produced  by  inunction  of  iodide  of  mercury  ointment, 
the  part  being  subsequently  exposed  to  the  rays  of  the  midday  sun ; 
such  treatment  is  generally  impracticable  in  this  country.     The 

*  Patel,  '  Tumeurs  benignes  du  corps  thjToide  donnant  des  metastases,. 
Rev.  de  Chirurgie,  1904. 


SURGERY  OF  THE  NECK  895 

exhibition  of  thyroid  extract  or  of  the  active  principle  of  the  gland 
isolated  by  Baumann  and  called  '  thyro-iodine  '  is  sometimes 
followed  by  a  diminution  of  a  simple  goitre. 

In  cases  where,  in  spite  of  such  treatment,  the  growth  persists  or 
increases  in  size,  operative  treatment  sliould  be  undertaken  in  order 
to  remove  the  tumour  or  a  part  of  the  gland.  Total  extirpation, 
as  already  mentioned,  results  in  myxoedema ;  but  as  long  as  a  suffi- 
cient portion  of  the  secreting  substance  is  left,  whether  it  is  derived 
from  the  isthmus  or  from  one  of  the  lobes,  no  such  sequela  need  be 
feared.  In  fact  goitres  should  be  treated  much  in  the  same  way  as 
other  new  growths,  viz.,  by  removal  when  small;  there  is  still,  un- 
fortunately, a  considerable  tendency  amongst  practitioners  and 
patients  to  leave  them  untouched  until  they  are  of  large  size,  thus 
greatly  increasing  the  risk  of  the  operation. 

Partial  thyi'oideciorny  is  conducted  as  follows :  An  incision  is  made 
over  the  most  prominent  part  of  the  tumour,  either  along  the  lower 
third  of  the  anterior  border  of  the  sterno-mastoid,  or  transversely 
across  the  neck  in  order  that  the  scar  may  be  less  visible.  The 
plat3'sma  and  deep  fascia  are  divided,  and  the  sterno-mastoid,  sterno- 
hyoid, sterno-thyroid,  and  omo-h5'-oid  drawn  aside,  or,  if  need  be, 
divided.  The  lobe  to  be  removed  is  thus  exposed  within  its  capsule, 
which  should  not  be  opened.  The  limits  of  the  mass  are  defined  by 
the  finger  or  a  blunt  dissector,  and  the  vessels  entering  or  leaving  it 
are  secured.  The  superior  thyroid  vessels  are  doubly  ligatured  and 
divided  at  the  upper  end  of  the  growth,  the  middle  thyroid  vein  is 
secured  at  the  middle  of  its  outer  border,  whilst  the  inferior  thyroid 
vessels  are  dealt  with  below,  special  care  being  taken  to  avoid  the 
inferior  or  recurrent  laryngeal  nerve  by  tying  the  vessels  as  near  to 
the  gland  as  possible.  The  lobe  is  now  freed  from  the  underlying 
structures,  as  also,  if  need  be,  the  isthmus  from  the  trachea.  In 
detaching  the  latter,  the  surgeon  must  not  forget  that  the  cartila- 
ginous rings  may  have  been  absorbed,  and  that  the  walls  of  the 
trachea,  being  then  merely  fibrous  in  nature,  are  easily  wounded. 
The  isthmus  is  divided,  and  any  bleeding  vessels  secured;  or  if 
necessary,  it  may  be  ligatured  before  division.  The  wound  is  closed 
by  buried  sutures  for  muscles  and  fascise,  and  a  Halstead's  intra- 
dermic  stitch  for  the  skin.  A  drainage-tube  may  be  required  for 
twenty-four  hours,  as  it  is  difficult  to  employ  much  pressure  on  the 
neck.  Healing  by  first  intention  should  be  the  invariable  result,  and 
the  scar  almost  invisible. 

The  question  as  to  the  desirability  or  not  of  employing  a  general 
anaesthetic  in  these  operations  has  been  much  discussed.  Some 
surgeons,  and  notably  Kocher,  advise  that  local  anaesthesia 
(Schleich's  infiltration  method)  should  be  always  employed;  many 
others  reserve  that  procedure  for  the  worst  cases,  and  trust  to  a 
skilled  anaesthetist  to  administer  safely  a  general  anaesthetic  to  the 
maj  ority  of  the  patients.  With  this  latter  view  we  personally  concur. 
When  the  growth  is  retro-sternal  or  the  trachea  much  compressed, 
the  intra-tracheal  administration  of  ether  is  desirable. 


896 


A   MANUAL  OF  SURGERY 


Fihro-adenomata,  or  Cysts,  when  multiple  or  deeply  placed,  are 
treated  by  extirpation  of  the  affected  lobe ;  but  if  the  new  growth  is 
single  and  superficial,  it  may  be  safely  enucleated  by  dividing  the 
skin  and  muscles  as  before,  incising  the  gland  substance  and  capsule 
down  to  the  growth,  which  is  readily  shelled  out. 

Exophthalmic  Goitre,  or,  as  it  is  often  termed.  Graves'  or  Base- 
dow's disease  (Fig.  431),  is  a  condition  characterized  by  a  diffuse 
enlargement  of  the  thyroid  body,  which  often  pulsates  forcibly 
owing  to  the  dilatation  of  the  vessels  (particularly  those  in  the 
capsule),  associated  with  marked  anaemia,  severe  palpitation  and 
cardiac  irritability  (tachycardia),  and  protrusion  of  the  eyeball 
(exophthalmos  or  proptosis).  The  disease  is  probably  due  to  some 
derangement  of  the  sympathetic  or  central  nervous  system,  asso- 
ciated with  definite  changes  in  the 
thyroid  body  which  result  in  the 
excessive  absorption  of  thyroid  secre- 
tion, either  normal  or  vitiated  in 
character.  The  enlargement  of  the 
thyroid  body  is  not  always  marked, 
and  indeed  may  be  scarcely  notice- 
able, but  microscopic  changes  will 
always  be  found.  The  gland  is 
more  solid  in  texture  than  usual; 
the  alveoli  are  small  and  crowded 
together,  and  often  contain  no 
colloid ;  papillary  proliferation  of  the 
columnar  epithelium  lining  the 
walls  is  present.  The  gland  is  always 
extremely  vascular. 

The  patients  usually  affected  are 
females,  about  the  middle  period 
of  life,  whose  menstrual  functions 
are  often  impaired.  Overwork, 
worry,  and  severe  mental  strain, 
are  apparently  responsible  for  the 
onset  of  the  symptoms  in  many  instances,  and  a  sudden  shock  or 
fright  accounts  for  others.  The  protrusion  of  the  eyeball  is  a 
marked  feature  of  most  cases,  and  is  sometimes  due  to  an  increase 
of  the  orbital  fat.  Contraction  of  the  so-called  muscle  of  Miiller 
(unstriped  muscular  fibres  stretched  across  the  spheno-maxillary 
fissure)  has  also  been  suggested  as  a  more  plausible  theory.  When 
the  patient  looks  down,  the  upper  eyelid  does  not  immediately 
follow  the  eyeball,  allowing  the  white  sclerotic  to  be  seen  between 
the  hd  and  the  cornea  (von  Graefe's  sign).  A  fine  fibrillary  tremor 
of  the  hmbs  is  also  commonly  observed  in  these  cases.  The  patient 
is  always  extremely  nervous,  and  the  pulse-rate  high ;  any  exertion 
or  excitement  increases  the  irritability  of  the  heart's  action,  and 
may  induce  considerable  respiratory  distress.  The  blood  shows  an 
increase  in  the  lymphocytes,  although  the  leucocytes  generally  are 


Fig.  431 . — Exophthalmic  Goitre. 
(From  a  Photograph.) 


SURGERY  OF  THE  NECK  897 

diminished  in  number.  Left  to  itself,  the  disease  in  some  cases  tends 
to  improve,  but  in  others  it  may  progress  to  a  fatal  issue  from 
asthenia  or  cardiac  complications. 

Treatment  consists  in  freeing  the  patient,  if  possible,  from  all 
sources  of  irritation  and  worry  by  absolute  rest  in  bed,  whilst  bro- 
mides, iron,  and  perhaps  iodide  of  potassium,  are  administered  in- 
ternally, attention  being  also  directed  to  correcting  menstrual 
derangements,  or  any  other  abnormalities  of  function  or  structure ; 
thus,  the  cure  of  a  nasal  catarrh  by  cauterizing  the  nasal  mucosa  has 
several  times  led  to  a  rapid  amelioration  of  the  symptoms.  Phos- 
phate of  soda  has  been  found  useful  in  some  cases,  and  Kocher 
speaks  favourably  of  it  when  conjoined  with  suitable  hygienic 
measures.  1  hymus  and  suprarenal  extracts  have  sometimes  proved 
beneficial,  as  also  the  blood-serum  or  dried  blood  of  animals  after 
thyroidectomy  (antithyroidin) . 

Surgical  treatment  by  removal  of  a  portion  of  the  gland  is  often 
followed  by  excellent  results,  although  the  proceeding  is  not  devoid 
of  serious  risk,  and  should  not  be  hghtly  undertaken.  Half  of  the 
gland  has  usually  been  removed,  but  some  surgeons  have  been 
satisfied  with  tying  three  of  the  thyroid  arteries  in  order  to  starve 
the  growth.  General  anaesthesia  is  decidedly  dangerous  in  these 
cases,  and  it  is  better  to  rely  on  local  anaesthesia,  either  of  the 
Schleich  type,  or  by  cocainization  of  the  superficial  cervical  nerve, 
which  can  be  exposed  at  the  posterior  border  of  the  sterno -mastoid 
at  the  level  of  the  thyroid  cartilage;  2  or  3  drops  of  a  2  per  cent, 
solution  should  be  introduced  within  its  sheath.  Patients  are  also 
very  liable  to  syncope  after  the  operation,  and  occasionally  to  a 
curious  train  of  symptoms  probably  due  to  excessive  absorption  of 
thyroid  secretion.  Ihe  temperature  a  few  hours  after  operation 
rises  suddenly  to  104°  or  105°,  the  pulse-rate  is  greatly  accelerated, 
and  the  patient  becomes  delirious  and  finally  comatose,  dying  in  that 
state  in  about  forty-eight  hours.  The  wound  should  be  at  once 
opened  up,  and  probably  a  considerable  quantity  of  a  thin  glairy 
fluid  will  be  found  within  it ;  this  should  be  soaked  up  by  repeatedly 
packing  the  wound  with  dry  sterile  wool,  or  a  drainage-tube  may  be 
inserted.  In  the  cases  that  recover,  a  gradual  improvement  usually 
shows  itself,  but  the  full  benefit  of  the  operation  is  rarely  gained 
under  six  or  twelve  months,  and  even  then  the  exophthalmos  often 
persists. 

Malignant  Disease  of  the  Thyroid  Body  is  more  frequently  can- 
cerous in  nature  than  sarcomatous,  usually  taking  the  forrn  of  an 
adenoid  cancer,  and  almost  always  preceded  by  some  variety  of 
simple  goitre.  The  tumour  grows  rapidly,  infiltrating  the  surround- 
ing parts,  and  causing  enlargement  of  the  lymphatic  glands,  and 
secondary  deposits  in  the  viscera  and  elsewhere.  The  trachea  is 
severely  compressed,  and  in  some  cases  perforated ;  the  main  vessels 
are  frequently  surrounded  by  the  growth,  and  not  merely  displaced 
as  in  the  simple  variety.  Myxoedema  may  ensue  as  a  late  comph- 
cation,  owing  to  the  total  destruction  of  the  glandular  substance. 

57 


898  A   MANUAL  OF  SURGERY 

Treatment  by  extirpation  can  only  be  undertaken  in  the  early 
stages. 

Acute  Goitre  is  but  rarely  met  with,  consisting  of  a  rapid  enlarge- 
ment of  the  thyroid  body,  which  attains  a  considerable  size  in  the 
course  of  a  few  days  or  weeks.  It  affects  young  subjects,  and  is 
generally  fatal  from  asphyxia  due  to  pressure  on  the  trachea  or 
spasm  of  the  glottis.  Removal  of  one  lobe  under  local  ansesthesia  is 
the  only  treatment  that  holds  out  any  prospect  of  cure. 

Inflammation  oi  the  Thyroid  Body,  or  acute  thyroiditis,  occasion- 
ally supervenes  as  a  complication  of  an  ordinary  goitre.  It  is  almost 
always  infective  in  nature,  the  cocci  reaching  it  from  without,  as  from 
tappmg  cysts  or  from  a  punctured  wound,  or  from  within  the  body 
in  a  pyaemic  embolus,  suppuration  being  usually  induced;  it  some- 
times occurs  as  a  sequela  of  the  acute  specific  fevers,  or  may  follow 
a  blow.  The  gland  becomes  enlarged,  hot,  and  tender;  fever  and 
rigors  follow,  and  the  presence  of  pus  is  indicated  by  superficial 
cedema  and  fluctuation.  1  he  early  treatment  consists  in  the  applica- 
tion of  fomentations  and  perhaps  leeches,  or  in  the  use  of  an  ice 
compress.  Ihe  patient  is  kept  in  bed,  purged,  and  carefully  dieted. 
Under  such  a  regime,  resolution  may  occur ;  but  if,  as  happens  more 
frequently,  pus  forms,  free  incisions  should  be  made. 

Accessory  Thyroids  sometimes  develop  above  or  below  the 
isthmus,  or  are  closely  attached  to  one  of  the  lateral  lobes.  They 
ma}-  be  connected  with  the  thyroid  body,  moving  up  and  down  with 
it  on  deglutition ;  or  they  may  be  independent  of  it,  occurring  in  any 
part  of  the  thyro-glossal  duct,  and  even  in  the  base  of  the  tongue,  in 
that  situation  resembling  a  dermoid  cyst.  If  troublesome,  they 
should  be  removed  and  subjected  to  microscopic  examination,  as 
their  structure  varies,  and  there  is  a  possibility  of  recurrence. 

Myxcedema  (or  cachexia  strumipriva)  is  a  curious  condition,  which,  as 
already  mentioned,  supervenes  when  the  thyroid  body  is  totally  removed,  or 
so  absolutely  disorganized  or  infiltrated  by  a  new  growth  as  to  be  functionless. 
Although  it  is  possible  that  we  have  still  much  to  learn  of  the  duties  of  this 
organ,  yet  it  is  known  that  the  elimination,  if  not  the  development,  of  mucin  in 
the  body  is  controlled  by  it,  and  that  its  absence  leads  to  an  accumulation  of 
this  substance  in  the  blood  and  tissues.  The  condition  and  appearance  of 
the  individual  are  very  characteristic.  The  face  is  puffy,  waxy  white,  and 
expressionless,  with  perhaps  a  hectic  flush  over  the  malar  eminences;  the 
tongue  is  enlarged ;  the  limbs  become  thickened  and  clumsy  by  an  increase 
in  bulk  of  the  soft  tissues;  there  is  often  a  puffy  mass  occupying  the  supra- 
clavicular fossa,  which,  however,  does  not  pit  on  pressure.  The  mental 
faculties  are  dulled,  and  all  intellectual  processes  are  slow;  the  temperature 
is  subnormal,  and  the  heart's  action  weakened.  Left  to  itself,  death  will 
supervene  from  asthenia  sooner  or  later;  should  the  case  be  treated  by  thyroid 
gland  or  extract  (half  a  gland,  raw  or  lightly  cooked,  twice  a  week,  or  a 
5-grain  tabloid  once  or  twice  a  day),  the  SAinptoms  soon  disappear,  and  the 
change  from  the  dull,  heavy  condition  of  mj-xoedema  to  one  of  normal  health 
of  mind  and  body  is  almost  miraculous. 

Similar  treatment  should  be  employed  for  myxcedematous  cretins,  who 
often  start  growing  rapidly  as  soon  as  treatment  commences. 

The  Parathyroid  Glands  are  small  ovoid  bodies,  usually  four  in 
number;  situated  behind  the  thyroid  gland,  and  generally  near  the 


SURGERY  OF  THE  NECK  899 

termination  of  the  inferior  thyroid  artery.  Microscopically  they 
consist  of  columns  of  epithelial  cells  with  large  nuclei,  embedded  in 
a  rich  capillary  stroma.  Spaces  are  often  found  in  them  containing 
a  colloid  material,  which  is  not  considered  identical  with  that  found 
in  the  thyroid  vesicles.  Their  function  is  not  definitely  known,  but 
their  complete  removal  in  animals  causes  acute  convulsive  attacks, 
together  with  the  condition  known  as  tetany,  and  death  in  a  few  days 
from  coma.  The  tetany  formerly  ascribed  to  removal  of  the  thyroid 
body  is  in  reality  due  to  disease,  absence  or  removal  of  the  para- 
thyroids. It  is  also  considered  possible  that  the  changes  in  the 
thyroid  body  in  Graves'  disease  are  in  some  way  due  to  lesions  in  the 
parathyroids,  but  the  exact  relationship  is  not  yet  certain. 

The  Thymus  Gland  is  an  occasional  source  of  trouble  in  that  it 
persists  and  becomes  enlarged  instead  of  disappearing.  Normally 
it  reaches  its  greatest  dimensions  about  the  age  of  two  years,  and 
then  gradually  wastes  so  that  by  puberty  it  is  represented  by  a  mass 
of  fatty  tissue,  with  perhaps  a  few  remnants  of  the  original  organ. 
Its  persistence,  and  still  more  its  enlargement,  are  indicated  by 
fulness  of  the  root  of  the  neck,  dulness  over  the  sternum,  perhaps  by 
evidences  of  mediastinal  pressure  on  the  large  veins,  and  certainly 
by  increasing  dyspnoea.  A  thymic  asthma,  partaking  of  the  nature 
of  laryngismus  stridulus,  has  been  described;  but  more  important  is 
the  association  of  an  enlarged  thymus  with  generalized  lymphatic 
hyperplasia,  and  a  large  spleen  in  the  condition  known  as  status 
lymphaticus  [q.v.),  which  may  be  the  cause  of  sudden  death  under 
anaesthetics.  The  thymus  is  also  enlarged  in  some  cases  of  Graves' 
disease.  Tracheotomy  is  useless  in  the  treatment  of  the  somewhat 
severe  dyspnoea  sometimes  present,  and  operative  interference  for 
the  removal  of  the  enlarged  gland  has  been  undertaken  with  success 
in  some  cases.  Lymphadenoma  and  lymphosarcoma  have  also  been 
known  to  affect  this  organ. 


CHAPTER  XXXIII. 
SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST. 

Examination  of  the  Upper  Air-Passages.— Before  the  student  can  understand 
aflEections  of  this  region,  it  is  absolutely  essential  for  him  to  master  the  use 
of  the  laryngoscope.  This  consists  of  a  circular  mirror  set  at  an  angle  on  the 
end  of  a  metal  stem,  which  is  inserted  into  the  patient's  widely-opened  mouth 
in  such  a  way  that  it  rests  against,  and  slightly  elevates,  the  soft  palate.  A 
beam  of  light  is  thrown  into  the  mouth,  either  from  an  electric  head-lamp 
on  the  surgeon's  forehead,  or  reflected  by  a  frontal  mirror  from  a  suitable 
source  of  illumination.  The  patient's  tongue,  held  with  a  towel,  is  drawn 
well  forwards  so  as  to  enable  the  light  to  reach  the  larynx,  the  image  of  which 
is  seen  in  the  mirror.  Considerable  practice  is  needed  in  order  to  attain  any 
facility  in  the  use  of  this  instrument,  as  also  to  be  able  to  recognise  normal 
from  abnormal  structures.  The  use  of  cocaine  to  anaesthetize  the  fauces  is 
in  man}'  cases  indispensable.  It  must  be  remembered  that  the  image  is 
always  inverted,  so  that  the  anterior  portion  of  the  larynx  appears  behind, 
but  there  is  no  reversal  of  the  sides. 

A  new  appliance  has  been  recently  employed  to  see  the  interior  of  the 
air-passages  in  the  form  of  Killian's  bronchoscope  (Fig.  432).  This  consists 
of  a  straight  tube,  which  can  be  introduced  through  the  upper  air-passages 
thoroughly  cocainized  (upper  bronchoscopy),  or  through  a  tracheotomy 
incision  (lower  bronchoscopy),  and  can  then  be  carried  down  to  the  bifurcation 
of  the  trachea.  Smaller  tubes  slipped  down  inside  the  outer  allow  the  bronchi 
to  be  examined.  The  interior  is  illuminated  either  directly  or  by  reflection 
from  a  mirror.  By  this  means  foreign  bodies  have  been  extracted  from  a 
bronchus  on  many  occasions. 

Foreign  Bodies  in  the  Air-Passages.^ — Any  part  of  the  respiratory 

tract  may  be  partially  or  completely  obstructed  by  the  presence  of 
some  foreign  body,  the  effect  of  which  may  be  of  greater  or  less 
gravity  according  to  the  situation,  character,  and  size  of  the  in- 
truding substance. 

1.  In  the  Nasal  Passages,  see  p.  818. 

2.  Obstruction  occurring  at  the  pharyngeal  entrance  to  the  larynx 
is  usually  due  to  attempts  to  bolt  large  masses  of  food,  which,  be- 
coming (mpacted,  may  cause  immediate  death.  A  person,  eating 
a  meal  voraciously,  turns  black  in  the  face  and  falls  off  his  chair  dead. 
A  similar  result  has  followed  such  a  foolish  act  as  attempting  to 
swallow  a  billiard  ball.  If  the  obstruction  is  not  complete,  as 
when  a  plate  of  false  teeth  becomes  impacted,  great  dyspnoea  is 
caused,  and  absolute  inability  to'-'swallow,  the  symptoms  rapidly 
increasing  owing  to  oedema  of  the  submucous  tissue  of  the  glottis. 

900 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS.  AND  CHEST    901 

Accidents  of  a  similar  nature  may  occur  during  chloroform  narcosis, 
an  epileptic  fit,  or  drunkenness,  some  such  substance  as  a  plate  of 
teeth  being  dislodged  from  the  mouth,  or  a  mass  of  food  being 
vomited,  and  blocl^ing  the  entrance  to  the  larynx.  The  Treatment 
must  be  very  prompt,  since  there  is  no  time  to  lose.  The  mouth 
should  be  forced  open  by  the  handle  of  a  fork,  or  anything  suitable 
that  happens  to  be  near,  and  the  finger  rapidly  swept  round  the 
pharynx  so  as  to  dislodge  the  foreign  body.  Failing  this,  laryngo- 
tomy  must  be  performed  at  once,  and  artificial  respiration,  if  neces- 
sary, instituted.     In  less  urgent  cases  there  is  time  to  remove  the 


Fig.  432. — Killian's  Bronchoscope  in  Position. 

The  patient  is  generally  anaesthetized,  and  lies  on  his  back  with  the  head  thrown 
over  the  end  of  the  table.  After  introduction  of  the  main  tube  down  the 
trachea,  extension  tubes  can  be  inserted  to  explore  the  bronchi;  one  of 
the  latter  is  shown  in  the  above  sketch  reaching  down  to  the  bifurcation 
of  the  trachea. 

substance  from  the  mouth  with  the  assistance  of  a  frontal  mirror  and 
suitable  forceps. 

3.  In  the  Larynx. — A  foreign  body  enters  the  larynx  by  inhalation 
during  a  deep  inspiratory  effort,  when  the  glottis  is  widely  open. 
Anything  large  is  likely  to  be  stopped  above  the  larynx,  and  hence 
the  type  of  foreign  body  found  in  this  region  consists  of  small  coins, 
buttons,  nutshells,  or  a  small  tooth-plate.  It  may  cause  total 
obstruction  and  immediate  death,  or  may  enter  one  of  the  ventricles, 
and  only  produce  partial  obstruction,  as  evidenced  by  a  sudden  sense 
of  suffocation,  urgent  dyspnoea,  and  a  violent  attack  of  coughing, 
attended,  perhaps,  by  vomiting,  such  as  occurs  when  anything  is  said 


902  A   MANUAL  OF  SURGERY 

to  have  '  gone  down  the  wrong  way.'  The  voice  becomes  croupy  and 
hoarse,  respirations  are  stridulous,  and  any  movement  of  the  patient 
may  for  some  time  bring  on  a  spasmodic  fit  of  dyspncea.  After  a 
while  the  obstruction,  which  is  at  first  partial,  may  become  complete 
from  oedema  of  the  glottis,  whilst  perichondritis  and  ulceration  or 
necrosis  of  the  cartilages  may  be  induced.  Laryngoscopic  examina- 
tion should  reveal  the  situation  of  the  intruding  body.  The  Treat- 
ment consists  in  attempting  to  remove  it  through  the  mouth  with 
suitably  curved  forceps  guided  by  a  laryngoscope  (endo-laryngeal 
method) ;  or,  failing  that,  a  laryngotomy  is  performed,  and  the  body 
dislodged  if  possible  from  below.  Should  this  not  be  successful, 
thyrotomy  (p.  908)  must  be  undertaken. 

4.  In  the  Trachea. — To  lodge  in  this  situation  a  foreign  body  must 
be  small  enough  to  pass  through  the  rima  glottidis,  and  not  too 
heavy,  otherwise  it  drops  into  one  of  the  bronchi;  it  may  become 
impacted,  if  it  has  jagged  edges,  but  is  not  uncommonly  free.  It 
may  remain  in  one  spot,  only  moving  when  the  patient  alters  his 
position  or  coughs,  and  then  the  longer  it  stays,  the  less  moveable  it 
is,  owing  to  its  becoming  embedded  in  mucus. 

The  Symptoms  may  be  described  as  those  of  obstruction,  irritation, 
and  inflammation.  During  the  passage  of  the  body  through  the 
larynx,  the  patient  suffers  from  a  severe  attack  of  spasmodic 
dyspnoea  and  coughing,  which  may  last  for  some  time.  Later  on 
similar  attacks  may  be  induced  by  the  foreign  body  being  coughed  up 
against  the  lower  aspect  of  the  vocal  cords,  and  death  has  even 
resulted  from  its  impaction  in  the  larynx  brought  about  in  this  way. 
The  irritation  of  the  unusual  occupant  of  the  trachea  produces 
tracheitis,  with  frothy  expectoration  and  spasmodic  cough ;  the  lower 
it  lies,  the  less  the  irritation,  the  mucous  membrane  being  apparently 
less  sensitive  as  it  descends  from  the  larynx.  Treatment  consists  in 
the  introduction  of  a  Killian's  bronchoscope  so  that  the  foreign  body 
may  be  seen,  and  by  suitable  forceps  secured  and  removed.  If  such 
appliances  are  not  available,  a  low  tracheotomy  must  be  performed, 
with  a  good-sized  opening,  and  it  may  be  possible  to  reach  and 
remove  the  foreign  body;  or  the  patient  may  be  inverted  and  the 
back  well  concussed  in  order  to  dislodge  it.  Failing  this,  the  wound 
in  the  trachea  must  be  left  widely  open,  by  inserting  a  wire  stitch 
through  each  side  of  the  incision  and  tying  the  ends  behind  the  neck ; 
very  probably  the  body  will  be  expelled  through  it  during  an  attack 
of  coughing. 

5.  To  become  impacted  in  a  Bronchus  the  foreign  body  must  be 
sufficiently  small  to  pass  through  the  rima  glottidis,  and  heavy  and 
smooth  enough  to  allow  of  its  dropping  down  the  trachea ;  the  most 
common  articles  met  with  are  buttons,  pebbles,  slate  pencils,  a  pin, 
an  O'Dwyer's  tube,  or  the  inner  cannula  of  a  tracheotomy-tube.  Ihe 
right  bronchus  usually  becomes  obstructed,  the  reason  for  this  being 
that  although  the  left  bronchus  is  more  in  a  direct  line  with  the 
trachea,  yet  the  right  is  the  larger,  the  septum  between  them  lying 
to  the  left  of  the  middle  line.     A  series  of  sjonptoms  similar  to  those 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST    903 

already  described  manifests  itself,  viz.,  obstruction,  irritation,  and  in- 
flammation. The  obstruction  is  twofold:  immediate,  as  a  result  of 
the  passage  of  the  intruder  through  the  glottis,  a  condition  due  more 
to  spasm  than  to  mechanical  causes;  and  late,  as  a  sequence  of  its 
lodgment  in  the  bronchus.  Even  if  the  obstruction  is  at  first  partial, 
it  soon  becomes  complete  from  swelling  of  the  mucous  membrane; 
for  a  time  it  is  more  or  less  valvular  in  character,  allowing  exit  to  air 
during  expiration,  but  absolutely  preventing  its  entrance.  Collapse 
of  that  portion  of  the  lung  supplied  by  the  affected  bronchus  is  thus 
induced,  as  indicated  by  dulness  and  the  absence  of  breath-sounds. 
Irritation  and  inflammation  soon  follow,  resulting  in  bronchitis,  the 
formation  of  a  bronchiectasis,  and  peri-bronchial  pneumonia;  sup- 
puration ensues,  and  the  foreign  body  may  be  expelled  sooner  or  later 
with  a  sudden  gush  of  pus  during  a  fit  of  coughing.  Thus,  in  one 
case*  a  beech-mast  was  inhaled  in  November,  1812,  and  was  not 
extruded  till  May,  1822,  the  patient  having  in  the  meantime  de- 
veloped all  the  symptoms  of  a  bronchiectasis.  Sometimes  the 
abscess  may  extend  through  the  lung  substance  to  the  pleura,  setting 
up  a  localized  empyema,  through  which,  when  opened,  the  article  i? 
expelled.  In  other  cases  the  lung  becomes  riddled  with  abscesses, 
and  the  patient  dies  of  exhaustion. 

Treatment. — The  position  of  the  foreign  body  must  be,  if  possible, 
ascertained  by  careful  examination  of  the  lungs,  which  may  reveal 
a  certain  amount  of  collapse,  whilst  radiography  may  also  be  useful, 
and  Killian's  bronchoscope  may  permit  it  to  be  seen.  A  skilled 
laryngologist  will  probably  be  required  to  introduce  this  instrument 
through  the  mouth,  but  in  his  absence  any  surgeon  could  pass  it 
through  an  incision  in  the  trachea.  The  patient  is  advisably 
anaesthetized,  and  lies  on  the  back  with  his  head  hanging  over  the 
end  of  the  table.  Fine  tubes  can  be  passed  through  the  main 
cannula  so  as  to  enter  the  smaller  bronchi. f 

In  the  absence  of  this  appliance  a  low  and  extensive  tracheotomy 
is  performed,  and  the  bronchi  are  examined  by  a  long  bullet  probe, 
suitably  curved.  The  foreign  body  may  thus  be  felt,  and  its  removal 
accomplished  by  a  delicate  pair  of  forceps,  a  loop  of  wire,  or  a  coin- 
catcher.  Should  it  be  impossible  to  remove  it,  the  tracheotomy 
wound  is  left  open  for  a  time  in  the  hope  that  inflammatory  disturb- 
ance may  loosen  it,  and  it  may  be  coughed  up.  Abscess  of  the  lung, 
and  localized  empyema,  are  dealt  with  by  incision,  and  it  is  possible 
that  the  foreign  body  may  be  removed  by  this  means  through  the 
thoracic  parietes.  In  several  instances  tlie  chest  has  been  opened 
successfully  in  the  early  stages,  and  a  foreign  body  removed  by  direct 
incision  into  the  bronchus. 

Injuries  of  the  Larynx. — Several  conditions  arising  from  trau- 
matism of  the  upper  air-passages  have  been  already  described — e.g., 

*  Mr.  William  Rose,  senior,  Lancet,  August,  1843. 

\  For  the  employment  of  this  method  in  the  removal  of  a  pin,  see  Sir  St, 
Clair  Thomson,  Lancet,  May  7,  1910. 


504 


A   MANUAL  OF  SURGERY 


fracture  of  the  hyoid  bone  (p.  497),  and  incised  wounds,  as  in  cut 
throat  (p.  888). 

Occasionally  the  thyroid  or  other  cartilages  may  be  injured  or 
fractured  by  direct  violence,  as  in  garrotting,  causing  local  pain  and 
hsemorrhage,  and  possibly  some  obstruction  to  the  respiration.  As 
a  rule,  no  treatment  is  required  beyond  keeping  the  patient  quiet, 
but  should  symptoms  of  dyspnoea  arise,  intubation  or  tracheotomy 
must  be  undertaken. 


Diseases  of  the  Larynx. 

The  study  of  laryngeal  diseases  can  only  be  briefly  referred  to  here,  since  it 
is  now  so  extensive  as  to  require  special  text-books. 

Acute  and  Chronic  Laryngitis  are  conditions  of  but  slight  surgical  interest. 
The  acute  affection  arises  from  cold  or  over-exertion  of  the  vocal  apparatus, 

and  is  characterized  by  aphonia  (loss 
of  voice)  and  cough.  Locally,  the 
vocal  cords  are  seen  to  be  hyperaemic 
and  swollen.  The  Treatment  is  rather 
medical  than  surgical,  although  in 
children  intubation  or  tracheotomy 
mav  be  sometimes  required. 

Diphtheritic  Inflammation  of  the 
Larynx  (p.  133)  is  usually  met  with  as 
an  extension  of  a  similar  afEection 
of  the  fauces.  It  gives  rise  to  severe 
dyspnoea  from  obstruction,  and,  if  the 
condition  does  not  yield  to  the  injec- 
tion of  the  diphtheritic  antitoxin, 
will  probably  require  intubation  or 
tracheotomy. 

Acute  (Edematous  Laryngitis,  or 
oedema  of  the  glottis,  is  a  condition  of 
considerable  surgical  importance. 
Causes. — {a)  It  is  secondary  either 
to  some  other  laryngeal  afEection, 
such  as  acute  catarrhal  laryngitis  or 
acute  perichondritis,  or  more  rarely 
to  some  chronic  affection,  such  as 
syphilis  or  carcinoma;  or  (b)  it  may 
extend  from  inflammatory  conditions 
of  neighbouring  tissues,  such  as  the 
root  of  the  tongue,  or  the  submaxillary 
region — e.g.,  in  cellulitis  or  Ludwig's 
angina;  or  it  may  be  secondary  to  a 
retropharyngeal  abscess,  (c)  It  is  also 
not  unfrequently  seen  in  children 
from  drinking  scalding  water,  as  from 
the  spout  of  a  kettle,  or  sometimes  in 
adults  from  swallowing  corrosives. 
{d)  It  may  result  from  the  presence  of 
a  foreign  body,  {e)  It  has  also  been 
known  to  occur  as  part  of  the  general 
anasarca  of  chronic  Bright's  disease. 
Characters. — The  folds  of  mucous 
membrane  extending  on  either  side  of  the  epiglottis  both  to  the  root  of  the 
tongue  and  backwards  to  the  arytenoid  cartilages  become  swollen  and  cedem- 
atous   from   a  serous   effusion   into  the  submucous   tissue    (Fig.  433).     The 


Fig.  433. — CEdema  of  Glottis  from 
Behind.  (College  of  Surgeons' 
Museum.) 

The  base  of  the  tongue  is  seen  to  be  en- 
larged and  swollen,  and  the  aryteno- 
epiglottidean  folds  are  oedematous,  so 
that  the  entrance  to  the  larynx  is 
represented  by  a  mere  chink. 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS,  AND  CHEST    905 

same  condition  also  involves  the  interarylenoid  fold  and  the  false  vocal  cords 
(superior  thyro-arytenoid  folds) ,  extending  down  as  far  as  the  true  cords.  The 
process  is  checked  at  this  level  owing  to  the  absence  of  submucous  tissue,  the 
vocal  cords  consisting  of  elastic  fibres  covered  merely  with  a  layer  or  two  of 
squamous  epithelium.  The  epiglottis  becomes  folded  laterally  upon  itself  as  a 
leaf,  leaving  only  a  valve-like  chink,  which  permits  of  expiration  although  con- 
siderably checking  inspiration.  The  Symptoms  produced  by  this  condition  are 
those  of  mechanical  dyspnoea,  to  which  not  unfrequently  spasm  of  the  glottis 
is  superadded,  and  this  is  sometimes  of  sufficient  intensity  to  destroy  the 
patient's  life.  There  may  be  also  some  difficulty  in  swallowing,  owing  to 
associated  oedema  of  the  pharynx  and  oesophagus,  and  some  degree  of  febrile 
disturbance.  The  diagnosis  is  made,  either  by  passing  the  finger  into  the 
pharynx,  when  the  rigid,  swollen  epiglottis  can  be  felt,  or  by  laryngoscopic  ex- 
amination, when  the  slit-like  opening  of  the  glottis,  bounded  below  and  behind 
by  thickened  oedematous  folds  of  mucous  membrane,  can  be  seen.  Treatment 
consists  in  scarification  of  the  swollen  tissues  below  and  behind  the  epiglottis, 
which  can  be  effected  after  spraying  the  parts  with  cocaine  by  means  of  a  suit- 
able knife  guided  by  a  laryngoscope.  The  usual  result  is  a  rapid  diminution 
of  the  oedema,  and  additional  relief  may  be  gained  by  inhaling  steam  arising 
from  hot  water,  to  which  some  tinct.  benzoini  co.  has  been  added.     Fomen- 


/ 


Fig.  434. — -Gummatous  Disease  of  Fig.  435. — Tuberculous  Disease 

THE  Larynx.     (Tillmanns.)  of  the  Larynx,  with  Exten- 

Small  gummata  are  seen  invading  ^^^^     Ulceration      in    Front 

the    mucous    membrane    of    the  ^^°   Behind.      (Tillmanns.) 

epiglottis  and  front  of  the  larynx.  a,  b,  c,  Remains  of  the  epiglottis. 

tations  or  ice  compresses  applied  externally  are  also  useful,  especially  the 
latter.  In  more  severe  cases,  and  especially  in  children,  intubation  may  be 
necessary,  or  the  air-passages  may  be  opened  below  the  obstruction,  laryn- 
gotomy  sufficing  in  adults,  but  a  high  tracheotomy  being  needed  in  children. 
Syphilitic  Diseases  of  the  Larynx.  —  In  the  secondary  stage,  mucous 
tubercles  or  superficial  ulcers  occasionally  form  in  the  neighbourhood  of  the 
vocal  cords,  concurrently  with  the  rash  on  the  skin,  and  the  formation  of 
condylomata  and  mucous  tubercles  elsewhere.  These  are  most  likely  to 
occur  in  costermongers  or  those  who  have  to  speak  loudly,  and  may  then  lead 
to  a  good  deal  of  thickening  of  the  cords.  Apart  from  such  cases,  it  rarely 
causes  much  trouble  beyond  a  little  hoarseness.  No  special  treatment  is 
required,  although  possibly  the  parts,  if  ulcerated,  may  be  brushed  over  with 
a  solution  of  perchloride  of  mercury.  In  the  tertiary  period,  diffuse  gum- 
matous infiltration  or  localized  gummata  may  develop,  giving  rise  to 
destructive  ulceration,  which  especially  affects  the  epiglottis  and  aryteno- 
epiglottidean  folds,  and  may  spread  backwards  and  involve  the  whole  glottis 
(Fig.  434) .  Inflammation  of  the  perichondrium  is  likely  to  follow,  leading  to 
necrosis  of  the  cartilagej.  Hoarseness  and  dyspnoea  are  the  chief  s^rmptoms 
of  this  affection,  whilst  considerable  obstruction  may  be  caused  subsequently 
by  cicatrization  and  laryngeal  stenosis.  Treatment  consists  in  the  adminis- 
tration of  iodide  of  potassium  and  mercury,  whilst  ulcers  may  be  sprayed 
■with  perchloride  of  mercury  solution,  or  dusted  over  with  calomel  or  iodoform. 
Should  urgent  dyspnoea  arise,  tracheotomy  must  be  undertaken. 


906 


A   MANUAL  Of  SURGERY 


Tuberculous  Laryngitis  (Fig.  435)  is  occasionally  a  primary  manifestation, 
but  is  much  more  Ircquently  secondary  to  phthisis,  arising  from  infection  of 
the  mucous  membrane  owing  to  the  constant  passage  over  it  ot  the  sputum. 
It  usually  commences  at  the  posterior  part  of  the  larynx  in  the  neighbourhood 
of  the  arytenoid  cartilages,  as  a  submucous  infiltration,  which  breaks  down, 
and  leads  to  typical  tuberculous  ulcers,  similar  to  those  occurring  in  other 
viscera  (p.  182).  Considerable  destruction  of  tissue  ensues,  involving  the 
whole  circumference  of  the  larynx,  and  even  leading  to  perichondritis  and 
necrosis  of  the  cartilages.  Hoarseness,  cough,  pain  on  swallowing,  and 
perhaps  a  certain  amount  of  dyspnoea,  in  a  patient  suffering  from  phthisis, 
are  the  chief  symptoms  arising  from  this  affection,  the  prognosis  of  which  is 
always  of  a  grave  nature.  The  anaemic  condition  of  the  mucous  membrane 
is  an  important  diagnostic  sign  in  the  early  stages.  Treatment. — As  for  other 
tuberculous  affections,  constitutional  treatment  is  now  mainly  relied  on,  and 
for  choice  in  a  sanatorium,  whilst  absolute  silence  is  insisted  on.  Occasionally 
local  treatment  is  undertaken  by  the  laryngologist  in  the  form  of  topical  a]jplica- 
tions  of  lactic  acid,  and  the  removal  of  papillary  outgrowths  or  of  the  epiglottis. 
The  earlier  recognition  of  pulmonary  tuberculosis  and  its  more  effective  treat- 
ment is,  however,  reducing  the  number  of  cases  of  the  laryngeal  affection. 

Paralysis  of  the  Larynx  is  observed  in  a  variety  of  conditions,  but  is  only 
of  surgical  interest  when  arising  from  injury  or  division  of,  or  pressure  upon, 


Fig.  436. — Papillomata  of  the 
Larynx,  springing  from  the 
Right    Vocal    Cord.       (Till- 

MANNS.) 


Fig.  437. — Epithelioma  of  the 
Larynx,  involving  the  Right 
Vocal  Cord  and  Base  of  the 
Epiglottis.     (Tillmanns.) 


the  recurrent  laryngeal  nerve.  It  may  follow  the  removal  of  a  goitrous 
tumour  or  of  tuberculous  glands,  but  is  most  commonly  seen  in  connection 
with  aneurisms  of  the  innominate  or  aorta,  or  tumours  in  the  same  neighbour- 
hood— e.g.,  cancer  of  the  oesophagus,  the  actual  pressure  in  the  latter  case 
being  probably  exercised  by  secondarily  enlarged  lymphatic  glands.  Paralysis 
from  the  above  causes  is  generally  unilateral,  but  if  due  to  cancer  both  sides 
may  be  involved.  The  effect  of  complete  paralj-sis  of  one  recurrent  laryngeal 
is  to  produce  total  immobility  on  the  affected  side  of  the  vocal  cord,  which 
lies  in  what  is  known  as  the  '  cadaveric  position  ' — i.e.,  midway  between  that 
in  which  it  is  placed  during  phonation  and  during  inspiration.  Not  uncom- 
monly the  paralysis  is  incomplete,  and  then  merely  affects  the  abductor 
muscle  (the  crico-arytenoideus  posticus).  The  Symptoms  arising  from  uni- 
lateral recurrent  paralysis  are  often  slight,  the  voice  being  usually  but  little 
modified,  owing  to  the  healthy  cord  being  capable  of  passing  across  the  middle 
line.  If,  however,  both  sides  arc  completely  paralyzed,  absolute  aphonia, 
without  dyspnoea,  results;  but  if  only  the  abductors  are  involved,  the  voice 
may  be  unimpaired,  although  severe  dyspnoea  is  often  present,  and  this  may 
prove  fatal  unless  tracheotomy  is  promptly  performed. 

Papilloma  of  the  Larynx  (Fig.  436)  occurs  in  the  form  of  wart-like  masses, 
usually  growing  from  the  true  vocal  cords,  and  giving  rise  to  considerable 
hoarseness  and  perhaps  some  dyspnoea.  They  are  recognised  on  laryngoscopic 
examination,  and  may  be  removed  successfully  by  laryngeal  forceps,  after  the 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS,  AND  CHEST    907 

parts  have  been  efficiently  cocainized.  It  is  recommended  by  some  authorities 
to  destroy  the  growth  with  a  galvano-cautery,  but  there  is  always  a  certain 
liability  to  recur,  and  thyrotomy  may  be  required  in  a  few  cases  to  establish 
a  radical  cure. 

Epithelioma  Laryngis  occurs  in  patients  over  forty,  originating  as  a  papil- 
lary ONcrgrowth,  usually  near  the  base  of  the  epiglottis,  or  from  the  true  or 
false  cords  (Fig.  437).  The  tumour  gradually  spreads,  both  superficially  and 
deeply,  and  may  invade  the  cartilages,  giving  rise  to  necrosis.  At  a  later 
stage  it  extends  beyond  the  limits  of  the  larynx,  attacking  the  base  of  the 
tongue,  oesophagus,  and  even  the  lateral  walls  of  the  pharynx.  As  long  as 
the  disease  is  strictly  limited  to  the  larynx  (intrinsic),  the  growth  is  often 
unilateral,  causing  hoarseness  and  aphonia,  together  with  an  irritable  cough 
and  the  expectoration  of  blood-stained  muco-pus,  which  may  be  horribly 
offensive;  it  is  associated  with  but  little  tendency  to  affection  of  lymphatic 
glands.  When,  however,  the  growth  has  extended  to  surrounding  structures 
(extrinsic),  lymphatic  enlargement  follows,  and  the  disease  runs  its  usual 
course,  destroying  life  by  dyspnoea  and  exhaustion.  Pain  is  often  a  most 
distressing  sj^mptom,  being  referred  either  to  the  larynx  or  phar\Tix,  or, 
according  to  Ziemssen,  not  unfrequently  to  the  ear.  Treatment. — In  the  early 
stages  thyrotomy  and  efficient  curetting  and  cauterization  will  probably 
bring  about  a  cure.  Later  on,  removal  of  one  or  both  halves  of  the  larjnax, 
together  with  the  affected  glands,  will  be  required,  and  the  operation  may 
even  include  parts  of  the  tongue  and  pharyngeal  wall.  WTiere,  however,  the 
disease  has  spread  extensively,  its  total  extirpation  is  rarely  practicable,  and 
all  that  can  be  done  is  to  treat  symptoms  as  they  arise,  and  perform  tracheo- 
tomy when  necessary. 

Acute  and  Chronic  Perichondritis  are  affections  of  the  perichondrium,  usually 
ending  in  the  formation  of  an  abscess  and  in  necrosis  of  the  cartilage  involved. 
The  acute  variety  is  pyogenic,  and  due  to  traumatism  or  to  auto-infection, 
following  acute  fevers,  such  as  typhoid.  The  patient  complains  of  severe  pain 
and  tenderness  over  the  larynx,  with  fever,  dysphagia,  and  hoarseness. 
Dyspnoea  results  from  swelling  of  the  mucous  membrane,  and  oedema  of  the 
glottis  may  follow.  An  abscess  may  point  internally  or  externally,  and  on 
opening  it  the  cartilage  will  usually  be  felt  bare  and  perhaps  necrosed.  Treat- 
ment in  the  early  stages  consists  in  fomentations;  but  when  the  affection  is 
producing  dyspnoea,  and  an  external  swelling  is  present,  it  is  well  to  cut  do%vn 
on  the  cartilages  from  outside.  Should  this  fail  to  relieve  the  dyspnoea,  a 
tracheotomy  will  be  required.  The  chronic  variety  is  more  often  due  to 
tubercle,  sj'philis,  or  carcinoma:  in  it  an  abscess  forms  more  slowly  and  with 
less  constitutional  disturbance,  but  necrosis  ensues  none  the  less.  When  the 
abscess  points  externally,  it  should  be  opened  from  outside,  but  sometimes 
in  these  cases  it  is  possible  to  deal  with  it  from  within.  When  a  well-marked 
sequestrum  is  present,  it  must  be  removed  by  an  external  incision,  and  if 
need  be  thyrotomy  must  be  undertaken.  Distortion  or  stenosis  of  the 
larjmx  is  not  an  unusual  sequela,  possibly  necessitating  the  perpetual  use  of 
a  tracheotomy- tube. 

Operations  upon  the  Air-Passages. 

I.  Subhyoid  Pharyngotomy  was  devised  by  Malgaigne,  in  order  to 
provide  access  to  the  upper  parts  of  the  larynx  in  the  treatment  of 
foreign  bodies  or  tuberculous  disease.  A  transverse  incision  is  made 
through  the  thyro-hyoid  space,  the  pharynx  is  opened,  and  the  epi- 
glottis detached  from  the  base  of  the  tongue  (Fig.  438,  I.).  It  is  a 
proceeding  that  is  seldom  undertaken,  and  scarcely  necessary. 

A  much  more  satisfactory  procedure  is  Trans-hyoid  Pharyn- 
gotomy,* in  which  the  hyoid  bone  is  divided  in  the  middle  line 
*  See  Revue  de  Chirurgie,  May,  1900. 


9o8 


A   MANUAL  OF  SURGERY 


through  a  vertical  incision  extending  from  the  symphysis  menti  to 
the  thyroid  cartilage.  The  pharynx  can  then  be  opened  either  above 
or  below  the  level  of  the  hyoid  bone,  and  the  back,  of  the  tongue,  the 
posterior  wall  of  the  pharynx,  or  the  upper  part  of  the  larynx  freely 
exposed.  A  preliminary  tracheotomy  is,  of  course,  necessary.  We 
have  utilized  this  operation  both  for  the  removal  of  an  epithelioma 
of  the  epiglottis  and  back  of  the  tongue,  and  for  enucleating  a  sar- 
coma of  the  posterior  pharyngeal  wall, 
and  were  much  pleased  with  the  ap- 
proach given  to  these  parts. 

2.  Thyrotomy  (Fig.  438,  II.)  con- 
sists in  a  vertical  section  of  the  thy- 
roid cartilage,  and  may  be  required 
for  the  removal  of  foreign  bodies  or 
tumours,  or  for  the  radical  treatment 
of  laryngeal  tuberculosis  or  cancer. 
Tracheotomy  is  performed  as  a  pre- 
liminary measure,  and  the  trachea 
plugged  around  the  tube.  An  incision 
is  then  made  in  the  middle  line  of  the 
neck,  extending  from  the  hyoid  bone 
to  the  cricoid  cartilage.  The  crico- 
thyroid ligament  is  clearly  defined  and 
severed  transversely,  and  the  thyroid 
cartilage  accurately  divided  by  a 
knife,  cutting-pliers,  or  fine  saw.  The 
lateral  halves  are  separated,  and  the 
intralaryngeal  portion  of  the  operation 
proceeded  with.  When  closing  the 
wound,  the  greatest  care  must  be 
taken  to  bring  the  sides  together  in 
such  a  way  that  the  vocal  cords  are 
exactly  opposite  each  other,  or  phona- 
tion  will  be  considerably  impaired. 
This  is  best  ensured  by  making  a  hori- 
zontal nick  across  the  front  of  the 
cartilage  before  dividing  it. 

3.  Extirpation  of  the  Larynx  (Laryn- 
gectomy) is  always  a  serious  operation, 
which  is  never  undertaken  except  for  malignant  disease.  According 
to  the  site  of  the  tumour,  the  removal  may  be  partial  or  complete; 
for  a  growth  strictly  limited  to  one  side,  extirpation  of  that  half  will 
suffice,  and  admirable  results  have  followed  such  treatment,  distinct 
speech  remaining ;  but  if  the  whole  larynx  is  removed,  although  the 
patient  is  subsequently  able  to  whisper,  phonation  is  impossible  with- 
out mechanical  assistance,  whilst  if  the  disease  has  extended  beyond 
the  limits  of  the  lar5mx,  operative  interference  is  rarely  successful. 
Operation  for  Complete  Extirpation. — An  incision  is  made  in  the 
middle  hue  of  the  neck  from  the  hyoid  bone  to  below  the  cricoid 


Fig.  438. — Operations  on  the 
Air-Passages. 

I.,  Subhyoid  pharyngotomy; 
II.,  thyrotomy;  III.,  laryn- 
gotomy:  IV.,  cricotomy;  V., 
high  tracheotomy;  VI.,  low 
tracheotomy;  H.,  hyoid 
bone;  Thy.,  thyroid  cartil- 
age; Cr.,  cricoid;  G.Th.,  thy- 
roid body. 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS.  AND  CHEST     909 

cartilage      The  soft  parts  are  stripped  from  the  lateral  aspects  of  the 
thyroid  cartilage  with  raspatories,  the  sterno-hyoid,  sterno-thyroid, 
and  thyro-hyoid  muscles  being  divided  at  their  msertions,  and  the 
isthmus  of  the  thyroid  body  being  divided  between  ligatures  it 
necessary.     The  crico-tracheal  membrane  is  then  cut  through,  or  the 
trachea  itself  is  divided  on  the  slant,  and  either  fixed  m  the  lower 
angle  of  the  wound,  or  a  fresh  incision  is  made  a  little  lower  down, 
and  through  this  it  is  drawn  and  stitched  flush  to  the  skin.     At  this 
stage  it  is  often  wise  to  divide  the  thyroid  cartilage  longitudinally  so 
as  to  ascertain  exactly  the  extent  of  the  disease.     If  it  is  limited  to 
the  larynx,  removal  is  perhaps  best  effected  from  below  upwards, 
a  transverse  incision  at  the  level  of  the  hyoid  bone,  and  extending 
between  the  two  sterno-mastoid  muscles,  being  required  to  facilitate 
this  proceeding.     The  connections  of  the  constrictor  muscles  to  the 
cricoid  and  thyroid  cartilages  are  severed  by  scissors,  and  the  larynx 
can  now  be  drawn  forwards  and  separated  from  the  anterior  pharyn- 
geal wall,  which  must  be  left  intact  if  possible.     The  thyro-hyoid 
membrane  and  base  of  the  epiglottis  are  cut  through,  and  the  final 
steps  of  the  operation  consist  in  clearing  the  superior  cornua  of  the 
thyroid  and  dividing  the  lateral  thyro-hyoid  hgaments.     The  opera- 
tion is  not  particularly  difficult  or  dangerous,  provided  that  the 
surgeon  keeps  close  to  the  larynx,  and  that  the  disease  does  not 
extend  beyond  its  limits.     When  other  structures  such  as  the  base  ot 
the  tongue  have  been  invaded,  these  steps  must  be  modified  so  as  to 
secure    if  possible,  complete  removal  of  the  disease.     The  upper 
portion  of  the  oesophagus  has  even  been  included  m  the  scope  of  the 
operation.*     Finally,  the  rent  in  the  mucous  membrane  of  the 
pharynx  is  closed  by  sutures,  the  divided  muscles  are  drawn  together, 
and  the  incisions  in  the  skin  closed;  if  this  be  practicable,  healing 
by  first  intention  may  follow,  the  air-passages  being  thereby  entirely 
separated  from  the  pharynx.    Of  course,  phonation  is  lost  completely, 
but  the  patient  can  whisper,  and  by  means  of  suitable  apparatus 
this  can  be  magnified  and  utihzed  so  as  to  be  of  service.    In  not  a 
few  cases,  however,  it  is  impossible  to  close  the  wound  completely, 
and  then  'it  must  be  packed  and  allowed  to  heal  by  granulation. 

If  the  oesophagus  is  encroached  on  in  the  operation,  it  is  some- 
times feasible  to  restore  continuity  between  the  pharynx  and  the 
lower  end  by  means  of  a  flap  of  skin  turned  m,  or  the  wound  is 
allowed  to  granulate,  and  a  rubber  funnel  passed  so  as  to  prevent 
cicatricial  contraction,  and  to  allow  the  passage  of  food,  in  other 
cases  a  communication  can  be  estabhshed  between  a  pharyngeal 
fistula  above  and  a  gastrostomy  wound  below,  and  food  can  be 
carried  into  the  stomach  through  an  external  rubber  oesophagus 
worn  under  the  clothes.  ^     j.-l.       -a 

If  the  disease  is  hmited  to  one  half  of  the  larynx,  the  thyroid 
cartilage  is  cleft  in  the  middle  line,  and  the  operation  confined  to  the 
affected  side. 

*  Arthur  Evans,  Transactions  of  the  Royal  Society  of  Medicine.  Clinical 
Section,  vol.  iii..  p.  44,  and  vol.  iv.,  p.  142. 


910  A  MANUAL  OF  SURGERY 

4.  Laryngotomy  is  rarely  undertaken  except  for  the  relief  of 
dyspncea  arising  from  some  sudden  obstruction  to  the  respiration, 
and  is  thus  to  be  looked  on  as  an  operation  of  urgency.  It  is  required 
in  cases  where  the  entrance  to  the  larynx  is  obstructed  by  a  foreign 
body,  for  spasm  of  the  glottis,  or  for  accumulations  of  blood  in  the 
neighbourhood  of  the  larynx  during  an  operation.  It  is  readily 
performed  by  making  a  vertical  incision  over  the  situation  of  the 
crico-thyroid  membrane,  which  is  then  divided  transversely  along 
the  upper  border  of  the  cricoid  cartilage  (Fig.  438,  III.),  the  sterno- 
hyoid muscles  being,  if  necessary,  drawn  aside,  and  a  tube  inserted. 
Possibly  the  small  crico-thyroid  artery  arising  from  the  superior 
thyroid  may  require  a  ligature.  In  cases  of  great  urgency,  a  simple 
transverse  incision  may  be  made  with  a  penknife,  and  the  larynx 
opened,  the  margins  of  the  wound  being  held  aside  by  a  hairpin,  or 
by  the  handle  of  a  scalpel  turned  edgeways,  whilst  a  toothpick  will 
serve  temporarily  as  a  cannula .  Whenever  there  is  time  to  operate 
deliberately,  a  high  tracheotomy  is  the  better  practice,  since  a  tube 
inserted  through  the  crico-thyroid  space  gives  rise  to  conriderable 
irritation,  and  the  voice  may  be  subsequently  impaired  by  the  con- 
traction of  the  cicatrix.  A  special  laryngotomy-tube  is  required, 
the  lumen  of  which  is  not  circular,  but  oval  and  flattened  from  above 
downwards. 

In  children,  where  there  is  but  little  space,  the  proceeding  may  be 
modified  by  division  of  the  cricoid  cartilage,  and  even  of  the  first 
ring  of  the  trachea,  constituting  what  is  known  as  cricotomy  or 
laryngo-tracheotomy  (Fig.  438,  IV.). 

5.  Tracheotomy. — The  trachea  usually  consists  of  from  sixteen  to 
twenty  rings,  of  which  six  or  seven  are  situated  above  the  sternum. 
1  he  isthmuf  of  the  thyroid  body  generally  covers  the  third  and  fourth 
rings,  and  the  trachea  may  be  opened  either  above  or  below  it,  or 
even  sometimes  behind,  the  isthmus  being,  if  necessary,  divided. 
Tracheotomy  is  required  in  any  condition  in  which  there  's  serious 
obstruction  to  the  respiration — e.g.,  various  forms  of  laryngitis,  and 
especially  for  oedema  of  the  larynx  or  diphtheria;  for  stenosi?, 
tumours,  and  some  forms  of  paralysis  of  the  larynx;  occasionally  for 
the  removal  of  foreign  bodies,  either  in  the  larynx,  trachea,  or  one  of 
the  bronchi ;  or  for  compression  of  the  larynx  or  trachea  by  external 
tumours,  such  as  a  malignant  thyroid  body.  It  is  also  undertaken 
as  a  preliminary  measure  in  operations  on  the  mouth,  tongue, 
pharynx,  or  larynx,  in  which  there  is  any  likelihood  of  asphyxia  or 
secondary  septic  pneumonia,  owing  to  the  entrance  of  blood  or  septic 
discharges  into  the  air-passages.  As  a  general  rule,  the  high  opera- 
tion (that  is,  above  the  isthmus  of  the  thyroid  body)  is  to  be  pre- 
ferred, but  under  special  circumstances  it  may  be  advisable  to  open 
the  trachea  lower  down.  The  risk  attaching  to  the  high  operation  is 
considerably  less  than  to  the  low,  but  the  opening  is  made  nearer  to 
any  disease  which  may  exist  in  the  larynx.  For  the  removal  of 
foreign  bodies  from  the  bronchi  or  trachea,  the  low  operation  should 
always  be  employed. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS.  AND  CHEST    911 

'Ihc  high  operation  (Fig.  438,  V.)  is  performed  as  follows:  The 
patient  is  placed  on  the  back,  with  a  sandbag  or  pillow  beneath  the 
neck,  so  as  to  throw  the  head  backwards  and  put  the  structures  on 
the  stretch,  and  with  the  shoulders  somewhat  raised.  Ansesthesia 
may  be  induced  by  chloroform,  but  it  is  unnecessary,  and  indeed 
unwise,  to  push  the  anesthetic,  since  it  is  only  needed  for  the 
division  of  the  skin;  where  the  dyspnoea  is  considerable,  it  is  better 
to  employ  local  anaesthesia  by  the  infiltration  method  (q.v.).  The 
head  is  held  exactly  in  the  middle  line,  and  the  surgeon  feels  tor, 
and  identifies,  the  cricoid  cartilage.  The  incision  extends  from  this 
structure  downwards  for  about  i|  inches.  The  superficial  fascia  is 
divided,  and  the  interval  between  the  sterno-hyoid  muscles  made  out, 
so  as  to'enable  them  to  be  separated  one  from  the  other.  The  edges 
of  the  wound  are  drawn  aside  by  blunt  hooks,  which  should  both  be 
held  by  one  assistant,  so  as  to  ensure  equable  traction. 

Ihe  isthmus  of  the  thyroid  body  may  now  be  seen,  and,  if  pro- 
jecting unduly  upwards,  should  be  pushed  down  after  the  fascia 
along  its  upper  border  has  been  transversely  incised.     The  trachea 
is  next  clearly  exposed  by  using  the  handle  of  a  scalpel  and  dissecting 
forceps   and  should  be  fixed  and  steadied  by  inserting  a  sharp  hook 
into  the  lower  border  of  the  cricoid  cartilage.     The  wound  is  freed 
from  blood  as  far  as  possible,  and  the  trachea  opened  by  inserting  the 
point  of  the  scalpel  and  dividing  two  of  the  rings  from  below  up- 
wards.    A  deep  inspiration  is  usually  taken  at  once,  followed  by  a 
severe  fit  of  coughing,  and  if  the  operation  is  undertaken  for  diph- 
theria the  surgeon  must  be  careful  not  to  let  any  membrane  which 
may  then  be  expelled  enter  his  eyes,  nose,  or  mou^h.     The  insertion 
of  the  tube  is  in  many  cases  easy,  in  others  a  matter  of  some  difficulty ; 
a  good  deal  depend:  upon  the  age  of  the  patient,  the  urgency  of  the 
symptoms,  and  the  depth  from  the  surface  at  which  the  trachea 
lies.     Anything  which  suffices  to  separate  the  lips  of  the  tracheal 
incision— e.g.,  the  handle  of  a  scalpel  introduced  and  turned,   a 
couple  of  hooks,  or  dressing  forceps— will  form  an  efficient  guide 
for  this  purpose.     The  breathing  soon  becomes  quiet  and  regular, 
and  the  tube  is  fixed  in  position  by  tapes  passed  through  lateral 
openings  in  the  face-plate,  and  tied  round  the  neck.     No  dressing  is 
required  for  the  wound  except  a  few  layers  of  gauze  beneath  the  plate. 
Low  tracheotomy  (Fig.  438,  VT)  is  performed  in  almost  precisely 
the  same  way,  except  that  the  incision  extends  further  downwards 
even  reaching  to  the  episternal  notch,  although  the  deeper  part  of 
the  wound  should  never  pass  beyond  a  finger's  breadth  above  the 
sternum,  for  fear  of  opening  that  portion  of  the  cervical  fascia  which 
is  prolonged  downwards  to'the  pericardium,  or  of  wounding  the  left 
innominate  vein.     The  superficial  layers  of  fascia  are  divided,  and 
the  sterno-hyoid  and  sterno-thyroid  muscles  drawn  to  either  side  by 
retractors.     The  inferior  thyroid  veins  then  come  into  view,  and  may 
cau'^e  trouble  if  they  are  distended  with  blood,  as  is  so  frequently  the 
cas-^  in  patients  suffering  from  dyspnoea.     They  must  be  held  aside 
by  hooks  or  divided  between  ligatures,  and  the  deep  layer  of  fascia 


912 


A   MANUAL  OF  SURGERY 


behind  them  incised  so  as  to  expose  the  trachea,  which  is  cleared, 
fixed,  and  opened  in  the  same  way  as  described  above. 

Many  different  forms  of  tracheotomy-tube  have  been  used  from 
time  to  time,  but  the  essential  elements  of  which  it  consists  are  a 
double  cannula,  the  inner  portion  of  which  can  be  readily  removed 
and  cleansed;  it  should  always  be  longer  than  the  outer,  in  order 
to  prevent  any  plug  ot  mucus  being  left  within  the  outer  tube  on 
removal  of  the  inner.  A  face-plate,  or  some  similar  contrivance,  is 
attached  to  the  outer  cannula,  in  order  to  fix  and  steady  it.  One  of 
the  best  is  that  known  as  Parker's  tube  (Fig.  439),  which  has  a  handy 
introducer,  anO  's  perhaps  of  a  better  shape  than  most  of  the  others, 

following  more  closely  the  direc- 
tion of  the  trachea.  The  bivalve 
tube  is  another  useful  instrument ; 
the  outer  sheath  consists  of  two 
lateral  portions,  attached  to  a 
single  face-plate,  and  these  can  be 
pressed  together,  and  hence  with 
care  easily  inserted  through  the 
incision  in  the  trachea.  The  sur- 
geon must  see  that  both  limbs 
enter  the  trachea,  as  trouble  has 
arisen  from  one  limb  passing  out- 
side, and  the  other  inside,  thus 
hindering  the  introduction  of  the 
inner  tube.  Whatever  variety  of 
tube  is  preferred  by  the  surgeon, 
it  is  essential  to  have  several  sizes 
to  hand,  as  the  calibre  of  the 
trachea  varies  much  in  different 
patients.  In  cases  of  preliminary 
tracheotomy,  undertaken  to  pre- 
vent the  entrance  of  blood  during 
operations,  Hahn's  tube  may  be 
used  with  advantage ;  in  this  the 
outer  cannula  is  covered  with  a 
layer  of  compressed  sponge  which  swells  up  from  the  absorption  of 
moisture,  and  thus  occludes  the  lumen  of  the  trachea.  Trendelen- 
burg's tampon  is  recommended  by  some  for  the  same  object;  the 
outer  tube  is  here  ensheathed  with  a  thin  indiarubber  casing,  which 
can  be  distended  with  air  at  will. 

Difficulties  and  Dangers  of  the  Operation. — Although  the  above 
description  might  lead  the  student  to  suppose  that  tracheotomy  is  an 
easy  operation,  this  is  by  no  means  always  the  case,  partly  owing  to 
the  fact  that  it  frequently  has  to  be  undertaken  in  a  hurry,  with 
perhaps  inefficient  assistance,  and  in  a  bad  light,  and  partly  owing  to 
the  intense  vascular  engorgement  of  the  structures  met  with.  A  cool 
head  and  a  steady  hand  are  in  such  cases  of  infinitely  more  value  to 
the  operator  than  the  most  perfect  anatomical  knowledge.     The 


Fig.  439. — Parker's  Tracheotomy- 
Tube  AND  Introducer.  (Down 
Brothers.) 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     913 

following  arc  the  chief  conditions  which  may  lead  to  mistakes  and 

(i)  'Ihe  administration  of  any  general  anaesthetic  is  often  in- 
advisable in  semi-asphyxiated  patients,  since  complete  cessation  oj 
respinilion  may  be  caused  thereby,  possibly  from  spasm  of  the  glottis, 
Local  ancT2sthesia  by  the  infiltration  method  should  be  re  bed  on  m 
such  cases,  and  the  employment  of  /3-eucaine  and  adrenalin  has  been 
most  satisfactory. 

(2)  It  is  not  always  easy  to  find  the  trachea,  especially  in  the  necks  ot 
fat  children,  or  where  'it  is  hidden  by  an  unduly  large  thyroid 
isthmus,  or  possibly  by  the  projection  of  the  thymus  gland  into  the 
neck.  It  is  here  most  essential  to  remember  the  old  adage.  In  medio 
tutissimus  ibis,  although  occasionally  the  trachea  may  be  displaced 
from  the  middle  hne  by  some  external  growth,  and  can  then  only  be 
found  by  careful  exploration  with  the  finger. 

(3)  Hcemorrhage  is  generally  troublesome.  It  is  usually  venous  in 
character,  arising  either  from  the  anterior  jugular  vein  or  from  the 
inferior  thyroid  plexus.  If  possible,  it  should  be  controlled  by 
pressure-forceps  before  opening  the  trachea;  but  this  is  not  abso- 
lutely necessary  in  urgent  cases,  since  it  usually  ceases  as  soon  as 
easy  respiration  through  the  tube  has  been  established.  The  presence 
of  the  left  innominate  vein  in  front  of  the  trachea  must  not  be  for- 
gotten, although  it  but  rarely  reaches  above  the  sternum.  In  about 
8  per  cent,  of  all  subjects  an  arterial  twig  (the  thyroidea  ima)  courses 
upwards  from  the  innominate  artery  along  the  trachea,  to  reach  the 
isthmus  of  the  thyroid  body;  if  divided,  it  can  be  easily  secured  and 
tied.  Should  much  blood  be  inspired,  it  may  determine  the  occur- 
rence of  septic  pneumonia  at  a  later  date. 

{4)  The  possibility  of  the  entrance  of  air  into  veins  must  not  be  over- 
looked, although  it  is  an  uncommon  accident,  since  the  intravenous 
pressure  is  usually  increased. 

(5)  Not  unfrequently  considerable  mischief  has  been  done  by  an 
incautious  use  of  the  knife,  especially  if  the  operator  forgets  to  fix  the 
trachea  with  a  sharp  hook  before  opening  it.  The  knife  should 
always  be  entered  with  its  back  towards  the  episternal  notch,  and  the 
incision  made  from  below  upwards.  In  a  child  the  trachea  is  small ; 
and  if  it  is  moving  rapidly  up  and  down,  as  happens  in  urgent 
dyspnoea,  or  if  the  child  is  restless,  and  not  completely  under  the 
influence  of  an  anesthetic,  the  difdculty  is  manifestly  increased. 
Many  accidents  have  happened  from  this  cause— g.g.,  wounds  of  the 
large  veins  or  arteries  of  the  neck,  or  even  of  the  oesophagus  or  bodies 
of  the  vertebrse  !  . 

(6)  As  soon  as  the  trachea  is  opened  or  an  attempt  made  to  intro- 
duce the  tube,  a  severe  fit  of  coughing  is  induced,  which  is  sometimes 
so  prolonged  as  to  interfere  with  the  introduction  of  the  tube.  Under 
such  circumstances  the  incision  in  the  trachea  may  be  opened  up 
with  a  tracheal  dilator,  or  by  a  pair  of  sinus  forceps,  and  a  few  drops 
of  cocaine  swabbed  over  the  mucous  membrane. 

(7)  The  introduction  of  the  tube  is  a  matter  of  no  difficulty  if  the 
^^'  58 


914  A   MANUAL  OF  SURGERY 

surgeon  takes  the  precaution  of  not  removing  the  hook  until  this  is 
satisfactorily  accomplished.  Many  mistakes  have  followed  the  non- 
observance  of  this  rule;  thus,  the  tube  has  missed  the  trachea  alto- 
gether and  passed  into  the  fascial  interspace  in  front,  as  also  to  one 
or  other  side ;  as  before  mentioned,  the  outer  portion  of  a  bivalve  tube 
has  often  been  passed  with  one  limb  within  the  trachea  and  the  other 
outside.  A  very  dense  diphtheritic  membrane  has  also  been  a  cause 
of  difficult}',  in  that,  although  the  tube  has  been  really  passed  into 
the  trachea,  it  has  not  penetrated  the  membrane,  and  thus  has 
hindered  rather  than  helped  the  breathing.  In  all  cases  of  diphtheria 
the  trachea  should  be  freely  opened,  and  the  interior  carefully 
examined  by  separating  the  lips  of  the  incision  before  attempting  to 
insert  the  tube.  In  order  to  prevent  the  downward  passage  of  the 
membrane,  some  surgeons  have  recommended  that  the  lower  portion 
of  the  larynx  should  be  carefully  stuffed  with  antiseptic  gauze  above 
the  tube. 

After-Treatment.^ — The  patient  is  placed  in  bed,  in  a  room  kept  at 
a  uniformly  wann  temperature  (75°  F.),  the  air  being  moistened 
by  the  steam  issuing  from  one  or  more  bronchitis  kettles,  so  as  to 
make  up  for  the  absence  of  nasal  and  oral  respiration.  Draughts 
are  excluded  by  curtains,  and  nothing  should  be  placed  over  the 
entrance  to  the  tube,  so  that  respiration  may  not  be  hindered,  nor  the 
expectoration  of  mucus,  false  membrane,  etc.,  prevented.  One  of 
the  most  frequent  sources  of  extension  of  diphtheria  to  the  lungs,  or 
of  septic  pneumonia,  is  the  re-inspiration  of  material  which  has  been 
coughed  out  upon  a  portion  of  muslin  or  gauze,  placed  with  excellent 
intentions  over  the  mouth  of  the  tube.  A  nurse  should  be  in  con- 
stant attendance  on  the  patient,  in  order  to  wipe  away  all  such 
material  as  it  is  expelled. 

The  inner  portion  of  the  tube  is  removed  by  the  nurse,  and  cleaned 
two  or  three  times  a  day,  any  inspissated  mucus  upon  it  being  readily 
removed  by  the  use  of  a  solution  of  bicarbonate  of  soda  (20  grains 
to  I  ounce) .  The  outer  tube  is  also  removed  once  a  day  for  cleansing 
purposes,  but  only  by  the  medical  attendant.  Should  the  respira- 
tion become  impeded  by  a  collection  of  mucus  in  the  trachea,  a  fine 
feather  may  be  passed  down  the  tube  in  order  to  clear  it,  but  never  in 
diphtheritic  cases  ;  for  such  a  contingency  special  suction-tubes  have 
been  devised.  Attempts  have  been  made  to  clear  the  passages  by 
applying  the  hps  to  the  tube,  and  removing  the  block  by  suction; 
such  is,  however,  quite  unjusti liable,  and  several  promising  house- 
surgeons  have  in  this  way  lost  their  lives. 

The  period  for  which  the  tracheotomy-tube  is  kept  in  position 
varies  in  different  cases,  but  its  removal  should  always  be  under- 
taken at  as  early  a  date  as  possible,  for  fear  of  leading  to  impairment 
of  the  voice.  In  order  to  prevent  this,  the  inner  cannula  is  made  with 
a  hole  in  the  upper  end,  so  that  part  of  the  air  may  pass  through  the 
larynx.  If  the  patient  can  then  breathe  comfortably  when  the 
finger  is  placed  over  the  entrance  to  the  tube,  its  presence  is  no 
longer  necessary. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     915 

After-Complications  of  Tracheotomy. — {a)  The  tube  may  give  rise 
to  ulceration  of  the  trachea  if  it  is  not  correctly  shaped.  Thus,  if  too 
much  curved,  it  tends  to  irritate  the  anterior  wall,  and  cases  are 
known  in  which  it  has  caused  death  by  perforation  of  the  left 
innominate  vein.  If  insufficiently  curved,  the  posterior  wall  may 
become  affected,  and  the  oesophagus  laid  open.  In  cases  where  a 
tracheotomy-tube  has  to  be  worn  for  a  long  time,  it  is  advisable  to 
make  use  of  indiarubber  tubes. 

L:  {b)  Various  forms  of  septic  trouble  may  arise  in  the  wound,  lead- 
ing to  cellulitis  and  even  secondary  haemorrhage;  this  is  especially 


Fig.  440. — O'Dwyer's  Intubation  Apparatus.     (Down  Brothers.) 

The  cannulse  are  seen  below  on  the  right;  a  hinged  inner  tube  passes  through- 
out the  length  of  each,  and  the  upper  end  of  this  is  screwed  to  the  ex- 
tremity of  the  introducer  seen  in  the  middle;  when  it  has  been  inserted 
into  the  larynx,  the  trigger  of  the  introducer  is  drawn,  and  by  this  means 
the  inner  tube  is  loosened  and  can  be  easily  removed,  leaving  the  cannula 
in  position.  To  extract  the  tube,  the  rectangular  forceps  represented 
at  the  top  is  utilized;  the  point  of  the  forceps  is  inserted  into  the  top  of 
the  cannula,  and  then  by  opening  the  blades  the  cannula  is  fixed  and 
can  be  withdrawn.  A  useful  type  of  unilateral  gag  is  also  represented, 
and  a  small  gauge  to  indicate  the  size  of  cannula  required  at  different 
ages. 

dangerous  in  the  low  operation,  since  the  inflammation  may  extend 
to  the  mediastinal  tissues.  In  cases  of  diphtheria  the  wound  may 
also  become  affected  with  the  disease. 

(c)  Inflammation  of  the  trachea,  bronchi,  and  lungs  may  result 
either  from  the  entrance  of  cold,  or  unmoistened  air,  or  from  the 
inspiration  of  septic  or  diphtheritic  material. 

(d)  Difi&culty  is  sometimes  experienced  in  leaving  off  the  tube, 
owing  to  the  presence  of  granulations  obstructing  the  lumen  of  the 


9i6  A   MANUAL  OF  SURGERY 

trachea,  or  to  stenosis  of  the  trachea  or  larynx,  or  even  to  paralysis 
of  the  abductor  muscles,  especially  in  diphtheritic  cases.  The 
trachea  ma\'  also  be  kinked,  and  its  calibre  thus  diminished,  b}' 
cicatricial  union  of  the  skin  and  mucous  membrane.  Ihe  diagnosis 
of  the  cause  at  work  in  any  particular  case  can  only  be  made  by 
laryngoscopy,  or  careful  examination  of  the  wound  and  upper  portion 
of  the  trachea.  Granulations  may  be  scraped  away  under  an  anaes- 
thetic or  destroyed  by  caustics;  stenosis  of  the  larynx  is  overcome 
by  dilatation  with  an  O'Dwyer's  tube;  stenosis  of  the  trachea  may 
require  excision  of  the  affected  segment,  whilst  laryngeal  paralysis 
must  be  treated  by  the  use  of  electricity. 

[e)  Finally,  it  should  be  remembered  that  if  a  patient  (and  especi- 
ally a  boy)  is  condemned  to  the  perpetual  use  of  a  tracheotomy-tube, 
he  must  be  warned  of  the  possibility  and  danger  of  w^ater  getting  into 
the  trachea  and  his  being  drowned  thereby.  Certainly  one  death 
has  occurred  from  a  boy  bathing  under  these  circumstances  ! 

6.  Intubation  of  the  Larynx  is  a  means  of  treating  laryngeal 
obstruction  which  has  been  introduced  in  order  to  obviate  the  risks 
present  in  tracheotomy.  It  consists  in  the  passage  through  the 
mouth  of  a  suitably  curved  tube  into  the  larynx,  by  means  of  a 
specially  contrived  introducer.  The  best  patterns  to  emplo}'  for  the 
purpose  are  those  known  as  O'Dwyer's  tubes  (Fig.  440).  The  lower 
end  of  the  cannula  is  oval,  and  not  circular,  and  passes  between  the 
cords  into  the  larynx,  whilst  the  upper  enlarged  end  lies  over  the 
entrance ;  it  requires  changing  frequently  in  order  to  prevent  erosion 
of  the  mucous  membrane.  It  has  been  used  with  considerable  suc- 
cess in  cases  of  oedema  of  the  glottis  and  laryngeal  stenosis,  but  is 
scarcely  to  be  recommended  for  diphtheria,  owing  to  the  risk  of 
carrying  the  false  membrane  down  with  it.  The  actual  mortality  in 
a  large  series  of  cases  of  diphtheria  has  been  proved  to  be  much  the 
same  as  for  tracheotomy — viz.,  about  30  per  cent. 

Affections  of  the  Ribs  and  Sternum. 

Several  forms  of  Fracture  have  been  already  described  (pp.  498 
and  499). 

Acute  Suppurative  Inflammation  of  these  bones  is  very  unusual. 
Occasionally  an  acute  osteo-myelitis,  running  its  usual  course  to 
necrosis,  occurs  in  children ;  but  the  most  common  cause  is  typhoid 
fever  (p.  568).  The  affection  is  generally  of  a  subacute  type,  and  a 
more  or  less  extensive  carlo-necrosis  results.  Ihe  special  feature  of 
the  disease  is  the  tendency  of  the  bacihi  to  remain  in  a  latent  condi- 
tion in  the  tissues,  so  that  it  is  difficult  to  ensure  a  perfect  cure  apart 
from  complete  extirpation  of  the  affected  portion  of  bone.  Mere 
scraping  is  rarel}'  sufficient. 

Syphilitic  Disease  is  more  common  in  the  sternum  than  in  the  rib?. 
The  upper  part  of  the  sternum  is  that  usually  involved,  and  the 
affection  is  characterized  by  a  formation  of  gummata  in  and  upon 
the  bone,  which  erode  it,  usually  in  a  pitted  fcishion,  and  may  cause 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS.  AND  CHEST    9x7 
necrosis      The  usual  treatment  with  iodide  of  potassium  and  mer- 

■°ru^elCf re^aSkTribs  n.uch  more  ..^ 

mmmmm 

sever^  ribs  may  be  involved  at  the  f "«  t'f^^,,,  ^h?^f^<=i^=4«lf  J^^^^ 

f  nToiitsSe  the  chest      Treatment  in  these  cases  must  be  of  a  radical 
"totrfpSg  and  disinfection  are  often  meffiaent   and  th 
complete  removal  of  an  extensive  portion  of  the  rib  and 
^''?rS::S:f^^™n:S^S?course,  andmay^esent^n 

-To-'^sfrZteS-b-^^^^^^^^^ 

of  it  by  gouge  or  cuttmg-pbers,  m  order  to  gam  access  10  u     p 

the  ribs,  the  latter  in  the  sternum.     The  Pf  *^^,^/°^^P^^^^^^^ 

unless  special  precautions  are  taken  (p.  923)  ■ 

Surgical  Afiections  o£  the  Lungs  and  Pleural  Cavities. 


yi8  A  MANUAL  OF  SURGERY 

and  of  the  pleura,  as  indicated  by  loss  of  resonance  and  possibly  fric- 
tion sounds.  The  treatment  consists  in  keeping  the  patient  quiet  in 
a  warm  room,  at  the  same  time  carefully  regulating  the  bodily  func- 
tions.    Pain  is  often  relieved  by  strapping  the  side  of  the  chest. 

Laceration  of  the  Lung  is  usually  secondary  to  fracture  of  the  ribs, 
especially  if  due  to  direct  violence.  'Ihe  severity  of  the  symptoms 
necessarily  varies  with  the  character  and  extent  of  the  injury.  The 
patient  suffers  from  marked  shock  in  bad  cases,  associated  with  pain 
in  the  side  and  dyspnoea.  Evidences  of  hcsmorrhage  soon  follow, 
either  in  the  form  of  haemoptysis  or  hsemothorax.  If  the  wound  is  a 
small  one,  the  patient  complains  of  an  irritating  cough,  and  brings  up 
a  good  deal  of  blood-stained  frothy  mucus;  but  if  the  laceration  is 
extensive,  involving  some  of  the  larger  pulmonary  trunks,  a  quantity 
of  pure  blood  may  be  ejected,  even  leading  to  death  from  syncope, 
or  from  asphyxia,  owing  to  the  blood  filling  the  larger  bronchial 
tubes.  HcBmothorax  may  also  be  so  excessive  as  to  cause  the 
patient's  death  from  compression  of  the  lung.  It  results  in  a  gradu- 
ally increasing  area  of  dulness  extending  from  below  upwards, 
together  with  loss  of  breath-sounds  and  vocal  fremitus,  coming  on 
soon  after  the  injury  without  signs  of  inflammation,  but  with  the 
constitutional  signs  of  haemorrhage. 

Owing  to  the  laceration  of  the  pulmonary  vesicles,  air  tends  to 
escape  either  into  the  pleural  cavity,  giving  rise  to  the  condition 
known  as  pneumothorax,  or  into  the  cellular  tissue  of  the  body,  con- 
stituting surgical  emphysema.  Pneumothorax  is  always  associated 
with  more  or  less  collapse  of  the  lung,  and,  if  complete  or  produced 
suddenh',  is  almost  certain  to  lead  to  considerable  interference  with 
respiration,  and  possibly  to  severe  dyspnoea,  or  even  orthopnoea.  A 
slight  degree  of  pneumothorax,  or  a  complete  one,  if  produced  slowly, 
and  if  the  other  lung  is  healthy  and  no  strain  is  thrown  upon  it,  has 
but  little  functional  result.  The  air  which  finds  its  way  into  the 
pleura  in  connection  with  a  ruptured  lung,  having  been  filtered 
through  the  pulmonary  alveoli,  is  free  from  organisms,  and  hence 
does  not  cause  suppuration  or  putrefaction  of  the  blood-clot  present, 
unless  bronchitis  or  some  other  suppurative  condition  has  existed 
previously.  The  physical  signs  of  pneumothorax  consist  in  a  high- 
pitched  tympanitic  note  on  percussion,  and  on  auscultation  amphoric 
breathing  and  possibly  metaUic  tinkling.  As  soon  as  the  wound  in 
the  lung  commences  to  heal,  the  amphoric  sounds  disappear,  the 
effused  air  is  absorbed,  and  the  lung  gradually  expands — a  process 
which  may  take  four  or  five  days.  If  blood  is  also  present  in  the 
thorax,  a  condition  of  hsemo-pneumothorax  is  produced,  recognised 
by  a  splashing  or  succussion  sound  heard  on  shaking  the  patient. 
Surgical  Emphysema  almost  always  indicates  a  wound  of  both 
pulmonary  and  parietal  layers  of  the  pleura,  which  are  slightly 
separated  by  air,  constituting  a  localized  pneumothorax.  At  each 
inspiration  a  fresh  amount  of  air  enters  this  cavity,  and  is  expelled 
into  the  areolar  tissues  through  the  parietal  wound  at  each  expira- 
tion, being  forced  perhaps  to  a  considerable  distance  from  the  spot 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS.  AND  CHEST    919 

where  it  commences,  or  even  spreading  over  the  whole  body.  It  is 
of  no  serious  signihcance,  unless  extensive,  disappearing  rapidly 
after  the  wound  in  the  lung  has  commenced  to  heal,  thus  occluding 
the  opened  pulmonary  ah-eoh.  It  is  recognised  by  the  parts  be- 
coming swollen  and  puff}',  and  gi^'ing  a  sensation  of  fine  crackling 
crepitus  when  the  hand  is  pressed  over  them.  Occasionally  emphy- 
sema ma\'  arise  as  an  interstitial  condition,  when  the  parietal  pleura 
has  not  been  injured,  the  air  escaping  from  the  alveoli  along  the 
interalveolar  connective  tissue  into  the  root  of  the  lung,  and  then 
appearing  first  at  the  lower  part  of  the  neck.  This  is  often  a  con- 
dition of  grave  import. 

Such  are  the  ordinary  phenomena  observed  in  the  early  stages  of 
a  ruptured  lung.  The  effects  subsequently  produced  consist  in  a 
localized  traumatic  pleuro-pnemnonia,  associated  with  slight  eleva- 
tion of  the  temperature,  possibly  rusty  sputum,  and  often  severe 
dyspnoea.     In  the  worst  cases  death  may  result  from  asphyxia. 

Penetrating  Wounds  of  the  Lung,  due  to  direct  injury  and  often 
associated  with  fracture  of  the  ribs,  are  followed  by  very  similar 
effects.  The  story  is  modified,  however,  by  the  fact  that  the  ex- 
ternal wound  in  the  chest  wall  allows  of  the  exit  of  blood,  arising 
either  from  an  intercostal  artery,  the  internal  mammary,  or  from 
the  wounded  lung,  whilst  it  also  permits  the  entrance  of  bacteria 
with  the  air  into  the  pleural  cavity,  and  thus  may  change  the  re- 
sulting pleuro-pneumonia  from  a  simple  to  an  infective  inflamma- 
tion. Empvema  is  consequently  a  frequent  sequela,  whilst  the 
inflammation  of  the  lung  may  be  of  a  spreading  nature,  possibly 
terminating  in  suppuration  or  gangrene.  Surgical  emphysema  is 
also  induced  by  air  being  sucked  into  the  wound  during  inspiration, 
and  failing  to  escape  during  expiration,  owing  to  the  lips  of  the 
wound  fabling  together.  This  condition  may  ensue  even  when  the 
lung  itself  has  not  been  damaged. 

Treatment. — When  the  rupture  of  the  lung  is  due  to  a  subcuta- 
neous injury,  the  patient  should  be  kept  quiet  in  a  warm  room,  and 
the  side  strapped.  The  compression  of  the  chest  wall  must  some- 
times be  omitted  in  patients  where  the  irregular  ends  of  fractured 
ribs,  broken  by  direct  violence,  are  driven  inwards,  for  fear  of 
increasing  the  mischief  in  the  lung. 

Persistent  hsemoptysis  must  be  treated  by  keeping  the  patient 
absolutely  quiet,  and  allowing  him  to  suck  ice  continually.  _  Ergotin 
may  be  injected  hypodermically,  or  a  mixture  of  ergot,  opium,  and 
sulphuric  acid  administered;  the  opium  is  especially  needed  when 
great  restlessness  and  irritability  are  present.  Lactate  of  calcium 
mav  also  be  given  by  the  rectum.  Stimulants  are  necessarily  contra- 
indicated,  for  fear' of  again  starting  the  bleeding.  Haemothorax 
rarely  needs  special  treatment,  since  the  blood  soon  clots  and  is 
readily  absorbed;  but  occasionally  it  may  be  so  abundant  as  to  com- 
press the  lung  and  lead  to  d^'spncea,  and  under  these  circumstances 
it  may  be  necessary  to  aspirate  the  chest,  or  if  that  fail  (as  is  not 
unlikely)  to  open  up  the  pleural  cavity  and  remove  it.     This  must 


920  A   MANUAL  OF  SURGERY 

never  be  undertaken  until  sufficient  time  has  elapsed  to  permit  of 
thrombosis  in  the  wounded  vessels.  Decomposition  of  the  blood  in 
the  pleural  cavity  occasionally  happens  even  in  non-penetrating 
injuries,  the  bacteria  reaching  it  either  from  the  blood  or  from  the 
torn  bronchi ;  the  suppuration  and  fever  thereby  induced  necessitate 
the  opening  and  drainage  oi  the  pleural  sac. 

Simple  pneumothorax  seldom  requires  surgical  treatment,  since 
the  imprisoned  a'r  is  quickly  absorbed,  and  the  lung  re-expands; 
should  this  not  occur,  and  if  severe  dyspnoea  is  present,  it  may  be  ad- 
visable to  remove  the  air  by  aspiration.  Ihis  may  sometimes  fail, 
or  the  air  may  re-collect,  and  then  the  chest  wall  must  be  opened  so 
as  to  give  exit  to  the  air.  It  is  impossible  for  the  lung  to  re-expand 
against  the  pressure  of  air  confined  in  the  chest;  when  an  opening  is 
made,  the  aii  can  be  driven  out  by  a  vigorous  expiratory  movement, 
such  as  coughing,  which  also  forces  air  from  the  healthy  lung  into  the 
wounded  one  when  the  glottis  is  closed. 

Temporary  dyspnoea  may  be  overcome  by  the  inhalation  of 
oxygen ;  but  when  of  a  more  decided  character,  and  not  due  to  any 
condition  which  can  be  removed,  the  essential  treatment  is  to 
diminish  the  blood-pref;-ure,  and  thus  decrease  the  amount  of  blood 
cariied  to  the  uninjured  lung,  so  as  to  enable  it  to  cope  with  the 
work  of  blood-aeration.  This  may  be  accomplished  by  administer- 
ing antimonial  wine  (lo  to  15  minims  every  four  or  six  hours)  com- 
bined with  full  doses  of  liquor  ammonia  acetatis ;  but  in  urgent  cases, 
where  the  patient  is  becoming  cyanosed,  and  life  is  threatened  by 
asphyxia,  venesection  must  be  adopted.  The  blood  is  withdrawn 
from  the  arm  rapidly  and  freely,  and  as  it  flows  the  dyspnoea  passes 
off.  This  may  be  repeated  once  or  twice  in  addition  to  the  use  of  the 
medicine  before  the  full  effect  is  obtained  and  respiration  becomes 
unembarrassed. 

The  treatment  of  penetrating  wounds  of  the  thorax,  involving  the 
lung,  is  always  a  matter  of  considerable  difficulty.  The  skin  around 
the  opening  is  carefully  purified  and  shaved,  if  necessary,  and  a  limited 
exploration  of  the  wound  is  permissible,  so  as  to  determine  whether 
portions  of  the  clothing  have  been  carried  in,  or  a  rib  comminuted; 
all  such  loose  fragments  must  be  removed,  as  also  any  penetrating 
foreign  body,  such  as  a  bullet,  if  readily  accessible.  The  greatest 
gentleness  must,  however,  be  employed,  and  no  attempt  made  to  pass 
a  probe  into  the  pleural  cavity,  since  it  is  easy  to  dislodge  clots  lying 
in  the  pulmonary  tissues,  and  thereby  restart  the  bleeding.  If  the 
wound  itself  needs  sterilizing,  it  is  perhaps  best  to  touch  it  over  with 
pure  carbolic  acid  or  tincture  of  iodine  rather  than  to  irrigate  it,  and 
then  a  dry  antiseptic  dressing  is  applied  without  drainage. 

Immediate  operative  interference  is  only  required  under  two  con- 
ditions, viz.,  for  haemorrhage  and  for  hernia  of  the  lung. 

Hemorrhage  after  a  penetrating  wound  of  the"  chest  wall  may  be 
derived  either  from  a  vessel  in  the  parietes  (intercostal  or  internal 
mammary),  or  from  the  lung  itself.  The  recognition  of  the  source  of 
the  bleeding  is  not  always  easy,  but  it  is  probably  of  parietal  origin 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     921 

(a)  if  it  is  unaccompanied  by  haemoptysis ;  ib)  if  it  increases  obviously 
at  each  systole;  and  (c)  if  it  can  be  controlled  by  digital  compression. 
The  treatment  of  bleeding  from  the  internal  mammary  and  intercostal 
vessels  has  been  already  indicated  (p.  297). 

Pulmonary  hemorrhage  is  not  so  readily  controlled,  and  various 
plans  have  been  recommended.  Probably  the  best  method  consists 
in  keeping  the  patient  absolutely  quiet  in  the  horizontal  position, 
applying  cold  to  the  side,  and  giving  haemostatics,  as  indicated  above 
for  non-penetrating  wounds.  The  effect  of  this  will  be  to  cause  the 
blood  in  the  pleural  cavity  to  clot,  and  this  acts  as  a  tampon  to  the 
affected  viscus;  firmly  plugging  the  external  wound  may  limit  the 
loss  of  blood  and  determine  coagulation  more  quickly.  In  bad  cases 
the  haemorrhage  may  cease  only  when  the  patient  is  in  a  condition  of 
profound  collapse ;  intravenous  or  hypodermic  infusion  of  hot  saline 
solution  may  then  suffice  to  tide  over  the  period  of  danger  and  lead 
to  a  successful  result. 

1  he  question  of  opening  the  thorax  by  turning  up  a  large  flap  of 
the  chest  wall  (including  portions  of  several  ribs)  so  as  to  deal  directly 
with  the  injured  lung  has  been  raised  of  recent  years,  and  cases  in 
which  it  has  been  undertaken  have  been  recorded.  Further  ex- 
perience will  probably  decide  that  such  a  procedure  is  quite  unjustifi- 
able except  in  very  unusual  circumstances. 

1  he  later  treatment  of  these  cases  is  much  the  same  as  for  simple 
non-penetrating  injuries.  Should  symptoms  of  suppurating  pleurisy 
follow,  the  wound  must  be  freely  opened,  a  portion  of  rib  being  ex- 
cised, if  necessary,  and  the  cavity  drained,  as  for  empyema. 

Hernia  o£  the  Lung,  or  pneumocele,  is  a  rare  condition  in  which  a 
portion  of  the  lung  protrudes  through  an  opening  in  the  thoracic 
parietes  beneath  the  uninjured  skin.  It  may  occur  suddenly,  as  the 
immediate  consequence  of  a  laceration  of  the  intercostal  muscles  and 
pleura,  or  more  gradually,  being  then  due  to  the  yielding  of  a  cicatrix. 
It  is  most  usually  seen  about  the  fifth  intercostal  space,  but  has  been 
known  to  occur  in  the  root  of  the  neck  from  a  lesion  in  the  dome  of 
the  pleura.  It  is  recognised  by  the  appearance  of  a  rounded  swelling, 
increasing  in  size  on  coughing  or  making  expiratory  efforts,  and 
possibly  disappearing  entirely  on  holding  the  breath.  It  imparts  a 
crepitant  feeling  to  the  fingers  when  compressed,  and  on  ausculta- 
tion a  loud  vesicular  murmur  is  heard.  As  a  rule,  no  treatment  is 
advisable  in  this  condition  beyond  the  application  of  a  pad  or  truss. 

A  similar  condition,  arising  as  a  complication  of  an  open  wound, 
is  termed  a  Prolapse  of  the  lung.  An  attempt  should  always  be  made 
to  return  the  protruded  viscus,  and  to  prevent  its  recurrence  by 
suturing  the  aperture  through  which  it  has  escaped.  It  left  unre- 
duced, it  is  very  likely  to  become  gangrenous  from  strangulation,  and 
should  then  be  removed  by  the  application  of  a  ligature,  the  wound 
being  subsequently  closed. 

Empyema,  or  suppuration  within  the  pleural  cavity,  occurs  most 
frequently  as  a  sequela  of  an  acute  pneumonia,  being  perhaps  pre- 
ceded by  a  simple  pleurisy,  but  is  also  an  occasional  result  of  trau- 


922  A  MANUAL  OF  SURGERY 

matism.  It  is  not  unfrequently  associated  with  tuberculous  disease 
of  the  lung.  1  he  whole  pleural  cavity  may  be  involv'cd,  or  it  may  be 
limited  to  a  portion  of  it.  Thus,  a  basal  empyema  is  not  an  uncom- 
mon result  of  intra-abdominal  suppuration,  whilst  inter-lobular 
collections  of  pus  also  occur,  and  cause  sometimes  much  difficulty  in 
diagnosis.  Bacteriological  research  has  demonstrated  that  in 
children  more  than  half  of  the  cases  are  due  to  the  pneumococcus, 
either  alone  or  less  often  in  conjunction  with  streptococci,  whilst  in 
adults  the  streptococcus  is  the  commonest  organism.  A  description 
of  the  physical  signs  and  symptoms  belongs  rather  to  the  physician 
than  to  the  surgeon.  It  will  suffice  to  mention  here  that  in  a  total 
empyema  the  affected  side  of  the  chest  does  not  move  on  respiration, 
whilst  the  intercostal  spaces  may  bulge;  on  percussion  the  side  is 
dull,  except  perhaps  immediately  below  the  clavicle,  where  tym- 
panitic resonance  (Skodaic)  may  be  elicited.  On  auscultation  breath- 
sounds  are  absent,  except  in  the  vertebral  groove,  where  bronchial 
breathing  may  be  heard.  The  loss  of  vocal  fremitus  is  also  an 
important  sign.  A  certain  amount  of  fever  and  d3'spnoea  is  usually 
present  in  cases  of  empyema;  leucocytosis  is  well  marked,  and  the 
heart  and  other  viscera  may  be  displaced.  Left  to  itself,  an  empyema 
slowly  finds  its  way  to  the  surface,  and  perhaps  miost  commonly 
bursts  through  the  fifth  or  sixth  costal  interspace  in  front,  though 
sometimes  through  the  second,  owing  to  the  perforating  vessels 
being  larger  here  than  elsewhere.  An  extrathoracic  abscess  of  some 
size  may  develop,  and  the  opening  in  the  skin  may  not  correspond 
to  that  in  the  chest  wall.  A  localized  empyema  gives  rise  to  similar 
effects,  but  on  a  smaller  scale.  When  situated  on  the  left  side  in 
close  proximitj'  to  the  pericardium,  the  movements  of  the  heart  may 
be  transmitted  through  the  fluid  to  the  surface,  causing  a  pulsation 
which  can  be  seen  or  felt  {pulsating  empyema) . 

In  the  early  stages  the  pleura  is  but  little  altered  in  structure, 
although  a  certain  amount  of  lymph  may  be  deposited  on  it;  in  old- 
standing  chronic  cases  it  becomes  very  dense  and  firm,  owing  to  a 
development  of  fibro-cicatricial  tissue,  whilst  the  surface  is  converted 
into  a  layer  of  granulation  tissue,  similar  to  that  found  in  all  chronic 
abscesses.  The  lung  collapses  and  retreats  backwards  towards  the 
spine;  at  first  its  alveolar  texture  remains  unaltered,  and  the  early 
removal  of  the  exudation  enables  it  to  re-expand,  as  a  result  of  the 
atmospheric  pressure.  In  chronic  cases,  however,  there  are  two 
hindrances  to  this  expansion,  viz.,  the  density  of  the  thickened 
visceral  pleura,  which  resists  the  atmospheric  pressure,  and  the 
infiltration  and  sclerosis  of  the  lung  tissue  itself.  Under  these 
circumstances,  even  when  the  exudation  is  entirely  removed,  the 
lung  may  remain  collapsed,  and  Nature  then  attempts  in  several 
ways  to  remedy  the  mischief  and  obliterate  the  pleural  cavity; 
{a)  Ihe  opposite  lung  undergoes  expansion  and  hypertrophy,  and 
together  with  the  heart  projects  over  to  the  opposite  side;  {b)  the 
abdominal  viscera  and  diaphragm  are  displaced  upwards;  (c)  the 
chest  wall  falls  in,  and  the  spine  becomes  laterally  curved,  with  its 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS.  AND  CHEST    923 

convexity  to  the  sound  side ;  and  {d)  there  is  an  exuberant  growth  of 
granulation  tissue  from  the  surface  of  the  pleura.  In  a  certain  pro- 
portion of  cases  these  structural  changes  suffice  to  determine  a  cure, 
but  in  others  a  cavity  still  remains,  lined  with  thickened  pyogenic 
membrane,  and  discharging  pus  or  serum,  according  to  whether 
or  not  a  mixed  infection  is  present.  Under  these  circumstance? 
extensive  operative  interference  is  necessary. 

The  Diagnosis  of  empyema  is  readily  made  b)'  attention  to  the 
ph3'sical  signs,  and  confirmation  of  such  an  opinion  can  be  obtained 
by  puncture  with  a  sterilized  exploring  syringe.  A  medium-sized 
needle  should  always  be  employed  for  this  purpose,  and  it  is  well 
to  insert  it  along  the  top  of  a  rib  after  drawing  the  skin  up  or  down, 
so  that  on  removal  a  valvular  puncture  results.  The  character 
of  the  organisms  contained  in  the  sample  of  pus  thus  withdrawal 
should,  if  possible,  be  ascertained,  since  it  has  been  proved  that  the 
Prognosis  depends  much  on  this  point.  Thus,  an  empyema  due  to 
the  presence  of  pneumococci,  presumably  following  a  pneumonia, 
usually  runs  a  mild  course,  and  is  sometimes  cured  by  aspiration 
alone;  one  due  to  the  ordinary  pyogenic  cocci  is  more  acute,  and 
requires  drainage  with  or  without  resection  of  a  piece  of  rib.  The 
presence  of  tubercle  bacilli  renders  the  outlook  much  more  serious, 
whilst  the  addition  of  a  mixed  infection  to  any  of  the  above  aggra- 
vates the  process  and  much  impedes  a  cure.  The  chronicity  or  not 
of  the  affection  is  also  a  most  important  element,  since  the  later  the 
treatment  commences,  the  denser  are  the  adhesions  which  bind  down 
the  lung,  and  the  less  the  chance  of  its  re-expansion.  The  character 
of  the  pus  varies  with  the  organisms  present ;  with  pneumococci,  the 
pus  is  usually  yellow,  creamy,  and  laudable,  whilst  there  is  c  ft  en  an 
abundant  production  of  fibrinous  false-membranes ;  when  of  strepto- 
coccal origin,  the  pus  is  generally  thin  and  oily. 

Treatment  therefore  should  never  be  delayed;  the  earlier  it  is 
undertaken,  the  better  the  results. 

Aspiration  may  be  adopted  in  the  first  instance,  but  is  rather 
to  be  regarded  as  of  an  exploratory  nature,  though  a  cure  will 
occasionally  follow  when  the  empyema  is  of  pneumonic  origin.  It  is, 
however,  sometimes  of  value  in  very  extensive  effusions  with  dis- 
placement of  the  heart,  so  as  to  allow  the  latter  organ  more  gradu- 
ally to  return  to  its  proper  position;  by  this  means,  too,  it  becomes 
possible  to  administer  a  general  anesthetic  for  the  more  serious 
subsequent  operation.  In  double  empyema  (usually  seen  in 
children)  aspiration  also  is  desirable  as  a  preliminary  measure  so  as 
to  relieve  the  urgent  symptoms.  Both  sides  are  aspirated  in  the 
first  instance,  and  then  one  side  is  opened  and  drained  first,  and  after 
a  few  days  the  other  is  similarly  treated. 

Drainage  of  the  pleural  cavity  through  an  external  incision  is  the 
treatment  almost  invariably  necessary,  and  as  a  matter  of  mechanical 
convenience  it  is  usually  ad\isable  to  resect  a  portion  of  a  rib  in 
order  that  the  drainage-tube  may  not  suffer  compression ;  especially 
is  this  the  case  in  children.     The  best  site  for  opening  a  complete 


924  A   MANUAL  OF  SURGERY 

empyema  has  been  much  discussed,  and  it  is  probable  that  subse- 
quent drainage  is  facihtated  by  making  the  opening  well  back — e.g., 
in  the  ninth  space  just  external  to  the  scapular  line.  Possibly  in 
children  with  a  pneumococcal  empyema,  which  is  not  likely  to  need 
lengthy  drainage,  a  more  convenient  site  may  be  selected  in  the  fifth 
or  sixth  interspace,  just  behind  the  mid-axillary  line;  apart  from 
these  cases,  an  opening  here  is  usually  ineffective,  and  will  require  a 
subsequent  counter-opening  further  back.  An  incision  is  made  along 
the  course  of  a  rib  about  i|  inches  in  length,  and  the  periosteum 
stripped  up  from  both  the  superficial  and  deep  aspects  of  the  bone,  so 
as  to  enable  a  cur\-ed  raspatory  to  be  passed  beneath  it ;  at  least  i  inch 
of  the  rib  is  then  cut  aw-ay  with  bone  pliers.  Ihe  parietal  pleura  is 
opened  sufficiently  to  enable  the  finger  to  be  introduced  and  the 
cavity  explored,  as  also  to  allow  of  the  removal  of  flaky  masses  of 
fibrin.  A  large  drainage-tube  is  inserted,  just  long  enough  to  enter 
the  pleural  cavity,  but  not  to  project  into  it;  the  tube  is  carefully 
stitched  in,  and  the  wound  immediately  covered,  so  as  to  prevent  as 
far  as  possible  the  entrance  of  unfiltered  air.  Care  must  be  taken 
both  at  the  operation  and  at  the  subsequent  dressings,  to  prevent  the 
tube  being  sucked  into  the  thorax,  a  well-known  but  easily  prevent- 
able accident. 

Irrigation  of  the  chest  is  unnecessary  and  occasionally  dangerous ; 
several  cases  of  sudden  death  have  followed  this  practice,  probably 
due  to  reflex  irritation  of  the  vagus.  In  chronic  cases,  however, 
where  a  mixed  infection  is  present,  irrigation  is  often  beneficial,  but 
the  following  points  must  be  attended  to:  (i.)  The  fluid  employed 
must  be  sterile  and  unirritating ;  (ii.)  it  must  be  at  the  temperature 
of  the  body,  neithei  too  hot  nor  too  cold ;  (iii.)  it  must  not  be  injected 
with  such  force  as  to  impinge  against  the  pleura  or  against  the  upper 
surface  of  the  diaphragm;  and  (iv.)  free  exit  must  be  given  to  it, so 
as  to  prevent  tension  from  accumulation  within  the  pleural  cavity. 

If  such  treatment  is  undertaken  early,  the  lung  may  be  expected 
to  expand  quickly,  the  discharge  steadily  diminishing,  and  the 
wound  healing  without  delay;  but  this  does  not  always  occur,  and 
then  a  fistula  persists,  leading  into  a  cavity  lined  with  a  thick 
pyogenic  membrane,  discharging  a  variable  amount  of  pus.  The 
best  means  of  obtaining  a  cure  in  these  cases  consists  in  removal  of 
the  rigid  external  wall,  as  by  Estlander's  operation,  which  is  character- 
ized by  the  excision  of  portions  of  ribs  comprising  the  outer  wall  of 
the  cavity.  It  is  usually  carried  out  through  a  vertical  incision  in  the 
axillary  line,  the  ribs  being  freed  from  their  periosteal  connections ; 
the  amount  excised  necessarily  varies  according  to  circumstances, 
and  is  in  some  cases  very  extensive.  The  fistulous  track  is  enlarged, 
and  the  interior  of  the  pleura  carefully  curetted  and  washed  out,  so 
as  to  remove  all  necrotic  and  degenerating  tissue;  the  parietes  are 
then  allowed  to  fall  back  into  contact,  if  possible,  with  the  deeper 
layer,  a  drainage-tube  is  inserted,  and  the  side  firmly  bandaged. 
A  modification  of  this  proceeding  is  known  as  Schede's  operation, 
in  which  not  only  are  the  ribs  removed,  but  also  tlie  intervening 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS,  AND  CHEST     925 

tissues,  SO  that  the  subcutaneous  or  muscular  structures  in  the  flaps 
are  laid  down  upon  the  prepared  surface  of  the  deeper  layer  of  the 
pleura. 

Necessarily,  either  of  these  methods  of  treatment  is  associated 
with  considerable  deformity,  and  also  with  a  terrible  weakening  of 
the  side,  and  plans  have  been  suggested  to  obviate  this  by  removing 
portions  of  a  number  of  ribs  before  and  behind,  so  as  to  leave  the 
intervening  segment  free  to  collapse,  without  totally  destroying  the 
osseous  thoracic  boundary.  Another  proceeding  that  has  been 
recently  practised  with  occasional  success  is  the  stripping  of  the 
thickened  pleura  away  from  the  collapsed  lung,  so  as  to  enable  it  to 
expand  once  more  (pulmonary  decortication).  Obviously  such  a 
procedure  could  only  be  of  value  when  the  compression  of  the  lung 
has  not  been  followed  by  sclerosis ;  whilst  infection  of  the  pulmonary 
tissue  has  resulted  in  grave  inflammatory  disturbance  and  even 
death.  It  is  more  than  doubtful  whether  this  proceeding  is  ever 
justifiable. 

Considerable  assistance  in  gaining  re-expansion  of  a  collapsed 
lung  may  be  obtained  by  making  the  patient  undertake  forced  ex- 
piratory efforts  against  resistance — e.g.,  by  learning  to  play  some 
wind  instrument. 

Intrathoracic  Surgery  has  been  much  hindered  in  its  progress  owing 
to  the  frequent  development  of  pneumothorax,  which  fohows  open- 
ing the  pleural  cavity.  The  teaching  of  physiologists  would  lead  us 
to  anticipate  this  catastrophe  in  every  case  of  pleural  puncture ;  that 
it  does  not  occur  so  frequently  is  due  to  the  power  of  cohesion  of  the 
two  moist  smooth  surfaces  of  the  parietal  and  pulmonary  pleura; 
over  this  atmospheric  pressure  has  Httle  effect.  In  spite  of  this  a 
large  opening  into  the  pleural  cavity,  especially  if  conjoined  with 
digital  exploration  of  the  lung,  will  almost  certainly  result  in  a 
pneumothorax  which  may  injuriously  or  even  fatally  affect  the 
patient.  To  avoid  this  catastrophe,  all  that  is  needed  is  to  arrange 
that  the  intra-alveolar  pressure  shall  be  slightly  greater  than  the 
intra-pleural  pressure  when  the  chest  is  open,  and  this  desideratum 
may  be  obtained  in  one  of  two  ways : 

1.  By  mea.nsoiSmierbruch's  Chamber.  This  is  an  air-tight  cabinet 
in  which  the  surgeon  and  his  assistant  are  placed  for  the  operation 
together  with  the  patient's  trunk ;  the  patient's  head  projects  through 
an  air-tight  window,  the  neck  being  surrounded  by  an  india-rubber 
collar.  The  chamber  is  suitably  lighted,  and  ah  requirements  for  the 
operation  are  previously  placed  in  it.  The  doors  and  windows  are 
carefully  closed,  and  by  a  suitable  suction-pump  the  air  pressure  in 
the  chamber  is  reduced  to  such  an  extent  as  not  to  trouble  the 
operators,  and  yet  to  exercise  a  negative  pressure  on  the  exposed 
pulmonary  tissue,  and  thereby  to  prevent  its  collapse. 

2.  By  raising  the  pressure  in  the  pulmonary  alveoli  by  intra- 
tracheal insufflation  (p.  1350) .  This  is  easily  and  readily  accomplished 
by  any  of  the  modern  contrivances  for  the  administration  of  ether 
vapour  by  this  route— e.g.,  the  Elsberg  apparatus;  the  increase  of 


926  A   MANUAL  OF  SURGERY 

pressure  required  does  not  exceed  that  represented  by  lo  or  12  milli- 
metres of  mercury.  This  latter  method  is  far  the  simpler,  and  seems 
to  be  equally  effective. 

Pneumotomy,  or  incision  of  the  lung,  has  been  undertaken  for  not 
a  few  pulmonary  lesions,  and  the  results  obtained  have  been  rather 
variable,  i.  For  tuberculous  cavities  it  is  of  little  use.  They  are 
usually  situated  at  the  apex  of  the  lung  and  drain  well ;  the  original 
disease  is  not  removed;  and  the  general  health  is  frequently  so 
impaired  that  the  shock  of  the  operation  hastens  the  inevitably  fatal 
issue.  Hence  it  is  only  required  for  a  cavity  located  in  the  lower  half 
of  the  lung,  which  drains  badly,  and  the  difficulty  of  diagnosing  such 
a  condition  is  considerable.  2.  For  bronchiectases  pneumotomy, 
though  prima  facie  desirable,  has  given  but  httle  benefit,  since  it 
is  uncommon  for  only  one  dilatation  of  the  bronchus  to  exist.  In 
suitable  cases,  however,  where  there  is  a  good  deal  of  fcetid  secre- 
tion, which  is  with  difficulty  expelled,  it  may  be  useful.  3.  Gangrene 
of  the  lung  and  pulmonary  abscess  usually  follows  acute  septic 
pneumonia  in  debilitated  individuals.  The  expectoration  is  abun- 
dant and  extremely  offensive.  The  localization  is  made  partly 
with  the  stethoscope,  but  mainly  with  the  exploring  needle.  The 
gangrenous  area  is  often  near  the  base  of  the  lung.  Operation  is 
frequently  successful.  Of  course,  the  pulmonary  abscesses  of 
pyaemia,  being  multiple,  are  not  suited  to  operative  treatment. 
4.  In  hydatid  disease  of  the  lung,  incision  and  drainage  have  so 
considerably  reduced  the  mortality  that  this  method  of  treatment 
should  alone  be  adopted. 

As  to  the  technique  of  the  operation,  the  first  thing  is  to  locate  the 
mischief,  and  this  is  effected  partly  by  a  careful  attention  to  the 
physical  signs,  partly  by  the  use  of  an  exploring  needle  or  syringe. 
An  incision  is  then  made,  and  a  portion  of  one  or  more  ribs  removed. 
If  the  lung  is  adherent  to  the  thoracic  walls,  and  shows  no  sign  of 
retracting,  the  operation  may  be  continued;  but  if  no  adhesions  are 
present,  and  positive  intratracheal  pressure  is  not  inavailable,  it  may 
be  well  to  pack  the  wound  with  gauze  for  a  day  or  two,  so  as  to 
determine  their  formation  and  thus  shut  off  the  pleural  cavity.  It 
may,  however,  be  possible  to  stitch  the  pulmonary  to  the  parietal 
pleura,  and  thus  prevent  collapse.  The  lung  itself  may  be  punctured 
with  sinus  forceps  introduced  along  an  exploring  needle,  and  then 
opened,  or  may  be  incised  with  a  cautery.  The  abscess  or  other 
cavity  is  thus  emptied  of  its  secretion,  and  a  drainage-tube  inserted. 
As  a  general  rule  it  is  unwise  to  scrape  or  irrigate  it,  for  fear  of  a 
communication  existing  with  any  of  the  larger  bronchi. 

Pneumectomy,  or  excision  of  a  portion  of  the  lung,  has  been 
attempted  in  a  few  cases  of  tuberculous  disease  limited  to  the  apex; 
the  operation  is,  however,  quite  unjustifiable,  since,  if  the  affection 
is  localized  to  the  apex,  it  can  often  be  cured  by  hygienic  measures, 
whilst  if  it  is  more  diffuse  it  cannot  be  extirpated.  Primary  malig- 
nant tumours  of  the  lung,  moreover,  are  usually  central,  and  the 
diagnosis  can  rarely  be  made  early  enough  to  warrant  an  attempt  at 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS.  AND  CHEST     927 

removal.  The  only  conditions  under  which  it  is  justifiable  to  excise 
portions  of  lungs  are:  (a)  when  a  hernial  protrusion  has  become 
strangled  through  a  small  opening,  and  cannot  be  reduced;  and 
(b)  when  malignant  disease  of  a  rib  has  invaded  the  superficial 
portion.  In  the  former  case,  the  base  of  the  protrusion  is  transfixed 
and  ligatured  prior  to  being  cut  away;  in  the  latter  the  disease  is 
snipped  away  with  scissors,  and  bleeding  stayed  by  cautery,  ligature, 
or  plugging. 

The  creation  of  an  Artificial  Pneumothorax  has  occasionally  been 
employed  in  the  treatment  of  phthisis.  Mitrogen  is  employed  for 
the  purpose,  and  must  be  washed  and  filtered  before  admission  to 
the  pleural  sac.  It  is  doubtful  whether  the  procedure  has  any  real 
therapeutic  value. 

Wounds  o£  the  Heart. 

Wounds  of  the  Heart  and  great  vessels  are  so  generally  fatal,  either 
immediately  or  within  a  few  hours,  that  it  is  unnecessary  to  discuss 
them  in  any  great  detail.  They  may  be  divided  into  two  classes,  the 
non-penetrating  and  the  penetrating.  The  former  are  due  to  crushes 
of  the  chest  wall,  and  fragments  of  the  overlying  bones  may  be 
driven  into  the  heart  substance;  it  is  unusual  for  any  surgical  treat- 
ment to  be  practicable  in  such  cases.  Penetrating  wounds  (90  per 
cent,  of  the  whole)  have  of  late  years  been  brought  within  the  range 
of  surgical  art,  and  a  number  of  successful  cases  of  cardiac  suture 
have  been  reported.  The  right  ventricle  is  most  often  injured;  the 
left  auricle  least  frequently.  Wounds  of  the  auricles  are  more 
dangerous  than  those  of  the  ventricles,  as  the  thicker  and  more 
muscular  walls  of  the  latter  may  suffice  to  check  the  bleeding.  The 
outlook  depends  largely  on  the  nature  of  the  wound,  those  due  to 
small  penetrating  bodies,  such  as  stilettos,  etc.,  being  the  most 
favourable.  The  patient  may  die  from  immediate  cessation  of  the 
heart's  action;  or  from  intra-pericardial  pressure  of  blood;  or  from 
haemorrhage,  internal  or  external,  according  to  whether  or  not  the 
blood  can  escape.  If  the  patient  does  not  die  at  once,  he  suffers 
from  intense  shock  and  prostration,  combined  with  a  weak  and  turbu- 
lent action  of  the  heart,  great  pain  in  the  chest,  and  dyspnoea,  whilst 
the  pulse  is  scarcely  to  be  felt.  Purulent  pericarditis  is  likely  to 
ensue.  Treatment. — The  patient  must  be  kept  absolutely  quiet  and 
with  the  head  low  until  it  is  decided  whether  or  not  operative  inter- 
ference is  justifiable.  If  the  case  is  to  be  left,  the  external  wound  is 
purified,  but  no  attempt  made  to  explore  it  with  finger  or  probe  for 
fear  of  dislodging  clots.  If  operation  is  attempted,  an  anaesthetic  is 
carefully  administered  so  as  to  avoid  struggling,  and  a  suitable 
incision  made  in  the  chest  wall ;  possibly  the  best  plan  is  to  turn  up  a 
trap-door  flap  consisting  of  parts  of  the  fourth  and  fifth  ribs  or  their 
cartilages.  The  pericardium  is  freely  opened,  and  the  cardiac  wound 
gently  explored.  It  has  been  found  possible  to  stay  a  sudden  gush 
of  blood  by  introducing  one  or  more  fingers  into  the  ventricle.  Deep 
sutures  are  then  inserted  through  the  muscular  substance,  for  choice 


928  A    MANUAL  OF  SURGERY 

during  the  diastole,  and  tied ;  branches  of  the  coronary  artery  may 
require  ligature.  It  must  not  be  forgotten  that  cases  have  been 
reported  in  \vhicli  a  wound  of  the  heart  has  healed  spontaneously, 
and  the  patient  sur\i\  cd  for  years. 

Effusion  into  the  Pericardium,  whether  serous  or  purulent,  may 
require  surgical  treatment  in  order  to  relieve  symptoms  of  cardiac 
failure,  due  to  the  pressure  of  the  exudate.  The  sac  when  distended 
pushes  aside  the  pleurae  and  lungs,  and  also  is  enlarged  upwards, 
carrying  up  the  base  of  the  heart  and  rotating  the  apex  forwards  to  a 
slight  degree.  The  bare  interpleural  area  of  the  pericardium  is 
therefore  increased,  and  the  cavity  may  be  tapped  by  trocar  and 
cannula,  or  by  aspirator  either  close  to  the  left  border  of  the  sternum 
in  the  fifth  interspace,  or  i|  inches  from  the  left  margin  of  that  bone 
through  the  fourth  or  fifth  interspace,  so  as  to  avoid  the  internal 
mammary  trunk,  which  courses  down  about  half  an  inch  from  the 
border.  It  may  also  be  reached  with  safety  from  the  right  side  of 
the  sternum  in  certain  cases. 

For  suppurative  pericarditis  incision  and  drainage  are  necessary. 
This  may  be  readily  accomplished  by  removing  the  fourth  or  fifth 
costal  cartilage,  thereby  exposing  the  pericardium,  which  is  opened, 
washed  out,  and  a  drainage-tube  inserted.  Care  must  be  taken  to 
prevent  infection  of  the  mediastinal  tissues,  and  this  can  sometimes 
be  accomplished  by  stitching  the  pericardium  to  the  parietes  before 
opening  it.  Possibly  better  drainage  is  provided  by  operating 
through  the  costo-sternal  angle  (Allingham).  An  incision  is  made 
through  the  left  rectus  abdominis,  reaching  up  between  the  xiphoid 
and  the  seventh  costal  cartilages,  the  latter  being,  if  necessary, 
removed.  The  peritoneum  is  depressed;  the  interval  between  the 
sternal  and  costal  attachments  of  the  diaphragm  is  opened  up ;  and 
the  lowest  part  of  the  pericardium  is  thereby  exposed,  and  can  be 
easily  drained,      i  he  patient  is  propped  up  in  bed. 

Cardiolysis  is  an  operation  for  the  removal  of  a  portion  of  the 
chest  wall,  tying  in  front  of  the  heart,  with  the  object  of  replacing 
the  comparatively  unyielding  thoracic  wall  by  a  soft,  pliable  cover- 
ing. It  has  been  performed  in  cases  of  adherent  mediastino-peri- 
carditis  to  relieve  the  fixation  of  the  heart  to  the  chest  wall,  with  its 
consequent  mechanical  disadvantage;  and  also  for  cases  of  valvular 
disease  with  great  hypertrophy. 

The  parts  usually  removed  have  been  the  third,  fourth,  and  fifth 
left  costal  cartilages,  wath  or  without  a  piece  of  the  sternum,  and  the 
ends  of  the  corresponding  ribs.  It  is  desirable  to  remove  the  peri- 
chondrium, but  in  cases  of  adhesive  inflammation  this  may  be  almost 
impossible  without  wounding  the  underlying  structures. 


Asphyxia. 

Asphyxia,  or  Apnoea,  is  the  term  applied  to  indicate  the  condition  arising 
from  interference  with  or  stoppage  of  the  respiratory  act.  If  this  has  not 
proceeded  to  any  great  extent  it  is  termed  Dyspnoea  ;  when,  however,  the 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS.  AND  CHEST    929 

obstruction  is  so  marked  that  the  patient  is  obliged  to  maintain  the  upright 
sitting  position,  the  term  Orthopnoea  is  applied  to  it. 

The  Causes  of  asphyxia  may  be  classified  as  follows: 

I.  Conditions  arising  frona  the  presence  of  abnormal  contents  withm  the 
air-passages — e.g.,  foreign  bodies;  blood-clot  or  pus  from  the  bursting  of  an 
aneurism  or  abscess;  serum,  as  in  oedema  of  the  lung;  mucus  or  muco-pus,  as 
in  bronchitis;  the  consolidated  exudation  in  pneumonia;  diphtheritic  mem- 
brane; or  irrespirable  gases— e.^.,  nitrogen,  hydrogen,  carbonic  acid  gas,  etc., 
as  in  suffocation.  Death  by  drowning  usually  arises  from  a  similar  cause, 
viz.   the  replacement  of  air  by  water  in  the  respiratoiy  passages. 

2.'  Causes  arising  in  the  walls  of  the  air-passages,  such  as  diminution  of  their 
lumen  from  inflammatory  congestion,  as  in  oedema  of  the  glottis;  cicatricial 
stenosis ;  the  presence  of  new  growths,  or  the  displacement  of  parts,  as  m  cut 
throat ;  or  the  falling  back  of  the  root  of  the  tongue  after  partial  excision  of  that 
organ .  . 

3  Extrinsic  causes,  or  those  arising  outside  the  air-passages— e.^.,  m  the 
neck  :  strangling,  hanging,  garrotting,  etc.;  the  presence  of  tumours,  such  as 
goitres  or  aneurisms;  a  retropharyngeal  abscess  or  tumour;  and,  under  ex- 
ceptional circumstances,  displacement  backwards  of  the  sternal  end  of  the 
clavicle.  Within  the  thorax  gradually  increasing  obstruction  to  the  respira- 
tion may  be  caused  by  the  presence  of  tumours,  aneurisms,  or  effusion  into 
the  pericardium  or  pleura. 

4.  Nervous  causes— e.g-.,  paralysis  or  spasm  of  the  larynx,  and  paralysis  of 
the  diaphragm,  either  from  peripheral  lesions,  such  as  the  pressure  of  aneurisms, 
or  tumours  on  the  nerve  trunks,  or  from  central  causes,  such  as  a  lesion  m  the 
upper  part  of  the  spinal  cord  or  medulla.  It  may  also  arise  from  paralysis  of 
the  respiratory  centre,  as  from  an  overdose  of  chloroform. 

5.  In  many  forms  of  cardiac  disease  the  lungs  may  become  engorged  with 
stagnant  blood,  leading  gradually  to  dyspnoea,  orthopnoea,  and  finally  asphyxia, 
owing  to  the  increasing  difficulty  in  eliminating  the  excessive  accumulation  of 
carbonic  acid. 

The  Treatment  of  the  different  conditions  giving  rise  to  asphyxia  cannot 
here  be  dealt  with  in  extenso,  but  merely  the  general  plan  of  treatment  in- 
dicated. A  rapid  examination  is  at  once  made,  to  ascertain,  if  possible,  the 
cause  of  the  mischief,  and  whether  its  onset  has  been  gradual  or  sudden.  If 
it  has  been  graduallv  developing,  it  is  not  uncommonly  due  to  some  thoracic 
condition  which  cannot  be  relieved;  if,  however,  its  onset  has  been  sudden, 
and  not  the  result  of  anv  evident  lesion,  the  neck  and  chest  should  be  bared, 
and  examined  for  signs  of  traumatism,  the  mouth  opened,  the  tongue  drawn 
forwards,  and  the  glottis  examined  with  the  finger  to  see  that  the  passages 
are  clear.  The  patient  should,  if  necessary,  be  removed  into  fresh  air,  and 
artificial  respiration  at  once  commenced.  Breathing  can  sometimes  be  excited 
by  alternately  dashing  hot  and  cold  water  over  the  thorax,  whilst  electric 
stimulation  of  the  phrenic  nerve  may  also  be  undertaken,  one  electiode  being 
placed  over  the  neck  and  the  other  on  the  epigastrium.  The  administration 
of  oxygen  instead  of  air  is  useful  during  the  earlier  stages,  whilst  if  the  con- 
dition is  due  to  cardiac  disease  with  distension  of  the  right  side  of  the  heart, 
venesection  holds  out  the  best  hope  of  rehef.  Obstruction  withm  the  larynx 
needs  tracheotomy  or  intubation,  as  also  other  conditions  associated  with 
pressure  on  the  trachea. 

Artificial  Respiration  is  required  in  a  variety  of  surgical  conditions,  and  can 
be  undertaken  by  what  is  known  as  Sylvester's  method.  In  this  the  patient 
lies  on  his  back,  with  a  pillow  beneath  the  shoulders,  the  mouth  opened,  and 
the  tongue  drawn  forwards.  The  arms  are  then  grasped  just  above  the  elbows 
and  drawn  upwards  above  the  patient's  head,  so  as  to  expand  the  chest 
through  the  action  of  the  great  pectoral  muscles.  This  position  is  maintained 
for  about  two  seconds,  and  then  the  arms  are  lowered  to  the  side,  and  pressed 
firmly  against  the  ribs,  so  as  to  determine  a  forcible  expiratory  act.  At  the 
end  of  about  two  seconds  more  the  arms  are  again  elevated,  and  the  same  cycle 
passed  through  This  should  be  repeated  about  fifteen  times  a  minute,  and 
the  operator  must  be  careful  not  to  use  too  great  violence,  or  to  hurry  over  it 
unnecessarilv,  as  harm  rather  than  good  thereby  results. 

59 


930  A   MANUAL  OF  SURGERY 

Another  less  satisfactory  method  consists  in  alternately  compressing  the 
lower  part  of  the  thorax  and  abdomen  with  the  hands,  so  as  to  drive  out  a 
certain  amount  of  air,  and  then  by  suddenly  relieving  the  pressure  the  elastic 
expansion  of  the  chest  walls  draws  in  a  fresh  su])i)ly. 

In  the  Treatment  of  the  Apparently  Drowned  the  air-passages  must 
be  cleared  as  quickly  as  possible.  During  the  struggles  of  the 
drowning  man  water  enters  the  trachea  and  is  churned  up  with 
mucus,  saliva,  and  perhaps  blood  into  a  froth  which  does  not  easily 
escape,  but  must  be  slowly  squeezed  out  by  the  application  of 
pressure  to  the  back,  whilst  the  patient  is  lying  face  down.  At  the 
same  time  artificial  respiration  must  be  maintained,  and  it  is  obvious 
that  Sylvester's  method  is  not  an  ideal  plan  under  these  circum- 
stances. The  late  Dr.  R.  L.  Bowles  elaborated  a  procedure  for  these 
cases  which  admirably  suits  their  requirements,  and  we  have  much 


Fig.  441. — Treatment  of  the  Apparently  Drowned — •Movement  No.  i 

pleasure  in  quoting  his  instructions  verbatim,  and  introducing  the 
illustrations  which  he  kindly  placed  at  our  disposal: 

'  Treat  the  patient  at  once  and  on  the  spot.  Undo  any  tight 
clothing.  Kneel  and  place  the  patient  on  the  right  side  and  quickly 
wipe  out  the  mouth  and  throat. 

'  If  there  are  no  signs  of  breathing,  spread  a  handkerchief  on  the 
ground  where  the  patient's  mouth  will  come,  and  carry  out 

'  Movement  No.  i.— Turn  the  patient  flat  on  the  stomach,  and  at 
once  with  widespread  hands  press  gently  but  firmly  for  three  or 
four  seconds  on  the  back  of  the  ribs  on  both  sides  to  squeeze  out  the 
froth,  fluid,  or  foul  air  (Fig.  441).  Then  suddenly  remove  the  hands 
to  allow  the  entrance  of  air  by  the  natural  recoil  of  the  ribs,  and  pro- 
ceed to 

'  Movement  No.  2. — With  the  right  hand  grasp  the  patient's  left 
shoulder;  with  the  left  hand  take  his  left  wrist,  place  it  against  his 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS.  AND  CHEST     931 

hip,  and  roll  him  towards  you  on  to  his  right  side  (Fig.  442).     This 
movement  should  take  about  two  seconds 
'  Repeat  first  and  second  movements  in  succession  for  ten  mmutes 


Fig.  442.— Treatment  of  the  Apparently  Drowned— Movement  No.  2. 


Fig.  443. Treatment  of  the  Apparently  Drowned — Movement   No.   3. 

or  more  (if  necessary),  when  some  of  the  froth  or  fluid  will  have 
drained  away  from  the  lungs,  and  then  proceed  to 

'  Movement  No.  3.— Each  time  the  patient  is  rolled  from  the 


932  A   MANUAL  OF  SURGERY 

stomach  on  to  the  right  side,  take  hold  of  the  left  or  uppermost  arm 
and  raise  it  above  the  head  in  a  line  with  the  body.  This  movement 
expands  the  chest  still  more  and  allows  air  to  enter  the  upper  left 
lung  (Fig.  443)-  Then  bring  the  arm  down  to  the  side,  roil  the 
patient  on  to  the  stomach,  and  begin  again  at  movement  No.  i,  and 
continue  each  movement  in  succession  as  before,  for  an  hour  or  until 
signs  of  natural  breathing  begin. 

'  Always  turn  the  patient  on  to  the  right  side,  never  on  the  left, 
and  under  no  circumstances  on  the  back.  From  time  to  time  wipe 
away  froth  from  the  mouth  and  nose. 

'  The  neck  should  be  kept  fairly  straight  and  the  chin  away  from 
the  breast-bone ;  the  head  may  then  be  left  to  take  care  of  itself,  and 
the  face  will  take  no  harm,  as  it  will  remain  chiefly  on  its  side,  and 
yet  perfect  drainage  will  be  ensured.' 


CHAPTER  XXXIV. 


DISEASES  OF  THE  BREAST. 

Congenital  Malformations  of  the  breast  are  much  more  common  than 
is  generally  supposed.  One  or  more  accessor}'  breasts  {polymastia)  or 
nipples  are  found  either  below 
the  normal  one  or  just  above 
it ;  sometimes  they  have  been 
found  in  the  axilla,  on  the 
outer  side  of  the  thigh,  or 
other  unusual  situations. 
They  are  often  of  a  most  rudi- 
mentary nature,  but  in  a  few- 
cases  have  secreted  milk. 
Very  rarely  the  breasts  are 
entirely  absent  [amazia).  Oc- 
casionally the  male  breast 
becomes  enlarged  to  the  or- 
dinar\'  size  of  a  \-irgin's  breast 
(gynecomastia) ;  the  organ  is 
usuallv  functionless,  since  the 
overgrowth  mainl\'  affects  the 
stroma,  although  lactation 
has  been  known  to  occur. 
The  condition  may  be  asso- 
ciated with  imperfect  or  irreg- 
ular development  of  the  sexual 
organs . 

Diffuse  Hypertrophy  of  the 
breast  (Fig.  444)  consists  of  a  p^^ 
general  enlargement  of  the 
organ,  both  gland  substance 
and  interstitial  tissue  partici- 
pating in  the  process,  and 
hence  the  breast  becomes  lirm 
and   indurated.     It    may    be 

uni-  or  bi-lateral,  perhaps  more  frequently  the  latter,  and  generally 
occurs  in  adolescents.  The  size  varies  considerably,  but  the  breasts 
mav  become  enormous,  hanging  down  by  their  weight,  and  perhaps 
to  such  an  extent  as  to  rest  on  the  knees  of  the  patient  when  sitting. 

93.S 


444- 


Diffuse   Hypertrophy    of 
THE  Breasts. 

It  occurred  in  a  girl  aged  sixteen  and  a 
half  years,  and  both  organs  had  to  be 
removed.  The  left  breast  weighed 
9^  lbs.,  the  right  breast  9  lbs. 


934 


A    MANUAL  OF  SURGERY 


They  are  usually  painless,  although  sometimes  neuralgia  is  noticed. 
Functionally  they  are  useless,  as  even  if  the  patient  becomes  preg- 
nant, secretion  of  milk  but  rarely  occurs.  No  cause  can  be  assigned 
for  the  overgrowth,  and  the  only  treatment  is  amputation,  when 
the  increased  size  is  causing  discomfort. 


Affections  of  the  Nipple. 

Fissures  of  the  Nipple  (cracked  nipples)  seldom  occur  apart  from 
lactation,  and  may  usually  be  traced  to  a  want  of  care  and  cleanliness 
on  the  part  of  the  mother,  associated  with  a  tender  condition  of  the 
skin,  which  might  have  been  prevented  by  bathing  the  parts  during 

the  later  weeks  of  preg- 
nancy with  spirit,  so  as  to 
harden  them.  The  actual 
lesion  is  brought  about  by 
leaving  the  nipples  wet 
after  nursing.  The  super- 
ficial layers  of  epithelium 
become  macerated,  and  are 
easily  rubbed  off,  thus  ex- 
posing the  more  delicate 
and  sensitive  deeper  parts, 
which  are  irritated  and  in- 
flamed by  the  repeated  acts 
of  suction.  As  a  result, 
nursing  becomes  painful, 
and  if  persisted  in,  the 
wound  may  be  infected, 
the  inflammation  spread- 
ing to  the  breast  substance 
along  the  ducts  or  lym- 
phatics, or  extending  along 
the  superficial  lymphatics 
to  the  axillary  glands. 
Treatment. —  The  best 
way  to  prevent  the  occurrence  of  cracks  is  to  bathe  the  nipples  with 
some  dilute  antiseptic,  such  as  boric  acid  lotion,  immediately  after 
nursing,  and  then  to  dry  them  thoroughly.  If  at  all  tender,  a  little 
powdered  boric  acid  and  starch  may  be  dusted  over  them  in  the 
intervals.  When  a  fissure  has  i  cmed,  it  should  be  dressed  with 
cooling  or  antiseptic  lotions — e.g.,  lotio  plumbi  or  lotio  acidi  borici. 
Sometimes  more  stimulating  applications  are  required,  such  as  a 
solution  of  sulphate  of  copper,  or  even  of  nitrate  of  silver.  It  is  also 
recommended  to  paint  the  sore  with  equal  parts  of  glycerine  and 
sulphurous  acid. 

Eczema  of  the  Nipple  may  be  of  a  simple  nature,  needing  nothing 
but  ordinary  treatment,  or  it  may  take  on  special  features,  being 
then  known  as  Paget's  Disease  {dermatitis  maligna) ,  a.  condition  really 


b'lG.  445. — Chanckk  tU'  UN':  XipVLii.  (From 
Photograph  and  Sketch  lent  by  Pro- 
fessor RusHTON  Parker,  of  Liverpool. 


DISEASES  OF  THE  BREAST  935 

due  to  a  carcinomatous  development  in  the  skin.  It  is  seen,  but 
very  rarely,  in  parts  other  than  the  breast.  It  presents  a  smooth, 
red,  raw  surface,  discharging  a  yellowish  viscid  fluid,  and  may 
occasionally  spread  widely  beyond  the  areola.  The  progress  is 
very  slow,  but  the  condition  is  almost  invariably  followed  by  a 
cancerous  tumour  in  the  breast,  which  may  resemble  either  a'  duct 
cancer  or  an  ordinary  scirrhus.  No  local  treatment  is  of'  any 
avail,  and  the  disease,  when  once  recognised_^witli  certainty,  is  best 
treated  by  removal  of  the  breast  and  axillary  glands. 

Abscess  of  the  Areola  is  not  uncommon  in  young  girls  about  the 
age  of  puberty,  arising  in  the  sebaceous  follicles,  and  requiring  no 
special  notice. 

Chancre  of  the  Nipple  (Fig.  445)  is  rarely  seen  in  the  mothers  of 
syphilitic  children  (CoUes's  law,  p.  171),  but  much  more  commonly 
in  wet-nurses.  It  usually  presents  as  a  shallow  ulcerated  surface 
with  a  well-marked,  raised,  and  indurated  border.  Not  uncom- 
monly the  condition  is  symmetrical. 

Primary  Tumours  of  the  Nipple  are  met  with,  such  as  papilloma, 
sebaceous  cysts,  and  occasionally  epithelioma. 

Inflammatory  Affections  of  the  Breast. 

Acute  Mastitis  is  most  often  observed  in  puerperal  women,  owing 
to  the  sudden  establishment  of  function  in  the  breast  after  the  birth 
of  a  child,  and  to  its  maintained  activity  during  lactation.  It 
usually  results  from  a  sore  or  cracked  nipple,  through  which 
pyogenic  organisms  find  their  way  into  the  lymphatics  or  acini  of 
the  breast  substance.  In  the  former  case  the  inflammation  is 
mainly  interstitial  in  character,  the  pus  diffusing  itself  widely 
between  the  lobules;  in  the  latter  the  pus  is  primarily  intra-alveolar. 
Simple  obstruction  to  one  or  more  of  the  ducts  from  inflammation 
of  the  nipple,  without  any  external  wound,  also  determines  an  attack 
of  mastitis,  which  is  frequently  non-suppurative  in  character.  In 
non-puerperal  women  acute  mastitis  may  result  from  injury,  or 
may  be  pysemic  in  origin.  Occasionally  a  metastatic  inflammation 
of  the  breast  occurs  after  the  disappearance  of  the  parotid  swelling 
in  mumps;  whilst  in  girls  about  the  age  of  puberty  a  subacute  in- 
flammation, involving  both  the  breast  and  areola,  and  even  ter- 
minating in  suppuration,  has  been  observed.  In  newly -born 
infants  a  similar  inflammation,  sometimes  running  on  to  suppura- 
tion, has  been  seen,  possibly  resulting  from  an  infection  of  the  gland 
ducts  during  birth  with  cocci  from  the  maternal  passages.  A  slight 
enlargement,  with  congestion  of  the  breasts,  often  occurs  after 
birth,  and  may  be  aggravated  by  the  foolish  habit  followed  by 
ignorant  midwives  of  pulling  or  forcibly  squeezing  them  in  order 
'  to  break  the  nipple-strings.' 

Signs  and  Symptoms. — x\n  inflamed  breast  is  characterized  by  the 
organ  becoming  swollen,  acutely  painful,  and  tender.  The  gland 
lobules  are  felt  to  be  enlarged  and  indurated,  whilst  if  lactation  is 


936  A   MANUAL  OF  SURGERY 

progressing,  the  secretion  is  to  some  extent  impaired ;  but  owing  to 
the  inability  of  the  mother  to  allow  the  child  to  relieve  the  organ, 
on  account  of  the  pain  produced  thereby,  considerable  tension 
results  from  accumulation  of  milk.  If  suppuration  follows,  the 
skin  over  the  breast  becomes  red  and  oedcmatous,  and,  according 
to  the  situation  of  the  pus,  three  different  forms  of  acute  abscess 
of  the  breast  are  described:  {a)  Supramammary  abscess  is  the  term 
applied  to  a  collection  of  pus  in  the  subcutaneous  tissues  or  beneath 
the  nipple;  it  is  often  unconnected  with  the  organ,  or  may  originate 
in  the  superficial  lobules.  It  does  not  burrow  deeply,  and  comes 
readily  to  the  surface,  {b)  An  intramanimary  abscess  is  the  most 
common  variety,  the  pus  developing  within^  and  distending  the 
lobules,  or  infiltrating  the  cellular  tissue  around  them ;  it  is  usually 
diffused  widely  throughout  the  organ,  and  may  point  at  several  spots . 
When  very  acute,  or  in  debilitated  women,  especially  if  it  has  been 
allowed  to  progress  without  treatment,  the  inflammatory  process 
may  actually  determine  gangrene  of  the  glandular  tissue,  (c)  A 
submammary  abscess  forms  in  the  cellular  tissue  beneath  the  breast. 
It  may  spread  from  the  deep  lobules,  but  more  frequently  results 
from  disease  of  some  of  the  adjacent  ribs  or  cartilages,  or  starts 
as  a  cellulitis.  In  these  cases  the  breast  is  pushed  forwards,  and 
becomes  prominent,  floating,  as  it  were,  on  a  bed  of  pus.  The 
abscess  usually  points  at  the  periphery  of  the  organ,  perhaps  in 
several  places,  but  most  commonly  at  the  lower  and  outer  quadrant. 

Inflammation  of  the  breast  occurs  in  women  who  are  anaemic  and 
weakly.  Even  the  simple  forms  are  associated  with  fever  and 
malaise,  and  these  become  exaggerated  if  suppuration  ensues, 
owing  partly  to  the  pain,  and  partly  to  the  absorption  of  toxins. 

The  Treatment  of  simple  acute  mastitis  consists,  in  the  first  place, 
in  supporting  the  inflamed  gland  by  means  of  a  sling  or  bandage,  and 
in  binding  the  arm  to  the  side,  so  as  to  keep  at  rest  the  pectoral 
muscle,  on  which  it  hes.  Fomentations  are  then  apphed,  and  any 
tension  due  to  retained  secretion  is  relieved  by  the  breast-pump. 
The  bowels  are  opened,  and  the  patient  placed  on  a  light  and  nourish- 
ing diet,  whilst  stimulants  and  tonics,  such  as  iron  and  quinine,  may 
be  judiciously  administered. 

As  soon  as  the  acute  stage  has  passed,  friction  with  wann  oil,  or 
the  inunction  of  a  belladonna  ointment,  is  advisable. 

When  suppuration  is  threatening,  the  breast  may  be  poulticed 
until  fluctuation  is  detected;  but  under  no  circumstances  must  the 
abscess  be  allowed  to  burst  into  the  poultice,  and  thus  become  septic. 
If  such  a  practice  is  permitted,  chronic  suppuration  ensues,  and  the 
breast  may  become  riddled  with  sinuses.  The  most  rigid  asepsis 
must  be  maintained  in  these  cases,  and  as  soon  as  pus  is  evidently 
present,  an  incision  should  be  made  to  permit  of  its  escape.  In  the 
supramammary  variety  it  matters  Httle  in  which  direction  the  cut 
is  made,  since  the  pus  is  always  superficial  to  the  breast  tissue.  In 
the  true  intramammary  abscess  the  incisions  should  radiate  from  the 
nipple.     One  or  more  may  be  needed,  and  these  should  be  made 


DISEASES  OF  THE  BREAST  937 

with  a  free  hand,  so  as  to  allow  of  the  insertion  of  the  finger,  and 
the  opening  up  of  any  pockets  or  lobules  which  are  distended  with 
matter.  A  large  drainage-tube  is  inserted  for  a  time,  and  gradually 
shortened  da}'  by  day,  until  its  entire  removal  is  permissible.  When 
the  chief  incisions  are  needed  above  the  nipple,  it  is  often  wise  to 
make  a  counter-opening  in  the  lower  half  of  the  breast,  and  generally 
on  the  outer  side,  to  permit  of  more  efhcient  drainage.  With  such 
treatment  the  best  of  results  may  be  attained,  and  it  is  interesting 
to  note  how  quickl}^  the  contour  of  the  breast  is  restored,  and  how 
slight  is  the  permanent  injury  inflicted  on  the  parts.  The  sub- 
mammary abscess  is  best  opened  towards  the  lower  and  outer  side, 
but  also  at  any  spot  where  pus  points. 

If  discharging  sinuses  persist  after  an  abscess  has  burst,  their 
orifices  should  be  enlarged,  and  their  walls  thoroughly  scraped  and 
disinfected;  deep  cavities  should  be  efficiently  drained  and  packed 
with  gauze,  so  as  to  ensure  the  wounds  healing  by  granulation ;  the 
arm  must  also  be  kept  to  the  side. 

Chronic  Mastitis  occurs  in  two  forms — one,  a  localized  affection 
of  one  segment  of  the  breast  (chronic  lobar  mastitis),  the  other 
involving  the  smaller  lobules  and  interstitial  tissue  (chronic  lobular 
or  interstitial  mastitis). 

1.  Chronic  Lobar  Mastitis  is  by  no  means  unfrequent  as  a  result  of 
imperfect  involution  of  the  organ  at  the  cessation  of  lactation,  but 
may  arise  from  blows  or  squeezes,  and  especially  in  young  women; 
it  may  also  follow  a  subacute  or  acute  attack,  which  has  not  ended 
in  suppuration.  It  is  characterized  by  an  enlargement  of  one  or 
more  lobes  of  the  organ,  which  are  usually  tender,  and  often  exces- 
sively painful,  the  pain  being  of  a  neuralgic  character,  and  increased 
during  menstruation.  The  condition  is  of  comparatively  little 
importance,  but  may  give  rise  to  a  great  deal  of  anxiety  and  worry. 
x\ll  that  is  necessary  in  the  shape  of  Treatment  is  to  support  the  part 
and  keep  the  arm  at  rest  in  a  sling,  whilst  an  ointment  containing 
belladonna,  or  a  belladonna  plaster,  may  be  applied. 

2.  Chronic  Lobular  or  Interstitial  Mastitis  is  an  affection  which 
occurs  not  unfrequently  in  women  with  small  or  atrophic  breasts, 
who  have  passed,  or  are  near  to,  the  climacteric.  It  is  also  met  with 
at  an  earlier  age  in  unmarried  women,  involving  the  whole  of  one 
or  both  breasts,  or  limited  in  its  development  to  a  portion  of  one 
breast,  and  then  being  sometimes  mistaken  for  a  mahgnant  tumour. 
Pathologically,  it  is  characterized  by  diffuse  overgrowth  of  the 
connective  tissue,  which  becomes  thickened  and  perhaps  sclerosed, 
This  is  associated  with  well-marked  epithelial  proliferation,  so 
that  sometimes  in  the  earlier  stages  the  acini  are  filled  with  a  thick 
cheesy  or  grumous  material  which  can  be  squeezed  out  in  thread- 
like masses,  often  of  a  dirty  brown  or  greenish-yellow  colour.  Cysts 
are  formed  in  the  gland  tissue,  partly  b}^  liquefaction  of  this  pro- 
liferated epithelium,  partl}^  by  exudation  into  the  acini  of  serous 
fluid,  which  is  unable  to  find  an  exit  owing  to  the  pressure  of  the 
interstitial  growth.     Such  are  known  as  '  involution  cysts,'  and  the 


938 


A   MANUAL  OF  SURGERY 


fluid  contained  therein  is  usually  clear  and  limpid;  but  may  be 
brown  and  turbid,  from  admixture  of  blood ;  intracystic  growths  are 
not  present.  As  a  rule,  many  of  these  cysts  are  scattered  widely 
through  the  breast  substance,  but  they  are  small  and  insignificant ; 
occasionally  one  or  more  of  them  become  notably  enlarged,  and 
simulate  a  tumour,  especially  when  covered  in  by  a  mass  of  thickened 
glandular  tissue. 

Clinical  History.— The  condition  often  passes  unnoticed  in  the 
early  stages,  until  a  distinct  lump  has  formed,  which  is  nodular  and 
indurated  to  the  touch,  and  often  very  painful. 
The  breast  may  be  somewhat  enlarged,  and 
there  is,  perhaps,  some  retraction  of  the  nipple, 
owing  to  contraction  of  the  interstitial  tissue; 
but  this  is  by  no  means  an  essential  feature. 
A  scanty  serous  discharge  from  the  nipple  is 
sometimes  noticed.  The  skin  seldom  becomes 
adherent  to  the  swelhng,  whilst  the  lymphatic 
glands  in  the  axilla  may  be  enlarged  and 
tender,  but  they  are  never  hard.  On  careful 
examination  of  the  breast,  the  affection  is 
rarely  found  to  be  limited  to  one  particular 
region,  for  although  a  distinct  enlargement  of 
one  portion  may  be  present,  yet  the  whole 
organ  feels  more  or  less  '  lumpy,'  and  not 
unfrequently  the  other  breast  participates  in 
the  same  change.  Small,  rounded,  elastic 
spots  can  often  be  detected,  and  indicate  the 
presence  of  cysts.  There  may  be  but  little 
pain,  although  this  is  sometimes  one  of  the 
most  marked  features  of  the  case;  it  is  of  a 
neuralgic  type,  and  usually  increased  at  the 
menstrual  periods. 

If  left  to  run  its  course,  the  disease  may 
remain  much  in  the  same  condition  for  many 
years,  and  even  in  time  disappears ;  but  more 
iNG  FROM  Chronic  frequently  it  slowly  progresses,  and  then  results 
Interstitial  Mas-  jj^  q^q  q^  three  conditions :  [a)  General  atrophy, 
the  breast  becoming  shrunken,  hard,  and 
nodular,  [b)  More  frequently  general  cystic 
disease  (Fig.  446)  follows,  a  condition  in  which 
the  organ  becomes  transformed  into  a  number 
of  cysts  held  together  by  dense  connective 
tissue,  (c)  There  is  some  question  as  to  whether  or  not  cancer  is  a 
sequela  of  this  disease;  there  is  abundant  evidence  to  prove  that  any 
continued  source  of  irritation  in  an  organ  like  the  breast  renders  an 
individual  with  a  cancerous  inheritance  more  liable  to  its  develop- 
ment, especially  if  it  commences  at  or  about  the  climacteric. 

The  Diagnosis  is  sometimes  easy,  but  the  condition  often  simulates 
somewhat  closely  a  scirrhous  tumour.     The  chief  points  of  distinc- 


FiG.  446.  —  General 
Cystic  Disease  of 
THE  Breast,  result- 


titis. 

In  this  case  both  breasts 
were  equally  affected , 
and  were  removed 
at  the  same  time. 


DISEASES  OF  THE  BREAST  939 

tion,  however,  lie  in  the  facts  (i.)  that  the  whole  breast  is  more  or 
less  involved;  (ii.)  that  the  opposite  organ  is  very  often  similarly 
affected;  (iii.)  that  enlargement  of  the  axillary'glands  is  less  common 
than  in  scirrhus,  and  even  if  enlarged  they  are  not  hard,  as  in  the 
latter  disease;  (iv.)  that  the  skin  is  usually  free  from  the  mass; 
(v.)  that  the  tumour  is  never  adherent  to  the  pectoral  fascia,  nor  is 
it  of  the  stony  hardness  of  a  scirrhus;  and  (vi.)  that  it  is  often  more 
disseminated  and  less  defined  than  a  cancerous  growth,  (vii.)  More- 
over, on  careful  palpation  with  the  fiat  of  the  hand,  it  is  often 
impossible  to  make  out  any  distinct  lump,  the  so-called  tumour 
merging  into  the  surrounding  tissues;  this  never  occurs  in  scirrhus, 
the  growth  always  being  easily  detected  with  the  flat  of  the  hand. 
Small  cysts  can  also  be  felt  as  localized  elastic  spots  in  the  inflam- 
matory mass.  Of  course  it  is  possible  for  the  two  conditions  to 
co-exist,  and  in  doubtful  cases  an  exploratory  incision,  and  micro- 
scopic examination  of  a  portion  of  the  tissue,  can  alone  be 
depended  on. 

Treatment. — In  the  early  stages,  and  especially  in  the  younger 
patients,  friction  with  some  sedative  application  containing  bella- 
donna may  be  used  at  the  same  time  that  the  breast  is  supported, 
and  freed  from  the  irritation  of  badly-fitting  stays.  Firm  and 
equable  pressure,  as  by  strapping,  is  also  useful  in  some  cases  whilst 
iodides  may  be  administered.  If  a  definite  tumour  is  present,  or 
if  many  C5^sts  can  be  detected,  and  especially  if  the  patient  is  anxious 
and  worried  about  herself,  it  is  wise  to  remove  the  affected  portion 
or  even  better  to  excise  the  whole  breast,  especially  when  there  is 
a  family  history  of  malignant  disease. 

Localized  or  Encysted  Chronic  Abscess  is  usually  associated  with 
pregnancy,  and  is  characterized  by  the  formation  of  an  indurated 
mass  in  the  breast  substance,  which  slowly  softens,  giving  rise  to  a 
sense  of  fluctuation,  although  when  the  abscess  walls  are  very  thick ., 
as  is  often  the  case,  it  maybe  exceedingly  difficult  to  detect  this. 
Retraction  of  the  nipple  is  not  uncommonly  present,  and  the  axillary 
glands  may  be  enlarged.  The  condition  has  frequently  been  mis- 
taken for  a  tumour,  but  is  recognised  from  it  by  its  incorporation 
with  the  breast  substance,  by  its  lack  of  definition,  and  by  the  fact 
that  on  careful  examination  elasticity  can  be  felt  at  its  centre,  which 
is  almost  always  less  resistant  than  the  margin,  whereas  the  opposite 
is  the  case  with  a  tumour.  In  cases  of  doubt  the  insertion  of  a 
grooved  needle  or  an  exploratory  incision  will  settle  the  diagnosis. 
Sometimes  chronic  abscesses  of  the  breast  are  of  a  tuberculous 
nature. 

Treatment  consists  in  opening  the  abscess  cavity,  scraping  out  its 
interior,  disinfecting  with  pure  carbolic  acid,  if  tuberculous,  and 
draining  or  packing  it. 

Diffuse  Tuberculous  Disease  of  the  breast  is  not  very  uncommon. 
Scattered  nodules  of  caseous  material  are  developed  in  the  inter- 
acinous  tissue,  which  break  down  into  pus,  and  come  to  the  surface 
at  various  spots.    The  breast  may  thus  become  riddled  with  sinuses 


940  A   MANUAL  OF  SURGERY 

discharging  caseous  pus.  It  may  be  associated  with  tuberculous 
disease  of  the  lungs,  whilst  a  like  affection  may  arise  secondarily  in 
the  axillary  glands;  possibly  in  some  cases  the  primary  trouble  lies 
in  the  glands,  the  breast  being  subsequently  involved. 

Treatment  should  be  carried  out,  if  possible,  by  incision,  scraping, 
and  purification  of  the  cavities;  but  if  the  tuberculous  foci  are 
multiple,  it  is  wiser  to  amputate  the  breast. 

Occasionally  a  chronic  tuberculous  submammary  abscess  forms  as  a 
result  of  a  similar  affection  of  the  ribs  or  costal  cartilages.  It 
develops  slowly,  pushing  the  breast  forwards,  and  is  easily  recog- 
nised, although  the  causative  lesion  can  only  be  ascertained  by 
exploration.  It  must  be  opened  thoroughly,  and  its  wall  scraped 
and  disinfected,  whilst  attention  is  also  directed  towards  the  affected 
bone. 

Syphilitic  Diseases  of  the  Breast. — As  already  pointed  out,  a 
primary  sore  may  be  met  with  on  the  nipple;  secondary  mucous 
tubercles,  or  condylomata,  are  found  in  a  similar  situation  or  beneath 
a  pendulous  breast,  whilst  superficial  and  deep  gummata  have  in 
rare  cases  formed  in  the  tertiary  period  of  the  disease. 

Cysts  of  the  Breast. 

When  the  structure  of  the  breast,  its  abundance  of  ducts  and 
alveoli,  and  its  complex  lymphatic  distribution  are  considered,  it  is 
not  surprising  that  many  difierent  forms  of  cystic  change  are  asso- 
ciated therewith.     The  following  are  the  more  important: 

I.  Acinous  or  Retention  Cysts  arise,  as  the  name  suggests,  from 
some  obstruction  to  the  ducts  or  lobules,  whereby  the  secretion 
of  the  organ  is  unable  to  escape.  They  are  met  with  most  fre- 
quently in  women  during  or  after  the  puerperal  period,  a  milk 
cyst,  or  galactocele,  being  then  produced.  It  usually  results  from 
compression  of  one  or  more  of  the  ducts,  connected  with  a  sore 
nipple,  and  contains  inspissated  milk;  it  forms  a  rounded  swelling 
and  is  located  near  the  nipple.  The  wall  is  lined  with  epithelium 
and  surrounded  by  a  fibro-cicatricial  layer,  the  thickness  of  which 
increases  with  the  chronicity  of  the  case.  In  very  old-standing 
cases  the  fibrous  wall  becomes  very  dense,  and  may  cause  retraction 
of  the  nipple  and  puckering  of  the  skin,  closely  simulating  a  scirrhus. 
The  condition  is  treated  by  excising  or  draining  the  cavity. 

Similar  glandular  cysts  form,  as  already  described,  in  the  course 
of  chronic  interstitial  mastitis,  and  are  then  known  as  involution 
cysts  ;  in  long-standing  cases,  general  cystic  disease  of  the  breast 
may  follow. 

Retention  cysts  have  also  been  described  as  resulting  from  irrita- 
tion of  the  nipple,  as,  for  instance,  when  a  young,  non-pregnant 
woman  constantly  puts  a  baby  to  her  breast ;  it  may  also  occur  apart 
from  such  irritation  in  young  and  vigorous  unmarried  women,  as  an 
expression  of  the  inherent  capacity  of  the  gland  for  functional 
development.     The  organ  becomes  enlarged,  the  epithelium  pro- 


DISEASES  OF  THE  BREAST  941 

liferates,  and  a  thin  serous  fluid  is  secreted,  wliich  does  not  entirely 
escape,  and  by  its  distension  of  the  lobules  gives  rise  to  what  may  be 
termed  iryitation  cysts.  They  may  in  time  undergo  spontaneous 
absorption,  but  Erichsen  describes  a  case  of  this  nature  in  which 
the  swellings  did  not  disappear  until  the  patient  subsequently  became 
pregnant.     Chronic  interstitial  mastitis  may  sometimes  supervene. 

Again,  one  frequently  finds  cystic  dilatation  of  the  ducts  and 
lobules  arising  in  connection  with  certain  tumours  of  the  breast,  such 
as  duct  papilloma,  duct  cancer,  or  cysto-adenoma.  In  the  latter 
cases  haemorrhage  from  the  contained  growth  is  often  seen,  giving 
rise  to  a  blood-stained  discharge  from  the  nipple.  A  scirrhous 
growth  also  occasionally  starts  from  the  wall  of  an  acinous  cyst. 

In   most   of   these   retention   cysts,    discharge   from   the   nipple 
occurs  on  squeezing  the  organ. 
.  2.  Interacinous  Cysts  develop  in  the  interstitial  tissue  of  the  breast. 

[a)  Serous  Cysts  originate  from  a  dilatation  of  lymph  spaces. 
They  may  be  uni-  or  multi-locular,  perhaps  more  frequently  the 
latter.  They  are  lined  by  a  smooth,  shiny  layer  of  endothelium, 
and  contain  serum,  perhaps  blood-stained,  and  in  old-standing 
cases  cholesterine ;  being  separate  from  the  gland  substance,  they 
never  give  rise  to  a  discharge  from  the  nipple,  and  intracystic  growths 
are  unknown.  They  are  usually  surrounded  by  a  wall  of  connective 
tissue  which  may  become  exceedingly  thick  and  dense.  Occasion- 
ally, however,  they  project  under  the  skin,  and  if  the  walls  remain 
thin,  fluctuation,  and  even  translucency,  can  be  observed,  leading 
to  the  condition  sometimes  badly  termed  a  hydrocele  of  the  breast. 

The  Diagnosis  of  a  serous  cyst,  if  the  wall  is  thick,  is  often  a 
matter  of  considerable  difficulty,  as  it  resembles  in  many  ways  a 
scirrhus.  It  is  recognised,  however,  by  the  facts  that  the  growth 
is  incorporated  with  the  breast  substance,  usually  occurring  near  its 
under  surface;  that  on  careful  examination  an  elastic  resistance 
is  transmitted  to  the  fingers,  quite  distinct  from  the  stony  hardness 
of  a  scirrhus ;  that  there  is  no  retraction  of  the  nipple  and  no  enlarge- 
ment of  the  axillary  glands,  whilst,  as  a  rule,  the  patient  complains 
of  but  little  pain.  The  diagnosis  in  cases  of  doubt  may  be  readily 
determined  bj^  inserting  a  grooved  needle,  or  by  an  exploratory 
incision,  which  should  be  made  of  sufficient  depth  to  ensure  the 
thorough  division  of  the  mass,  for  fear  that  a  small  cyst  surrounded 
by  walls  of  fibrous  tissue,  half  an  inch,  or  even  an  inch,  in  thickness, 
should  be  mistaken  for  a  solid  tumour. 

Treatment. — Although  it  may  suffice  to  lay  the  cavity  open  and 
drain  it,  it  is  decidedly  wiser  to  remove  it  completely. 

(&)  True  Hydatid  Cysts  are  occasionally  met  with,  manifesting  the 
general  characteristics  described  at  p.  233. 

3.  Cysts  may  also  arise  in  connection  with  cancerous  or  sar- 
comatous tumours,  from  degeneration  of  tissue  in  the  former  case, 
and  from  haemorrhage  into  the  substance  of  the  latter. 

4.  Dermoid  Cysts  are  described;  but  it  is  a  little  doubtful  whether 
old  galactoceles  have  not  been  mistaken  for  them. 


942  A   MANUAL  OF  SURGERY 


Tumours  of  the  Breast. 


In  investigating  any  case  of  tumour  of  the  breast,  the  surgeon 
must  never  arrive  at  a  hasty  conclusion,  but  only  give  an  opinion  as 
to  its  nature  after  careful  and  detailed  examination.  Thus,  the  age 
and  previous  history  of  the  patient  should  be  considered,  as  also  the 
family  history.  Simple  tumours  generally  arise  at  an  earlier  date 
than  the  malignant,  whilst  the  sarcomata  usually  affect  younger 
individuals  than  the  carcinomata.  There  can  be  little  doubt,  more- 
over, as  to  the  occasional  tendency  of  tumours  to  run  in  families. 
The  length  of  time  for  which  the  swelhng  has  been  observed  should 
be  ascertained,  and  whether  or  not  it  varies  in  size  at  the  menstrual 
periods.  The  general  appearance  of  the  patient  should  be  noted,  as 
also  the  fact  whether  or  not  pain,  local  or  neuralgic,  is  experienced. 
It  is  not  unusual  for  pain  to  be  referred  to  that  part  of  the  shoulder 
supplied  by  the  posterior  division  of  the  second  intercostal  nerve,  the 
anterior  branch  of  which  goes  to  the  breast.  A  careful  inspection 
of  the  organ  should  then  be  made,  comparing  it  with  the  opposite 
breast,  so  that  any  signs  of  asymmetry  may  be  noted.  Dimpling  of 
the  skin,  projection  of  the  tumour  or  of  the  whole  gland,  and  the 
situation  and  condition  of  the  nipple,  are  the  chief  points  to  which 
attention  should  be  directed.  Examination  of  the  tumour  with  the 
flat  of  the  hand,  accompanied  by  gentle  pressure  of  the  finger-tips, 
must  then  be  undertaken;  it  is  not  enough  to  pick  up  the  breast 
substance  between  the  fingers,  as  thereby  false  impressions  are 
obtained.  The  relation  of  the  tumour  to  the  gland,  its  shape,  its 
consistency,  whether  fluctuating  or  not,  and  its  mobility  on  super- 
ficial, deep,  and  surrounding  parts,  should  all  be  investigated.  To 
this  end  the  breast  must  also  be  examined  with  the  arm  raised  well 
above  the  head,  so  as  to  put  the  fibres  of  the  pectoralis  major  on 
the  stretch;  transverse  movement  of  the  organ  across  the  fibres  is 
always  possible,  unless  the  growth  is  fixed  to  the  thoracic  wall; 
movement  in  the  direction  of  the  fibres  is  at  once  hmited  if  the 
tumour  has  invaded  the  muscle,  or  even  if  the  overlying  fascia  is 
seriously  involved.  Finally,  the  lymphatic  glands  in  the  axilla 
must  be  carefully  examined,  as  also,  in  suspicious  cases,  the  supra- 
clavicular glands  and  the  opposite  breast  and  armpit. 

The  chief  types  of  tumour  met  with  in  the  breast  may  be  arranged 
in  three  groups:  the  adenomata,  the  sarcomata,  and  the  cancers. 
A  few  other  conditions  have  been  observed,  but  are  so  rare  that 
they  need  no  special  description — e.g.,  lipoma,  fibroma,  chondroma, 
and  osteoma. 

Adenoid  Tumours  of  the  Breast. — ^This  group  includes  the  two 
forms  of  fibro-adenoma  (the  hard  and  the  soft)  and  the  cysto- 
adenoma.  All  are  characterized  by  the  existence  of  spaces  lined 
with  epithelium,  which  does  not  extend  beyond  the  basement 
membrane.  The  spaces  may  contain  a  variable  quantity  of  fluid, 
and  in  some  cases  intracystic  growths  are  a  prominent  feature. 
The  interstitial  tissue  is  sometimes  of  a  very  embryonic  type. 


DISEASES  OF  THE  BREAST 


9-13 


A  pure  Adenoma  is  said  to  occur,  but  is  very  uncommon.  Its 
texture  would  be  identical  with  ordinary  mammary  tissue,  and  its 
characters  with  those  of  a  fibro-adenoma,  except  that  it  is  a  httle 
softer. 

The  Hard  Fibro-adenoma  (or  Adeno-fibroma)  is  the  most  common 
mammary  tumour  met  with  in  young  people  before  the  age  of  thirty ; 
it  is  often  attributed  to  a  blow  or  squeeze,  and  doubtless  correctly. 
It  occurs  as  a  more  or  less  rounded  or  oval  mass,  which,  if  placed 
superficially,  moves  freely  in  the  breast  substance,  and,  indeed,  may 
be  described  as  floating  in  it  (Fig.  447) ;  if  situated  deeply,  it  still 
appears  quite  moveable,  but  its  definition  is  less  evident.     Some- 


FiG.  447.— Fibro-Adenoma  Maumje^   (From  Museum  of  Royal  College 

OF  Surgeons.) 

times  several  such  growths  are  found  in  the  same  breast.  A  fibro- 
adenoma is  usually  firm  and  more  or  less  elastic  in  consistency,  of 
slow  growth,  and  it  may  be  either  painless,  or  in  antemic  and  neurotic 
women  exceedingly  painful,  the  pain  often  increasing  at  the  men- 
strual periods.  There  is  no  concurrent  enlargement  of  the  axillary 
glands,  unless  arising  from  other  causes,  and  no  retraction  of  the 
nipple,  with  which  it  is  entirely  unconnected;  the  skin  over  it  does 
not  dimple.  The  general  health  is  unimpaired  unless  the  patient 
is  suffering  from  an  associated  anaemia.  On  section  the  tumour  is 
of  a  grayish-white  colour,  becoming  pink  on  exposure  to  the  air. 
It  is  more  or  lessHoHated  in  texture,  being  compared  by  Virchow 
to  the  section  of  a^cabbage ;  no  juice  can  be  obtained  on  scraping  the 


944 


A   MANUAL  OF  SURGERY 


cut  surface  with  a  scalpel,  although  on  pressure  some  fluid  of  a 
thick  glutinous  or  mucoid  nature  may  escape.  ]\licroscopically,  the 
tumour  consists  of  imperfectly  developed  glandular  elements,  sur- 
rounded by  a  considerable  amount  of  firm  interstitial  tissue  (Fig.  6i). 
but  ducts  are  never  present.  The  tumour  is  distinctly  encapsuled, 
except  at  the  one  spot,  through  which  vessels  enter,  and  at  which 
it  is  connected  with  the  neighbouring  mammary  tissue.  It  is  stated 
that  fibro-adenomata  are  occasionally  converted  into  sarcomata, 
thus  changing  their  type  from  simple  to  malignant;  the  evidence, 
however,  as  to  this  is  not  conclusive. 

The  Diagnosis  is  readily  made  if  the  above  signs  are  considered. 
An  adenoma  differs  from  chronic  interstitial  mastitis  or  a  serous 
cyst  by  its  exact  definition  and  free  mobility,  whilst  from  malignant 


Fig.    448. — Cysto-Adenoma    Mamm^.      (Museum^of    Royal    College    of 

Surgeons.) 

The  intra-cystic  growths  are  seen  projecting  from  a  large  cyst,  into  which  a 
bristle,  passed  down  the  nipple,  enters.  A  glass  rod  has  also  been  passed 
into  the  cyst  through  a  perforation  in  the  skin. 

tumours  it  is  distinguished  by  its  slow  rate  of  growth,  and  its  freedom 
from  adhesions  either  to  the  skin  or  to  surrounding  parts. 

The  Treatment  consists  in  its  removal,  which  is  easily  affected  by 
cutting  down  upon  the  tumour  in  a  direction  radiating  from  the 
nipple,  until  the  capsule  is  reached,  when  the  mass  is  enucleated  from 
its  surroundings  with  a  few  touches  of  the  knife.  When  the  growth 
is  situated  deeply  in  the  upper  half  of  the  breast,  a  crescentic  incision 
may  be  made  along  the  lower  and  outer  border  of  the  organ,  and 
by  iDurrowing  upwards,  the  breast  can  be  turned  over  sufficiently  to 
permit  the  tumour  to  be  removed  from  the  deep  aspect;  the  scar 
will  be  subsequently  hidden  (Thomas's  operation). 

The  Soft  Fibro-adenoma  differs  from  the  above  mainly  in  the 
increased  rate  of  growth,  in  its  soft  consistency,  and  in  the  fact  that 


DISEASES  OF  THE  BREAST 


945 


the  interstitial  tissue  is  of  a  more  embryonic  character,  and,  indeed, 
is  often  of  a  mucoid  nature;  it  is  sometimes  incorrectly  termed  an 
adeno-sarcoma.  It  usually  occurs  in  women  at  a  somewhat  earher 
period  of  life  than  cancer — viz.,  between  the  ages  of  twenty-five 
and  thirty-five.  It  may  consist  from  the  first  of  a  localized  tumour, 
increasing  rapidly  in  size,  or  it  may  possibly  commence  as  a  hard 
ftbro-adenoma,  which,  after  remaining  quiet  for  a  time,  takes  on 
a  more  active  development.  It  remains,  however,  throughout  its 
course  strictly  encapsuled,  and  when  large  may  lead  to  pressure- 
atrophy  of  the  true  gland  substance.  It  is  soft  and  elastic  in  con- 
sistency, usually  painless,  and  freely  moveable  on  the  surrounding 
breast  tissue.  The  skin  over  it  remains  healthy,  although  distended 
and  atrophic  when  the  tumour  is  of  large  size;  thej nipple|shows 


u.A^ ^IC 

Fig.  449. — Cysto-Adenoma  Mamm^.    (From  a  Photograph.) 

no  sign  of  retraction;  the  axillary  glands  are  not  involved,  and 
there  is  no  systemic  invasion.  On  removal  the  section  is  similar 
to  that  of  a  fibro-adenoma,  but  cysts  are  often  present,  as  also  areas 
of  mucoid  softening,  somewhat  resembUng  sago.  It  can  be  readily 
removed  in  its  entirety,  and  does  not  tend  to  recur. 

Cysto- adenoma  [Syn.  :  Cysto-sarcoma,  Adenocele,  Intracanalicular 
Adenoma,  etc.)  is  a"  condition  characterized  by  a  marked  develop- 
ment of  intracystic  growths,  consisting  of  newly  -  formed  fibrous 
tissue  covered  with  epithelium,  within  the  dilated  acini  of  a  newly- 
formed  mass  of  adenomatous  tissue,  or  within  the  smaller  ducts 
(Fig.  448).  It  usually  has  a  definite  capsule,  and  then  the  normal 
gland  tissue  may  be  pressed  aside,  and  perhaps  atrophies.  Several 
cysts  are,  as  a  rule,  present,  and  may  be  of  great  size,  the  intrac3-'stic 
growths  also  varving  in  amount.     Sometimes  there  is  only  one  large 

60 


946  A   MANUAL  OF  SURGERY 

cauliflower-like  mass  in  a  cyst ;  sometimes  there  are  several  smaller 
pedunculated  growths.  The  epithelium  covering  them  is  cuboidal 
or  columnar;  they  are  exceedingly  vascular,  and  haemorrhage  into 
the  cavity  of  the  cyst  frequently  occurs,  as  also  a  blood-stained 
discharge  from  the  nipple.  They  are  due  to  a  proliferation  of  the 
interacinous  tissue,  which  pushes  the  epithelial  wall  of  the  duct  or 
acinus  before  it.  The  tumour  produced  is  irregular  or  lobulated 
in  outline,  owing  to  the  projection  of  the  cysts  (Fig.  449) ;  it  is 
usually  painless,  and  unaccompanied  by  enlargement  of  the  axillary 
glands;  if  of  large  size,  blue  veins  are  seen  coursing  over  it.  In  the 
later  stages  the  capsule  becomes  adlierent  to  the  integument,  and 
finally,  owing  to  the  pressure  of  the  tumour,  the  skin  may  give  way, 
allowing  the  growth  to  protnide.  This  will  be  followed  by  the 
development  of  a  f ungating  mass,  which  bleeds  readily,  and  becomes 
extremely  offensive.  With  care  a  probe  can  be  passed  between  the 
intracystic  portion  of  the  growth  and  the  thinned  and  stretched 
skin,  which  has  merely  given  way,  and  is  not  incorporated  with 
it;  this  fact  is  a  ready  means  of  distinguishing  this  condition  from 
a  fungating  encephaloid  cancer.  The  tumour  is  essentially  benign 
in  nature:  it  is  never  disseminated  generally,  and  can  be  readily 
and  completely  removed,  so  that  there  is  but  little  tendency  to 
recur.  In  the  early  stages  it  is  unnecessary  to  take  away  the  entire 
breast  if  the  tumour  can  be  efficiently  dealt  with  otherwise,  but  in 
the  later  stages  the  whole  organ  should  be  excised. 

Somewhat  similar  in  nature  to  the  above  is  the  condition  known  as 
a  duct  papilloma.  This  is  characterized  by  the  development  of  a 
soft  polypoid  papillomatous  mass,  generally  of  small  size,  in  the 
interior  of  one  of  the  terminal  galactophorous  ducts,  which  in  con- 
sequence becomes  dilated.  A  discharge  of  blood-stained  serum 
results,  and  there  is  usually  but  little  tumour  to  be  felt,  although 
the  nipple  may  be  slightly  pushed  forwards  and  rendered  prominent. 
It  is  often  the  precursor  of  a  duct  cancer.  Amputation  of  the 
breast  will  in  many  cases  be  needed,  but  it  may  be  feasible  in  some 
to  deal  with  the  tumour  alone. 

Sarcoma  Oi  the  Breast  is  not  a  common  disease  (2  to  8  per  cent,  of 
all  mammary  tumours).  It  originates  in  the  connective  tissue  of 
the  organ,  being  deeply  placed  in  its  substance,  or  perhaps  more 
frequently  developing  in  the  outer  and  upper  quadrant.  It  is  of 
two  chief  types:  [a]  The  round-celled  sarcoma  forms  a  soft,  somewhat 
elastic  swelling,  which  grows  rapidly,  and  although  often  limited 
at  first  by  a  fibrous  membrane,  the  capsule  sooner  or  later  yields, 
allowing  the  growth  to  become  diffused  through  the  organ.  It 
sometimes  gives  rise  to  secondary  growths  in  the  axillary  glands,  or 
becomes  disseminated  throughout  the  body  by  means  of  the  blood- 
vessels. Cysts  often  occur  in  its  substance,  resulting  either  from 
haemorrhage  or  occasionally  from  the  dilatation  of  an  incorporated 
glandular  alveolus;  in  the  latter  case  the  cavity  will  be  lined  with 
epithelium.  iMyxomatous  changes  are  also  not  unfrequently  ob- 
served, and  in  the  more  rapidly  growing  recurrent  tumours  the  mass 


DISEASES  OF  THE  BREAST  ^47 

is  often  a  true  myxo-sarcoma.  It  usually  occurs  in  women  between 
the  ages  of  thirty  and  forty — i.e.,  somewhat  earher  than  scirrhus— 
whilst  its  rapid  growth  and  the  absence  of  retraction  of  the  nipple 
or  dimpling  of  the  skin  are  useful  diagnostic  features.  Should 
pregnancy  follow,  the  tumour  may  increase  in  size  at  an  alarming 
rate.  In  the  infiltrating  forms  it  is  ahnost  impossible  to  distinguish 
it  from  encephaloid  cancer,  except  on  microscopic  examination. 
{h)  A  spindle-celled  sarcoma,  or  fibro-sarcoma,  is  also  met  with, 
forming  a  rounded  or  oval  tumour,  more  limited  than  the  abovei 
and  growing  less  rapidly.  It  somewhat  simulates  an  adenoma,' 
but  IS  more  closely  connected  with  the  breast  substance.  The 
axdlary  glands  are  but  rarely  involved,  and  the  sarcomatous  nature 
IS  recognised  by  the  microscope  and  by  the  great  tendency  of  the 
growth  to  recur  even  after  apparently  complete  removal;  on  account 
of  this  latter  feature,  the  name  of  '  recurrent  fibroid  tumour  ' 
(Paget)  was  formerly  applied  to  it.  The  recurrences  generally 
take  place  at  gradually  diminishing  intervals,  and  the  tumour  may 
then  become  softer  and  more  vascular;  occasionally  the  tendency 
to  recur  seems  to  wear  itself  out  after  the  performance  of  several 
operations. 

The  Treatment  of  sarcoma  mammae  consists  in  the  removal  of  the 
entire  organ  at  as  early  a  date  as  possible,  together  with  the  axillary 
glands. 

Cancer  of  the  Breast. 

No  organ  of  the  body,  with  the  exception  of  the  uterus,  is  more 
frequently  the  seat  of  cancer  than  the  female  breast ;  it  also  occurs  in 
the  male  subject,  but  is  about  a  hundred  times  less  common  than 
in  the  other  sex. 

.ffitiology.— Cancer  of  the  breast  is  usually  met  with  after  the  age 
of  forty,  although  the  disease  may  occur  at  a  much  earher  date.  It 
equally  affects  women  who  have  borne  children  and  nulhpar^,  and 
the  question  whether  or  not  the  woman  has  nursed  her  children 
seems  to  have  but  little  influence.  The  left  breast  is  more  often 
affected  than  the  right.  It  is  frequently  attributed  to  some  injury, 
such  as  a  blow  or  squeeze;  whilst  there  is  little  doubt  that  badly- 
fittmg  stays  are  responsible  for  a  certain  percentage  of  the  cases. 
It  not  uncommonly  follows  eczema  of  the  nipple,  especially  that 
variety  known  as  Paget's  eczema;  chronic  interstitial  mastitis  may 
also  possibly  be  an  occasional  precursor  of  this  affection.  The 
question  as  to  heredity  is  one  exceedingly  difhcult  to  decide,  and, 
although  it  may  be  a  marked  feature  of  some  cases,  it  is  somewhat 
doubtful  whether,  as  a  general  rule,  it  has  any  considerable  in- 
fluence. 

Two  distinct  types  of  cancer  are  met  with  in  the  breast— viz., 
the  spheroidal-celled  acinous  cancer  (including  the  acute  form,  and 
the  more  chronic  type  known  as  scirrhus)  and  duct  cancer.  Colloid 
degeneration  of  either  of  the  former  varieties  has  been  observed, 
but  is  very  uncommon. 


948 


A   MANUAL  OF  SURGERY 


I.  Spheroidal-celled  Acinous  Cancer  includes  the  great  majority  of 
cases;  the  division  into  scirrhus  and  acute  cancer  depends  clinically 
on  the  rate  of  growth  and  degree  of  hardness,  pathologically  on  the 
greater  or  less  amount  of  fibrous  stroma  present  in  any  particular 
case. 

Scirrhus  usually  commences  as  a  hard  circumscribed  mass, 
situated   most  commonly  in  the  upper  and  outer  quadrant  of  the 


Fig.  450. — Section  of  Scikkhls  of  the  Breast,  showing  Retraction 
OF  THE  Nipple,  Infiltration  of  the  Fat,  and  Secondary  Nodules 
IN  the  Underlying  Muscles.     (King's  College  Hospital  Museum.) 

organ.  It  is  closely  united  to,  if  not  absolutely  incorporated  with, 
the  breast  substance,  and  on  careful  digital  examination  its  margin 
is  quite  indefinite  (Fig.  450).  In  the  early  stages  it  is  entirely  dis- 
tinct from  the  skin,  which  moves  freely  over  its  surface;  but  as 
growth  proceeds,  the  stroma  contracts,  and,  by  dragging  on  the 
suspensory  ligaments  of  Cooper  passing  from  the  glandular  sub- 
stance to  the  skin,  the  latter  structure  becomes  more  or  less  fixed, 
and  hence,  on  attempting  to  move  it  upon  the  tumour,  an  appear- 


DISEASES  OF  THE  BREAST 


949 


ance  of  dimpling  results.  At  the  same  time,  the  whole  breast  is 
acted  upon  in  a  similar  manner,  so  that  the  affected  organ  some- 
times seems  to  be  sn.aller  than  the  other;  and,  since  the  upper  half 
of  the  gland  is  usually  affected,  the  nipple  may  be  drawn  up  so  as 
to  lie  at  a  higher  level  than  its  fellow,  as  well  as  being  retracted 
from  the  drag  of  the  growth  on  the  galactophorous  ducts  (Fig.  451J. 
The  tumour  itself  is  rarely  of  great  size,  so  long  as  it  retains  its 
scirrhous  nature;  it  is  sometimes  extremely  painful  and  tender, 
but  not  uncommonly  the  pain  is  intermittent,  and  of  a  neuralgic 
t\'pe,  extending  to  the  shoulder,  and  perhaps  only  elicited  on 
manipulation.  As  the  growth  increases  in  size,  it  becomes  adherent 
to   the   pectoral   fascia,    and   may   even   infiltrate  the  underlying 


Fig.  451. — SciRRHUs  of  the  Left  Breast.     (From  a  Photograph.) 

The  retraction  of  the  nipple  and  its  elevation  above  the  level  of  the  other 

are  well  seen. 

muscular  substance,  so  that  on  examination,  with  the  arm  extended 
and  abducted,  it  is  found  that,  although  moveable  across  the  fibres 
of  the  muscles,  the  breast  cannot  be  moved  \^dth  them. 

The  lymphatic  glands  in  the  axilla  soon  become  enlarged,  the 
disease  rarely  lasting  many  months  without  this  complication. 
Those  running  with  the  long  thoracic  vessels  under  cover  of  the 
pectoraHs  major  are  first  involved,  and,  as  the  case  progresses,  the 
remaining  axillary  and  subscapular  sets  become  similar!}'  affected, 
and  even  after  a  time  the  supracla\'icular.  \'\'hen  the  inner  or  deeper 
part  of  the  breast  is  attacked,  the  disease  may  spread  to  the  medi- 
astinal glands  along  the  lymphatics,  which  accompany  the  nutrient 
vessels  arising  from  the  internal  mammary  trunk;  and  thus  intra- 
thoracic deposits  develop,  which  even  extend  along  the  subpleural 


95° 


A   MANUAL  OF  SURGERY 


connective  tissue,  and  affect  the  pleural  cavity  and  lungs.  In  those 
cases  where  the  primary  growth  is  situated  near  the  inner  border 
of  the  breast,  the  free  lymphatic  anastomosis  across  the  mitidle 
hne  allows  of  the  transmission  of  the  disease  to  the  glands  in  the 
opposite  axilla,  and  sometimes  a  similar  affection  of  the  opposite 
breast  arises  from  this  cause. 

The  skin  may  be  implicated  in  many  ways,  {a)  Ihe  dimphng 
which  is  met  with  over  the  tumour  in  the  early  stages  has  already 
been  mentioned.  As  the  case  proceeds,  the  cancer  extends  out- 
wards along  the  suspensorv  bands  of  fascia,  so  that  the  skin  itself 
becomes  invaded,  feeling  firm  and  brawny,  and  looking  congested 
and  purplish  in  colour,  whilst  a  branny  desquamation  is  usually 


Fig.  ^^2. — Diffuse  Cancer  of  the  Breast,  showing  Retraction  of  the 
Nipple,  Infiltration  of  the  Lymphatics  of  the  Skin,  and  Swelling 
OF  the  Arm  due  to  Lymphatic  Obstruction  from  Involvement  of 
the  Axillary  and  Supraclavicular  Glands. 

present.  A  crack  or  fissure  at  length  forms,  giving  exit  to  a  little 
serous  discharge,  which  at  first  scabs  over,  but  finally  leaves  an 
ulcerated  surface,  which  slowly  extends,  and  may  attain  consider- 
able dimensions.  A  typical  scirrhous  ulcer  is  hollowed  out  and 
excavated;  its  surface,  if  kept  clean,  is  covered  with  smooth  granu- 
lations, discharging  a  considerable  amount  of  sanious  fluid,  but  if 
neglected,  it  becomes  sloughy  and  offensive;  it  is  surrounded  by  a 
projecting  elevation  of  the  tumour  substance,  forming  a  sort  of 
rampart  around  it.  (6)  Less  commonly  the  disease  becomes 
disseminated  through  the  lymphatics  of  the  skin,  giving  rise 
to  a  series  of  firm  cord-like  thickenings  radiating  from  the 
nipple    (Fig.  452).      The  skin  itself  is  thickened  and  firmer  than 


DISEASES  OF  THE  BREAST 


951 


usual,  so  that  it  is  impossible  to  pinch  it  up;  the  mouths  of 
the  sebaceous  glands  are  enlarged  and  very  evident,  giving  it  a 
coarse  appearance  like  '  pig-skin,'  or  the  rind  of  an  orange  {peati 
d' orange  of  French  authors).  Later  the  colour  becomes  dusky, 
and  numerous  button-like  nodules  of  cancer  develop  here  and  there ; 
the  sebaceous  glands  may  exude  an  abundant  secretion,  which 
becomes  inspissated  on  the  surface  into  crusts  or  scabs,  which  are 
independent  of  any  ulceration.  This  process  often  extends  widely 
beyond  the  limits  of  the  breast,  invading  the  whole  thoracic  wall, 
and  even  running  over  the  shoulder  to  the  back  of  the  head  or  neck 
(cancer  en  cuirasse) ;  in  its  most  typical  form  it  is  slow  in  develop- 
ment, the  patient  perhaps  living  for  many  years,  (c)  Occasionally 
one  meets  with  a  much  more  rapid  form  of  cancerous  lymphangitis, 
in  which  the  skin  becomes  affected  with  what  is  supposed  to  be  a 
'  weeping '  eczema ;  the  sur  - 
face  is  red,  hot,  and  infil- 
trated, and  on  examining 
it  with  a  lens  the  dilated 
13/mphatics  can  be  seen 
from  which  the  secretion 
oozes.  The  process  spreads 
widely  and  rapidly,  and 
cancerous  nodules  appear 
here  and  there  in  the  infil- 
trated area;  the  prognosis 
is,  of  course,  very  grave. 

In  the  later  stages,  the 
patient  passes  into  a  state 
of  cachexia,  becoming 
emaciated  and  exhausted. 
Ulcerated  surfaces  of  con- 
siderable size  may  exist, 
and  the  tumour  is  fixed  to 
the  thoracic  wall,  even  in- 
vading the  ribs.  The  arm 
on  the  affected  side  is 
swollen  and  brawny,  owing 

to  the  pressure  of  enlarged  giands  on  the  main  lymphatics  and 
veins  of  the  limb,  constituting  a  condition  of  solid  or  lymphatic 
oedema  (Fig.  453).  Severe  neuralgic  pain  of  the  arm  results  Jfrom 
involvement  of  or  pressure  upon  the  brachial  neives  iii  the 
supraclavicular  fossa.  Secondary  deposits  also  develop  in  the 
viscera,  especially  the  pleura,  lungs,  and  liver,  and  may  lead  to 
various  symptoms.  Not  unfrequently  recurrence  takes  place  in  the 
connective  tissue  between  the  rib  cartilages  and  the  pleura,  and 
nodules  of  growth  develop,  which  may  in  time  project  forwards 
through  one  of  the  intercostal  spaces  (usually  the  second) .  Deposits 
in  the  bones  (p.  596)  are  also  not  unusual,  the  sternum,  vertebrae,  and 
upper  ends  of  femur  and  humerus  being  perhaps  most  often  affected . 


Fig.  453. — Lymphatic  CEdema'of  the  Arm 
Secondary  to  Carcinoma  Mamm^,  which 

HAD  recurred  AFTER  OPERATION. 


952  A   MANUAL  OF  SURGERY 

Severe  pain  is  caused  by  such  lesions,  followed  probably  by  spon- 
taneous fracture,  which  may  heal  quite  effectively  or  remain  un- 
united.    Finally,  death  from  exhaustion  ends  the  scene. 

Acute  Cancer  is  fortunately  not  common,  and  appears  as  a  some- 
what soft,  rapidly  growing  tumour,  which  quickly  infiltrates  the 
whole  organ,  and  gives  rise  to  secondary  lymphatic  and  visceral 
affections  at  a  much  earlier  date  than  scirrhus.  It  does  not  cause 
retraction  of  the  nipple  or  dimpling  of  the  skin,  the  latter  structure 
being  distended,  and  with  blue  veins  coursing  under  it.  The  breast 
becomes  enlarged  and  prominent ;  the  skin  is  stretched  and  gradually 
invaded  by  the  tumour,  and  if  ulceration  follows,  a  foul  fungating 
mass  sooner  or  later  sprouts  up  through  the  opening.     This  variety 


i 


> 


Fig.  454. — Atrophic  Cancer  of  Both  Breasts.     (From  a  Photograph.  ) 

The  nipples  are  both  retracted,  and  the  skin  around  puckered  and  fixed  to  the 
growth.  On  the  right  side  the  axillary  glands  are  obviously  enlarged. 
The  patient  was  an  old  woman  over  70  years  of  age. 

usually  attacks  young  women  under  thirty-five  years  of  age,  and  runs 
a  rapidly  destructive  course,  especially  if  it  occurs  during  pregnancy 
or  lactation,  when  it  is  likely  to  be  mistaken  for  an  acute  mastitis. 

Finally,  in  elderly  women,  a  chronic  form  of  cancer  is  met  with 
known  as  Atrophic  Scirrhus  (Fig.  454),  in  which  the  disease  lasts  for 
many  years  without  much  definite  extension.  Cases  have  been 
known  to  persist  for  fifteen  or  twenty  years,  the  patient  at  length 
dying  of  some  intercurrent  malady,  although  in  the  great  majority 
dissemination  has  ultimatel}'  occurred.  The  special  characters  are 
due  to  the  excessive  contraction  of  the  stroma,  as  a  result  of  which 
the  cellular  elements  become  crushed,  and  practically  destroyed. 
The  nipple  is  deeply  retracted,  and  the  tumour  and  breast  substance 
in  the  most  marked  cases  are  scarcely  discernible. 

2.  Duct  Cancer  is  a  somewhat  rare  form  of  the  disease,  the  exact 


DISEASES  OF  THE  BREAST  953 

nature  of  which  is  still  uncertain,  and  there  is  very  little  doubt 
that  several  distinct  types  have  been  described  under  this  name.  It 
is  sometimes  characterized  by  the  development  of  one  or  more 
nodules  of  a  malignant  papillomatous  nature  within  the  dilated 
ducts,  and  usually  situated  not  far  from  the  nipple.  These  growths 
are  covered  with  columnar  epithehum,  and  may,  indeed,  be  looked 
upon  as  forms  of  columnar  cancer.  They  are  exceedingly  vascular, 
and  a  blood-stained  discharge  from  the  nipple  is  usual.  They  always 
grow  slowly,  and  when  situated  near  the  skin  give  rise  to  a  round 
dusky  red  swelling.  The  nipple  is  not  retracted,  and  lymphatic 
enlargement  not  constant.  In  other  cases  the  dilated  alveoli  are 
occupied  by  masses  of  proliferated  epithelial  cells  of  a  spheroidal 
type,  which  arrange  themselves  into  more  or  less  definite  papilloma- 
tous growths,  whilst  cystic  degeneration  also  occurs.  Either  of 
these  varieties  may  be  associated  with  a  development  of  ordinary 
scirrhus  in  some  other  part  of  the  breast.  The  diagnosis  can  only 
be  established  with  certainty  by  microscopic  examination  after 
removal. 

Adeno-carcinoma  is  the  term  given  by  Halstead  to  a  condition 
very  similar  to  the  latter  variety  of  duct  cancer.  The  growth  con- 
sists of  tubular  spaces  heavily  lined  with  epithelium;  it  develops 
slowly,  but  frequently  fungates  through  the  skin,  and  presents  as 
a  localized  pedunculated  growth,  which  readily  bleeds.  1  he  axillary 
glands  are  usually  free  from  infection,  and  the  prognosis  is  good. 

The  duration  of  cancer  varies  considerably  in  the  different  forms. 
The  encephaloid  type  runs  a  rapid  course,  and  will  probably  destroy 
the  patient's  hfe  in  six  to  twelve  months.  Duct  cancer  is  very 
shghtly  malignant,  whilst  atrophic  scirrhus  is  similarly  slow  in 
growth,  and  in  both  death  may  be  postponed  for  a  considerable 
period,  or  is  often  due  to  some  intercurrent  malady.  Cancer  en 
cuirasse  is  variable  in  its  course,  being  sometimes  tolerably  rapid, 
and  at  others  chronic;  it  cannot  be  cured  by  operation  on  account 
of  its  early  and  extensive  dissemination.  A  circumscribed  scirrhous 
tumour  is  stated  to  end  fatally,  on  an  average,  in  two  or  three  years 
if  no  operative  treatment  is  undertaken,  whilst  removal  of  the  mass 
will  probably  add  another  year  or  eighteen  months  to  the  patient's 
life.  These  figures  are,  however,  derived  from  statistics  of  opera- 
tions performed  before  the  general  adoption  of  the  more  exact  and 
extensive  measures  which  are  now  usualh'  undertaken,  and  it  is 
likely  that  they  underestimate  considerably  the  benefits  derived 
from  such  interference. 
The  Pathological  Anatomy  of  cancer  is  discussed  at  p.  218. 
The  Diagnosis  of  scirrhus  from  chronic  interstitial  mastitis  and 
chronic  abscess  or  cyst  has  been  already  considered  (p.  939)-  From 
tumours  of  the  adenoid  type  it  is  easily  distinguished.  The  stony 
hardness  of  a  scirrhus,  its  union  with  the  breast  substance,  its 
limited  mobility,  the  dimpling  of  the  skin,  retraction  of  the  nipple, 
and  enlargement  of  the  axillary  glands,  are  the  chief  local  character- 
istics to  be  noted.     Non-malignant  tumours  are  more  elastic  to 


954  A   MANUAL  OF  SURGERY 

the  touch,  more  moveable,  and  usually  quite  circumscribed  in  out- 
line, whilst  the  skin,  though  expanded,  does  not  become  adherent; 
the  nipple  is  rarely  retracted,  and  the  axillary  glands  remain  of 
normal  size.  It  is  often  impossible  to  distinguish  a  cancerous  from 
a  sarcomatous  tumour,  except  on  microscopic  examination;  a  round- 
celled  sarcoma  closely  resembles  an  acute  cancer,  although  it  is 
usually  more  circumscribed— at  any  rate,  in  the  early  stages.  A 
fibrosarcoma  may  sometimes  be  mistaken  for  scirrhus,  but  it  is 
more  defined  in  outline,  does  not  cause  retraction  of  the  nipple  or 
dimphng  of  the  skin,  whilst  lymphatic  enlargement  is  not  a  constant 
accompaniment.  A  cysio-adenoma  presents  no  difficulty  in  diag- 
nosis if  the  skin  is  entire,  and  the  cysts  prominent;  but  when 
ulceration  has  taken  place,  and  a  fungating  bleechng  mass  protrudes, 
it  is  not  unhke  the  later  stage  of  an  encephaloid  cancer  or  fungating 
round-celled  sarcoma.  It  can  be  distinguished,  however,  by  the 
fact  that  a  probe  can  sometimes  be  passed  under  the  skin  for  some 
distance  into  the  cavity  of  the  cyst,  whilst  lymphatic  enlargement  is 
rare.  For  the  diagnosis  of  scirrhus  from  a  tense  single  cyst,  see  p.  941. 
Treatment. — This  necessarily  consists  in  the  removal  of  the  tumour 
by  operation  in  all  cases  where  there  seems  a  reasonable  chance  of 
eradicating  the  disease.  The  only  conditions  that  would  contra- 
indicate  operation  are  extensive  adhesions  to  the  thoracic  walls,  the 
juesence  of  visceral  deposits,  and  extensive  diffusion  of  a  rapidly 
growing  acute  cancer  in  a  young  subject.  Atrophic  scirrhus  is  often 
left  alone,  on  the  plea  that  the  prognosis  is  so  favourable  as  to 
render  operation  unnecessary;  if,  however,  the  patient  is  fairly 
strong,  there  is  no  objection  to  it,  and  it  certainly  seems  wise  to 
remove  a  cancerous  focus,  however  chronic  it  be.  Disease  of  both 
breasts,  although  rendering  the  prognosis  more  grave,  is,  cceteris 
paribus,  no  hindrance,  since  both  organs  have  been  removed  success- 
fully, even  at  one  operation.  Speaking  generally,  rapidly  growing 
tumours  in  vigorous  patients  are  very  unfavourable  cases  to  deal 
with,  whilst  slow  growth  of  the  tumour,  and  definite  limitation  of 
its  outline,  are  favourable  signs. 

In  the  old  days,  only  the  more  prominent  portion  of  the  breast 
was  removed  with  the  tumour,  and  consequently  recurrence  was  so 
extremely  common  that,  if  5  or  10  per  cent,  of  the  patients  were 
really  cured,  it  was  thought  to  be  as  much  as  any  surgeon  could 
reasonably  expect.  Since  we  have  learnt  more  of  the  anatomy  of 
the  organ  and  of  the  evolution  of  the  disease  (for  which  we  are 
mainly  indebted  to  Heidenhain  and  Stiles),  more  extensive  pro- 
ceedings have  been  undertaken,  with  a  gradual  amelioration  in  the 
results,  so  that  several  surgeons  have  been  able  to  report  50  to 
60  per  cent,  of  their  cases  as  free  from  recurrence  at  the  end  of  three 
years.  It  was  suggested  by  Volkmann  that  any  case  which  remains 
free  from  recurrence  for  three  years  may  be  claimed  as  a  cure,  but 
this  is  now  generally  considered  too  short  a  period,  since  the  disease 
sometimes  reappears  at  a  much  later  date  (even  nine  or  ten  yearsl. 
The  breast  is  a  much  more  extensive  organ  than  was  foimerly 


DISEASES  OF  THE  BREAST  955 

supposed,  its  lobules  extending  upwards  nearly  as  high  as  the 
clavicle,  outwards  into  the  axilla,  and  for  some  distance  downwards, 
so  that  removal  merely  of  the  prominent  part  of  the  gland  may 
leave  much  behind,  and  thereby  favour  recurrence.  Moreover,  the 
deeper  lymphatics  pass  into  the  fascia  covering  the  pectoralis  major, 
and  so  to  the  axilla;, hence,  this  structure  should  alwa\'s  be  taken 
away,  as  well  as  a  thin  layer  of  the  muscular  fibres,  but  the  wiser 
course  is  to  remove  the  whole  of  the  sternal  portion  of  the  pectorahs 
major,  lea\'1ng  only  the  clavicular.  Many  surgeons  also  remove 
the  pectoralis  minor  muscle;  this  procedure  certainlv  favours  the 
axillary  dissection,  and  does  not  seem  to  have  any  harmful  influence 
on  the  subsequent  movements  of  the  arm.  xAgain,  lymphatics  travel 
along  the  fibrous  bands  reaching  from  the  breast  tissue  to  the  over- 
hing  skin,  and  thus  this  latter  must  never  be  dissected  back  from 
over  the  tumour.  The  nipple  should  under  no  circumstances  be  left 
behind,  since  all  the  interlobular  h-mphatics  converge  to  a  plexus 
around  it,  and  thence  pass  to  the  axilla  by  three  or  four  main  trunks. 
The  axilla  itself  should  be  opened  in  every  case,  and  entireh*  cleared 
of  its  lymphatic  contents,  since  deposits  in  the  glands  are  often  found 
on  microscopic  examination,  where  no  chnical  evidence  of  their 
presence  had  been  pre\-iously  noted.  It  is  also  important  to  remove 
the  breast  and  axillary  tissues  in  one  piece,  so  as  to  avoid  dix'ision 
of  the  lymphatics  and"  possible  infection  of  the  wound  with  their 
cancerous  contents. 

Operation  for  Cancer. — The  patient  hes  on  the  back,  with  the  head 
directed  towards  the  opposite  side,  and  the  arm  raised  to  a  little 
more  than  a  right  angle,  so  as  to  put  the  pectoralis  on  the  stretch. 
An  aseptic  towel  should  be  WTapped  round  the  head,  so  as  to  keep 
the  hair  out  of  the  way,  and  a  similar  sterilized  towel  may  be  placed 
below  the  chin  on  a  cross-bar,  to  form  a  barrier  between  the 
anaesthetist  with  his  apparatus  and  the  field  of  operation.  The 
axilla  should  be  pre\4ously  shaved,  and  the  skin  carefully  purified. 
The  incisions  employed  vary  with  the  size  and  position  of  the 
tumour;  the  primary  object  is  to  remove  the  growth  together  wath 
the  whole  gland  and  all  its  accessible  h-mphatic  connections;  the 
question  of  being  able  to  close  the  wound  subsequently  is  quite  a 
secondary  and  minor  consideration.  x\s  a  rule,  sufficiently*  wide 
undercutting  \^-ill  allow  very  extensive  wounds  to  be  closed;  but 
when  this  is  impossible,  skin-grafting  can  be  adopted,  and  no  lengthy 
convalescence  need  ensue.  Fig.  455  suggests  the  tj-pes  of  incision 
that  may  ser^^e  for  the  removal  of  tumours  on  the  outer  and  inner 
sides  of  the  breast  respectiveh'.  Slight  modifications  will  suggest 
themselves  when  the  growth  is  in  other  positions. 

^^"hen  the  incisions  have  been  made,  they  are  deepened,  but  not 
directly  inwards.  The  skin  around  is  dissected  up  so  that  the 
subcutaneous  connective  tissue  may  be  removed  together  with  the 
breast  over  a  wide  area  extending  as  high  as  the  cla\icle  above, 
down  to  the  epigastric  notch  below,  and  behind  the  posterior  border 
of  the  axilla  on  the  outer  side.     The  surface  of  the  pectoralis  major 


956 


A   MANUAL  OF  SURGERY 


is  then  exposed  throughout  the  whole  length  of  the  inner  or  upper 
incision,  the  connective  tissue  over  it  being  turned  downwards.  The 
junction  between  the  sternal  and  clavicular  portions  is  defined,  and 
opened  up  by  finger  and  knife  throughout  its  whole  length.  The 
insertion  of  the  sternal  portion  is  divided  about  an  inch  from  the 
humerus,  and  then  the  finger  is  introduced  under  its  origin  from  the 
sternum  and  costal  cartilages,  and  this  is  severed  by  the  knife  close 
to  the  bone.  Several  perforating  branches  of  the  internal  mammary 
will  be  divided  in  this  procedure,  and  must  be  at  once  secured,  so 
as  to  prevent  their  retraction  through  the  intercostal  spaces.  The 
pectorahs  minor  comes  into  view,  and  is  divided  at  its  costal  attach- 
ments and  also  close  to  the  coracoid  process. 

The  breast  and  underlying  tissues  can  now  be  drawn  downwards 


,jmM^ 


■P^*^-  455- — Incisions  for  Removal  of  Cancerous  Breast  when  the 
Tumour  is  Situated  in  the  Upper  and  Outer,  or  in  the  Inner 
Segment  Respectively. 

and  outwards,  thereby  opening  up  the  axilla  freely;  the  next  step 
consists  in  thoroughly  clearing  it.  The  main  vessels  are  first  defined 
below  the  lower  border  of  the  pectoralis  minor  close  to  the  outer 
angle  of  the  wound;  a  layer  of  fascia  needs  division  in  order  to 
accomplish  this.  The  dissection  is  then  carried  inwards  along  the 
vessels  and  nerves,  which  are  freed  from  fat  and  glands  both  in 
front  and  behind,  if  necessar5^  Arterial  and  venous  branches  are 
best  secured  by  ligature  before  division.  If  the  glands  are  closely 
adherent  to  the  vein,  it  is  wise  to  excise  a  portion  of  it  rather  than 
to  attempt  to  peel  them  off.  The  most  careful  search  for  glands 
must  be  made  in  the  apex  of  the  axilla,  and  in  removing  them  every 
effort  must  be  used  not  to  rupture  the  glands  by  careless  handling, 
as  thereby  dissemination  of  cancer  cells  may  occur. 


DISEASES  OF  THE  BREAST  957 

The  suj'gcon  next  proceeds  to  remove  the  fat  and  fascia  from  the 
serratus  magnus  on  the  inner  side  of  the  wound,  care  being  taken  to 
secure  the  lateral  branches  of  the  intercostal  arteries  as  they  are 
divided,  and  to  protect  the  nerve  of  Bell.  The  subscapularis  is  then 
cleared,  and  possil)ly  the  subscapular  vessels  may  need  division,  but 
the  subscapular  nerves  must  be  spared.  Not  unfrequently  there  are 
many  enlarged  lymphatic  glands  in  this  part  of  the  axilla.  When 
this  has  been  effected,  but  little  more  remains  to  be  done  except  to 
free  the  breast,  pectorals,  and  connective  tissue  from  their  external 
attachments,  and  this  is  quickly  accomplished  by  a  few  sweeps  of 
the  knife. 

An  enormous  wound  results,  and  during  the  later  stages  the 
exposed  tissues  must  be  protected  as  far  as  possible  by  covering  them 
with  warm  steriHzed  cloths.  Bleeding-points  are  secured,  the 
wound  washed  out  with  hot  sterile  salt  solution,  and  preparations 
made  for  closing  it.  Surrounding  parts  may  need  to  be  extensively 
undermined,  or  even  plastic  proceedings  carried  out  in  order  to  bring 
forwards  redundant  skin  from  the  side  and  back.  As  a  general  rule 
the  wound  can  be  more  or  less  completely  closed  by  the  exercise  of 
a  little  patience  and  ingenuity.  Under  no  circumstances  should 
the  upper  part  of  the  wound  be  left  open,  as  thereby  the  axillary 
contents  would  be  exposed,  and  harmful  cicatrices  might  form. 
Should  any  part  be  left  open,  it  is  probably  wise  to  defer  a  grafting 
operation  till  later.  Deep  tension  stitches  are  often  useful,  and  the 
margins  of  the  wound  are  approximated  by  ordinary  catgut  or  silk 
sutures.  Drainage  is  usually  desirable,  and  the  tube  may  be  placed 
through  an  opening  made  for  it  in  the  posterior  axillary  wall.  A 
large  and  efficient  dressing  is  applied  back  and  front  to  receive  the 
sero-sangiiineous  discharge,  which  is  sure  to  be  abundant.  The 
arm  is  left  at  right  angles  to  the  side  throughout  the  healing  with 
the  object  of  preventing  the  subsequent  stifcess  and  limitation  of 
movement,  which  was  so  marked  formerly  when  the  arm  was 
bandaged  to  the  side.  The  first  dressing  will  be  required  in  twent}^- 
four  or  forty-eight  hours,  and  the  drainage-tube  may  then  be 
removed.     Healing  should  be  complete  in  from  ten  to  twelve  days. 

The  immediate  results  of  this  operation  are  exceeding^  satisfac- 
tory, the  mortality  being  under  5  per  cent.  The  ultimate  results 
necessarily  vary  with  the  period  at  which  the  operation  is  under- 
taken, with  the  extent  and  character  of  the  disease,  and  with  the 
thoroughness  and  skill  of  the  operator. 

When  the  supraclavicular  glands  are  enlarged,  the  operation  must 
also  include  the  supraclavicular  fossa  in  its  scope,  as  recommended 
by  Halstead;  he,  indeed,  goes  so  far  as  to  maintain  that  the  posterior 
triangle  should  be  cleared  of  its  lymphatic  contents  in  all  cases, 
whether  or  not  enlarged  glands  can  be  detected  beforehand,  and 
states  that  in  a  considerable  percentage  cancerous  invasion  will  have 
already  occurred.  Without  going  quite  so  far  as  this,  we  would 
advise  that  wherever  there  is  much  axillary  involvement,  the  supra- 
clavicular fossa  should  alwavs  be  cleared.     The  cervical  incision  is 


958  A   MANUAL  OF  SURGERY 

a  curved  one,  extending  along  the  posterior  border  of  the  stcrno- 
mastoid,  and  outwards  along  the  clavicle.  This  flap  is  dissected 
up,  and  all  the  fat  and  glands  are  removed  from  before  backwards, 
the  internal  jugular  vein  being  the  starting-point.  Of  course,  the 
greatest  care  is  taken  to  avoid  the  thoracic  duct  or  right  lymphatic 
trunk.  Some  surgeons  have  even  proposed  to  divide  the  clavicle, 
but  this  seems  to  be  a  needless  proceeding.  The  axillary  and  the 
supraclavicular  wounds  can  easily  be  made  continuous  under  the 
clavicle. 

Local  recurrence  after  operation  is  always  due  to  incomplete  removal 
of  the  growth,  or  to  infection  of  the  wound  during  the  operation. 
The  surgeon  must  ever  keep  m  mind  that  although  in  a  healthy 
organism  the  implantation  of  cancerous  material  has  apparently 
but  little  or  no  efiect,  yet  in  a  cancerous  individual  positive  results 
are  only  too  certainly  obtained.  The  recurrence  appears  either  in 
the  neighbourhood  of  the  cicatrix,  the  most  usual  situation,  or  in 
adjacent  lymphatic  glands,  in  the  other  breast,  or  in  the  retrocostal 
connective  tissue.  The  progress  is  often  slow,  but  occasionally  the 
disease  spreads  more  rapidly  than  if  no  operation  had  been  under- 
taken. To  prevent  the  likelihood  of  this,  exposure  to  X  rays  after 
the  operation  may  advisably  be  adopted. 

Diffuse  cancer  of  the  skin  en  cuirasse  is  not  suitable  for  operative 
treatment,  but  much  may  be  done  by  exposure  to  the  X  rays  (p.  56) 
or  by  radium. 

It  has  been  suggested  to  treat  lymphatic  or  solid  oedema  by  intro- 
ducing subcutaneous  strands  of  carefully  sterilized  silk  from  below 
upwards  into  the  healthy  tissues  so  as  to  act  as  artificial  Ijmphatics. 
In  some  of  the  cases  hitherto  reported  improvement  has  followed 
to  a  certain  extent. 

Some  years  back  Beatson  of  Glasgow  proposed  to  treat  inoperable 
cases  by  double  oophorectomy  and  the  administration  of  thj-roid 
extract.  Many  patients  have  been  dealt  with  in  this  way,  and  the 
results  gained  thus  far  show  that,  whilst  a  few  cases  have  been  appar- 
ently cured,  in  a  much  larger  number  no  effect  was  produced,  but 
that  in  quite  an  appreciable  proportion  the  disease  seems  to  have 
been  temporarily  controlled  (perhaps  for  j^ears),  and  the  pain  and 
discomfort  very  definitely  diminished.  The  operation  should  of 
course  only  be  undertaken  in  w^omen  who  have  not  yet  reached  the 
climacteric. 

Amputation  of  the  Breast  for  non-malignant  conditions  is  a  very 
different  operation  to  that  described  above.  The  incisions  usually 
employed  are  crescentic  and  placed  obliquely ;  they  need  not  include 
much  more  skin  than  that  indicated  by  the  breadth  of  the  areola. 
The  integument  is  dissected  up  from  the  glandular  tissue  on  either 
side,  and  the  organ  freed  from  its  attachments  to  the  pectoral  fascia; 
the  axilla  is  frequentl}-  not  opened. 


CHAPTER  XXXV. 

ABDOMINAL  SURGERY. 

General  Remarks  on  Abdominal  Operations.— No  branch  of  the 
sur<^ical  art  has  grown  so  rapidly  or  attained  such  importance  as  that 
directed  to  the  abdominal  contents.  Operations  which  formerly 
were  advisably  rare  are  now  of  everyday  occurrence,  and  no  surgeon 
hesitates  to  open  the  peritoneal  ca\dty  whenever  it  appears  necessary, 
and  even  sometimes  merely  with  the  object  of  exploring  the  con- 
dition of  its  contents.  Success  is,  however,  entirely  dependent 
on  a  minute  and  careful  attention  to  details,  which  can  only  result 
from  attentive  observation  and  considerable  experience.  The 
peritoneum  carefuUv  treated  is  a  good  friend  to  the  surgeon;  it 
resents,  however,  rough  handling  or  prolonged  exposure,  and  serious 
inflammatory  trouble  may  foUow  slovenly  work,  jeopardizing  the 
patient's  hfe,  or  even,  if  he  live,  gi\dng  rise  to  such  disabilities  and 
discomfort  as  mav  impair  his  usefulness.  In  no  department  of 
operative  surgery  is  rapid  and  yet  minutely  careful  work  so  well 
repaid.  The 'following  are  a  few  points  which  may  prove  helpful 
to  those  aspiring  to  success  in  this  important  branch  of  surgery : 

The  patient  should  be  prepared,  when  circumstances  permit,  by 
re°Tilating  the  diet  and  bowels  for  some  days  previously,  and 
thoroughly  cleansing  the  teeth  and  mouth,  so  that  the  intestinal 
canal  may  be  as  free  from  organisms  as  possible ;  a  course  of  internal 
antiseptics,  such  as  salol,  calomel,  or  /3-naphthol,  may  be  advisable. 
During  the  prexious  da\^  an  effective  purgative  is  given  —  e.g., 
I  ounce  of  castor  oil — and"  an  enema  may  be  desirable  in  the  morning 
to  ensure  that  the  lower  gut  is  empty.  The  abdominal  wall  is 
shaved,  as  also  the  pubes,  and  purified  beforehand  in  the  usual 
way,  special  care  being  directed  to  the  umbihcus,  where  dirt  is  very 
liable  to  lodge. 

No  food  should  be  allowed  by  mouth  for  three  or  four  hours,  and 
immediately  before  being  placed  on  the  table  the  bladder  should  be 
emptied,  if  need  be,  by  catheter.  If  the  proceedings  are  likely  to  be 
protracted,  it  is  ad\'isable  to  give  a  rectal  injection  of  warm  saline 
solution,  or  of  beef-tea  and  coffee,  half  an  hour  beforehand,  and 
possiblv'a  h\'podermic  injection  of  strychnine  (gr.  ^^). 

The  patient  should  be  warmly  wTapped  up  and  protected  from 
cold,  no  unnecessarv  exposure  being  allowed.  The  operating  room 
should  be  well  warmed,  and  not  below  70°  F. ;  a  temperature  of 

959 


96o 


A   MANUAL  OF  SURGERY 


80°  F.,  though  trying  for  the  surgeon  and  his  lielpers,  is  better  lor 
the  patient.  Complete  anaesthesia  is  desirable,  so  as  to  chminisli 
shock,  but  this  should  be  obtained  with  as  small  a  dose  of  anctsthetic 
as  possible.  Intraperitoneal  operations  are  not  painless,  for 
although  the  visceral  peritoneum  is  not  acutely  sensitive,  yet  the 
parietal  layer  is,  as  well  as  that  included  in  the  mesenteries,  and  any 
handling  of  these  structures  gives  rise  to  pain  and  necessarily  to 
increased  shock,  if  the  patient  is  conscious.  If  the  patient  is  very 
collapsed  before  the  operation,  as  in  emergency  work — e.g.,  perfora- 
tion of  the  stomach — it  is  often  advisable  to  administer  ether  dis- 
solved in  saline  solution  by  the  intravenous  method. 

As  a  general  rule  the  patient  lies  flat  on  the  table,  but  if  the 
operation  involves  the  pelvic  viscera,  the  Trendelenburg  position  is 
often  adopted.  In  it  the  patient  is  placed  with  the  head  con- 
siderably below  the 
rest  of  the  body,  which 
is  more  or  less  inverted 
(Fig.  456).  The  knees 
are  bent  over  the  end 
of  the  table,  and  help 
to  keep  the  body  in 
position.  The  head- 
piece of  the  table 
must  be  lowered,  or 
the  neck  will  be  bent 
forwards  into  a  posi- 
tion that  impedes  re- 
spiration. The  arms 
must  not  be  kept 
above  the  head,  or 
musculo-spiral  paraly- 
sis may  follow;  they 
are  best  placed  behind 
the  patient's  back  or 
close  to  the  sides.  This  position  must  not  be  adopted  when  it  is 
probable  that  the  pelvis  is  occupied  by  a  fluid  inflammatory 
exudate,  nor  in  conditions  where  obstruction  is  present,  and  the 
stomach  is  likely  to  be  filled  with  offensive  material  which  might 
gravitate  into  the  mouth  and  suffocate  the  patient. 

Antiseptics  are  avoided  as  far  as  possible  in  intraperitoneal 
operations;  after  efficient  sterilization  of  the  hands  of  the  surgeon 
and  his  assistants  and  of  the  skin  of  the  patient,  nothing  is  employed 
in  the  shape  of  lotion  except  sterilized  salt  solution.  Instruments 
are  boiled  previously  and  counted.  Swabs  are  best  done  up  in 
packets  of  a  dozen,  wrapped  in  gauze;  it  is  thus  easy  to  keep 
account  of  the  number  employed.  Gauze  strips  for  packing,  ab- 
dominal cloths,  etc.,  are  dealt  with  in  the  same  way;  a  careful  lecord 
of  the  number  employed  must  be  made.  If  irrigation  of  the  abdomen  is 
required,  warm  salt  solution  is  the  best  lotion  to  use  for  the  purpose 


Fig.  456.- 


-Trendelenburg's  Position  for 
Pelvic  Operations. 


ABDOMINAL  SURGERY  961 

Parietal  Incision. — In  planning  the  incision  for  any  abdominal 
operation,  throe  desiderata  have  to  be  kept  in  view:  (i.)  Suitable 
access  should  be  provided  to  the  part  to  be  explored ;  naturally  the 
middle  line  gives  the  best  approach  in  the  majority  of  cases,  where 
a  general  exploration   is   desirable,  and  in  many  other  conditions 
it  is  most  useful.     But  when  dealing  with  such  structures  as  the 
appendix  or  gall-bladder,   an  incision  placed  laterally  is  usually 
more  convenient.     It  is  always  well  to  remember  that  incisions 
should  not  be  placed  too  near  to  the  bony  or  cartilaginous  boundaries 
of  the  abdominal  wall,     (ii.)  It  must  be  so  placed  as  to  ensure  an 
effective  blood-supply,  and  thereby  avoid  as  far  as  possible  the  risk 
of  defective  union  or  a  post-operative  hernia.     Naturally  the  middle 
line  from  this  point  of  view  is  not  always  desirable,  and  the  linea 
semi-lunaris  is  even  worse.     Particularly  is  this  the  case  when  the 
linea  alba  has  been  stretched,  and  the  recti  muscles  separated  one 
from  the  other.     Perhaps  the  best  incisions  from  this  point  of  view 
are  those  which  pass  through  muscular  fibres,  sphtting  and  separat- 
ing them,  but  not  dividing  them.     MacBurney's  incision  for  the 
removal  of  a  quiescent  appendix  (p.  1053)  is  of  this  nature;  it  gives 
a  sufficient  approach  when  there  are  no  adhesions,  and  when  the 
appendix  is  not  displaced.     Should  these  conditions  not  be  present, 
or  if  the  patient  is  very  stout,  it  will  prove  most  inconvenient ;  a 
similar  incision  may  also  be  used  in  ihac  colostomy.     Lennander's 
trap-door  incision  is  somewhat  similar  in  character.     It  consists 
m  opening  the  sheath  of  the  rectus  in  front,  displacing  the  muscle 
in  or  out,  and  then  making  the  incision  in  the  posterior  layer  of  the 
sheath,  and  through  the  peritoneum,  so  as  not  to  correspond  with 
that  in  front,     (iii.)  A  point  to  which  considerable  attention  has 
been  given  in  recent  years  is  the  nerve-supply  of   the  abdominal 
wall.     As  far  as  possible  the  incisions  should  be  planned  so  as  to 
avoid  division  of  the  motor  nerves,  especially  those  going  to  the 
rectus  abdominis,  inasmuch  as  paralysis  of  this  muscle  may  result 
in  considerable  discomfort,  and  loss  of  tone  of  the  abdominal  wall 
may  follow.     From  this  point  of  view  an  incision  through  the  hnea 
semi-lunaris  is  one  of  the  worst  that  could  be  devised.     To  avoid 
trouble  of  this  type,  various  suggestions  have  been  made  which 
will  be  noted  in  the  descriptions  of  different  operations  mentioned 
in  this  chapter. 

Some  surgeons  have  recommended  a  transverse  incision  of  the 
abdominal  wall,  especiallv  in  deaHng  with  pelvic  lesions;  the  chief 
difficulty  Hes  in  gaining  effective  union  of  the  divided  ends  of  the 
rectus  muscles.  "To  prevent  their  retraction  the  fibres  must  be 
carefuUv  stitched  with  mattress  sutures  to  the  anterior  wall  of  the 
sheath  before  being  divided;  on  the  whole  this  method  of  approach 
has  not  commended  itself  to  the  majority  of  surgeons,  and  it  is  not 
much  employed. 

As  far  as"  possible  the  muscles  and  aponeuroses  should  always 
be  cleanly  divided,  and  it  is  wise  to  see  that  bleeding  is  stopped 
before  opening  the  peritoneum ;  this  membrane  can  usually  be  picked 


962  A   MANUAL  OF  SURGERY 

up  by  dissecting  forceps,  and  opened  with  scissors  or  a  knife;  air 
rushes  into  the  cavity,  and  it  is  easy  to  secure  the  margins  with 
Spencer-Wells,  or  other  suitable  forceps.  Holding  these  well  up,  the 
incision  can  be  prolonged  up  or  down  as  far  as  may  be  considered 
necessary. 

The  intestines  must  be  carefully  guarded  during  the  intraperi- 
toneal portion  of  the  operation,  as  if  they  are  unduly  exposed  to  the 
air,  the  endothelial  lining  is  quickly  shed,  and  adhesions  may  form 
subsequently,  whilst  bacterial  invasion  from  the  gut  is  favoured. 
If  they  have  to  be  withdrawn  from  the  abdomen,  they  should  be 
wrapped  in  cloths  wrung  out  of  warm  salt  solution,  and  it  is  the 
assistant's  duty  either  to  replace  these  from  time  to  time  by  warm 
cloths,  or  better  to  keep  them  moist  and  warm  by  pouring  fresh  salt 
solution  over  them;  no  unnecessary  handling  of  intestine  is  per- 
mitted. If  any  infective  focus  is  to  be  opened,  or  the  intestine 
incised,  the  surrounding  parts  must  be  carefully  protected  from 
infection  by  '  walhng  off  '  the  area  of  operation ;  this  is  effected 
by  surrounding  it  with  abdominal  cloths  of  suitable  size  and  material, 
or  strips  of  sterilized  white  gauze,  wrung  out  of  warm  salt  solution, 
or  by  placing  them  in  directions  where  pus  or  other  fluid  might 
gravitate.  A  record  of  these  must  be  kept,  and  it  is  wise  not  to  cut 
any  of  them  into  smaller  pieces.  It  is  undesirable  to  use  dry  gauze 
for  this  purpose,  as  it  is  likely  to  stick  to  the  intestine,  and  its 
removal  may  disturb  the  endothelial  covering. 

Closure  of  the  Wound. — A  careful  toilette  of  the  peritoneum  must 
be  undertaken  before  the  abdomen  is  closed.  All  bleeding  is  stopped 
and  blood-clot  removed ;  swabs  are  counted,  and,  if  thought  neces- 
sary, the  site  of  operation  cleansed  with  steriHzed  salt  solution  at 
a  temperature  of  about  105°  F.  Many  different  methods  of  closing 
the  parietal  incision  have  been  adopted,  but  perhaps  the  best  consists 
in  first  securing  the  peritoneum  by  a  continuous  catgut  or  silk 
stitch;  then  the  muscular  coats  are  approximated  by  deep  inter- 
rupted stitches,  either  of  purified  silk  or  of  catgut,  which  remain 
buried;  and,  finally,  the  skin  is  united  by  means  of  a  continuous 
suture  of  catgut  or  silk,  which  is  subsequently  removed.  In  some 
parts  it  is  difficult  to  secure  the  peritoneum  separately,  and  then  it 
is  well  to  include  everything  except  the  skin  by  deep  interrupted 
sutures,  and  some  surgeons  even  include  the  skin  in  the  grasp  of 
these  deep  stitches. 

Drainage  is  not  usually  called  for  in  abdominal  operations.  If 
the  surgeon  is  careful  in  his  manipulations,  and  avoids  measures 
which  are  liable  to  lead  to  subsequent  oozing,  the  peritoneum  may 
be  closed  with  safety.  When  adhesions  likely  to  bleed  have  been 
divided,  or  raw  surfaces  left  such  as  occur  after  enucleating  a 
parovarian  cyst  from  the  broad  ligament,  some  means  should  be 
provided  whereby  any  considerable  effusion  of  fluid  can  escape, 
and  this  can  often  be  best  effected  by  the  use  of  a  rubber  drainage- 
tube  or  a  Keith's  glass-tube,  which  can  be  removed  in  twenty-four 
hours.     Into  the  latter  it  is  perhaps  as  well  to  introduce  a  strip  of 


ABDOMINAL  SURGERY 


963 


aseptic  gauze,  which  will  act  as  a  lamp-wick,  and  along  which, 
b}'  capillary  action,  the  effusion  finds  its  way  into  the  general  dressing 
placed  over  the  wound. 

On  the  other  hand,  when  an  infected  focus  has  been  opened  and 
needs  to  be  drained — e.g.,  an  acute  appendix  abscess — surrounding 
parts  must  be  protected  from 
the  spread  of  infection,  and 
this  is  best  accomplished  by 
the  use  of  a  rubber  drainage- 
tube,  around  which  sterile 
gauze  is  packed  in  such  a  way 
as  to  induce  the  formation  of 
protective  adhesions. 

After  -  Treatment.  —  x\fter 
the  completion  of  the  opera- 
tion, the  patient  is  replaced  in 
bed  with  the  head  low;  but 
this  position  need  not  be  main- 
tained for  any  length  of  time, 
and  after  a  gastro-enteros- 
tomy,  or  in  cases  of  diffuse 
peritonitis,  it  is  better  to  place 
him  in  the  Fowler  position 
(p.  97G)  at  once.  If  there  is 
much  shock,  hot-water  bottles 
are  placed  in  the  bed,  and  a 
rectal  injection  of  hot  coffee 
(4  or  5  ounces)  is  desirable. 
The  continuous  administra- 
tion of  hot  saline  solution 
per  rectum  is  also  inaugurated 
at  once;  this  is  best  under- 
taken by  emplo5dng  an  ap- 
paratus similar  to  that  repre- 
sented in  Fig.  457.  The  fluid 
is  kept  at  a  temperature  of 
105°  to  110°  F.  in  a  thermos 
flask,  and  allowed  to  escape 
through  a  suitable  dripper 
into  a  tube  which  passes 
6  inches  up  the  rectum ;  the 
fluid  is  introduced  into  the 
rectum  very  slowly,  so  that  it 
takes  perhaps  an  hour  and  a  half  to  administer  a  pint.  This  is 
generally  tolerated  very  well,  and  may  be  continued  for  a  day  or 
two.  It  is  of  value  not  only  to  relieve  shock,  but  also  to  make  good 
the  results  of  haemorrhage,  to  allay  thirst,  and  to  assist  in  ridding 
the  body  of  harmful  toxic  products  by  increasing  diuresis  and 
diaphoresis . 


Fig.  457. — Apparatus    for   Saline 
Infusion. 

The  flask  to  hold  the  fluid  is  supported 
by  a  bar  fixed  to  the  bedpost,  and  the 
rate  of  flow  is  regulated  by  the  tap 
placed  just  below  the  flask  and  above 
the  glass  dripper. 


964  A   MANUAL  OF  SURGERY 

Sedatives  may  be  employed  if  the  patient  is  restless  or  irritable,  and 
a  hypodermic  of  morphia  (gr.  J)  or  hydrochloride  of  heroin  (gr.  -^) 
may  be  administered.  Where  there  is  no  necessity  to  steady  the 
bowel  in  order  to  gain  adhesions,  heroin  is  the  better  drug  to  employ, 
since  its  paralyzing  effect  on  the  secretions  is  so  much  less ;  but  in 
some  cases,  where  it  is  desirable  to  localize  an  infection,  morphia 
is  more  suitable.  At  the  same  time  it  is  important  to  use  as  little 
sedative  as  possible,  and  in  not  a  few  cases  of  simple  operation,  such 
as  the  removal  of  an  appendix,  it  will  sufllce  to  introduce  into  the 
rectum,  immediately  after  the  operation,  30  grains  of  bromide  of 
potassium  and  15  or  20  grains  of  aspirin. 

The  feeding  of  abdominal  cases  has  undergone  a  certain  amount 
of  change  during  recent  years.  There  is  no  necessity  to  observe  the 
prolonged  abstention  from  food  that  used  to  be  practised.  Natur- 
ally, after  the  anaesthetic  nothing  is  given  by  mouth  for  some  hours, 
but  if  the  patient  does  not  complain  of  sickness  there  is  no  reason 
why  fluids  should  not  be  administered  after  a  short  interval,  and 
if  the  patient  feels  inclined  to  take  his  ordinary  diet  next  day, 
this  may  be  quite  well  permitted;  in  fact,  the  tendency  of  the 
modern  surgeon  is  rather  to  look  on  a  simple  abdominal  operation 
as  merely  an  incident,  and  to  interfere  with  normal  nutrition  as  little 
as  possible.  In  the  more  serious  cases,  especially  with  nervous 
patients  where  vomiting  is  hkely  to  ensue,  greater  care  must  be 
taken.  No  food  is  permitted  to  enter  the  stomach  for  the  day  of 
operation,  and  then,  when  post-operative  vomiting  comes  to  an 
end,  hot  water  in  teaspoonful  doses  should  alone  be  administered. 
Towards  the  end  of  the  first  twenty-four  hours  a  little  tea  or 
albumin  water,  or  milk  and  water,  may  be  given,  and  gradually 
the  diet  may  be  increased.  Special  directions  will  be  found  for  the 
feeding  of  particular  cases,  such  as  gastro-enterostomy,  where  the 
continuity  of  the  intestinal  canal  has  been  interfered  with. 

Not  uncommonly  there  is  a  good  deal  of  discomfort  and  abdominal 
distension  for  the  first  day  or  two.  This  is  usually  due  to  a  collec- 
tion of  flatus,  which  the  patient  is  unable  to  expel.  Relief  is  best 
obtained  by  the  administration  of  a  turpentine  enema  (i  ounce  of 
turpentine  to  i  pint  of  soap  and  water),  which  may  need  to  be 
repeated.  If  the  condition  persists,  and  is  accompanied  by  flatu- 
lence and  vomiting  {perilonism),  suggesting  the  possible  onset  of 
peritonitis,  the  administration  of  a  saline  purgative — e.g.,  20  grains 
of  sulphate  of  soda  every  half  hour — or  five  doses  of  i  grain  each  of 
calomel  every  hour,  may  stop  the  process  by  re-establishing  peristal- 
sis, removing  bacteria  and  their  products,  and  lessening  the  vascular 
tension.  A  hypodermic  injection  of  strychnine  or  of  eserine  may 
also  help  by  its  direct  stimulating  action  on  the  muscular  coat  of 
the  intestine.  Enemata  containing  castor  oil  (jii.)  and  olive  oil 
(siv.),  as  well  as  turpentine  (gi.),  are  also  sometimes  employed. 

The  Treatment  of  the  Wound  requires  no  special  attention.  The 
stitches  are  generally  removed  at  the  end  of  eight  or  ten  days,  and 
the  scar  may  then  be  supported  by  a  collodion  dressing  or  suitable 


ABDOMINAL  SURGERY  965 

strapping.  External  support  in  the  form  of  a  belt  is  sometimes 
thought  desirable,  and  to  be  effective  must  be  sufficiently  extensive. 
Where  there  has  been  suppuration  and  the  wound  has  healed  by 
granulation,  it  is  often  desirable  to  keep  the  parts  together  by  the 
use  of  strapping  for  some  months,  so  as  to  prevent  the  abdominal 
muscles  from  dragging  upon  the  scar  and  separating  the  united 
segments  of  the  abdominal  wall.  For  this  purpose  an  unirritating 
zinc-oxide-rubber  strapping  is  obtainable.  Treatment  of  this  type 
is  much  more  effective  than  the  use  of  a  belt,  and  should  particu- 
larly be  employed  after  the  draining  of  abscesses,  and  in  appendicitis 
where  the  muscles  have  had  to  be  divided. 

Stitch  Suppuration  is  a  troublesome  and  irritating  sequela  of 
abdominal  operations.  It  may  be  due  to  faulty  technique,  but 
occurs  quite  apart  from  this.  The  most  careful  steriHzation  of 
suture  material  will  not  always  prevent  its  occurrence,  and  then  it 
must  be  attributed  either  to  tying  the  suture  too  tightly  and 
strangling  the  tissue  within  its  grasp,  or  to  its  becoming  drawn  too 
tight  owing  to  post-operative  abdominal  distension,  and  to  auto- 
infection  of  this  strangled  tissue,  or  of  some  collection  of  blood 
around  it.  Not  a  few  cases  have  also  been  attributed  to  the 
employment  of  sutures  taken  directly  out  of  spirit,  which  acted 
thereby  as  a  caustic.  All  suture  material  should  be  carefully 
washed  in  sterilized  salt  solution  or  weak  antiseptic  lotion  before 
using  it  for  this  purpose.  The  trouble  may  start  early  or  late,  and 
its  occurrence  is  not  unfrequently  indicated  by  a  shght  but  per- 
sistent rise  of  temperature  (say,  "to  100°  every  night),  associated, 
perhaps,  with  an  increased  rate  of  pulse.  The  external  wound 
may  apparently  heal  perfectly,  and  then  ten  or  twelve  days  after 
the  operation  the  cicatrix  yields,  and  a  quantity  of  pus  may  escape. 
Under  these  circumstances  efficient  drainage  should  be  arranged, 
and  if  need  be,  the  exposed  stitches  must  be  removed.  Of  course, 
this  process  weakens  the  abdominal  wall,  and  extra  precautions 
must  be  taken  to  prevent  the  formation  of  a  ventral  hernia. 

Intestinal  Sutures. — The  interior  of  the  bowel  is  occupied  by 
.  material  which,  as  long  as  it  remains  in  its  proper  place,  is  innocuous 
enough;  but  should  it  find  its  way  into  the  peritoneal  cavity,  an 
acute  and  often  fatal  peritonitis  is  almost  certain  to  follow.  Hence, 
every  union  made  by  the  surgeon  must  be  air-  and  water-tight, 
and  capable  of  accommodating  itself  to  varying  degrees  of  intra- 
intestinal  pressure.  It  is  also  essential  that  on  its  peritoneal  aspect 
the  Hne  of  union  should  present  nothing  but  serous  membrane,  as 
otherwise  adhesions  are  likely  to  form,  and  the  comfortable  action 
of  the  bowel  may  be  subsequently  impaired.  Special  forms  of 
stitches  have  therefore  been  adopted,  the  more  important  of  which 
are  described  below. 

Lemhert's  Suture,  originally  proposed  at  the  end  of  the  eighteenth 
century,  has  for  its  object  the  bringing  of  surfaces  of  peritoneum 
together  without  encroaching  on  the  mucous  membrane ;  any  stitch 
which  involves  the  whole  thickness  of  the  wall  is  liable  to  be  followed 


966 


A   MANUAL  OF  SURGERY 


by  leakage  of  the  intestinal  contents,  and  possibly  by  peritonitis. 
The  needle  is  passed  at  right  angles  to  the  axis  of  the  wound  through 
a  small  fold  of  the  serous  and  muscular  coats,  going  down  to  the 
submucosa;  each  fold  is  placed  about  jV  inch  from  the  margin  of 
the  incision  (Fig.  458).  On  drawing  up  and  tightening  the  stitch, 
the  margins  of  the  wound  are  tucked  in  (Fig.  459),  and  only  the 
serous  coats  brought  into  apposition.     A  series  of  similar  stitches 


^■/y 


Fig.  459. — Lembert's  Suture 
SEEN  IN  Section,  to  show 
Character  of  Approxima- 
tion. 

I.,  Suture;  a,  serosa;  b,  mus- 
cularis;  c,  mucosa. 


Fig.  458. — ^Lembert's  Suture  as  applied  for 
A  Longitudinal  Wound  of  the  Bowel. 

The  stitches  are  carried  well  beyond  the  ex- 
tremities of  the  incision,  so  as  to  obliterate 
the  groove  always  caused  by  this  method 
of  suturing. 

are  inserted  along  the  whole  extent  of  the  wound,  numbering  about 
ten  or  twelve  to  the  inch,  or  it  may  be  carried  on  as  a  continuous 
stitch.  In  closing  a  longitudinal  incision  in  this  way,  a  groove  will 
be  formed  at  either  end  which  must  be  obliterated  by  two  or  three 
extra  sutures.     For  a  small  puncture  the  same  type  of  stitch  is 


Fig.  460. — Czerny-Lembert         Fig.  461. — Halstead's^Mattress  Suture. 
Suture. 

I.,  Stitch  securing  divided  mucous  membrane;  11.,  ordinary  Lembert  suture, 
for  the  serous  coats;  a,  serosa;  b,  muscularis;  c,  mucosa. 

utilized,  but  it  may  be  introduced  circularly  around  the  opening  like 
a  purse-string,  and  by  tightening  it  the  margins  of  the  aperture  are 
turned  in  and  buried  (Fig.  499). 

The  Czerny-Lembert  Suture  is  very  similar  in  its  nature,  but  con- 
sists of  two  rows  :  the  first  has  for  its  object  the  closure  of  the  wound 
in  the  mucous  membrane  (Fig.  460,  L),  and  in  a  longitudinal  wound 
this  may  be  of  the  continuous  type ;  the  second  row  consists  of  the 
ordinary  Lembert  stitches,  continued  or  interrupted  according  to 
the  requirements  of  the  case  (Fig.  460,  IL).     By  this  means  the 


ABDOMINAL  SURGERY 


967 


Fig.  462. — ^Wolfler's  Suture. 

,  Stitch  through  serous  and  mus- 
cular coat  applied  and  tied  from 
within;  II.,  stitch  uniting  divided 
mucous  membrane  over  the 
former,  so  as  to  cover  it  in;  a,  se- 
rosa; b,  muscularis;  c,  mucosa. 


knots  of  the  first  series  of  sutures  are  covered  over  and  buried  by 
the  second  row.  When  carefully  introduced,  these  stitches  not  only 
serve  to  approximate  the  divided  walls  of  the  intestine,  but  also  are 
valuable  haemostatic  agents,  especially  if  inserted  continuously. 

Ha  I  stead's  Mattress  Suture  (Fig.  461)  is  a  very  useful  one,  and 
constantly  utilized.  It  consists  practically  of  a  double  Lembert, 
a  loop  being  thus  formed  at  one 
end,  whilst  the  knot  is  tied  at  the 
other.  It  is  introduced  with  ex- 
actly the  same  precautions  as  the 
original  Lembert. 

Occasionally  it  happens  that  two 
segments  of  bowel  have  to  be 
stitched  together  from  inside,  since 
the  surgeon  cannot  reach  the  outer 
coats  owing  to  this  portion  being 
fixed.  Thus,  in  an  exploratory 
gastrotomy  it  may  be  necessary 
to  stitch  up  the  posterior  wall  of 
the  stomach  after  having  opened 
it  from  the  front.  The  stitches 
must  then  be  inserted  by  what  is  known  as  Wolfler's  Method 
(Fig.  462).  They  are  first  passed  through  the  serous  and  muscular 
coats  on  either  side  (I.),  the  knots  being  tied  on  the  inner  aspect — 
i.e.,  towards  the  lumen  of  the  open  viscus.     The  mucous  membrane 

is  then  secured  by  a 
second  row  of  stitches 
(II.),  so  as  to  cover  over 
1:he  first  series  of  knots. 
In  many  forms  of  intes- 
tinal anastomosis  this 
plan  has  also  to  be  em- 
ployed; as  soon  as  possi- 
ble, however,  one  changes 

to  the  Czerny-Lembert 
Fig.  463. — Cushing's  Right-Angled  Suture   j^pfV,Q(4 

FOR  Uniting  the    Sero-Muscular  Coats  :     ,     ^  •  7  ^    t       7  j 

OF  THE  Stomach  or  Intestine.  Lushing  s  Rtght- Angled 

For  the  sake  of  clearness  the  preliminary  row  j:   1  ° '  1   -^'         j- 

of  stitches  through  the  mucous  membrane    USeiUl  one  Wlien  SUIiaces 
is  omitted  in  this  diagram.  of  some  extent  have  to  be 

approximated  by  a  con- 
tinuous stitch.  The  suture  is  introduced  at  one  end  of  the  incision 
and  tied  according  to  the  usual  Lembert  method,  and  then  it  is  carried 
on  as  a  continuous  Lembert  suture,  except  that  the  needle  is  intro- 
duced parallel  to  the  margins  of  the  wound  and  at  a  distance  of 
about  i  inch  from  it,  instead  of  at  right  angles  to  it.  The  edges  are 
thereby  tucked  in  very  neatly.  Of  course  the  mucous  membrane 
is  first  dealt  with  separately  by  some  form  of  continuous  suture.  It 
may  be  employed  very  advantageously  in  gastro- enterostomy  or 
any  similar  procedure. 


g6S  A   MANUAL  OF  SURGERY 

Injuries  of  the  Abdominal  Wall. 

These  may  be  divided  into  three  main  classes — contusions,  non- 
penetrating and  penetrating  wounds;  but,  of  course,  the  most 
important  point  about  them  is  as  to  whether  or  not  visceral  com- 
plications are  present. 

Simple  Contusions  of  the  abdominal  parieties  differ  but  little  from 
those  of  any  other  region  of  the  body.  Any  form  of  lesion,  from  a 
slight  bruise  to  an  extensive  muscular  laceration,  may  be  included 
in  this  category.  The  rectus  is  the  muscle  most  often  involved,  and 
its  laceration  may  result  not  only  from  injury,  but  also  as  a  conse- 
quence of  sudden  and  forcible  contractions,  e.g.,  in  tetanus.  Blood 
is  extravasated  between  or  under  the  muscles,  and  a  well-marked 
haematoma  may  follow.  In  connection  with  the  rectus  the  haemor- 
rhage may  be  limited  by  the  linse  transversse  if  it  only  involves  the 
anterior  aspect,  but  may  diffuse  itself  widely  through  the  sheath  if 
the  back  of  the  muscle  is  torn.  All  abdominal  ha^matomata  are 
very  liable  to  suppurate,  the  abscess  either  pointing  locally  or 
burrowing  widely  between  the  muscular  planes,  and  coming  to 
the  surface  at  some  weak  spot,  e.g.,  Petit's  triangle  or  the  external 
abdominal  ring.  The  pus  is  usually  redolent  of  the  B.  coli,  suggesting 
that  the  organism  found  its  way  into  the  extravasated  blood  from 
some  damaged  coil  of  intestine  in  the  neighbourhood.  Occa- 
sionally the  parietal  peritoneum  is  torn,  causing  shock  and  intra- 
peritoneal extravasation  of  blood.  In  almost  all  cases  of  abdominal 
contusion  shock  is  an  important  early  symptom,  but  in  the  absence 
of  visceral  lesions  it  is  neither  severe  nor  prolonged. 

Treatment  consists  in  keeping  the  patient  in  bed  until  the  tender- 
ness and  pain  have  disappeared.  Shock  is  dealt  with  in  the  usual 
way ;  and  fomentations  or  a  firm  compress  of  dry  hot  wool  will  give 
much  comforting  support.  Rupture  of  the  rectus  muscles  necessi- 
tates the  adoption  of  the  sitting  position,  with  the  knees  flexed  over 
pillows:  at  a  later  date  support,  as  by  strapping  or  a  well-fitting 
abdominal  belt,  will  be  required. 

Non-Penetrating  Wounds  of  the  Abdominal  Wall  have  no  special 
significance,  and  if  uncomplicated  by  visceral  lesions  are  treated  on 
general  principles.  If  the  epigastric  artery  is  divided,  extensive 
extravasation  is  likely  to  ensue;  the  wound  must  then  be  enlarged, 
and  the  bleeding  points  secured.  If  the  abdominal  muscles  are 
widely  divided,  steps  should  be  taken,  after  thorough  purification, 
to  draw  together  the  severed  muscular  or  aponeurotic  fibres  by 
deep  stitches,  so  as  to  diminish  the  tendency  to  a  ventral  hernia. 

Penetrating  Wounds  of  the  Abdominal  Wall  may  occur  with  or 
without  injury  or  protrusion  of  the  abdominal  viscera.  In  all  cases 
there  is  a  certain  amount  of  haemorrhage,  greater  or  less  according 
to  the  size  of  the  vessels  divided,  and  of  shock,  which  latter  is  very 
marked  when  the  viscera  are  injured,  whilst  mere  protrusion  without 
injury  may  cause  but  little  effect.  Thus,  cases  are  on  record  in 
which  a  patient  has  walked  to  the  surgeon  for  treatment,  supporting 


ABDOMINAL  SURGERY  969 

some  coils  of  intestine  in  his  hands.  The  protruded  viscera,  usually 
small  intestine  or  omentum,  are  often  large  in  amount  compared 
with  the  size  of  the  opening,  causing  them  to  be  more  or  less  con- 
gested or  even  strangled.  Necessarily,  in  all  cases  the  great  danger 
is  that  of  diffuse  septic  peritonitis,  caused  either  by  rupture  of  the 
intestine  or  by  infection  from  without. 

Treatment. — The  external  wound  is  carefully  cleansed,  whilst 
protruding  viscera  are  similarly  purified.  If  omentum  has  escaped, 
it  is  wise  to  ligature  and  remove  it,  whether  it  is  injured  or  not. 
Intestine  should  be  carefully  washed  with  warm  saline  solution  and 
replaced;  if  slightly  bruised,  it  may  be  returned,  but  the  external 
wound  should  not  be  entirely  closed,  and  a  drainage-tube  or  gauze 
wick  is  inserted,  so  that  if  bacillary  invasion  or  faecal  extravasation 
occurs  subsequently  a  ready  exit  is  provided.  Small  incisions  or 
punctures  must  be  infolded  and  sutured,  but  when  small  intestine 
is  seriously  damaged,  enterectomy  should  be  undertaken  if  the 
patient's  general  condition  is  sufficiently  good ;  otherwise  it  must  be 
fixed  to  the  abdominal  wall,  and  a  temporary  artificial  anus  pro- 
vided. With  the  large  intestine,  this  latter  course  is  required  more 
often,  and  especially  in  cases  where  the  bowel  is  loaded  with  faeces ; 
the  gut  must  then  be  fixed  in  the  wound  as  in  colostomy,  and  the 
defect  dealt  with  at  a  subsequent  period. 

In  cases  where  it  is  not  certain  whether  the  peritoneum  has  been 
implicated,  the  surgeon  should  always  enlarge  the  wound  so  as  to 
make  sure,  and  if  the  serous  membrane  has  been  involved,  he  should 
carry  his  investigations  still  further,  and  ascertain,  if  possible, 
whether  any  damage  has  been  done  to  the  viscera. 

The  external  wound  must  (with  the  exception  mentioned  above) 
be  carefully  closed  with  sutures,  so  as  to  minimize  the  risk  of  a 
subsequent  ventral  hernia. 

Visceral  Complications  are  hkely  to  be  associated  with  any  injury 
to  the  abdominal  wall,  and  may  transform  it  into  a  lesion  of  the 
gravest  import.  The  habihty  to  visceral  injury  varies  with  the 
character  of  the  violence,  and  with  the  condition  of  the  abdominal 
wall  and  of  the  subjacent  viscera.  If  the  blow  is  shght,  the  effects 
are  probably  not  serious,  and  the  patient  merely  suffers  from  a 
localized  contusion  with  some  amount  of  shock.  If  the  blow  is 
expected,  and  the  muscles  are  rigid,  but  Httle  harm  may  follow, 
even  when  the  violence  is  great;  but  when  the  abdominal  wall  is 
relaxed  and  the  blow  unexpected,  a  shght  injury  may  do  much 
mischief.  Hollow  viscera,  such  as  the  stomach,  intestine,  or  bladder, 
may  be  torn,  and  when  distended  they  are  more  liable  to  such  an 
accident.  Sohd  viscera,  such  as  the  liver,  spleen,  or  kidnej^s,  may 
be  bruised  or  torn,  and  grave  haemorrhage  may  result  theVefrom; 
a  soft  fatty  condition  of  the  organs,  especially  of  the  liver,  may 
predispose  to  such  a  lesion.  Displacement  of  organs  may  some- 
times occur,  and  it  must  not  be  forgotten  that  any  sudden  sharp 
concussion,  especially  if  directed  to  the  epigastrium,  is  hable  to 
be  followed  by  severe  shock  from  irritation  of  the  subjacent  solar 


970  A   MANUAL  OF  SURGERY 

plexus,  and  life  itself  may  be  destroyed  in  this  way  by  syncope 
without  the  appearance  of  an  evident  lesion.  The  omenta,  mesen- 
teries, and  peritoneal  ligaments  may  also  be  torn,  and  give  rise 
immediately  to  haemorrhage,  or  subsequently  to  the  formation  of 
apertures  or  bands,  which  may  determine  obstructive  phenomena 
at  a  later  date.  Thus,  a  blow  in  the  epigastrium  was  followed  by 
detachment  of  the  round  ligament  of  the  liver  from  the  falciform 
ligament,  constituting  a  band  which  compressed  the  transverse  colon. 

The  clinical  history  of  these  injuries  will  be  described  under  the 
various  organs,  and  only  a  few  general  statements  need  be  made 
here.  It  is  obvious  that  a  serious  responsibility  rests  upon  the 
medical  attendant  in  any  case  of  abdominal  injury,  and  that  the 
gravest  results  may  follow  a  mistaken  conclusion  as  to  the  nature 
of  the  lesion,  or  a  hesitant  policy  in  undertaking  operation.  In 
a  large  proportion  of  cases  abdominal  injuries,  even  including 
rupture  of  intestine,  are  amenable  to  treatment  by  operation,  if 
only  it  is  performed  sufficiently  earl\-;  if,  however,  it  is  delayed 
until  the  gut  is  paralyzed  and  peritonitis  well  established,  death  is 
almost  certain  to  ensue  whether  the  abdomen  is  opened  or  not. 
Unfortunately,  no  absolute  rules  can  be  laid  down  as  to  when  opera- 
tion is  necessary,  but  the  surgeon  should  remember  that  exploration 
in  a  doubtful  case  will  probably  do  far  less  harm  than  by  waiting 
until  the  diagnosis  is  made  certain  by  an  outbreak  of  diffuse  in- 
flammation, providing  always  that  the  patient  is  not  so  profoundly 
collapsed  as  to  contra-indicate  all  interference. 

Cases  of  serious  abdominal  injury  group  themselves  into  three  sets : 
(i)  Where,  in  addition  to  a  localized  lesion  of  the  parietes,  there  is 
severe  shock  due  to  contusion  of  viscera,  but  with  no  justification  for 
laparotomy ;  (2)  where  there  is  serious  intraperitoneal  haemorrhage,  as 
from  a  ruptured  liver  or  spleen,  or  a  tear  of  the  mesentery ;  and  (3) 
where  a  hollow  viscus  is  opened,  and  peritonitis  is  at  once  lighted  up. 

Shock  is  almost  always  w^ell  marked  in  abdominal  lesions,  but 
unless  there  is  a  serious  wound  of  some  viscus,  it  usually  passes  off 
in  less  than  twenty-four  hours  if  the  patient  is  left  quietly  in  bed. 
Jntraperito7ieal  hcemorrhage  causes  various  symptoms  according  to 
its  amount  and  site  of  origin;  in  addition  to  the  initial  shock,  the 
general  signs  characteristic  of  this  condition  show  themselves,  viz., 
pallor,  restlessness,  '  air-hunger,'  and  possibly  the  large-waved 
hemorrhagic  pulse.  Dulness  may  be  noted  in  one  or  both  flanks, 
according  to  the  situation  of  the  lesion,  being  influenced  by  the 
attachment  of  the  mesentery;  thus  blood  from  the  liver  may  gravi- 
tate into  and  for  a  time  be  limited  to  the  right  lumbar  region  and 
ihac  fossa  without  reaching  the  pelvic  cavity ;  blood  from  the  spleen 
will  pass  freely  down  into  the  pelvis  along  the  left  side  of  the 
mesentery,  producing  dulness  in  the  left  loin  and  not  in  the  right. 
It  must  be  remembered,  however,  that  a  large  quantity  of  blood 
may  escape  into  the  peritoneal  cavity  without  the  production  of  any 
recognisable  area  of  dulness;  it  is  then  lodged  under  the  costal  arch, 
or  amongst  the  intestines,  or  in  the  pelvis.     When  the  bleeding  is 


ABDOMINAL  SURGERY  971 

less  severe,  the  patient  complains  of  a  severe  tearing  pain,  becomes 
pallid  and  anjemic,  but  may  recover,  and  the  blood  be  absorbed; 
not  unfrcquently  the  temperature  runs  up  after  the  initial  shock  has 
passed,  and  remains  up  for  some  days.  The  onset  of  peritonitis  is 
indicated  by  persistence  of  the  collapse,  and  vomiting  or  hiccough, 
whilst  the  abdomen  becomes  distended,  its  wall  is  held  rigidly  steady, 
and  the  breathing  becomes  thoracic;  probably  some  fixed  spot  of 
maximum  tenderness  will  be  noted,  especially  when  the  intestine  is 
injured. 

Treatment. — The  patient  having  been  put  to  bed,  and  the  initial 
shock  combated  in  the  usual  way,  a  most  careful  examination  of  the 
patient  and  his  abdomen  is  instituted.  Conditions  which  indicate 
immediate  operation  are:  {a)  the  signs  of  intraperitoneal  hgemor- 
rhage;  (6)  blood-stained  vomiting,  indicating  a  rupture  of  the 
stomach;  (c)  a  fixed  and  rigid  abdominal  wall  coming  on  quickly 
after  an  injury,  with  severe  pain  and  locahzed  tenderness,  suggesting 
a  rupture  of  the  intestine ;  and  [d]  the  phenomena  due  to  a  ruptured 
bladder.  Under  such  circumstances,  no  delay  is  justifiable,  and, 
even  if  severe  shock  is  present,  operation  should  be  commenced, 
unless  death  is  evidently  imminent.  A  large  intravenous  injection 
of  hot  saHne  solution  will  usually  rally  the  patient  sufficiently  to 
warrant  the  surgeon  in  proceeding,  or  better  still,  ether  may  be 
administered  by  the  intravenous  method.  If,  however,  well- 
marked  shock  is  present,  with  perhaps  localized  pain,  but  with  no 
absolute  e\ddence  of  visceral  lesions,  expectant  treatment  should  be 
adopted.  The  patient  is  kept  warm  in  bed;  perhaps  a  little  opium 
is  administered  to  allay  pain  and  restlessness  and  to  check  peristal- 
sis, but  as  httle  as  possible  should  be  given,  since  symptoms  are  so 
completely  masked  thereby.  If  there  is  any  vomiting,  rectal  ali- 
mentation should  be  employed  after  the  lower  bowel  has  been  washed 
out.  If  the  manifestations  of  intraperitoneal  haemorrhage  subse- 
quently make  themselves  e\adent,  or  if  at  the  end  of  not  more  than 
twent^'-four  hours  the  patient  is  still,  more  or  less,  in  a  condition 
of  collapse,  and  especially  if  he  complains  of  a  fixed  tender  spot 
with  a  rigidly  contracted  abdominal  wall  over  it,  or  if  vomiting  or 
hiccough  has  supervened,  then  operation  can  still  be  undertaken 
with  some  prospect  of  success. 

There  are  but  few  other  conditions  of  the  abdominal  wall  which 
require  notice.  The  rectus  muscle  may  be  torn  as  a  result  of  injury 
or  of  tetanic  comnilsions,  and  a  hernia  is  very  likely  to  follow.  One 
of  the  segments  may  become  spasmodically  contracted,  constituting 
what  is  known  as  a  '  phantom  tumour,'  usually  occurring  in  hys- 
terical females,  and  disappearing  under  an  anaesthetic. 

Aiieetions  of  the  "Dmbilicus. 

The  various  forms  of  umbilical  hernia  are  described  elsewhere. 
Inflammation  and  Ulceration,  perhaps  running  on  to  eczema,  may 
arise  from  want  of  cleanliness  after  separation  of  the  cord.     Tetanus 


972  A   MANUAL  OF  SURGERY 

neonatorum  probably  owes  its  origin  to  this  source,  as  also  the 
erysipelas  of  infants,  both  of  which  diseases  are  exceedingly  fatal, 
whilst  the  latter  is  often  accompanied  by  sloughing  of  the  neigh- 
bouring abdominal  parietes.  The  eczcmatous  condition  merely 
requires  cleanliness,  and  the  application  cither  of  an  antiseptic 
dusting-powder  or  of  some  simple  ointment.  In  adult  life  inflam- 
mation is  occasionally  seen  as  a  result  of  the  accumulation  of  dirt 
in  the  umbilical  fossa;  this  accumulates  at  times  to  such  an  extent 
as  to  constitute  a  calculus,  which  gives  rise  to  suppuration  and 
ulceration. 

Occasionally  a  Polypoid  Excrescence  is  met  with  growing  from 
the  umbilicus,  and  is  probably  derived  from  the  remains  of  the 
umbilical  vesicle.  On  microscopic  examination,  it  is  found  to 
consist  of  a  number  of  tubular  glands  held  together  by  connective 
tissue.     All  that  is  needed  is  to  ligature  the  base  and  cut  it  away. 

Warts  and  Nsevi  are  also  found  here,  but  have  no  special  features. 
Cancer  of  the  umbilicus  may  be  primary,  occurring  either  as  a 
squamous  epithelioma,  starting  in  the  skin  as  a  result  of  prolonged 
irritation,  or  as  a  columnar  carcinoma,  arising  in  some  foetal  relic. 
More  frequently  it  is  secondary  to  some  deep  abdominal  focus, 
such  as  cancer  of  the  stomach  or  ovary. 

Umbilical  FistiUee  not  unfrequently  occur,  and  may  be  congenital 
or  acquired.     Three  varieties  are  described: 

{a)  A  F cecal  Fistula  of  congenital  origin  arises  from  non-closure  of 
the  vitello-intestinal  duct,  and  opens  into  the  intestine  either 
directly,  or  by  means  of  a  passage  of  greater  or  less  length,  which 
corresponds  to  Meckel's  diverticulum,  and  is  connected  with  the 
lower  part  of  the  ileum.  Sometimes  this  passage  is  closed  at  the 
intestinal  end,  and  then  only  discharges  mucus.  Acquired  cases 
are  usually  due  to  perforation  of  the  bowel  following  strangulation 
of  an  umbilical  hernia,  or  to  tuberculous  peritonitis. 

{b)  A  Congenital  Urinary  Fistula  is  due  to  non-closure  of  the 
urachus;  occasionally  merely  a  sinus  persists,  leading  towards  the 
bladder,  but  not  opening  into  it.  It  may  be  dealt  with  by  excision 
of  the  mucous  membrane,  its  destruction  by  the  galvano-cautery,  or 
by  freshening  the  edges  and  subsequent  sutiire. 

(c)  A  Biliary  Fistula  sometimes  forms  at  the  umbilicus,  resulting 
from  an  abscess  connected  with  the  gall-bladder. 

Affections  of  the  Peritoneum. 

Peritonitis  arises  from  many  different  conditions  and  presents 
many  diverse  manifestations.  It  may  be  acute  or  chronic  in  its 
course,  localized  or  diffuse  in  its  distribution,  and  protective  or 
rapidly  destructive  in  its  results. 

.etiology. — Peritonitis  is  almost  invariably  due  to  the  action  of 
micro-organisms,  and  the  symptoms  largely  depend  on  the  toxaemia 
determined  thereby.  The  bacteria  light  up  an  inflammatory  re- 
action characterized  by  effusion  of  varying  type;  in  the  mildest 


ABDOMINAL  SURGERY  973 

forms  it  is  usually  abundant  and  localized,  in  the  severer  types  it 
is  generalized,  and  in  the  worst  cases  death  in  ay  ensue  from 
toxtemia  before  there  lias  been  time  for  the  development  of_^marked 
anatomical  changes. 

1.  Infection  may  start  from  any  part  of  the  intestinal  canal  or  its 
adnexa,  included  in  the  abdomen,  from  stomach  to  rectum.  It  may 
be  due  to  traumatic  or  pathological  rupture  or  perforation,  to  the 
extension  outwards  of  ulcers,  to  the  impaction  of  foreign  bodies,  or 
the  damaging  influence  of  interference  with  the  blood-supply,  as  in 
strangulation,  volvulus,  etc.  The  vermiform  appendix  is  the  com- 
monest site  of  onset  of  this  group  of  cases.  The  Streptococcus 
pyogenes  and  B.  coli  are  the  organisms  most  frequently  present,  but 
some  of  the  other  inhabitants  of  the  intestine,  especially  those'that 
are  anaerobic,  are  occasionally  causative.  On  the  whole  the  gastric 
contents  are  less  noxious  than  those  of  the  intestine,  and  the  fluid 
contents  of  the  small  gut  are  more  hable  to  be  diffused,  and  therefore 
do  more  harm  than  the  more  soHd  fasces  in  the  large. 

2.  A  somewhat  similar  type  of  origin  causes  puerperal  peritonitis, 
the  organisms  (usuaUy  streptococci,  but  of  any  pyogenic  form) 
extending  from  the  uterus  through  the  lymphatics  of  the  broad 
ligament,  etc.,  to  the  peritoneum;  it  is  therefore  possible  for  the 
mischief  to  limit  itself  to  the  pelvic  viscera. 

3.  Infection  may  occur  from  without,  as  in  perforating  wounds, 
operations,  etc.,  any  of  the  ordinary  pyogenic  organisms  being 
responsible,  but  especially  the  streptococcus.  The  hkelihood  of 
infection  depends  largely  on  the  peritoneum  remaining  unbraised; 
rough  handling  and  prolonged  exposure  are  only  too  likely  to  destroy 
the  surface  endothelium  and  diminish  its  resisting  powers,  whilst 
the  same  conditions  check  the  power  of  absorbing  fluids,  and  hence 
permit  of  bacterial  growth. 

4.  Peritonitis  may  be  due  to  the  gonococcus,  and  then  has  usually 
spread  up  the  Fallopian  tube  (p.  982) ;  to  the  pneumococcus,  probably 
as  a  blood  infection,  or  secondary  to  pneumonia  or  pleurisy,  the 
bacteria  travelhng  through  the  lymphatics  of  the  diaphragm  (p.  982) ; 
and  possibly  to  the  organism  of  acute  rheumatism,  then,  perhaps, 
starting  in  the  appendix. 

5.  The  B.  tuberculosis  is  responsible  for  the  development  of  a 
chronic  tuberculous  peritonitis. 

6.  Simple  chronic  peritonitis  is  of  a  protective  character,  and 
arises  when  any  irritative  lesion  of  a  viscus  slowly  approaches  the 
peritoneal  surface,  which  becomes  thickened  in  consequence.  Ad- 
hesions of  various  types  may  result  from  this  reaction,  and  grave 
developments  (obstruction,  strangulation,  etc.)  may  follow  at  a  later 
date. 

7.  A  group  of  cases  occurs  in  which  the  causative  lesion  is 
mechanical  or  chemical  in  the  first  place — e.g.,  extravasation  of  bile 
from  a  ruptured  gall-bladder,  or  the  irritation  produced  by  torsion 
of  a  wandering  spleen,  of  an  ovarian  cyst,  or  even  of  the  omentum. 
Severe  reaction  follows  such  a  lesion,  but  it  is  possible  that  the  focus 


974  A   MANUAL  OF  SURGERY 

may  be  shut  oft  from  the  general  cavity  by  plastic  adhesions,  and  be 
thereby  encapsuled  or  absorbed;  or  the  inflammation  may  extend 
to  neighbouring  coils  of  intestine,  and  when  once  these  become 
paralyzed  bacterial  invasion  is  almost  certain  to  follow,  and  septic 
peritonitis  to  ensue. 

It  is  interesting  to  note  that  a  localized  immunity  can  be  developed 
in  the  peritoneal  cavity  of  animals  by  injecting  gradually  increasing 
doses  of  toxic  material;  it  is  probable  that  a  similar  condition  obtains 
in  man,  and  this  explains  why  the  sites  of  old  peritonitic  trouble  are 
often  favourable  for  operations,  an  attack  of  generalized  inflamma- 
tion being  unusual. 

Varieties. — From  a  purely  clinical  standpoint,  peritonitis  may  be 
discussed  under  two  main  headings^ — the  acute  and  the  chronic. 
The  acute  is  again  divided  into  the  diffuse  and  localized,  and  the 
chronic  into  the  simple  and  the  tuberculous. 

I.  Acute  Diffuse  Peritonitis  results  from  infection  of  the  peritoneal 
cavity  with  a  large  dose  of  infective  material  (as  by  rupture  of  the 
stomach  or  intestine),  or  by  the  introduction  of  a  small  dose  of 
virulent  organisms  when  the  resisting  powers  are  low. 

Pathological  Anatomy. — The  peritoneal  surface  becomes  con- 
gested and  a  little  sticky,  and  its  shiny  appearance  is  lost  as  a  result 
of  the  proliferation  of  the  endothelial  cells  and  a  commencing 
oedema  of  the  subserous  connective  tissues;  this  change  is  most 
advanced  in  the  neighbourhood  of  the  site  of  infection,  but  rapidly 
spreads,  and  in  the  gravest  forms  of  peritoneal  toxaemia,  where 
death  takes  place  under  twenty-four  hours,  there  is  but  little  other 
evidence  of  the  disease.  In  the  great  majority  of  cases,  however, 
effusion  occurs;  sometimes  the  fibrinous  element  is  most  marked, 
the  intestines  being  matted  together,  and  the  fibrin  thickest  along 
the  lines  of  contact  of  adjacent  coils;  sometimes  there  is  an  abundant 
serous  exudation,  but  more  frequently  it  is  sero-purulent  or  consists 
simply  of  pus,  which  may  gravitate  to  the  loins  and  pelvis,  or  travel 
upwards  under  the  diaphragm,  or  be  shut  up  in  pockets  by  the 
development  of  adhesions.  The  effusion  is  intensely  infective, 
and  the  surgeon  should  always  protect  his  hands  by  rubber  gloves, 
since  any  wounds  caused  during  operation  or  in  the  post-mortem 
examination  are  likely  to  be  followed  b}^  severe  cellulitis  or  even 
septicemia.  Gas  may  be  present,  resulting  either  from  the  laying- 
open  of  an  air-containing  viscus,  or  from  the  presence  of  a  gas- 
producing  organism. 

The  intestinal  walls  become  paralyzed,  as  a  direct  result  of  the 
toxins  upon  the  contained  nervous  plexuses,  and  in  consequence 
the  contents  of  the  gut  stagnate  and  undergo  decomposition.  The 
omentum  becomes  congested  and  infiltrated  with  eftusion,  or  even 
pus;  it  may  occasionally,  however,  form  a  barrier  across  the 
abdomen,  shutting  off  the  lower  from  the  upper  part,  and  thus  limit- 
ing the  mischief  to  one  or  other  section. 

The  toxins  developed  in  the  exudate  are  absorbed  by  the  peri- 
toneum,   and   whilst   causing   a   generalized   toxaemia   of   varying 


ABDOMINAL  SURGERY  975 

severity,  they  may  also  determine  a  well-marked  subperitoneal 
oedema.  The  rapidity  of  absorption  is  very  considerable,  especially 
from  the  under  surface  of  the  diaphragm,  where  the  lymphatics 
are  practically  continuous  with  the  peritoneal  cavity,  and  quickly 
carry  toxins  and  bacteria  to  the  mediastinal  glands.  The  upper 
half  of  the  abdomen  is  therefore  a  less  favourable  site  for  peritonitic 
trouble  than  the  lower,  and  all  available  means,  such  as  position, 
drainage,  etc.,  must  be  employed  to  limit  or  prevent  the  extension 
of  the  trouble  in  this  direction. 

Symptoms. — The  onset  varies  somewhat  with  the  cause  of  the 
affection;  but  when  due  to  traumatic  infection  from  without,  the 
symptoms  usually  commence  with  abdominal  pain  and  distension, 
together  with  flatulence  and  vomiting.  The  pain  may  be  localized 
at  first  to  some  particular  region,  or  is  referred  to  the  umbilicus ; 
soon,  how^ever,  it  becomes  diffuse,  and  is  associated  with  exquisite 
tenderness  and  great  distension.  In  a  typical  case  the  phenomena 
are  very  characteristic.  The  patient  lies  on  his  back  with  the  knees 
drawn  up,  partly  to  relax  the  abdominal  muscles,  partly  to  prevent 
the  bedclothes  touching  the  body.  The  abdomen  is  distended,  hard, 
and  extremely  tender;  it  is  at  first  generally  tympanitic,  but  later 
on,  if  effusion  should  become  marked,  dulness  may  be  noted  in  the 
flanks,  although  this  is  not  a  common  feature.  The  pulse  is  quick, 
hard,  and  wiry  in  the  early  stages,  though  later  it  becomes  weak, 
rapid,  and  compressible.  The  respirations  are  quick,  shallow,  and 
thoracic  in  character.  The  temperature,  perhaps  raised  at  first  as 
a  result  of  the  causative  lesion,  sometimes  becomes  subnormal  from 
toxaemia  before  the  end  is  reached.  Vomiting  is  usually  a  prominent 
symptom,  associated  perhaps  with  hiccough ;  to  commence  with,  the 
contents  of  the  stomach  alone  are  expelled,  but  later  on  the^^  may 
be  mixed  with  bile,  or  with  the  decomposing  contents  of  the  upper 
coils  of  intestine.  Though  very  constant  and  troublesome,  it  is 
much  less  distressing  than  that  which  arises  from  intestinal  obstruc- 
tion, and,  owing  to  the  pain  induced  by  any  sudden  contraction 
of  the  abdominal  muscles,  the  patient  ejects  the  vomit  with  but 
little  force.  Constipation  and  the  absolute  arrest  of  flatus  are 
almost  always  present  in  peritonitis,  owing  to  the  cessation  of 
peristalsis  induced  by  the  inflammation,  and  hence  meteorism  is 
a  marked  symptom.  As  the  case  progresses,  the  patient's  strength 
rapidly  diminishes,  his  face  becomes  pinched  and  drawn  {fades 
Hippocrafica) ,  the  extremities  are  cold,  the  temperature  is  usually 
subnormal,  and  death  results  from  collapse  and  toxaemia. 

When  due  to  sudden  perforation  of  the  bowel,  the  onset  of  the 
symptoms  is  associated  with  profound  shock,  and  the  course  is  very 
rapid  if  the  opening  is  large,  and  the  intestinal  contents  early  extra - 
vasated.  Vomiting,  too,  is  usually  more  marked  than  when  due  to 
other  causes.  If,  however,  the  perforation  is  small,  the  immediate 
shock  is  less,  and  the  symptoms  progress  more  graduall}'. 

As  already  mentioned,  there  are  certain  grave  cases  in  which  the 
general  toxaemia  is  the  most  marked  phenomenon,  and  these  may 


976 


A   MANUAL  OF  SURGERY 


succumb  from  exhaustion  in  from  twelve  to  twenty-four  hours. 
The  majority  of  cases,  however,  last  for  three  or  four  days.  Recovery 
is  heralded  in  by  a  diminution  or  cessation  of  the  vomiting  and  the 
passage  of  flatus,  whilst  the  pulse-rate  falls,  and  the  local  symptoms 
gradually  clear  up.  . 

Treatment— In  the  early  stages,  if  the  diagnosis  is  m  doubt,  or 
the  desnability  of  operation  is  in  question,   the  patient  is  kept 


Fig.  464. 


Fig.  465. 

Figs.  464  and  465. — Diagrams  to  Represent  the  Value  of  Fowler's 
Position  in  the  Treatment  of  Inflammatory  Affections  within 
the  Abdomen. 

In  Fig.  464  the  patient  is  horizontal,  and  it  is  obvious  that  an  inflamed  appen- 
dix lying  over  the  brim  of  the  pelvis  will  cause  effusion,  which  drains  in 
two  directions:  upwards  towards  the  liver  (shaded  dark)  and  diaphragm, 
and  downwards  to  the  pelvis.  In  Fig.  465  the  body  is  in  Fowler's  posi- 
tion, and  the  resulting  effusion  will  collect  in  the  pelvis. 

quietly  in  bed,  and  preferably  in  what  is  known  as  Fowler's  position 
(Fig.  465) — i.e.,  with  the  head  and  trunk  raised  from  the  horizontal 
plane  about  30°  or  40°,  so  as  to  determine  the  flow  of  fluid  exudate 
down  towards  the  pelvis  rather  than  backwards  into  the  kidney 


ABDOMINAL  SURGERY  977 

pouches,  whence  it  may  spread  up  to  the  dangerous  subdiaphrag- 
matic area.  No  food  is  administered  by  the  mouth,  and  no  purga- 
tive given ;  the  lower  bowel  may  be  emptied  by  enema,  and  subse- 
quently saline  injections  administered  to  relieve  thirst.  Morphia 
and  opium  are  used  with  the  utmost  caution  as  long  as  the  diagnosis 
is  uncertain,  for  fear  of  masking  symptoms.  By  determining  a 
cessation  of  vomiting  and  a  false  sense  of  comfort,  unjustified  hopes 
may  be  encouraged,  and  delay  in  operation  result ;  at  the  same  time 
they  may  be  useful  in  localizing  the  trouble  and  allowing  adhesions 
to  form.  Whilst  the  patient  is  being  prepared  for  operation  and  the 
necessary  arrangements  are  being  made,  a  moderate  dose  of  morphia 
may  save  him  much  suffering  and  help  to  conserve  his  powers. 

The  actual  scope  and  particular  features  of  the  operation  vary 
naturally  with  the  many  causes  that  may  have  been  operative  in 
determining  the  outbreak  of  the  condition,  and  these  will  be  suitably 
referred  to  afterwards.     It  is  only  possible  here  to  deal  with  the 
general  features.     The  incision  is  made  in  the  hnea  alba,  unless  the 
causative  lesion  is  obviously  on  one  side,  as  in  the  case  of  a  per- 
forated appendix;  and  the  lower  half  of  the  abdomen  is  opened 
rather  than  the  upper,  unless  the  latter  is  distinctly  indicated.     The 
objects  of  the  operation  are  threefold:  (i)  To  find  and  deal  with  the 
cause  of  the  affection,  such  as  a  perforation  which  needs  to  be 
closed,    or   a  perforated   or  gangrenous  appendix  which  must   be 
removed.     (2)  To  cleanse  the  peritoneum  and  remove  the  effusion. 
Some  surgeons  rely  on  mopping  up  the  exudate  with  dry  sterile 
swabs,  and  if  it  is  locahzed,  and  not  diffuse,  this  may  act  excellently. 
When,    however,    there   is    a   considerable   sero-purulent   effusion, 
occupying  the  pelvis,  and  perhaps  spreading  up  through  the  kidney 
pouches  to  the  under  surface  of  the  diaphragm,  irrigation  of  the 
cavity  is  probably  desirable.     Sterile  salt  solution  at  a  temperature 
of  about  107°  is  used,  and  the  whole  proceeding  should  be  effected 
without  the  escape  of  much  of  the  intestine.     Counter-openings  in 
the  loins  or  above  the  pubes  may  be  required  to  give  exit  to  the 
fluid,  and  then  the  end  of  a  steriHzed  rubber  tube  coming  from  the 
irrigator  is  carried  here  and  there  through  the  abdomen  by  the  hand, 
and  the  exudate  effectively  washed  out  through  glass  or  rubber 
tubes  placed  in  the  various  incisions.     It  is  most  undesirable  to 
allow  the  escape  of  many  coils  of  intestine,  and  general  evisceration 
wdth   the   object  of  cleansing  the  intestines  adds  seriously  to  the 
shock,  and  usually  does  more  harm  than  good.     '  Quickly  in  and 
more  quickly  out '  is  an  ideal  that  ought  to  be  striven  after.    It  must 
be  remembered  that  the  peritoneum  has  a  considerable  power  of 
absorption,  and  unless  the  inflammation  has  gone  very  far,  this  may 
be  rehed  on  to  a  considerable  extent  to  deal  with  inflammatory 
exudates,  which  are  not  frankly  purulent.    (3)  Drainage  is  necessary 
in  almost  all  cases,  and  may  be  effected  by  the  use  of  glass  or  rubber 
tubes  with  or  without  gauze  wicks.     When  employing  a  Keith's 
tube,  the  enclosed  gauze  wick  is  removed  twice  a  day,  and  any 
effusion  lying  at  the  bottom  sucked  up  through  a  sterile  rubber 

62 


978  A   MANUAL  OF  SURGERY 

catheter  attached  to  the  nozzle  of  a  glass  syringe.  It  is  probably 
wise  to  omit  the  glass  tube  at  the  end  of  forty-eight  hours,  and 
replace  it  by  a  smaller  and  shorter  rubber  tube,  which  in  turn  is 
followed  by  a  gauze  drain  as  soon  as  the  discharge  diminishes 
sufficiently.  The  abdominal  wall  is,  of  course,  only  partially 
closed  after  these  proceedings. 

When  intestinal  distension  is  very  great,  so  that  it  may  be 
difficult  to  reach  the  cause  of  the  trouble  or  to  return  the  extruded 
viscera,  it  may  be  ad\isable  to  tap  a  coil  of  small  intestine  and 
empty  the  contents,  or  to  stitch  in  a  rubber  tube  and  allow  the 
bowel  subsequently  to  empty  itself,  dealing  with  the  fistula  so 
produced  at  a  later  date.  The  reduction  of  the  distension  is  an 
essential  element  if  a  successful  issue  is  to  follow,  but  undue  manipu- 
lation must  be  avoided.  If  the  bowel  is  merely  tapped  and  at  once 
closed,  it  may  be  advisable  to  follow  the  plan  suggested  by  McCosh 
of  injecting  several  ounces  of  a  saturated  solution  of  Epsom  salts 
before  closing  the  abdomen.  With  the  same  end  in  view  the 
hjrpodermic  administration  of  strychnine  or  eserine  may  be 
employed  after  the  operation  with  the  idea  of  stimulating  the  un- 
striped  muscle  fibres  of  the  intestinal  wall. 

As  soon  as  the  patient  has  recovered  from  the  anaesthetic,  he 
should  be  raised  from  the  recumbent  to  the  sitting  posture  {Fowler's 
position),  with  a  view  to  permitting  the  fluid  effusion  to  gravitate 
into  the  pelvis.  Continuous  infusion  of  salt  solution  into  the  rectum 
{proctoclysis)  or  subcutaneous  tissues  should  also  be  employed  in 
order  to  dilute  the  toxins  and  facihtate  their  ehmination  (p.  963). 
For  infusion  into  the  subcutaneous  tissues  the  outer  side  of  the 
thighs  will  be  convenient.  Two  needles  are  introduced,  only  one  of 
which  is  used  at  a  time.  Four  or  five  ounces  are  injected  on  one 
side,  and  then  the  other  limb  is  employed;  the  needles  are  kept  in 
place  whilst  the  fluid  is  being  absorbed.  Improvement  in  the  con- 
dition of  the  patient  shows  itself  almost  at  once  by  a  fall  of  tem- 
perature and  of  pulse;  the  vomiting  ceases  or  becomes  less  urgent, 
pain  and  tenderness  decrease,  and  the  patient  looks  and  feels  better. 
On  the  second  day  the  bowels  are  hkely  to  become  distended  with 
flatus,  and  it  is  necessary  to  obtain  relief;  this  is  best  effected  by 
a  turpentine  enema  in  the  first  place,  followed  by  a  dose  of  castor 
oil,  or  of  sulphate  of  soda,  or  repeated  small  doses  of  calomel.  As 
soon  as  the  bowels  have  acted  well,  the  urgency  of  the  symptoms 
diminishes,  and  it  is  probable  that  the  patient  will  recover. 

The  wound  requires  constant  dressing  for  some  time,  as  there 
wiU  be  a  good  deal  of  discharge,  and  perhaps  the  fatty  and  fascial 
margins  of  the  wound  will  slough.  The  tubes  are  gradually  dis- 
pensed with  as  the  discharge  diminishes,  and  replaced  by  gauze 
drains;  and  when  the  deeper  tracks  have  filled  with  granulations, 
the  superficial  wounds  may  be  drawn  together  with  strapping,  and 
thus  the  strength  of  the  abdominal  wall  may  be  maintained.  It 
will  be  wise  to  order  an  efficient  belt  or  support  after  operations  of 
this  type. 


ABDOMINAL  SURGERY  979 

2.  Acute  Localized  Peritonitis  usually  arises  in  connection  with 
some  limited  lesion  of  the  abdominal  contents,  which  is  of  such  a 
nature  as  to  permit  of  the  general  peritoneal  cavity  being  shut  off 
by  adhesions,  the  process  being  thereby  locahzed.  It  is  frequently 
followed  by  suppuration,  the  abscess  being  thus  intraperitoneal, 
although  not  involving  the  general  peritoneal  cavity.  The  abscesses 
arising  in  connection  with  appendicitis  or  pelvic  peritonitis  are  not 
uncommonly  of  this  nature.  They  may  burst  through  the  barrier  of 
adhesions,  and  thus  light  up  a  diffuse  inflammation  of  the  peritoneal 
sac,  or  they  may  burrow  to  the  surface  and  point  externally,  or  open 
into  one  of  the  hollow  viscera. 

The  Symptoms  complained  of  are  deep  pain  and  tenderness,  more 
or  less  localized  to  the  affected  area,  together  with  fever,  vomiting, 
and  constipation.     At  first  no  swelKng  or  tumour  is  to  be  made  out, 
but  a  feeling  of  resistance  may  be  noticed  in  the  abdominal  wall, 
which  is  held  tense  and  rigid,  as  if  guarding  some  focal  point  of 
mischief.     As  the  effusion  increases  in  amount,  a  tumour  dull  or 
tympanitic  on  percussion  may  become  evident ;  it  is  mainly  due  to  a 
matting  together  of  the  intestines  and  omentum,  but  is  often  asso- 
ciated with  a  variable  amount  of  effusion ;  if,  however,  it  is  placed 
deeply,  the  dulness  may  be  absent  owing  to  the  fixation  of  one  or 
more  coils  of  intestine  in  front  of  the  inflammatory  focus.     If  an 
abscess  forms  and  travels  towards  the  surface,  the  abdominal  wall 
becomes  infiltrated,  red,   and  oedematous,  the  component  tissues 
being  brawny  to  the  touch,   and  cutting  hke  bacon.     Finally,   a 
fluctuating  area  presents  itself  in  the  midst  of  this  indurated  mass, 
and  the  abscess  either  discharges  itself  or  is  opened.     The  pus  con- 
tained therein  is  often  offensive,  owing  to  the  presence  of  the  B.  coli. 
Of  course  this  process  is  attended  with  considerable  increase  in  the 
pain    and    constitutional    disturbance.     If    the    cavity   is    opened 
aseptically  and  drained,  it  rapidly  contracts  and  a  cure  is  accom- 
plished,  although  intraperitoneal  adhesions  may  persist  and  lead 
to  subsequent  trouble  from  hampering  the  intestinal  movements. 
If  a  communication  is  established  with  the  intestine,  a  faecal  fistula 
is  apt  to  follow ;  whilst  if  the  cavity  becomes  septic,  chronic  suppura- 
tion may  result,  and  thereby  the  patient's  health  and  strength  are 
undermined.     The   determination   as  to   the   existence  or   not   of 
suppuration  is  by  no  means  easy,   and  a  blood  count,   perhaps 
repeated  more  than  once,  is  often  of  the  greatest  value  (see  p.  62). 

Treatment. — In  these  cases  resolution  can  sometimes  be  obtained 
by  keeping  the  patient  absolutely  quiet  and  on  a  low  diet,  with 
perhaps  a  little  morphia,  and  by  appljdng  fomentations  locally, 
whilst  the  lower  bowel  is  emptied  by  an  enema.  Such  a  course 
must,  however,  not  be  persisted  in  for  too  long  when  suppuration 
is  likely  to  have  occurred,  for  fear  of  the  inflammation  spreading 
to  the  general  peritoneal  cavity,  or  of  the  abscess  bursting  into  it. 
An  early  exploratory  laparotomy  is  ad\dsable  under  such  circum- 
stances. The  line  of  treatment  marked  out  for  appendicitis  (p.  1056) 
is  that  which  should  always  be  followed. 


gSc  A   MANUAL  OF  SURGERY 

3.  Simple  Chronic  Peritonitis  in  itself  rarely  requires  surgical 
attention,  since  it  is  to  be  looked  on  rather  as  a  protective  than  as  a 
destructive  process.  It  is  characterized  by  infiltration  and  thicken- 
ing of  the  peritoneum,  whereby  the  intestinal  wall  is  strengthened 
and  bacterial  invasion  hindered.  It  is  localized  or  diftuse  in 
character,  and  arises  as  the  result  of  some  pre-existing  inflammation. 
In  the  more  diffuse  forms  the  intestines  may  be  hopelessly  matted 
together,  or  the  omentum  rolled  up  and  contracted  into  a  rounded 
cord-like  mass,  lying  transversely  across  the  upper  part  of  the 
abdomen;  chronic  obstruction  is  almost  certain  to  arise  sooner  or 
later  from  this  condition. 

More  frequently  it  is  the  consequence  of  some  localized  injury 
or  inflammation.  In  the  former  plastic  lymph  is  deposited  over 
any  breach  of  continuity  of  the  serous  membrane,  and  to  this  the 
omentum  or  intestine  becomes  adherent;  the  under  surface  of  a 
laparotomy  wound  is  not  unfrequently  affected  in  this  way.  Local- 
ized areas  of  inflammation  are  similarly  liable  to  originate  adhesions, 
which  are  thus  found  in  connection  with  gastric  ulcers,  an  inflamed 
vermiform  appendix,  enlarged  mesenteric  glands,  or  a  pyosalpinx. 
Under  favouring  circumstances  many  such  adhesions  are  absorbed 
in  the  early  stages;  but  if  they  persist,  they  are  modified  by  the 
intestinal  movements,  and  are  likely  to  become  lengthened  and 
rounded,  thus  originating  the  bands  and  cord-like  structures  so  often 
the  causes  of  acute  obstruction.  The  anatomical  arrangements  of 
the  omentum  explain  why  this  structure  is  so  frequently  involved  in 
this  process,  and  thereby  it  constitutes  one  of  the  most  important 
agents  for  checking  the  spread  of  inflammatory  affections.  Intes- 
tinal adhesions  often  give  rise  to  no  symptoms ;  but  sometimes  they 
determine  attacks  of  colic  and  of  irregular  peristalsis,  and  occa- 
sionally an  adhesion  to  the  abdominal  wall — g.g.,  one  springing  from 
the  stomach — causes  a  localized  constant  pain  which  justifies  ex- 
ploration. 

4.  Tuberculous  Peritonitis. — This  disease  is  almost  limited  to 
young  people,  and  is  usually  secondary  to  some  other  focus  of  tuber- 
culosis— e.g.,  in  the  intestine,  mesenteric  glands,  Fallopian  tube,  testis, 
etc.  It  is  sometimes  limited  in  its  development  to  a  portion  of  the 
peritoneal  cavity,  especially  when  originating  from  the  pelvis  or 
vermiform  appendix,  but  is  more  frequently  diffuse.  It  manifests 
itself  in  several  different  ways,  which  may  be  associated  with  or  follow 
one  another:  (i)  In  the  ascitic  variety  the  peritoneum  becomes  thick 
and  hyperaemic,  and  is  studded  over  with  tubercles,  some  of  them 
small,  gray  and  translucent,  others  larger  and  undergoing  caseation. 
The  effusion  is  generally  abundant,  and  consists  of  straw-coloured  or 
opalescent  serum,  perhaps  blood-stained  in  the  more  active  cases. 
Flakes  of  fibrin  may  be  found  covering  the  membrane  here  and  there, 
but  there  is  no  extensive  matting  of  the  intestines.  Occasionally  the 
effusion  becomes  encysted,  giving  rise  to  localized  fluid  swellings  shut 
in  between  the  coils  of  intestine.  (2)  In  the  fibrous  variety  the  in- 
testines are  matted  together  by  extensive  adhesions,  and  between 


ABDOMINAL  SURGERY  981 

them  foci  of  tubercle  are  found.  The  mesentery  may  become  in- 
filtrated and  shrink,  fixing  the  intestines  back  en  bloc  to  the  posterior 
abdominal  wall.  The  omentum  is  often  invaded,  and  contracts 
upwards  to  form  a  sausage-like  tumour  lying  transversely  above  the 
umbilicus.  There  is  but  little  effusion,  and  that  is  usually  encap- 
suled.  It  is  obvious  that  such  a  condition  is  very  likely  to  lead  to 
obstructive  phenomena,  due  to  kinking  of  the  mtestme.  (3)  The 
siippnrative  variety  is  characterized  by  the  presence  of  tuberculous 
foci  of  some  size  between  the  coils  of  intestine;  caseation  and  sup- 
puration follow,  and  the  abscesses  are  hkely  either  to  open  into  the 
intestine,  possibly  into  two  coils,  causing  thereby  a  fistulous  com- 
munication {fistula  himncosa),  or  perhaps  to  travel  to  the  surface 
and  open  externally,  and  then  most  frequently  at  the  umbilicus, 
possibly  giving  rise  to  a  faecal  fistula. 

In  each  of  these  varieties  acute  manifestations  may  develop  at 
any  time  as  a  result  of  infection  from  the  bowel  with  the  B.  coh,  and 
then  the  symptoms  of  acute  diffuse  peritonitis  may  supervene. 

The  Symptoms  are  extremely  variable,  and  the  early  stages  ol  the 
disease  are  sometimes  not  easy  to  recognise. 

A  few  cases  have  an  acute  onset  with  abdominal  pam  and  disten- 
sion, and  continued  pyrexia  which  may  suggest  the  existence  of 
enteric  fever.  The  abdominal  wall,  however,  is  not  rigid ;  the  tender- 
ness is  not  great ;  there  is  well-marked  evidence  of  free  fluid,  and 
though  vomiting  and  constipation  may  be  present,  they  are  not 
marked  features.  Naturally  the  patient  in  such  a  condition  wastes 
quickly.  .  , 

In  the  more  chronic  forms  the  earhest  symptoms  are  weakness  witn 
some  shght  abdominal  discomfort,  and  not  uncommonly  diarrhoea, 
alternating  perhaps  with  constipation.  The  temperature  becomes 
of  a  hectic  type,  and  periods  of  improvement  may  alternate  vnth 
attacks  of  increasing  pain  and  weakness.  On  the  whole,  the  patient 
gradually  gets  worse,  his  wasted  frame  comparing  markedly  with  the 
protuberant  and  enlarged  belly.  The  phenomena  discoverable  on 
abdominal  palpation  vary  considerably  with  the  conditions  present 
within. 

Treatment  in  the  early  stages,  and  especially  m  the  acute  variety, 
is  often  successfully  undertaken  by  the  physician.  Hygienic 
measures  are  adopted,  the  patient  living  in  the  fresh  air,  and,  ol 
course,  being  always  in  the  recumbent  position.  Plenty  ot  good 
digestible  food  is  given,  as  also  cod-liver  oil  and  perhaps  intestinal 
antiseptics,  such  as  salol,  creasote,  etc.  The  external  apphcation  to 
the  abdomen  of  iodine,  either  as  a  paint  or  an  ointment,  is  much 
commended  by  some  physicians,  whilst  Scott's  dressing  is  relied  on 
by  others.  Tuberculin  injections  may  also  be  of  value.  Should  the 
condition  undergo  no  improvement,  it  may  be  justifiable  to  operate. 
When  chronic  ascitic  accumulation  is  present,  all  that  is  needed  is  to 
remove  the  fluid  by  tapping  or  laparotomy;  in  the  latter  case  irriga- 
tion is  not  required,  and  the  wound  should  be  closed  completely  ,in 
nearly  75  per  cent,  of  the  cases  a  cure  may  be  anticipated.     Possibly 


982  A   MANUAL  OF  SURGERY 

it  may  be  well  to  ascertain  first  the  condition  of  the  opsonic  index, 
and,  if  need  be,  to  raise  it  by  injections  of  tuberculin.  In  the  acute 
forms  tuberculous  infection  of  the  wound  usually  follows  the  escape 
of  the  highly  infective  fluid  from  the  peritoneal  cavity,  and  healing 
may  be  thereby  delayed;  hence  it  is  undesirable  to  operate  in  such 
cases.  Where  diffuse  or  localized  suppuration  is  present,  adhesions 
which  can  be  reached  may  be  gently  broken  down,  and  exit  given  to 
the  pus;  but  no  prolonged  search  after  suppurating  foci  should  be 
made,  or  the  intestine  may  be  torn.  The  results  of  treatment  in  this 
variety  are  not  nearly  as  satisfactory  as  in  the  former,  at  least  40  per 
cent,  of  the  cases  dying.  As  to  the  way  in  which  cure  is  established, 
two  factors  probably  co-operate:  (i)  the  removal  of  the  exudation 
and  its  contained  toxins;  and  (2)  a  flushing  of  the  intra-abdominal 
tissues  with  blood  plasma  (a  well-ascertained  fact  after  laparotomy) 
and  the  effect  of  the  antibodies  contained  therein,  the  tubercles 
thereby  having  their  vitalit}'  destroyed.  In  this  connection  one 
may  note  the  statement  that  too  early  a  laparotomy  does  but  little 
good,  an  insufficient  amount  of  antibody  having  presumably  de- 
veloped in  the  system. 

Pneumococcal  Peritonitis  is  in  the  majority  of  cases  secondary  to  a  similar 
infection  of  tlie  lungs  or  pleura,  the  organisms  being  transmitted  by  the  blood 
or  through  the  lymphatics  of  the  diaphragm;  less  frequently  the  primary  focus 
is  in  the  pharynx  or  middle  ear.  Occasionally  the  trouble  is  apparently 
primary,  the  pneumococci  finding  their  way  through  a  healthy  mucous  mem- 
brane, as  from  the  bowel  or  appendix,  or  more  directly  b}'  the  Fallopian  tube. 
The  disease  is  specially  common  in  female  children,  and  usally  sets  in  acutely. 
In  some  cases  the  trouble  quickly  becomes  circumscribed,  and  a  chronic 
encapsuled  abscess  results;  in  other  cases  the  course  is  acute,  and  the  sjonp- 
toms  are  persistent  and  more  violent.  In  the  former,  pain  and  vomiting  are 
moderately  severe  in  the  early  stages,  but  diarrhoea  is  often  present,  and 
pyrexia  is  moderate  Pus  is  likely  to  accumulate  slowly,  and  without  marked 
pain  and  discomfort;  at  first  it  occupies  the  lower  part  of  the  abdomen,  but 
gradually  encroaches  on  the  whole  cavity,  and  typical  dulness  may  be  noted, 
whilst  the  patient  wastes  rapidly.  In  some  cases  the  pus  has  pointed  at  the 
umbilicus,  and  a  spontaneous  cure  has  followed  its  discharge.  In  the  more 
acute  cases  the  course  is  very  similar  to  the  diffuse  pyococcal  type  described 
above;  prostration  is  generally  rapid,  and  death  early;  the  only  distinguishing 
feature  is  the  existence  of  diarrhoea  in  some  cases.  The  pus  is  usually  like  that 
in  a  pneumococcal  empyema  (p.  923),  with  abundance  of  false  membrane,  but 
in  other  cases  it  is  of  the  ordinary  t5-pe;  pneumococci  can  easily  be  found  in  it. 
A  blood  count  will  show  a  well-marked  leucocytosis,  which  is  usually  absent  in 
the  worst  forms  of  pyococcal  peritonitis.  Treatment  consists  in  laparotomy 
and  drainage  in  the  more  acute  varieties,  but  in  the  milder  the  patient  must  be 
carefully  watched  for  localizing  phenomena. 

Gonorrhoea!  Peritonitis  almost  always  occurs  in  women  as  a  direct  extension 
of  a  gonococcal  inflammation  upwards  from  the  uterus,  being  preceded  or 
accompanied  by  the  phenomena  of  salpingitis  or  ovaritis;  it  has,  however, 
been  known  to  develop  in  men.  There  is  usually  a  definite  history  of  gonor- 
rhoea with  a  more  or  less  abundant  discharge,  but  the  attack  generally  follows 
a  menstrual  period,  or  the  manipulation  of  the  tubes  and  ovaries.  The  onset 
is  sudden  and  acute,  the  patient  complaining  of  severe  pelvic  pain,  which  is 
accompanied  by  vomiting,  abdominal  distension,  and  fever.  A  swelling  may 
be  felt  above  the  brim  of  the  pelvis.  Under  suitable  treatment  the  trouble 
often  abates  rapidly,  and  the  patient  recovers;  but  adhesions  are  likely  to  be 
left,  determining  sterility,  or  the  tubes  may  remain  full  of  pus  (pj'osalpinx). 
In  other  cases  exudation  is  abundant,  though  there  is  a  tendency  to  limitation 


ABDOMINAL  SURGERY 


983 


of  the  trouble,  and  the  prognosis  is  generally  favourable.  „.^/^  «  "  f/,  ^^^^^^^^^^ 
in  absolute  rest,  fomentations  to  the  abdomen  hot  ^^g'^Vow  .  r^'Xn 
suitable  limitation  of  diet.  If  rapid  improvement  does  not  follow  a  median 
laparotomy  should  be  undertaken  in  order  to  let  out  the  pus  and  permit  of 
suitable  drainage.  The  tubes  and  ovaries  should  always  be  explored  m  such 
cases,  and  may  perhaps  need  to  be  removed. 

Subphrenic  Abscess  is  the  term  applied  to  a  suppurating  focus 
which  IS  hi  more  or  less  intimate  relation  with  the  under  surface  of  the 
diaphragm.  Two  main  varieties  are  described,  viz.,  the  mtrapen- 
toneal,  which  is  much  the  more 
common,  and  the  retro-  or  extra- 
peritoneal. The  former  are  not 
unfrequently  subhepatic  as  well  as 
subdiapJiraginatic . 

The  causes  are  very  diverse, 
and  the  manifestations  vary  some- 
what with  the  causative  lesion. 
I .  The  stomach  is  the  most  frequent 
source  of  the  trouble,  the  infection 
being  due  to  the  extension  of  a 
chronic  ulcer.  If  the  anterior 
wall  is  involved,  the  pus  will  be 
Hmited  by  the  lesser  omentum 
and  stomach  behind,  by  the  dia- 
phragm and  left  lobe  of  the  Hver 
above,  by  the  falciform  Hgament 
on  the  right,  and  by  adhesions  be- 
tween the  stomach  or  omentum 
and  anterior  abdominal  wall  below 
(Fig.  466).  This  type  of  abscess 
usually  points  to  the  left  of  the 


Fig.  466. — Diagram  of  Subphrenic 
AND  Subhepatic  Abscess,  due  to 
Extension  from  an  Ulcer  of  the 
Anterior  Wall  of  the  Stomach. 

S,  Stomach;  C,  colon;  I,  small  intes- 
tine; L,  hver;  GO, great  omentum; 
SO.  small  omentum;  LPS,  lesser 
peritoneal  sac ;  P,  pancreas;  D,  duo- 
denum. 


ensiform  appendix.  Should  the 
ulcer  be  situated  on  the  anterior 
wall  near  to  the  fundus,  the  abscess 
may  get  into  close  relationship 
with  the  spleen,  and  point  beneath 
the  left  costal  margin.  When  the 
abscess  arises  in  relation  with  the 

posterior  wall,  the  lesser  sac  of  the  peritoneum  may  be  filled  with  pus, 
which  is  prevented  from  escaping  from  the  foramen  of  Winslow  by 
adhesions,  whilst  the  stomach  itself  is  pushed  forwards,  and  the  pus 
travels  up  and  presents  above  it  to  the  left  of  the  middle  Hne.  More 
often  the  lesser  sac  has  been  previously  obhterated,  and  the  abscess 
develops  in  the  retroperitoneal  tissues'.  2.  Ulcer  of  the  duodenum 
may  give  rise  to  very  similar  conditions.  If  the  ulcer  is  in  the  first 
or  second  part,  an  intraperitoneal  abscess  is  likely  to  form,  bounded 
by  the  liver,  colon,  omentum,  and  anterior  abdominal  wall;  occa- 
sionally the  pus  also  tracks  up  behind  the  liver.  When  retroperi- 
toneal suppuration  occurs  in  connection  with  the  duodenum,  the 


984  A   MANUAL  OF  SURGERY 

pus  travels  up  between  the  liver  and  diaphragm,  or  downwards 
towards  the  loin.  3.  The  appendix  vcrmiformis  is  also  a  cause  of 
subphrenic  abscess,  the  pus  burrowing  behind  the  peritoneum, 
or  hnding  its  way  along  the  inner  or  outer  walls  of  the  ascend- 
ing colon.  4.  It  may  be  caused  by  extension  of  suppuration  from 
the  liver,  colon,  intestine,  or  from  retroperitoneal  structures,  such 
as  the  kidney,  ribs,  or  vertebrae.  According  to  Fenwick,  however, 
80  per  cent,  of  all  cases  of  subphrenic  abscess  are  due  to  ulceration 
of  the  stomach  or  duodenum. 

The  abscess  thus  induced  may  contain  pus  alone  or,  in  addition, 
gas,  which  is  derived  either  from  a  direct  communication  with  the 
bowel,  or  from  the  activity  of  the  B.  coli  without  any  definite  open- 
ing being  present.  It  was  to  this  condition  that  Leyden  originally 
gave  the  name  of  subphrenic  pyo-pneiimothorax.  The  extension  of 
the  abscess  along  the  under  surface  of  the  diaphragm  often  leads  to 
that  structure  being  displaced  considerably  upwards,  and  to  a  second- 
ary infection  of  the  pleura,  either  by  lymphatic  absorption  and  ex- 
tension, or  by  an  actual  solution  of  continuity.  The  effect  is  an  effu- 
sion of  serum  or  piis  into  the  base  of  the  pleural  cavity,  the  latter 
constituting  a  basal  empyema.* 

The  Symptoms  vary  considerably.  They  may  be  preceded  by  those 
referable  to  the  causative  lesion,  and  their  onset  may  be  sudden  or 
gradual.  Ordinary  febrile  phenomena,  and  perhaps  one  or  more 
rigors,  may  occur,  whilst  the  patient  complains  of  pain  in  the  upper 
part  of  the  abdomen,  together  with  vomiting  and  constipation.  The 
pain  is  often  increased  on  respiratory  movements,  and  may  extend 
upwards  to  the  shoulder.  On  palpation,  the  abdominal  muscles  on 
one  or  other  side  are  held  rigidly  contracted,  but  possibly  a  swelling, 
either  dull  or  tympanic  according  to  its  contents,  may  be  noted. 
There  may  be  some  bulging  of  the  intercostal  spaces.  On  the  right 
side  the  diaphragm  may  be  pushed  up,  and  the  liver  downwards ;  and 
if  the  abscess  contains  gas,  an  area  of  tympanitic  resonance  may  be 
noted  between  the  dulness  of  the  liver  and  the  resonance  of  the 
lung.  On  the  left  side  the  heart  may  be  pushed  upwards  together 
with  the  diaphragm,  and  the  absence  of  lateral  displacement  of  the 
heart  is  an  important  diagnostic  feature  from  a  pure  empyema  or 
pneumothorax.  The  X  rays  will  sometimes  be  useful  in  recognising 
displacement  upwards  of  the  diaphragm,  and  immobility  of  the 
affected  half.  A  blood  count  is  important  in  indicating  the  existence 
of  suppuration. 

The  Treatment  consists  in  opening  and  draining  the  abscess 
wherever  it  is  most  accessible.  In  many  cases  this  can  be  effected 
through  the  anterior  abdominal  wall  along  the  lower  margin  of 
the  ribs,  but  even  then  a  counter-opening  is  often  needed.  \\'hen 
the  abscess  does  not  project  anteriorly,  the  best  situation  for  an 
opening  is  through  the  pleural  cavity,  as  for  some  abscesses  of  the 
liver.     The  incision  lies  behind  the  mid-axillary  line,  a  portion  of  the 

*  For  a  complete  and  masterly  study  of  subphrenic  abscess,  by  the  late 
Mr.  Harold  L.  Barnard,  see  British  Medical  Journal,  February  15  and  22,  1908. 


ABDOMINAL  SURGERY  985 

eighth  or  ninth  rib  being  excised.  If,  as  often  happens,  there  is  also 
an  empyema,  this  is  drained,  and  then  an  additional  opening  can 
be  made  through  the  diaphragm  if  one  does  not  already  exist ;  if, 
however,  the  pleural  cavity  is  not  affected,  the  serous  membrane 
covering'  the  upper  surface  of  the  diaphragm  must  be  stitched  to  the 
parietal  pleura  before  the  diaphragm  is  incised. 

Ascites. — By  this  term  is  meant  an  accumulation  of  fluid,  and  that 
usually  of  a  serous  type,  within  the  peritoneal  cavity.  It  results 
chiefly  from  lesions  which  fall  to  the  care  of  the  physician— viz., 
cirrhosis  of  the  liver,  chronic  Bright's  disease,  and  various  cardiac 
affections.  It  is  also  a  consequence  of  any  obstructive  pressure  on 
the  portal  vein,  as  by  malignant  glands  in  the  portal  fissure  secondary 
to  carcinoma  of  the  stomach  or  of  the  intestine,  or  by  fibrous 
adhesions,  the  consequence  of  duodenal  ulceration  or  stones  m  the 
gall-bladder.  Fluid  also  collects  in  the  abdomen  as  the  result  of 
diffuse  malignant  deposits  scattered  over  the  peritoneum,  or  from 
the  presence  of  mildly  irritative  foci,  such  as  hydatid  cysts,  etc. 
Chylous  ascites  is  a  condition  in  which  the  fluid  is  milky  from  an 
admixture  of  chyle,  and  usually  results  from  rupture  of  the  recep- 
taculum  chyli  in"^ consequence  of  the  pressure  on  the  thoracic  duct 
above  it  of  malignant  glands  secondary  to  cancer  of  the  stomach. 
Encysted  ascites  results  from  the  distension  of  a  portion  of  the  cavity 
which  has  been  shut  off  bv  inflammatory  adhesions. 

The  Physical  Conditions  resulting  from  ascites  are  easy  of  recog- 
nition. The  abdomen  is  distended,  hke  a  barrel,  but  with  bulging 
flanks .  Dulness  is  present  in  the  loins  when  the  patient  is  recumbent , 
and  extends  forwards  to  about  the  same  level  all  round,  the  only 
resonant  area  being  about  the  umbiUcus ;  this  is  due  to  the  floating 
forward  of  the  intestines.  On  rolhng  the  patient  over  to  one  side, 
the  dull  and  resonant  areas  shift,  the  part  that  is  highest  becoming 
resonant.  This  sign  is  occasionally  absent  if  the  mesentery  is  short 
or  if  the  intestines  are  tied  down  posteriorly.  On  flicking  the  abdo- 
men, a  well-marked  thrill  is  usuafly  transmitted  from  one  side  to  the 
other.  Necessarily,  the  fluid  also  finds  its  way  into  any  diverticula 
of  the  peritoneum,  such  as  an  unclosed  funicular  process  or  a  hernial 
sac.  The  diagnosis  of  ascites  should  not  be  difficult,  but  the  prac- 
titioner must  not  be  satisfied  until  he  has  discovered  the  cause,  and 
this  may  not  be  easy  even  when  the  fluid  has  been  removed,  so  that 
the  abdominal  viscera  become  palpable. 

Treatment  necessarily  varies  with  the  cause  of  the  accumulation. 
Should  it  persist,  and  the  patient's  breathing  be  hampered  by  the 
abdominal  distension,  removal  by  paracentesis  is  essential.  The  usual 
plan  adopted  is  to  seat  the  patient  on  a  chair  and  to  encircle  the 
abdomen  with  a  flannel  binder,  the  ends  of  which  are  spht  to  withm 
6  inches  of  the  middle  hne.  The  unslit  portion  is  placed  over  the 
abdominal  wall  in  front,  whilst  the  divided  portions  cross  behind,  and 
are  held  by  assistants,  so  as  to  make  continuous  pressure  upon  the 
abdominal  contents.     The  bladder  is  completely  emptied,  and  then 


986  A   MANUAL  OF  SURGERY 

the  abdomen  is  carefully  percussed,  and  a  spot  of  absolute  dulness 
selected;  here  a  small  incision  is  made  with  a  scalpel  after  careful 
purification  of  the  skin,  and  a  suitable  trocar  and  cannula  inserted. 
The  median  line  below  the  umbihcus  is  the  place  usually  chosen  for 
the  puncture,  but  there  is  no  objection  to  inserting  the  trocar  through 
the  flanks.  Some  surgeons  prefer  to  withdraw  the  fluid  more  slowly, 
so  as  to  prevent  the  shock  often  experienced  from  its  rapid  removal. 
Two  or  three  Southey's  trocars  and  cannulse  may  then  be  inserted. 

Not  unfrequcntly  the  fluid  re-accumulates,  and  the  process  has  to 
be  repeated  after  a  time.  When  the  cause  of  the  collection  is 
doubtful,  the  practitioner  will  take  the  opportunity^  offered  b\^  the  lax 
abdominal  wall  to  palpate  the  viscera ;  light  ma}^  also  be  thrown  on 
an  obscure  case  b}^  a  cytological  examination  of  the  fluid.  In  malig- 
nant disease,  cancer  cells  and  blood  may  often  be  found.  If  the 
cause  is  still  uncertain,  an  exploratory  laparotomy  may  be  advisable. 

In  cases  due  to  hepatic  cirrhosis,  Epiplopexy  (the  Talma-Morison 
operation)  may  possibly  be  of  some  use.  The  object  is  to  reheve  the 
obstruction  to  the  portal  system  by  opening  up  fresh  communica- 
tions between  it  and  the  systemic  veins.  The  method  consists  in 
fixing  the  great  omentum  to  the  abdominal  wall  and  determining 
the  formation  of  adhesions;  necessarily  the  peritoneum  has  to  be 
drained  and  kept  dry  during  this  procedure,  and  the  question  arises 
as  to  whether  this  drainage  is  not  the  cause  of  the  improvement. 
The  mortality  is  not  inconsiderable,  especially  when  the  liver  is 
small;  the  best  results  have  been  gained  with  h3-pertrophic  cirrhosis. 
The  method  is  still  on  its  trial,  but  appears  to  be  justifiable  in  suit- 
able cases. 

Affections  of  the  Great  Omentum. 

The  omentum  is  of  great  surgical  importance  in  the  abdomen,  in 
that  it  covers  in  and  protects  the  viscera,  and  by  its  mobility  is  able 
to  apply  itself  to  many  a  weak  spot  where  perforation  or  infection 
might  occur,  and  thereby  guard  the  patient  from  serious  inflam- 
matory mischief.  The  result  of  this  process  is,  however,  the 
formation  of  adhesions  which  by  the  irritation  of  constant  movement 
may  stretch  and  become  rounded  and  cord-like,  and  various  forms  of 
intestinal  obstruction  (by  strangulation,  kinking,  etc.)  ma\-  result 
therefrom.  The  value  of  this  protective  power  of  the  omentum  is 
recognised  by  surgeons  in  the  employment  of  omental  grafts  to  add 
security  to  a  line  of  junction  in  the  intestinal  wall  with  which  they 
are  not  quite  satisfied.  It  is  only  occasionally  that  such  a  provision 
is  required.  The  best  method  to  adopt  is  to  detach  the  graft  entirely 
from  its  former  connections,  wrap  it  round  the  gut,  and  stitch  it  in 
place. 

The^omentum  may  be  torn,  and  holes  may  be  formed  in  it  as  a 
result  of  injury.  The  immediate  s3'mptoms  would  be  pain,  shock, 
and  the  phenomena  of  intraperitoneal  hemorrhage;  but  it  is  likely 
that  other  injuries  co-exist.  At  a  later  date  the  hole  might  be  the 
site  of  an  attack  of  internal  strangulation. 


ABDOMINAL  SURGERY  987 

Acute  Inflammation  (epiploitis)  has  been  lighted  up  as  a  result  of 
the  application  to  the  omentum  in  a  hernia  operation  of  a  septic  liga- 
ture. The  phenomena  vary  with  the  virulence  of  the  organisms,  an 
acute  diffuse  peritonitis  perhaps  resulting.  In  the  milder  forms  a 
localized  inflammatory  disturbance  follows,  with  all  the  phenomena 
of  a  limited  peritonitis ,  suppuration  may  ensue,  and  a  large  intra- 
peritoneal collection  of  pus  may  result. 

Torsion  of  the  omentum  is  an  occasional  complication  of  an  irre- 
ducible hernia,  and  that  usually  on  the  right  side.  The  lesion  gener- 
ally follows  some  heavv  strain,  and  results  in  venous  stasis,  effusion 
of  a  blood-stained  fluid,  the  formation  of  extensive  adhesions,  and 
possibly  gangrene  and  general  peritonitis,  if  left  long  enough.  The 
symptoms  often  start  abruptl}'  with  colicky  pain  in  the  right  ihac 
fossa  and  scrotum,  together  with  constipation  and  sickness;  the 
hernial  swelling  becomes  enlarged,  and  extending  upwards  from  the 
ihac  region  a  sensitive  mass  may  be  detected  on  palpation,  which  is 
dull  on  percussion,  and  sometimes  reaches  to  the  epigastrium.  The 
temperature  is  normal,  though  the  pulse-rate  is  accelerated.  Treat- 
ment is  ob^dously  operative,  and  consists  in  removal  of  the  omentum. 

Chronic  peritonitis,  whether  simple  or  tuberculous,  maj^  cause  the 
omentum  to  be  rolled  up  into  a  more  or  less  sohd  mass,  which  lies 
transversely  across  the  abdomen  a  little  above  the  umbilicus.  There 
is  usually  a  band  of  clear  resonance  between  it  and  the  hepatic 
dulness,  w^hich  is  of  great  diagnostic  importance. 

The  omentum  also  becomes  infiltrated  with  secondary  cancerous 
nodules,  which  can  sometimes  be  palpated,  and  their  presence 
gives  important  indications  as  to  the  desirabihty  or  not  of  operative 
treatment.  Colloid  degeneration  is  not  uncommon  in  omental 
cancers,  and  huge  masses  of  this  growth  have  been  sometimes  dis- 
covered in  the  dead-house.  Omental  carcinoma  usually  leads  to  a 
considerable  effusion  of  fluid  into  the  peritoneal  sac. 


Affections  of  the  Mesentery. 

Wounds  result  from  penetrating  or  non-penetrating  injuries.  They 
are  usually  associated  with  laceration  of  the  intestine,  and  the  result- 
ing phenomena  will  be  those  of  hemorrhage,  followed  by  general 
peritonitis  from  the  intestinal  lesion.  Pure  mesenteric  wounds  not 
involving  the  bow^el  are  generally  due  to  penetrating  or  gunshot 
injuries.  Haemorrhage  to  a  varjdng  degree  may  result,  and  if  the 
patient  hves,  the  nutrition  of  the  intestine  may  be  seriously  en- 
dangered. If  such  a  lesion  is  found  on  exploration,  bleeding  points 
must  be  secured  and  the  opening  in  the  mesentery  closed ;  before  this 
is  accompHshed,  however,  careful  consideration  must  be  given  to  the 
vascular  supply  of  the  intestine,  as  the  ligature  of  a  main  branch  of  a 
mesenteric  artery  may  determine  gangrene,  and  necessitate  resection 
of  a  portion  of  the  bowel. 

Thrombosis  of  the  Mesenteric  Vessels,  apart  from  strangulation  or 
volvulus,  is  usually  the  result  of  emboHc  obstruction  of  the  artery, 


988  A   MANUAL  OF  SURGERY 

but  may  sometimes  commence  in  the  veins,  spreading  down  from  the 
liver,  or  originating  in  some  intestinal  ulcer.  The  process  is  associ- 
ated with  acute  pain,  and  is  followed  by  the  symptoms  of  acute 
obstruction.  The  bowel  becomes  engorged  with  venous  blood,  and 
dies;  it  is  often  occupied  by  a  blood-stained  effusion,  and  the  passage 
of  dark  tarry  stools  may  be  noted.  The  peritoneal  cavity  contains 
a  quantity  of  blood-stained  serum,  which  after  a  time  becomes  offen- 
sive. A  diagnosis  is  rarel}'  reached  apart  from  operation  for  the  ob- 
structive phenomena,  and  the  only  hope  for  the  patient  is  removal  of 
the  gangrenous  bowel  (if  that  be  possible),  and  a  temporary  entero- 
stomy. Should  the  patient  live,  a  very  doubtful  contingency,  the 
continuity  of  the  gut  may  be  subsequently  restored. 

The  Mesenteric  Glands  frequently  become  inflamed  in  consequence 
of  some  intestinal  lesion — e.g.,  typhoid  ulceration.  No  special  notice 
is  taken  of  this  occurrence,  unless  suppuration  ensues,  when  the 
abscess  must  be  opened.  In  less  severe  cases,  however,  it  is  often 
associated  with  a  patch  of  locahzed  peritonitis,  resulting  in  the  de- 
posit of  plastic  lymph;  to  this  some  other  viscus — e.g.,  the  free  end 
of  the  omentum,  the  fimbriated  extremity  of  the  Fallopian  tube,  the 
vermiform  appendix,  one  of  the  appendices  epiploicee,  etc.- — may 
become  adherent,  and  an  adhesion  may  develop  which  subsequently 
leads  to  intestinal  obstruction.  As  a  matter  of  fact,  the  great 
majority  of  intra-abdominal  bands  are  connected  at  one  end  with  the 
mesentery. 

Tuberculous  Disease  of  the  mesenteric  glands  is  a  common  affection 
in  children,  constituting  a  condition  known  as  tabes  mesenterica .  It  is 
probably  secondary  to  intestinal  lesions,  and  when  widely  diffused 
tlirough  the  mesentery  is,  of  course,  to  be  dealt  with  only  by  hygienic 
and  medical  measures.  The  results  of  such  treatment  are  frequently' 
very  satisfactory,  but  tuberculous  peritonitis  may  follow.  Some- 
times the  glands  undergo  calcification,  and  these  may  lead  to  a  mis- 
taken diagnosis  if  a  patient  is  examined  radiographically  for  sup- 
posed ureteral  calculus.  At  other  times  the  caseated  glands  may 
liquefy  and  give  rise  to  an  inflammatory  attack  that  may  be  mistaken 
for  appendicitis,  if  the  mesentery  of  the  lower  end  of  the  ileum  is 
involved.  Limited  masses  in  the  iliac  fossa  may  sometimes  be 
amenable  to  surgical  measures,  and  be  removed ;  whilst  occasionallj^ 
the  surgeon  has  to  deal  with  a  gland  which  has  suppurated,  and 
requires  to  be  opened  with  the  same  precautions  as  one  would  take 
in  dealing  with  an  appendix  abscess.  Adhesions  also  form  between 
the  glands  and  surrounding  parts,  and  intestinal  obstruction  may 
result. 

Cysts  of  the  mesentery  are  not  common,  and,  as  might  be  expected, 
they  are  usually  of  lymphatic  origin;  they  may  be  single,  containing 
either  lymph  or  chyle,  or  multiple,  then  constituting  a  cavernous 
lymphangioma.  Blood  cysts  have  also  been  known,  and  also  der- 
moids, which  are  usually  located  in  the  mesentery  of  the  ileum.  A 
rounded,  tense  intra-abdominal  swelling  gradually  develops  behind 
or  below  the  umbihcus;  it  is  freely  moveable  from  side  to  side,  and  is 


ABDOMINAL  SURGERY  989 

usually  accompanied  by  some  derangement  of  intestinal  movement 
or  function.  When  of  large  size,  the  swelling  is  dull,  but  is  (jften 
crossed  by  the  affected  loop  of  bowel;  it  may  possibly  be  mistaken 
either  for  an  ovarian  or  a  pancreatic  cyst.  The  diagnosis  is  usually 
made  on  the  operating-table,  and  the  treatment  consists  in  enu- 
cleation or  drainage,  with  or  without  removal  of  the  affected  coil  of 
intestine. 

Tumours  form  occasionally  in  the  root  of  the  mesentery  and  behind 
it,  constituting  the  retroperitoneal  lipoma  or  sarcoma.  The  former 
may  grow  to  a  large  size,  and  destroy  life  by  its  pressure  phenomena ; 
the  latter,  though  sometimes  resembling  the  former  in  structure, 
invades  surrounding  tissues  earlier.  The  diagnosis  is  uncertain  until 
the  abdomen  is  opened,  and  the  question  of  removal  is  dependent  on 
the  relation  of  the  growth  to  the  mesenteric  vessels,  which  must  not 
be  injured.  It  is  seldom  that  a  retroperitoneal  sarcoma  can  be 
enucleated. 

Affections  o£  the  Stomach. 

The  cardiac  orifice  lies  about  4  inches  behind  the  junction  oE  the  seventh 
costal  cartilage  with  the  sternum;  the  highest  part  of  the  fundus  reaches  the 
fifth  left  rib  in  the  mammary  line ;  the  pylorus  when  the  stomach  is  empty  is  in 
the  middle  line  midway  between  the  suprasternal  notch  and  the  symphysis 
pubis  (Addison's  transpyloric  plane).  When  the  stomach  is  full,  the  pylorus 
passes  more  or  less  to  the  right  of  the  middle  line  and  descends  slightly.  The 
lower  border  can  usually  be  defined  with  tolerable  accuracy  by  auscultatory 
percussion;  this  is  performed  by  applying"  a  stethoscope  over  the  centre  of  the 
stomach  area  and  percussing  outwaras  over  the  margin;  a  change  in  note  is 
readily  recognised  on  reaching  the  border  of  the  stomach. 

When  pathologically  dilated,  the  stomach  becomes  enlarged  downwards,  the 
pylorus  and  lesser  curvature  being  retained  more  or  less  in  position  by  the 
gastro-hepatic  omentum,  so  that  the  organ  pouches  down  towards  the  pelvis 
and  becomes  an  elongated  sac  in  which  fluids  accumulate  and  decompose  and 
gas  collects.  Peristaltic  waves  can  often  be  seen  crossing  the  viscus,  and  on 
succussion  or  tapping  the  organ  with  the  finger-tips,  gurgling  and  splashing 
sounds  are  heard.  The  stomach  can  be  inflated  and  its  exact  size  and  shape 
thereby  determined  more  accurately  either  by  passing  an  oesophageal  tube  and 
injecting  air  with  a  bicycle  pump,  or  by  the  administration  of  effervescent 
solutions,  such  as  tartaric  acid  and  bicarbonate  of  soda  (10  to  20  grs.  of  each), 
or  of  the  component  parts  of  a  Seidlitz-powder  separately  dissolved  in  water. 

Radiography  has  also  proved  of  service  in  demonstrating  the  activitj^  and 
shape  of  the  stomach  after  the  administration  of  a  bismuth  meal,  which  con- 
sists of  a  mixture  of  i  or  2  ounces  of  bismuth  oxychloride  in  gruel  or  bread 
and  milk  X-ray  photographs  or  screen  examinations  are  then  made  at 
intervals  so  that  the  changes  in  shape  of  the  stomach  as  indicated  by  the 
shadow  cast  by  the  bismuth  can  be  ascertained  (Figs.  467  to  470).  The 
greater  curvature  of  the  stomach  should  reach  to  a  little  below  the  level  of 
the  umbilicus  (this  owing  to  the  weight  of  the  bismuth  meal),  and  the  viscus 
should  empty  itself  in  about  four  hours.  Direct  visual  examination  of  the 
gastric  cavity  is  also  possible  (gastroscopy) . 

Much  may  be  learnt  of  the  functions  of  the  stomach  by  a  careful  examination 
of  its  contents  and  secretions.  This  is  best  accomplislied  by  administering  a 
test  meal  consisting  of  a  piece  of  toast,  or  a  rusk  and  a  cup  of  tea  without 
milk,  on  a  fasting  stomach.  This  is  withdrawn  in  one  or  one  and  a  half  hours 
by  a  stomach  pump  or  oesophageal  tube,  and  the  fluid  thus  obtained  is  exam- 
ined as  follows : 

{a)  Chemically — to  ascertain  the  amount  of  total  acidity,  the  amount  of  free 
hydrochloric  acid,  and  the  presence  or  not  of  lactic  acid. 


990  A   MANUAL  OF  SURGERY 

(b)  Microscopicallj- — -for  the  presence  of  yeasts,  sarcinae,  or  bacteria,  es- 
pecially the  long  non-motile  Oppler-Boas  bacilli;  shreads  of  tumour,  pus  cells, 
or  blood,  may  also  be  found.  The  healthy  stomach  is  practically  free  from 
organisms,  as  those  swallowed  with  the  food  soon  disappear.  Not  unfre- 
cjuentl}',  however,  they  are  found  in  the  empty  stomach  of  those  suffering  from 
pyorrhoea  alveolaris,  and  are  then  likely  to  be  of  the  same  character  as  those 
around  the  teeth. 

The  following  are  suggestive  samples  of  the  results  obtained  by  test  meals: 

1.  In  the  normal  stomach  the  amount  of  fluid  withdrawn  is  about  2  to 
4  ounces.  It  contains  no  undigested  food.  Free  hydrochloric  acid  is  about 
1-5  to  2-0  per  cent.     No  lactic  acid  or  organisms  are  found. 

2.  In  gastric  ulcer  the  amount  withdrawn  is  normal  in  quantity  or  decreased. 
Digestion  is  complete.  Free  hydrochloric  acid  is  increased  (hyperchlorhydria) 
— 2'5  to  3'0  per  cent.  No  lactic  acid,  organisms,  or  growth  found.  Blood  may 
be  present. 

3.  In  atony  of  the  stomach  the  amount  withdrawn  is  increased  (6  to  8  ounces) 
and  digestion  is  imperfect.  Free  hydrochloric  acid  is  decreased  or  absent 
(hjqDochlorhydria) — 0-5,  i-o,  or  o-o  per  cent.  Traces  of  lactic  or  butyric  acid 
present.     Yeasts  and  sarcinae  present. 

4.  In  carcinoma  of  the  fundus  the  amount  withdrawn  is  normal  or  increased 
3  to  5  ounces.  Hydrochloric  acid  is  absent,  but  lactic  acid  exists  (0-2  to 
0'5  per  cent.).  Oppler-Boas  bacilli  may  be  present,  and  fragments  of  growth 
or  blood  may  be  found. 

Rupture  of  the  Stomach  results  from  blows  or  falls  upon  the  epi- 
gastrium, especially  after  a  heavy  meal,  and  then  usually  involves 
the  pyloric  end  or  the  greater  curvature  near  the  cardiac  oriiice.  It 
may  also  follow  a  penetrating  injury,  such  as  a  stab  or  a  fall  upon  a 
spike  or  railings.  Neighbouring  viscera  are  not  unfrequently  in- 
volved in  the  lesion,  especially  the  liver  or  spleen. 

The  Symptoms  are  those  of  severe  and  prolonged  shock,  with  epi- 
gastric pain  and  vomiting,  the  ejected  material  sometimes  containing 
blood;  acute  septic  peritonitis  usually  ensues  in  a  very  short  time, 
causing  rapid  collapse  and  death.  Occasionally,  when  the  wound  is 
small,  or  the  organ  empty  at  the  time  of  the  accident,  there  is 
little  or  no  extravasation,  and  then  a  localized  intraperitoneal  abscess 
may  form,  shut  off  from  the  general  peritoneal  cavity  by  adhesions, 
and  sooner  or  later  bursting  and  discharging  into  the  stomach,  colon, 
or  one  of  the  hollow  viscera,  or  else  coming  to  the  surface  and  burst- 
ing externally;  sometimes  the  barrier  of  adhesions  gives  way,  and 
a  late  general  peritonitis  results.  If  the  posterior  wall  of  the  stomach 
is  alone  injured,  the  resulting  phenomena  are  very  similar  to  those 
due  to  the  perforation  of  an  ulcer  in  this  region  {q.v.). 

Treatment. — No  time  must  be  lost  in  undertaking  a  laparo- 
tomy when  the  diagnosis  is  tolerably  certain,  since  the  only  hope 
of  saving  the  patient's  life  lies  in  early  interference.  A  median 
incision  is  made  above  the  umbilicus,  the  situation  of  the  injury  in 
the  stomach  ascertained,  and  the  aperture  closed  by  a  double  row  of 
sutures  (Czern^^-Lembert),  which  infold  the  margins,  and  extend  a 
little  beyond  the  lesion  at  either  end  (Figs.  458  and  460).  All  extra- 
vasated  material  should  be  carefullv  sponged  or  swabbed  away,  and 
if  the  general  cavity  has  not  yet  become  inflamed,  irrigation  should 
be  avoided  for  fear  of  carrying  infective  material  to  other  regions.  If 
the  posterior  wall  is  also  injured,  as  by  a  bullet  wound,  an  opening 


ABDOMINAL  SURGERY 


99' 


RADIOGRAMS   OF  THE  STOMACH  AFTER  BISMUTH 

MEALS. 


Fig.  467. — Normal  Stomach.  Fig.  468. — Moderate  Gastroptosis. 


Pjg    469.— Hour-Glass  Contraction       Fig.  470.— Cancer  of  Stomach. 


OF  Stomach 


The  ,  excavation  of  the  upper 
border  of  the  shadow  marks 
the  site  of  the  cancer. 


992  A   MANUAL  OF  SURGIERY 

should  be  made  through  the  omentum  so  as  to  explore  and  cleanse 
the  lesser  sac  of  the  peritoneum.  If  the  case  has  been  operated  on 
early  and  there  is  but  little  peritoneal  inflammation,  it  may  be 
possible  to  close  the  parietal  wound  entirely;  but,  as  a  rule,  it  is 
necessary  to  insert  a  gauze  drain  in  the  upper  part  of  the  serous 
cavity.  If  the  general  cavity  is  inflamed,  the  treatment  suitable  to 
acute  peritonitis  must  be  instituted  (p.  976). 

Foreign  Bodies  in  the  stomach  consist  either  of  those  which  have 
been  swallowed  accidentally  or  intentionally,  or  of  concretions,  e.g., 
hairs,  wool,  etc.,  due  to  the  constant  ingestion  of  small  portions, 
which  remain  in  the  viscus  and  may  after  a  time  form  large  masses. 
The  presence  of  the  former  is  known  from  the  history,  whilst  the  latter 
may  give  rise  to  s3miptoms  of  gastric  irritation,  the  cause  of  which  is 
inexphcable  until  the  mass  has  attained  such  a  size  as  to  suggest  the 
presence  of  a  tumour.  The  onl}'  treatment  possible  for  a  foreign 
body  of  any  size  is  to  open  the  organ  and  remove  it  (gastrotomy) ; 
where,  however,  it  is  of  small  dimensions,  e.g.,  a  coin,  it  may  be 
allowed  to  pass  onwards. 

Acute  Phlegmonous  Gastritis  is  an  affection  due  to  bacterial  in- 
vasion of  the  submucous  coat  of  the  stomach,  which  is  infiltrated 
with  leucocytes  and  fibrinous  exudation,  together  with  many 
organisms,  especially  streptococci.  This  process  usually  ends  in 
suppuration,  wliich  may  manifest  itself  as  a  diffuse  purulent  infiltra- 
tion, or  as  a  more  or  less  localized  abscess;  or  the  whole  mucous 
lining  of  the  stomach  may  be  cast  off  as  a  slough  and  vomited.  Such 
a  condition,  if  not  fatal  from  exhaustion,  toxaemia,  or  general  peri- 
tonitis, will  be  followed  by  extensive  stenosis,  which  may  demand 
operative  treatment.  The  disease  usually  occurs  in  men  who  suffer 
from  chronic  d\^spepsia,  and  is  lighted  up  b}-  injudicious  dietary, 
excess  of  alcohol,  or  possibly  the  taking  of  corrosive  poisons.  It  may 
develop  as  a  secondary  result  of  ulceration  or  of  operation.  The 
symptoms  consist'of  Epigastric  pain,  persistent  vomiting,  and  marked 
restlessness,  going  o^  to  delirium  or  collapse ;  the  pulse  is  quickened, 
and  there  is  moderatj^Jfever.  The  diagnosis  is  usually  uncertain,  and 
treatment  is  conseqaently  merely  symptomatic.  Lavage  of  the 
viscus  will  be  of  some  use. 

Ulcer  o£  the  Stomaq^  is  an  exceedingly  common  ailment,  the  conse- 
quences of  wdiich  are  often  very  serious,  a  considerable  mortality 
being  associated  witbr  it,  its  complications,  or  its  sequelte.  Two 
chief  types  may  be  mentioned  here,  although  others  are  not  un- 
known. 

[a]  The  acute  ulcer  is  rarely  larger  than  a  sixpenny-piece,  and 
'  develops  with  almost  equal  frequency  at  any  spot  between  the 
cardia  and  the  pylorus  along  the  upper  margin  of  the  stomach,  and 
more  frequently  on  the  posterior  than  on  the  anterior  surface  '  (Fen- 
wick).  It  is  not  unusually  multiple,  two  ulcers  being  often  found 
exactly  opposite  one  another,  suggesting  an  infective  origin  of  the 
trouble.  They  are  circular  in  shape,  and  with  the  edges  sharply 
defined  and  clearly  cut ;  each  successive  coat  is  destroyed  to  a  lesser 


ABDOMINAL  SURGERY  993 

degree  than  the  one  internal  to  it,  so  that  the  sore  is  truncated  or 
funnel-shaped.  Should  perforation  occur,  the  opening  is  not  central, 
but  slightly  to  one  side.  These  acute  ulcers  heal  without  much  diffi- 
culty, as  is  evident  from  the  number  of  radiating  cicatrices  seen  on 
the  post-mortem  table.  They  give  rise  to  no  stenosis,  except  perhaps 
when  they  are  actually  situated  within  the  pyloric  orifice.  Haemor- 
rhage from  this  variety  is  not  uncommon,  but  rarely  fatal.* 

(6)  The  chronic  ulcer  may  attain  considerable  dimensions,  perhaps 
many  square  inches  of  each  surface  being  involved.  It  is  usually 
single,  and  situated  on  the  posterior  wall  near  the  pyloric  orifice, 
which  ma.y  be  involved  in  the  trouble  by  extension.  Its  shape  is 
very  variable,  though  in  the  earlier  stages  it  is  rounded ;  one  impor- 
tant type  is  the  horseshoe  ulcer,  which  spreads  down  along  either 
surface  from  the  lesser  curvature,  and  may  subsequently  cause  an 
hour-glass  contraction  of  the  organ.  The  edges  are  often  raised, 
hard,  and  infiltrated,  whilst  the  gastric  wall  is  generally  thick  and 
sclerosed.  In  old-standing  cases  there  may  be  considerable  destruc- 
tion of  tissue,  surrounding  viscera,  such  as  the  pancreas,  being  some- 
times exposed  thereby.  Haemorrhage  is  not  uncommon,  and  may 
prove  fatal;  one  of  the  larger  branches  of  the  coronary  artery,  or 
perhaps  the  splenic,  is  then  involved,  or  the  bleeding  may  arise 
from  one  of  the  enlarged  varicose  gastric  veins  which  are  often  found 
in  the  neighbourhood  of  an  old  ulcer.  Perigastric  inflammation  of 
an  adhesive  or  suppurative  type  is  almost  certain  to  occur,  and 
cicatricial  contraction  of  various  forms  is  likely  to  follow. 

Women  are  much  more  liable  to  gastric  ulcer  than  men,  in  the  pro- 
portion of  three  to  one ;  but  it  is  the  acute  variety  to  which  they  are 
most  prone,  and  from  which,  apart  from  perforation,  they  seldom 
die.  The  usual  age  of  such  patients  is  from  fifteen  to  thirty  years. 
Men,  on  the  other  hand,  are  more  liable  to  chronic  ulcers,  and  though 
acute  perforation  is  less  common,  they  are  subject  to  a  number  of 
serious  complications  which  may  prove  fatal.  Their  average  age 
when  attacked  is  from  thirty  to  fifty  years. 

Into  the  aetiology,  general  symptoms,  and  routine  treatment  of 
gastric  ulcers  it  is  unnecessary  to  enter;  they  are  sufficiently  de- 
scribed in  medical  text-books.  A  number  of  comphcations,  however, 
arise  which  may  require  surgical  assistance,  whilst  it  must  be  remem- 
bered that  the  mere  persistence  of  symptoms  may  justify  operative 
measures,  especially  since  the  observation  has  been  made  and  con- 
firmed that  malignant  disease  may  commence  on  the  site  of  an  old- 
standing  ulcer. 

I.  Excessive  and  Persistent  Haemorrhage  is  responsible  for  a  con- 
siderable proportion  of  the  deaths  from  gastric  ulcer.  It  may  arise 
from  arteries,  veins,  or  capillaries.  In  the  superficial  ulcers  of  young 
people  the  bleeding  is  usually  of  capillary  origin,  or  at  worst  is 
derived  from  some  small  arteriole.     In  the  more  chronic  ulcers 

*  See  Fenwick,  '  Ulcer  of  the  Stomach  and  Duodenum,'  J.  and  A.  Churchill, 
1900;  and  Mayo  Robson  and  Moynihan,  '  Diseases  of  the  Stomach  and  their 
Surgical  Treatment,'  Bailliere,  Tindall  and  Cox. 

63 


994  A   MANUAL  OF  SURGERY 

deeper  and  larger  vessels  may  be  laid  open,  and  it  is  in  such  instances 
that  a  fatal  result  may  follow;  thus  the  splenic  or  coronary  artery 
may  be  involved,  and  hopeless  haemorrhage  ensue.  Occasionally 
bleeding  occurs  as  a  generahzed  gastrorrhagia,  where,  on  opening  the 
stomach,  the  whole  surface  seems  to  weep  blood;  this  condition  is 
but  httle  understood.  It  is  uncommon  for  the  patient  to  succumb 
to  the  first  attack  of  bleeding,  which  yields  to  medical  treatment, 
and  hence  the  rule  of  practice  which  is  usually  adopted,  viz.,  to  treat 
the  first  acute  haemorrhage  by  medical  means ;  but  should  it  recur  or 
persist  unduly,  surgical  assistance  may  be  required. 

If  the  bleeding  is  small  in  amount,  but  recurs  constantly,  gastro- 
enterostomy should  be  undertaken,  in  order  to  put  the  organ  at  rest 
and  allow  the  ulcer  to  heal.  When,  however,  the  haemorrhage  is 
more  severe,  a  determined  attempt  must  be  made  to  find  the  bleeding 
spot  and  deal  with  it.  The  abdomen  is  opened  and  the  stomach 
carefully  explored.  Some  puckering  or  thickening  of  the  coats  may 
indicate  the  situation  of  the  ulcer;  failing  this,  a  free  opening  in  the 
longitudinal  axis  is  made  through  the  anterior  wall,  and  the  interior 
of  the  viscus  methodically  examined.  When  the  bleeding  point  has 
been  found,  it  may  be  possible  to  pick  it  up  and  tie  it ;  or  the  whole 
ulcer  may  be  picked  up  and  hgatured  en  masse  ;  or  the  base  of  the 
ulcer  may  be  cauterized;  or  excision  of  the  ulcer  may  be  practicable. 
Failing  these  measures,  gastro-enterostomy  will  be  indicated,  and 
the  result  is  usually  satisfactory. 

2.  Perforation  is  by  no  means  an  uncommon  occurrence,  and  un- 
less recognised  and  treated  early  is  fraught  with  the  greatest  danger. 
The  anterior  wall  is  more  frequently  involved  than  the  posterior 
(7  to  i),  owing  to  its  greater  mobihty,  which  prevents  the  formation 
of  protective  adhesions.  The  cardiac  end  is  more  often  affected  in 
young  people,  but  the  majority  of  perforations  are  to  be  found  near 
the  pylorus  and  towards  the  lesser  curvature  in  middle-aged  people 
with  chronic  ulcers.  In  20  per  cent,  of  the  cases  two  perforations 
are  stated  to  be  present  (Moynihan),  but  this  is  very  doubtful. 
The  character  of  the  perforation  varies  considerably;  it  may  be 
small  as  a  pin-prick,  or  as  large  as  a  threepenny  piece.  The  margins 
may  be  oedematous  and  inflamed,  or  in  cases  associated  with  chronic 
ulcers  may  be  thick  and  cicatricial  in  character,  with  no  tendency 
to  close  spontaneously.  The  symptoms  necessarily  vary  with  the 
size  of  the  perforation,  and  with  the  distension  or  liot  of  the  \ascus. 
If  a  large  opening  is  produced  in  the  anterior  wall,  so  that  the  gastric 
contents  are  allowed  a  free  entrance  into  the  peritoneal  cavity,  the 
patient  is  seized  with  severe  epigastric  pain  and  profound  shock, 
and  this  is  followed  by  acute  diffuse  peritonitis,  which  rapidly 
proves  fatal  if  surgical  interference  is  not  at  hand.  When  the  per- 
foration is  small  and  the  stomach  empty,  the  initial  symptoms  of 
pain  and  shock  may  quiet  down  in  twenty-four  hours,  and  the  patient 
recover  spontaneously;  the  opening  is  then  closed  by  lymph  or 
the  omentum.  Sometimes,  however,  a  gradual  leakage  occurs;  the 
onset  is  then  subacute;  the  primary  shock  is  often  inconsiderable, 


ABDOMINAL  SURGERY  995 

but  epigastric  pain  and  tenderness  are  present,  together  with  marked 
rigidity  of  the  abdominal  wall;  a  short  period  of  improvement 
follows  the  primary  shock,  and  then  the  symptoms  steadily  increase 
until  the  characteristic  features  of  general  peritonitis  supervene. 

The  Prognosis  of  gastric  perforation  is  exceedingly  grave,  since, 
unless  active  surgical  interference  is  obtainable  within  a  compara- 
tively short  time,  hopeless  peritonitis  ensues.  Statistics  indicate 
that  95  per  cent,  of  untreated  patients  die,  whilst  the  later  the 
operation,  the  worse  the  results.  If  operation  is  undertaken  within 
six  hours,  recovery  is  usual ;  if  within  twelve  hours,  it  is  not  unusual ; 
but  later  than  that  it  is.  most  uncertain. 

Treatment. — Should  it  be  decided  for  any  particular  reason  not  to 
operate  in  a  given  case,  the  horizontal  position,  rectal  feeding,  and 
the  use  of  morphia  to  check  peristalsis,  are  the  only  means  which 
hold  out  any  prospect  of  benefit.  Operation,  as  already  indicated, 
must  be  undertaken  at  as  earty  a  period  as  possible,  although  it  is 
often  wise  to  delay  for  an  hour  or  two  to  allow  the  patient  to  recover 
in  measure  from  the  initial  shock.  The  median  incision  is  the  best 
to  employ,  since  it  is  not  possible  to  be  certain  as  to  the  situation  of 
the  lesion.  The  rules  given  above  as  to  the  treatment  of  a  pene- 
trating injurj;'  hold  good  in  connection  with  this  subject,  especially 
as  to  the  use  of  swabs  for  the  removal  of  any  extravasated  gastric 
contents,  and  as  to  the  value  of  peritoneal  irrigation.  There  is  no 
need  to  excise  the  ulcer  when  found;  all  that  is  required  is  to  close 
the  aperture  by  means  of  Lembert's  sutures,  which  infold  and  bury 
the  perforation;  this  is  sometimes  a  matter  of  some  difficulty  when 
the  margins  are  thick  and  sclerosed.  In  a  few  cases  it  may  seem 
unwise  to  attempt  closure  of  the  lesion,  whilst  in  others  it  may  be  so 
situated  as  to  render  such  closure  impossible;  a  drainage-tube,  free 
from  lateral  openings,  is  then  introduced  into  the  stomach,  and  gauze 
packed  around  it  so  as  to  lessen  the  risk  of  intraperitoneal  leakage. 
The  patient  is  fed  by  the  rectum  for  some  time,  and  the  fistula 
usually  closes  without  much  difficulty  at  a  subsequent  date. 

The  operation  should  always  include  an  examination  of  the  lesser 
sac,  which  may  have  been  infected  through  the  foramen  of  Winslow 
or  by  a  second  perforation.  This  is  the  more  necessary  when  the 
clinical  s^nnptoms  point  to  a  serious  lesion,  and  nothing  is  found  in 
the  main  peritoneal  cavity  to  explain  them;  under  such  circum- 
stances, if  the  lesser  sac  is  also  free  from  inflammation,  the  vermi- 
form appendix  should  be  examined,  as  it  is  often  responsible  for 
many  atypical  conditions.  Another  point  may  also  require  con- 
sideration before  closing  the  abdominal  wound,  viz.,  whether  or  not 
it  may  be  desirable  to  undertake  a  gastro-enterostomy  at  once.  If 
the  opening  involves  the  p57loric  region  so  as  to  threaten  subsequent 
stenosis,  and  if  the  condition  of  the  patient  is  sufficiently  good,  the 
anastomosis  should  always  be  performed.  If  left  till  a  later  date, 
it  may  be  rendered  extremely  difficult  or  almost  impossible  by  the 
development  of  adhesions. 

After-treatment  is  as  for  all  cases  of  diffuse  septic  peritonitis  (p.  976). 


996  A   MANUAL  OF  SURGERY 

The  patient  is  placed  as  soon  as  possible  in  the  sitting  position. 
Mouth-feeding  is  of  course  forbidden  for  two  or  three  days,  and 
rectal  alimentation  relied  on.  Turpentine  enemata  are  employed  to 
relieve  distension  and  empty  the  bowel. 

3.  Perigastric  Inflammation  is  a  common  result  of  ulceration;  it 
may  be  either  adhesive  or  suppurative  in  character. 

Adhesive  Perigastritis  is  in  the  first  place  protective  in  nature,  con- 
sisting of  a  localized  thickening  of  the  serous  wall.  It  is  more 
marked  in  connection  with  chronic  than  with  acute  ulcers.  The 
posterior  gastric  wall  is  often  adherent  across  the  lesser  sac  of  the 
peritoneum  to  the  serous  membrane  \ymg  in  front  of  the  pancreas, 
and  this  fixity  may  be  one  of  the  factors  which  prevent  the  ulcer 
from  healing,  even  as  fixation  to  the  periosteum  over  the  tibia  delays 
healing  in  an  ulcer  of  the  leg. 

In  a  few  cases  adhesions  form  between  the  anterior  wall  of  the 
stomach  and  the  parietal  peritoneum,  and  these  may  give  rise  to  a 
localized  fixed  epigastric  pain,  usually  increased  considerably  by 
distension  of  the  organ.  It  can  sometimes  be  treated  by  abdominal 
section  and  di\'ision  of  the  adhesion  between  ligatures.  If  left  alone, 
not  only  may  it  cause  inconvenience  by  the  pain  induced,  but  it 
may  also  determine  internal  strangulation  or  obstruction. 

Suppurative  Perigastritis  may  follow  a  small  perforation  with 
limited  leakage,  but  is  more  usually  due  to  an  extension  of  the  ulcer 
and  an  invasion  of  the  perigastric  tissues  by  organisms  which  escape 
from  the  stomach.  The  result  of  this  is  the  formation  of  what  has 
been  already  described  as  a  subphrenic  abscess  (p.  989),  which  may 
or  may  not  contain  gas.  It  may  burst  anteriorly  through  the  abdo- 
minal wall,  or  may  perforate  the  diaphragm,  gi\'ing  rise  to  a  basal 
empyema ;  and  this  in  turn  may  burst  into  the  lung  or  through  the 
chest  wall,  so  that  fistulae  may  appear  in  various  places,  through 
which  the  contents  of  the  stomach  may  be  discharged. 

The  abscess  should  be  opened  and  drained  in  the  wa}^  already 
indicated,  but  should  a  fistula  form,  it  is  almost  hopeless  to  attempt 
to  deal  with  it  locally,  and  a  gastro-enterostomy  may  then  be 
required. 

4.  Stenosis  is  always  Hable  to  follow  the  cicatrization  of  ulcers  of 
the  stomach.  In  the  small  acute  ulcer  the  contraction  rarely  leads 
to  more  than  a  puckering  of  the  organ;  but  in  the  chronic  ulcers  of 
large  size  the  organ  may  be  much  altered  in  shape,  and  definite 
stenosis  may  arise.  If  the  contraction  is  in  or  near  the  cardiac 
orifice,  s^'mptoms  akin  to  oesophageal  stenosis  may  be  produced,  the 
patient  returning  his  food  shortly  after  swallowing  it .  If  the  pylorus 
is  affected,  the  stomach  is  often  much  dilated,  and  vomiting  of  a 
special  type  ensues  (see  Simple  Stenosis  of  the  Pj^orus,  p.  1002).  It 
is  important  to  note  that  muscular  spasm  plays  a  considerable  part 
in  the  production  of  these  symptoms  when  due  to  ulcer;  the  spasm 
is  probably  induced  by  the  hyper-acidity  of  the  gastric  juice  (hyper- 
chlorhydria)  w'hich  is  often  present. 

The  most  exaggerated  forms  of  gastric  stenosis  follow  the  cicatriza- 


ABDOMINAL  SURGERY 


997- 


tion  of  a  horse-shoe  ulcer,  and  this  constitutes  the  most  common 
cause  of  an  hour-glass  stomach ;  adhesive  perigastritis  and  cancer  are 
also  occasional  causes.     The  constriction  is  usually  situated  about 
4  inches  from  the  pylorus,  and  may  be  so  narrow  as  almost  to 
divide  the  organ  into  two  halves.     Generally  the  great  convexity  is 
drawn  up  towards  the  lesser,  and  thereby  two  pouches  are  formed 
which  sag  downwards ;  in  them  food  coUects  and  undergoes  decom- 
position.    Vomiting  more  or  less  of  a  pyloric  type  ensues  from  the 
distension  of  the  cardiac  pouch,  which  is  usually  much  the  larger. 
On  washing  out  the  organ  with  a  measured  quantity  of  water,  a 
smaller  quantity  often  returns,  some  being  retained  in  the  lesser  sac. 
On  palpation  this  latter  may  occasion  a  succussion  splash,  even  when 
the  organ  is  apparently  empty.     On  again  passing  the  tube  after  a 
short  interval,  offensive  fluid  may  return,  especially  if  the  pyloric 
pouch  has  been  palpated.     Distension  of  the  viscus  causes  a  definite 
bulging  on  the  left  side  of  the 
epigastrium  in  the  first  place; 
subsequently  this  may  diminish, 
and  the  pyloric  pouch  become 
evident     on    the    right    side. 
Sometimes  both   pouches   can 
be  distinctly  felt,  or  even  seen, 
as  well  as  the  sulcus  between 
them.  Radiography  after  a  bis- 
muth meal  will  often  demon- 
strate satisfactorily  the   exist- 
ence of  this  condition  (Fig.  469) . 
No  treatment  is  of  any  avail 
which  does  not  provide  for  the 
drainage  of  both  pouches  and 
the  efficient   emptying  of   the 
whole  organ.     A  few  cases  may 
be  treated  by  excision  of  the 
stricture,  or  by  its  longitudinal 
division  and   suture   transversely   by    a   method    similar   to    that 
employed  for  the  pylorus  (see  Pyloroplasty,  p.  1008).     In  the  great 
majority  of  cases  treatment  is  best  effected   by  a  double  gastro- 
enterostomy (Fig.  471),  which  gives  a  direct  communication  between 
each  segment  and  the  jejunum. 

5.  Finally,  cases  are  met  with  in  which  the  symptoms  of  gastric 
ulcer  persist  or  recur  in  spite  of  the  most  careful  dieting  and  treat- 
ment, and  it  is  now  considered  quite  justifiable  to  submit  such  cases 
to  operation.  Two  hues  of  treatment  are  possible,  {a)  The  ulcer 
may  be  excised,  if  it  be  in  a  convenient  position  for  such  a  proce- 
dure, and  if  the  infiltration  around  it  is  not  too  extensive.  This  is 
the  more  desirable,  since  many  cases  apparently  benign  are  really 
mahgnant,  and  the  cicatrices  of  such  conditions,  even  if  benign,  are 
hkely  to  become  mahgnant.  This  practice  is,  however,  seldom 
possible.     (&)  In  most  cases  gastro-enterostomy  (p.  1008)  should  be 


Fig.  471.— Treatment  of  Hour- 
glass Stomach  by  Double  Gastro- 
enterostomy. 


998  A    MANUAL  OF  SURGERY 

undertaken  in  order  to  relieve  symptoms  by  enabling  the  viscus  more 
rapidly  to  empty  itself  after  the  ingestion  of  food,  so  that  the  ulcer 
may  be  given  a  better  opportunity  of  healing.  In  some  cases 
excellent  results  follow  such  a  measure,  but  not  in  all. 

It  must  be  remembered  that  gastro-cnterostomy  is  not  a  magic 
charm  which  at  once  and  for  ever  cures  all  the  troubles  arising 
from  gastric  ulceration.  The  ulcer  is  still  present  when  the  opera- 
tion is  completed,  and  if  chronic  may  take  a  long  time  to  heal,  and 
require  a  continuance  of  the  dietetic  and  medical  treatment  that 
preceded  the  operation,  such  as  the  limitation  of  the  dietary  to  soft 
articles,  and  only  a  very  gradual  increase  in  the  hst  of  things  per- 
mitted, and  the  use  of  drugs,  such  as  an  alkahne  bismuth  mixture 
to  neutrahze  the  h}'perchlorh3-dria  usually  present.  The  teeth  must 
also  be  carefully  attended  to.  Sometimes  the  sj-mptoms  result  from 
an  atonic  gastritis  wdth  absence  of  HCl,  and  then  operation  will  do 
no  good.  In  fact,  it  is  probable  that  unless  some  degree  of  obstruc- 
tion is  present  to  the  onward  passage  of  food  through  the  pylorus  and 
duodenum,  gastro-enterostomy  does  but  httle  good.  It  is  quite 
clear  that,  unless  the  practitioner  selects  his  cases  for  operation  with 
great  care,  he  will  often  be  disappointed  with  the  results,  which 
do  not  by  any  means  always  conform  to  the  couleiir-de-rose  picture  of 
some  writers. 

Recurrence  of  Symptoms  after  Gastro-enterostomy  may  be  due  to 
many  causes :  (i.)  The  ulcer  may  have  broken  down  again,  as  a  result 
of  careless  or  unsuitable  eiiet,  or  of  a  general  loss  of  health  and 
tone.  A  servant  girl  going  back  to  her  old  work  and  habits  is 
very  liable  to  this,  (ii.)  Adhesions  between  the  ulcerated  stomach 
and  surrounding  parts  may  have  been  stretched  as  the  result  of 
some  traumatic  influence,  (iii.)  Adhesions  due  to  the  operation 
itself  may  be  present  and  give  rise  to  trouble,  (iv.)  The  opening 
into  the  jejunum  may  have  contracted,  and  difficulty  in  the  onward 
passage  of  the  food  may  again  be  present,  (v.)  A  peptic  ulcer  may 
have  developed  in  the  efferent  loop  of  the  jejunum  (p.  1012).  The 
history  and  character  of  the  symptoms  should  suffice  to  guide  the 
practitioner  to  a  correct  diagnosis. 

Treatment. — The  patient  should  be  put  to  bed  and  treated  on 
medical  lines  for  a  while;  this  will  suffice  in  most  instances  to  give 
relief.  Should  it  fail  and  s\TTiptoms  persist,  it  may  be  necessary  to 
open  the  abdomen  again  and  explore  the  parts  involved.  Adhesions 
may  be  divided,  and  if  it  seems  Hkely  that  the  opening  has  con- 
tracted, it  may  be  enlarged,  or  a  fresh  anastomosis  may  be  per- 
formed. 

Cancer  of  the  Stomach. — The  stomach  is  more  frequently  invaded 
by  cancer  than  any  other  organ  in  the  body  in  the  male  sex,  whilst 
in  females  it  comes  next  to  the  breast  and  uterus  in  order  of  fre- 
quency. Any  and  every  part  of  the  viscus  may  be  affected,  but  in 
60  per  cent,  of  the  cases  the  tumour  starts  in  or  about  the  pylorus. 
It  may  be  of  a  spheroidal-  or  columnar-celled  type,  but  is  often 
sufficiently  hard  to  warrant  the  use  of  the  term  '  scirrhous  '  which  is 


ABDOMINAL  SURGERY 


999 


usually  applied  to  it.  When  the  cardiac  end  is  attacked,  the  disease 
may  spread  from  the  oesophagus  and  is  a  squamous  epithelioma ;  but 
when  the  body  of  the  organ  is  invaded,  the  condition  is  generally 
a  columnar  carcinoma. 

Cancer  frequenth'  starts  at  the  site  of  an  old  ulcer,  but  often 
there  is  no  assignable  cause  for  its  onset,  except  an  indefinite 
history  of  injury.  It  may  occur  as  a  nodular  outgrowth,  perhaps 
covered  with  papillomatous  projections  and  early  undergoing  ulcera- 
tion ;  if  it  is  of  a  hard  type,  the  ulcerated  surface  has  a  characteristic 
everted  margin.  Sometimes  the  whole  organ  becomes  infiltrated  by 
a  diffuse  carcinomatous  growth,  constituting  a  firm  miass  incapable 
of  dilatation  or  much  contraction,  which  has  been  aptly  termed  the 
'  leather-bottle  stomach.'  At  the  pyloric  end  (Fig.  472)  the  growth 
is  always  of  a  hard  nature,   and  forms  an   annular  constriction. 


Fig.  472. — Cancer  of  Pyloric  End  of  Stomach.      (King's  College 
Hospital  Museum.) 

The  abrupt  limitation  of  the  growth  at  the  commencement  of  the  duodenum 

is  well  seen. 

through  which  it  may  be  difficult  to  pass  even  a  small  catheter;  it 
is  sharply  hmited  on  its  duodenal  aspect,  but  spreads  into  the  body 
of  the  organ,  and  especially  towards  the  lesser  curvature,  following 
the  main  hue  of  the  l^onphatic  stream.  The  lymphatic  glands  lying 
along  the  lesser  curvature  are  involved,  usuallj^  extending  as  far  as 
the  point  where  the  coronary  artery  reaches  the  stomach,  whilst  those 
along  the  pyloric  end  of  the  great  curvature  are  impHcated  to  a  less 
degree  (Fig.  476).  Thence  the  affection  spreads  to  the  hver  and  to 
the  cceliac  glands,  and  may  there  compress  the  inferior  vena  cava 
and  thoracic  duct.  Adhesions  form  around  the  growi;h,  but  are 
relatively  later  in  appearance  than  in  a  single  ulcer;  the}'  may  fix 
the  tumour  to  the  under  surface  of  th/e  liver,  to  the  head  of  the 
pancreas,  the  colon,  and  even  when  of  large  size  to  the  anterior 
abdominal  wall.       These  adhesions  often  prepare  the  way  for  an 


looo  A   MANUAL  OF  SURGERY 

extension  of  the  disease  to  the  peritoneum,  over  which  disseminated 
nodules  of  cancer  may  be  scattered,  giving  rise  to  a  considerable 
effusion  of  serous  fluid.  The  omentum  also  becomes  infiltrated,  and 
colloid  degeneration  is  not  unusual  in  this  region,  the  omentum 
being  converted  into  a  solid  translucent  mass,  looking  sometimes 
like  firm  sago  pudding. 

Speaking  generally,  the  malignancy  of  gastric  carcinoma  is 
decidedly  less  than  that  of  such  organs  as  the  breast  or  uterus,  in 
that  secondary  glandular  affections  are  later  in  developing,  and  even 
when  the  nearest  group  is  involved  it  may  be  some  time  before  the 
affection  spreads  to  distant  parts. 

Clinical  Phenomena. — Gastric  cancer  begins  with  certain  inde- 
finite symptoms,  the  significance  of  which  is  easily  overlooked  in  the 
early  stages,  so  that  a  thorough  and  exhaustive  examination  is  not 
made,  and  the  time  for  radical  interference  passes  without  the  disease 
being  recognised.  Pain  is  generally  the  eai-liest  symptom,  shght  at 
first,  but  gradually  increasing,  and  referred  to  the  epigastrium  or 
back.  Food  may  increase  or  reheve  it,  but  as  time  progresses  the 
pain  comes  on  independently  of  meals.  Acid  eructations  and  a  sense 
of  epigastric  oppression  soon  follow,  and  these  in  time  give  place  to 
actual  attacks  of  vomiting,  the  ejecta  perhaps  containing  blood,  but 
usually  not  till  late  in  the  case,  and  as  a  rule  not  in  great  quantit}-. 
Loss  of  appetite  and  steady  wasting  are  also  marked  features  in  the 
early  stages,  but  the  patient  usually  has  a  clean  tongue.  The  per- 
sistence of  such  a  group  of  symptoms  should  always  determine 
a  complete  investigation  of  the  stomach  and  its  functions,  (i.)  The 
epigastric  region  is  carefully  palpated,  and  the  nature  and  position  of 
any  unusual  swelling  noted.  It  may  be  desirable  to  inflate  the  organ 
with  air  or  gas  and  ascertain  its  exact  size;  by  this  means  it  is 
sometimes  possible  to  detect  a  tumour  which  would  otherwise  escape 
notice,  (ii.)  The  composition  of  the  gastric  juice  is  investigated  by 
the  use  of  a  test  meal  (p.  989).  In  cancer  the  amount  of  HCl  is 
usually  diminished,  whilst  that  of  lactic  acid  is  increased ;  the  latter 
is  probably  a  fermentation  product.  This  test  must  be  looked  on  as 
a  valuable,  but  not  as  a  constant,  indication  of  the  presence  of  cancer. 
HCl  is  generally  increased,  and  not  diminished,  in  the  cancer  that 
supervenes  on  a  chronic  ulcer.  Moreover,  HCl  is  absent  in  many 
gastric  lesions  other  than  cancer,  and  hence  the  results  of  this  inves- 
tigation must  always  be  considered  in  conjunction  with  the  clinical 
symptoms,  (iii.)  The  motor  power  of  the  viscus  is  very  considerabl}' 
lessened,  so  that  the  passage  of  its  contents  into  the  duodenum  is 
delayed;  this  is  due  to  a  chronic  interstitial  gastritis,  (iv.)  A  blood 
count  in  carcinoma  usually  reveals  a  well-marked  secondary  anaemia, 
together  with  a  moderate  leucocytosis  (p.  67).  (v.)  Microscopic 
examination  of  the  vomit  may  also  throw  light  on  the  case  by  the 
discovery  of  fragments  of  the  growth,  (vi.)  Radiographic  examina- 
tion after  a  bismuth  meal  may  reveal  a  decided  excavation  of  the 
normal  shadow  cast  bv  the  bismuth  whilst  still  in  the  stomach 
(Fig.  470). 


ABDOMINAL  SURGERY  looi 

To  these  general  signs  certain  special  ones  may  be  added,  varying 
with  the  location  of  the  growth,  i.  If  the  cardiac  end  is  involved,  a 
tumour  can  rarely  be  detected,  the  stomach  being  small  and  con- 
tracted. The  patient  complains  chiefly  of  pain  on  swallowing,  and 
the  vomiting  occurs  immediately  after  each  meal.  The  symptoms 
are  practically  those  of  oesophageal  cancer. 

2.  When  the  pylorus  is  affected,  a  tumour  can  often  be  felt  a  httle 
above  and  to  the  right  of  the  umbilicus,  which  is  at  first  rounded 
and  nodular ;  it  is  moveable  in  the  early  stages,  but  later  on  becomes 
fixed  by  adhesions ;  it  is  firm  in  consistence,  and  somewhat  tender  on 
manipulation  and  pressure,  and  may  receive  pulsation  from  the 
underlying  aorta.  Owing  to  the  stenosis  of  the  pylorus,  which 
almost  invariably  accompanies  this  condition,  the  stomach  becomes 
dilated,  and  its  great  curvature  displaced  downwards,  perhaps  almost 
into  the  pelvis.  In  this  a  large  accumulation  of  fluid  takes  place, 
which  can  be  heard  splashing  about  when  the  patient  is  moved; 
every  day  or  two  he  brings  up  a  large  quantity  of  fluid  and  decom- 
posing food,  covered  with  a  yeast-like  scum,  and  sometimes  contain- 
ing sarcinae  in  abundance.     Hsematemesis  is  not  uncommon. 

3.  When  the  body  of  the  organ  is  involved,  a  tumour  may  or  may 
not  be  felt,  according  to  its  situation.  In  these  cases  the  amount  of 
pain  and  vomiting  depends  on  the  degree  of  ulceration  of  the  growth, 
and  is  sometimes  comparatively  slight,  especially  if  the  exit  to  the 
organ  through  the  pylorus  is  not  obstructed.  It  is  quite  possible 
that  the  tumour  may  have  attained  considerable  proportions  before 
it  is  discovered.  The  '  leather-bottle  '  stomach  can  be  sometimes 
detected  as  a  solid  mass  emerging  from  under  the  left  costal  margin. 
The  organ  is  not  dilated,  and  the  vomiting  has  no  special  characters ; 
hsematemesis  is  usually  absent,  but  the  dyspeptic  phenomena  are 
pronounced. 

In  the  latter  stages  pressure  phenomena  manifest  themselves. 
Ascites  may  result  from  compression  of  the  portal  vein;  jaundice, 
from  implication  of  the  common  bile-duct;  oedema  of  the  legs  and 
varix  of  the  superficial  abdominal  veins  may  arise  from  pressure 
upon  the  inferior  vena  cava,  whilst  the  peritoneal  cavity  may  be 
distended  with  chyle  owing  to  the  pressure  of  lymphatic  glands  on 
the  receptaculum  chyli  or  thoracic  duct.  All  these  later  signs  are 
indications  that  the  time  has  passed  when  radical  treatment  is 
possible.  A  similar  indication  is  given  by  enlargement  of  a  gland  in 
the  left  supraclavicular  fossa,  which  sometimes  occurs;  this  results 
from  dissemination  of  cancer  cells  up  the  thoracic  duct. 

Treatment. — When  the  symptoms  of  chronic  gastritis  persist  in 
spite  of  careful  dieting  and  treatment,  and  the  patient  is  losing  flesh, 
one  should  always  look  on  the  case  with  suspicion.  Granted  that 
the  examination  of  the  gastric  juice  reveals  the  characteristic  changes 
referred  to  above,  and  still  more  when  a  blood  count  indicates 
leucocjrtosis  and  a  diminishing  quantity  of  haemoglobin,  then  an  ex- 
ploratory operation  is  quite  justifiable  whether  a  tumour  is  to  be  felt 
or  not.      On  the  other  hand,   the  discovery  of  a  tumour  in  the 


I002  A   MANUAL  OF  SURGERY 

epigastrium  does  not  warrant  an  operation.  It  is  quite  possible  that 
under  such  circumstances  the  disease  has  extended  beyond  the  reach 
of  surgery,  and  therefore,  unless  there  are  distinct  indications  for 
palliative  treatment — e.g.,  the  signs  of  pyloric  stenosis — the  patient 
is  often  better  left  to  the  care  of  the  physician.  Of  course,  in  many 
cases  an  operation  is  undertaken  in  the  almost  vain  hope  of  being 
able  to  do  something  to  prevent  the  patient  being  condemned  to 
certain  death ;  but  when  ascites,  jaundice,  or  definite  evidences  of  dis- 
semination are  present,  the  surgeon  should  be  very  chary  of  inter- 
fering. 

For  cancer  of  the  cardiac  orifice,  gastrostomy  (p.  1005)  may 
possibly  be  desirable,  the  artificial  stoma  being  placed  nearer  to 
the  pylorus  than  usual. 

For  cancer  of  the  body  of  the  stomach,  a  partial  or  total  gastrec- 
tomy (p.  1007)  may  be  feasible  in  the  absence  of  massive  adhesions; 
but  the  conditions  which  permit  of  such  procedures  are  unusual.  If 
there  is  any  evidence  of  obstruction  to  the  passage  of  food,  a  gastro- 
enterostomy (p.  1008)  is  undertaken;  owing  to  the  usual  location  of 
the  carcinoma  on  the  posterior  w^all,  the  surgeon  may  be  driven 
to  utilize  the  anterior  operation.  Sometimes  the  disease  is  so 
extensive  that  even  this  procedure  is  impracticable;  the  patient's 
nutrition  is  then  likely  to  fail  rapidly,  but  possibly  life  may  be 
prolonged  (if  such  be  desirable)  by  the  formation  of  an  artificial 
opening  into  the  jejunum  (jejunostomy),  through  which  he  may  be 
fed  without  using  the  stomach. 

For  cancer  of  the  pylorus,  operation  is  more  frequentl}-  possible. 
If  the  mass  is  comparatively  moveable,  and  there  are  but  few 
adhesions,  removal  of  the  diseased  portion  of  the  organ  may  be 
undertaken,  and  even  should  secondary  deposits  be  present  in  the 
liver,  the  patient  is  probably  better  off  after  such  a  procedure  than 
if  left  alone.  When  the  growth  is  firmly  adherent  to  adjacent 
viscera,  gastro-enterostomy  is  alone  practicable,  and  will  be  most 
beneficial. 

Failing  all  operative  measures,  the  patient's  nutrition  must  be 
maintained  by  such  food  as  causes  him  the  least  discomfort,  and 
considerable  relief  will  be  experienced  from  regular  and  sj-stematic 
lavage  of  the  organ.     Opium  will  be  needed  for  pain. 

Simple  Stenosis  of  the  Pylorus  results  from  a  number  of  different 
conditions.  It  gives  rise  to  hypertrophy  and  dilatation  of  the 
stomach,  which  becomes  enlarged  downwards,  and  forms  a  sac,  in 
which  food  collects  perhaps  for  days,  and,  undergoing  fermentative 
changes,  is  finally  ejected  in  large  quantities,  mixed  with  frothy 
mucus  and  a  yeast-like  scimi  containing  an  abundance  of  sarcinse. 
The  stomach  may  in  time  almost  reach  the  pelvis,  the  pylorus  being 
dragged  down  with  it. 

The  causes  of  this  condition  are  as  follows:  (i)  Most  frequently 
it  is  due  to  the  heahng  of  a  gasiric  ulcer,  situated  within  or  close 
to  the  pyloric  orifice;  in  the  acute  form,  w^here  the  ulcers  are 
small,   spasm  as   a  result   of  the   associated  hj-perchlorhydria  is 


ABDOMINAL  SURGERY  1003 

an  important  element  in  aggravating  the  symptoms  caused  by  a 
slight  contraction.  The  treatment  in  these  cases  is  at  first  medical, 
and  includes  daily  washing  out  of  the  organ.  Should  it  fail  to  give 
relief,  operation  is  required,  and  consists  in  excision  of  the  pylorus 
or  in  gastro-enterostomy.  (2)  It  may  result  from  the  contraction 
of  extrinsic  adhesions.  These  may  be  massive  or  band-like;  in  the 
former  case  the  pylorus  is  imbedded  in  the  newly-formed  fibrous 
tissue;  in  the  latter  it  is  kinked,  and  subsequently  contracted. 
Such  adhesions  may  be  secondary  to  gastric  ulcer,  or  may  arise 
from  an  inflamed  gall-bladder  (peri-cholecystitis) .  Operative  treat- 
ment is  usually  necessary  in  order  to  divide  the  adhesions,  or  to 
remedy  the  dilatation  by  gastro-enterostomy.  (3)  It  is  occasionally 
met  with  as  a  congenital  hypertrophy  of  the  pylorus,  in  which  the  over- 
growth chiefly  involves  the  muscular  fibres.  It  usually  occurs  in 
male  children,  and  the  pylorus  is  transformed  into  a  sohd  cylindrical 
mass,  about  an  inch  in  length,  pale  in  colour,  and  as  hard  as  cartilage. 
Symptoms  commence  within  two  or  three  weeks  of  birth ;  after  taking 
food  there  is  not  much  evidence  of  pain,  although  the  child  may 
appear  to  be  uncomfortable,  and  relief  is  obtained  by  vomiting.  But 
little  food  appears  to  pass  into  the  intestine,  so  that  constipation  is 
marked  and  the  child  soon  wastes.  The  stomach  becomes  enlarged 
after  a  time,  as  in  the  other  varieties,  and  the  pylorus  can  sometimes 
be  palpated  as  a  moveable  tumour.  There  has  been  a  good  deal  of 
discussion  as  to  the  treatment  of  these  cases,  but  practically  it 
is  limited  to  two  procedures:  [a]  The  pylorus  is  dilated  by  a 
modification  of  Loreta's  method,  metal  dilators  of  the  Hegar  type 
being  employed  (Burghard);  or  (6)  pyloroplasty  is  relied  on  by 
others.  Gastro-enterostomy  is,  of  course,  desirable,  but  the  mor- 
tahty  is  high,  the  children  not  having  sufficient  vitality  to  stand 
such  a  serious  operation. 

Gastroptosis  is  a  condition  met  with  not  very  unfrequently,  in 
which  the  stomach  is  displaced  downwards  and  dilated,  usually  as  a 
complication  of  a  generalized  enteroptosis  (Glenard's  disease,  q^.v.), 
and  hence  is  likely  to  be  associated  with  dropping  of  the  liver  and 
mobility  of  the  right  kidney.  The  symptoms  produced  are  those  of  a 
chronic  atonic  gastritis  with  a  dilated  stomach;  vomiting  is  not  a 
marked  sign,  but  acid  eructations,  gastric  discomfort,  and  constipa- 
tion are  very  troublesome,  and  the  patient  steadily  loses  weight; 
neurasthenic  manifestations  are  prominent.  The  downward  dis- 
placement of  the  stomach  may  be  such  as  to  permit  the  pancreas  to 
be  felt  above  the  lesser  curvature.  Haematemesis  is  sometimes 
present,  but  the  acidity  is  normal  or  diminished,  and  the  diagnosis 
from  gastric  ulcer  is  thereby  determined.  Radiographic  examina- 
tion after  a  bismuth  meal  assists  in  determining  the  extent  of  the 
displacement  (Fig.  468) .  Treatment  consists  in  lavage  and  electricity 
to  the  organ  in  the  first  place  with  careful  dieting,  and  external 
support  by  a  suitable  belt  is  of  some  value.  In  more  advanced  cases, 
operative  treatment  is  necessary,  and  many  different  methods  have 
been  suggested.    Theoretically,  it  is  desirable  to  hft  the  stomach 


1004  A   MANUAL  OF  SURGEHY 

by  folding  up  and  shortening  the  lesser  omentum,  as  suggested  by 
Beyea;  but  unfortunately  this  structure  is  often  so  thin  and  attenu- 
ated as  to  render  this  procedure  impossible.  Eve*  points  out  that  it 
is  essential  in  many  cases  to  deal  with  the  liver  first,  fixing  it  up  to 
the  anterior  abdominal  wall  by  suitable  sutures,  and  then  the  lesser 
curvature  of  the  stomach  may  be  raised  by  passing  sutures  through 
it  and  through  the  liver  itself  along  the  attachment  of  the  lesser 
omentum.  Four  or  five  sutures  of  this  type  will  fix  the  stomach 
satisfactorily.  It  may  be  needful  in  a  few  cases  to  diminish  the  size 
of  the  cavity  by  the  formation  of  a  series  of  tucks  or  folds  in  the 
anterior  wall  by  sutures  passing  from  above  downwards  [gastro- 
plication) ;  whenever  obstruction  is  present,  gastro-enterostomy  will 
also  be  required. 

Acute  Dilatation  of  the  Stomaehf  is  a  curious  condition  occasion- 
ally met  with  in  surgical  practice,  as  an  unexpected  and  unwelcome 
sequela  of  injury  or  operation,  and  that  by  no  means  necessarily 
hmited  to  the  abdomen.  It  is  rather  more  common  in  medical  work, 
arising  either  without  apparent  cause,  or  in  the  course  of  debilitating 
illnesses.  It  is  characterized  by  a  sudden  onset,  the  vomiting  of 
enormous  quantities  of  fluid,  and  severe  general  symptoms,  which 
usually  terminate  fatally  in  a  few  days.  The  stomach  becomes 
enormously  dilated,  even  sagging  down  into  the  pelvis,  and  the  walls 
are  more  or  less  paralyzed,  as  peristalsis  is  rarely  e\'ident.  The 
pathology  of  this  condition  is  uncertain,  but  it  is  possibly  due  to 
constriction  of  the  third  piece  of  the  duodenum  by  the  root  of  the 
mesentery  through  a  downward  drag  of  the  intestines.  Treatment 
consists  in  regular  lavage,  and  in  some  cases  the  abdominal  decubitus 
has  given  rehef ;  rectal  ahmentation  is  required.  Surgical  treatment 
is  very  unhkely  to  do  good,  unless  there  is  some  associated  obstruc- 
tion near  the  pylorus. 

Operations  upon  the  Stomach. 

1 .  Washing  outthe  Stomach  is  needed  in  cases  of  poisoning,  in  chronic 
catarrh,  in  dilatation  of  the  organ,  and  as  a  preHminary  to  some 
operations  in  which  its  cavity  is  to  be  laid  open.  It  may  be  accom- 
phshed  by  the  ordinary  stomach-pump,  or  by  the  simpler  method  of 
passing  a  long  tube  of  good-sized  cahbre,  to  the  upper  end  of  which 
is  attached  a  funnel.  Fluid  is  introduced  through  the  funnel,  and 
syphoned  out  by  lowering  it  below  the  level  of  the  stomach. 

2.  Gastrotomy,  or  opening  the  stomach,  is  required  for  the  removal 
of  foreign  bodies  from  it  or  from  the  lower  end  of  the  oesophagus,  for 
exploratory  purposes,  and  as  a  means  of  dilating  simple  strictures  of 
either  the  pyloric  or  cardiac  orifices  (Loreta's  operation). 

Operation. — An  incision  is  made  in  the  middle  line  above  the 
umbilicus  unless  there  is  some  special  indication  to  the  contrary. 

*  Sir  F.  S.  Eve,  Trmisactions  of  Medical  Society,  vol.  xxxiii.,  p.  252. 
t   For  further  details,  see  '  Acute  Dilatation  of  the  Stomach,'  byH.  Campbell 
Thomson,  M.D.     Bailliere,  Tindall  and  Cox,  1902. 


ABDOMINAL  SURGERY 


1005 


The  peritoneum  is  opened,  and  the  stomach  recognised  by  its  posi- 
tion immediate!}'  under  the  Hver,  and  by  the  thickness,  pink  colour, 
and  opacity  of  its  walls.  If  the  omentum  or  transverse  colon  pre- 
sents in  the  wound,  it  must  be  pushed  down,  and  the  stomach  looked 
for  above.  The  spot  where  the  stomach  is  to  be  opened  is  now 
selected,  and  the  part  drawn  out  and  carefully  packed  around  with 
sterilized  gauze  so  as  to  prevent  contamination  of  the  general 
peritoneal  cavity.  The  incision  is  made  in  the  long  axis  of  the 
stomach,  and  the  finger  inserted.  The  removal  of  a  foreign  body 
must  be  undertaken  with  great  care, 
so  as  not  to  inflict  injury  on  the 
organ,  the  wound  being  enlarged,  if 
necessary.  The  stomach  is  subse- 
quently closed  by  Czerny-Lembert 
sutures,  and  replaced;  all  traces  of 
blood,  etc.,  are  removed,  and  the 
external  wound  is  closed  in  the 
usual  way. 

The  cardiac  orifice  is  not  easily 
reached,  as  it  lies  deeply  just  in 
front  of  the  aortic  opening  in  the 
diaphragm.  It  can  be  dilated  by 
the  fingers  or  by  suitable  dilators, 
and  a  foreign  body  by  this  means 
removed  from  the  lower  end  of  the 
oesophagus.  The  utmost  gentleness 
must  be  observed  in  this  proceeding, 
as  serious  symptoms  may  be  caused 
by  irritation  or  injury  of  the  pneumo- 
gastric  nerves,  the  terminations  of 
which  pass  through  this  opening  in 
the  diaphragm. 

The  operations  on  the  [pyloric 
orifice  are  dealt  with  below. 

3.  Gastrostomy  consists  in  the 
formation  of  a  permanent  artificial 
opening  into  the  stomach,  through 
which  the  patient  can  be  fed.  It 
is  needed  in  cases  of  malignant 
disease  or  intractable  stenosis  of  the 
oesophagus,  where  the  patient  is  exposed  to  the  risk  of  starvation, 
owing  to  his  inabihty  to  take  nourishment.  It  is  most  important 
that  the  opening  should  be  of  a  valvular  type  so  that  there  shall  b  e 
no  escape  of  gastric  juice,  followed  by  irritation  and  digestion  of  the 
surrounding  skin,  which  were  so  constantly  seen  in  the  old  days. 
The  chief  methods  of  operation  are  those  known  as  Frank's,  Witzel's, 
and  the  Kader-Senn  procedure. 

Frank's  Operation. — Fenger's  obhque  incision   (Fig.  473,  A)  for 
exposure  of  the  stomach  is  first  made,  the  viscus  withdrawn  and 


Fig.  473. — Incisions  utilized 
Various  Abdominal  Operations. 

A,  Fenger's  incision  for  exposing 
the  stomach;  A^,  additional  in- 
cision in  Frank's  gastrostomy; 
B,  incision  for  exposing  the  gall- 
bladder ;  C,  incision  for  opera- 
tions on  appendix;  D,  left  iliac 
colostomy;  E,  median  incision 
for  ovariotomy  or  suprapubic 
cystotomy;  F,  for  radical  cure 
of  inguinal  hernia  or  varicocele ; 
G,  for  femoral  hernia;  i,  anterior 
superior  iliac  spine;  2,  pubic 
spine. 


ioo6 


A  MANUAL  OF  SURGERY 


examined,  and  a  silk  sling  passed  through  the  serous  and  muscular 
coats  at  the  site  selected  for  the  artificial  opening,  so  that  a  cone- 
shaped  portion  of  the  wall  can  be  drawn  up  into  the  wound.  The 
parietal  peritoneum  is  then  sutured  all  round  to  the  base  of  the  cone, 
so  as  to  shut  it  off  from  the  general  serous  cavity.  A  second  in- 
cision (A^),  about  I  inch  in  length,  is  now  made  on  the  outer  side  of 
the  first  wound,  parallel  to  it,  and  about  i^-  inches  from  it.  The 
bridge  of  skin  and  subcutaneous  tissue  between  the  two  is  separated 
from  the  subjacent  structures,  and  the  apex  of  the  cone  of  gastric 
wall  drawn  under  the  bridge  into  the  second  wound.  A  small  opening 
is  then  made  into  the  viscus  through  the  apex,  and  the  mucous 


Fig.  474.  Fig.  475. 

Gastrostomy  (Frank's  Modified  Operation). 

In  Fig.  474  the  base  of  the  cone  is  seen  sutured  to  the  peritoneum  and  sheath 
of  the  rectus;  in  Fig.  475  the  stomach  has  been  opened,  a  tube  stitched  in, 
and  the  sutures  passed  through  the  rectus  are  in  place. 

membrane  stitched  accurately  to  the  skin.  The  remainder  of  this 
incision  is  then  closed  in  the  ordinary  way,  as  also  the  first.  Healing 
readily  occurs,  and  a  valvular  opening  is  established,  through  which 
the  patient  may  be  fed  at  once. 

As  a  modification  of  this  procedure,  a  vertical  incision  (as  suggested 
by  Kocher)  is  emploj^ed  instead  of  the  oblique,  extending  for  3  or 
4  inches  downwards  from  the  eighth  costal  cartilage  and  passing 
through  the  substance  of  the  rectus  muscle  (Fig.  474),  which  is  split 
by  the  fingers  or  handle  of  the  knife  into  two  portions.  A  cone- 
shaped  portion  of  the  stomach  wall  is  withdrawn,  and  its  base 
stitched  to  the  parietal  peritoneum  and  posterior  la3'er  of  the  sheath 


ABDOMINAL  SURGERY  1007 

of  the  rectus.  A  small  hole  is  made  in  the  apex  of  the  cone,  and  into 
this  a  piece  of  rubber  drainage-tube,  free  from  lateral  openings,  and 
not  larger  than  a  No.  10  catheter,  is  stitched,  so  that  about  i-|  inches 
project  inside  the  cavity  (Fig.  475) .  The  halves  of  the  rectus  muscle 
are  freed  from  the  posterior  layer  of  the  sheath  and  drawn  together 
by  sutures,  so  as  to  cover  in  all  the  exposed  gastric  wall  except  the 
apex  of  the  cone,  which  with  the  tube  is  drawn  to  the  upper  end  of 
the  wound,  and  projects  from  it.  The  incision  in  the  skin  is  then 
closed,  and  finally  the  serous  and  muscular  coats  of  the  projecting 
portion  are  carefully  stitched  to  the  skin.  The  results  of  this  pro- 
cedure have  been  most  satisfactory,  many  cases  having  run  their 
course  without  a  drop  of  gastric  juice  escaping.  The  amount  of  food 
at  first  administered  is  small,  and  rectal  feeding  may  be  required  in 
addition ;  but  it  is  gradually  increased  until  perhaps  17  ounces  can 
be  retained  four  times  a  day.  The  patient  should  be  kept  in  the 
recumbent  posture  for  three  weeks.* 

Witzel's  Operation  consists  in  making  a  valvular  opening  into  the 
stomach  by  introducing  and  stitching  a  tube  into  it  as  in  the  last 
proceeding,  and  then  burying  the  projecting  portion  as  far  as  possible 
by  suturing  the  serous  and  muscular  coats  together  over  it.  The 
stomach  is  then  fixed  to  the  abdominal  parietes  and  the  skin  closed. 
The  result  of  this  operation  is  very  good,  but  the  fixation  to  the 
abdominal  wall  is  not  so  secure  as  in  the  former  plans,  and  inasmuch 
as  the  newly-formed  passage  is  lined  with  serous  membrane  con- 
traction is  liable  to  occur.  It  may  be  employed  advisably  when  the 
stomach  is  small,  and  it  is  difficult  to  find  enough  tissue  for  the  per- 
formance of  Frank's  operation. 

In  the  Kader-Senn  Operation  a  tube  is  stitched  into  the  stomach 
and  buried  in  the  stomach  wall  by  a  series  of  purse-string  sutures 
introduced  at  intervals  of  about  ^  inch.  The  stomach  itself  is  then 
secured  to  the  margins  of  the  abdominal  incision. 

4.  Gastrectomy. — A  good  many  cases  have  now  been  reported  in 
which  a  limited  portion  of  the  gastric  wall  has  been  removed  success- 
fully, either  for  simple  or  mahgnant  ulcers  or  growths.  Incisions  are 
made  so  as  to  include  the  mass,  and  the  wound  is  subsequently 
closed  by  Czerny-Lembert  sutures. 

Total  excision  of  the  stomach  has  been  undertaken  for  extensive 
mahgnant  disease,  which,  however,  has  left  enough  of  the  oesophageal 
end  free  to  allow  of  its  apposition  and  fixation  either  to  the  upper  end 
of  the  duodenum,  or,  if  that  cannot  be  brought  across  to  it,  to  a 
suitable  coil  of  the  jejunum. 

5.  Partial  gastrectomy  for  malignant  disease  of  the  pyloric  end  of 
the  stomach  is  now  frequently  undertaken  and  with  excellent  results, 
if  the  patient  is  not  too  debilitated  and  if  too  many  adhesions  are  not 
present. 

Operation. — ^The  abdomen  is  opened  by  a  median  incision,  through 
which  the  diseased  area  is  explored,  and  a  final  decision  made  as  to 

*  For  further  details,  see  Carless,  '  On  Gastrostomy,'  King's  College  Hos- 
pital Reports,  vol.  v.,  1897-1898,  and  in  Edinburgh  Medical  Journal,  July,  1902. 


ioo8 


A   MANUAL  OF  SURGERY 


the  practicability  or  not  of  removing  it.  If  an  operation  is  deter- 
mined on,  the  growth  is  carefully  isolated  from  surrounding  parts  by 
dividing  the  attachments  of  the  great  and  lesser  omenta,  any  en- 
larged glands  being  also  included  in  the  scope  of  the  operation. 
Clamps  are  then  applied  to  the  stomach  and  duodenum,  and  the 
surrounding  part  of  the  abdomen  carefully  protected  with  sterilized 
gauze.  The  mass  is  now  removed  (Fig.  476),  the  incisions  being  so 
placed  as  to  extend  beyond  the  pylorus  about  f  inch  into  the  duo- 
denum on  the  one  side,  and  on  the  other  so  as  to  include  the  greater 
portion  of  the  lesser  curvature,  thereby  remo\ang  the  lymphatic 
glands.  Bleeding-points  are  secured,  and  the  two  incisions  com- 
pletely closed,  no  attempt  being  made  to  appose  or  unite  them.  The 
first  part  of  the  jejunum  is  then  drawn  up,  and  an  ordinary  gastro- 
enterostomy performed ;  this  is 
sometimes  undertaken  as  a  pre- 
liminary operation. 

The  chief  danger  of  the  opera- 
tion is  shock,  but  if  this  can  be 
avoided  by  careful  protection 
of  the  viscera,  by  the  preven- 
tion of  haemorrhage,  and  by 
rapidity  of  execution,  a  good 
result  may  be  expected.  The 
patient  is  fed  per  rectum  for  the 
first  forty-eight  hours,  if  possi- 
ble, but  after  that  interval 
small  quantities  of  fluid  may  be 
allowed,  and  the  dietar}^  gradu- 
ally increased. 

6.  Pyloroplasty  consists  in 
incising  the  pylorus  and  reclos- 
ing  the  incision  in  such  a  way  as  to  increase  the  cahbre  of  the  tube. 
It  has  been  performed  for  various  types  of  stricture,  but  is  now  rarely 
employed  (except  for  congenital  stenosis),  having  been  replaced  by 
gastro-enterostomy.  The  operation  commences  b}'  clearing  the 
pylorus  from  adhesions.  A  longitudinal  ir/  ision  is  then  made 
through  the  stricture,  and  by  a  httle  carelul  manipulation  this 
wound  can  be  opened  out  and  brought  log';:ther  in  a  transverse 
manner  so  as  greatly  to  increase  the  lumen  of  the  orifice  (Fig.  477). 
Two  rows  of  stitches  are  inserted,  one  through  the  mucous  mem- 
brane, and  the  other  through  the  muscular  and  serous  coats. 

7.  Gastro-enterostomy,  or,  more  correctly,  gastro-jejunostomy,  is 
constantly  resorted  to  in  the  treatment  of  gastric,  pyloric,  or 
duodenal  lesions,  and  in  careful  and  skilful  hands  the  death-rate  is 
now  small  (well  under  10  per  cent.).  Indications. — i.  For  obstruc- 
tion to  the  onward  course  of  the  food,  whether  in  the  stomach, 
pylorus,  or  duodenum,  and  whether  simple  or  malignant  in  origin. 
2.  For  persistent  phenomena  of  ulceration,  either  of  stomach  or 
duodenum,  in  spite  of  suitable  treatment,  but  it  is  doubtful  whether 


Fig.  476. — Cancer  of  Pylorus,  in- 
dicating THE  Situation  of  the 
Lymphatic  Glands  along  the  Two 
Curvatures,  and  of  the  Incisions 

NEEDED    to    INCLUDE    THEM. 


A BDOMINA L  S URGER Y 


loog 


it  is  uf  much  value  apart  from  a  lesion  which  obstructs  more  or  less 
the  passage  of  food.  3.  For  recurrent  haemorrhage  under  similar 
conditions,  in  order  to  put  the  parts  at  rest  by  rapidly  emptying  the 
stomach,  or  by  diverting  the  food  from  the  duodenum.  4.  As  a  part 
of  the  modern  operation  of  pylorectomy  or  hemi-gastrectomy. 

The  operation  consists  in  the  formation  of  an  artificial  communica- 
tion between  the  stomach  and  intestine.  It  is  important  that  the 
selected  portion  of  bowel  should  be  the  upper  part  of  the  jejunum, 
since,  if  the  communication  is  established  too  low,  a  much  greater 
absorbing  surface  is  isolated,  with  the  result  that,  even  if  the  opera- 
tion is  immediately  successful,  the  patient  gradually  loses  ground 
owing  to  lack  of  nutriment;  and  the  rapidity  of  the  emaciation  will 
increase  as  the  communication  is  placed  further  from  the  duodenum. 

Operation. — The  abdomen  is  opened  in  the  middle  line  and  the 
stomach  is  readily  found;  a  careful  examination  of  the  parts  is  made 
to  confirm  the  necessity  for  the  anastomosis  and  to  select  the  most 
favourable  site.  This  should  be  placed  on  the  posterior  wall  of  the 
stomach,  if  possible,  close  to  the  greater  curvature,  but  well  away 
from  the  growth  or  ulcer,  and  yet  as  near  to  the  pylorus  as  is  prac- 


FiG.  477. — Pyloroplasty. 

The  contracted  bowel  is  divided  longitudinally,  and  the  aperture  thus  made 
opened  out,  so  that  it  can  be  brought  together  transversely. 

ticable.  The  selected  spot  in  the  jejunum  must  be  as  near  to  its 
commencement  as  possible,  so  as  to  leave  only  a  short  loop  between 
its  origin  and  the  anastomosis.  The  anti-mesenteric  border  is 
utilized,  and  the  jejunum  must  be  so  placed  that  the  peristaltic  wave 
passing  from  stomach  to  jejunum  shall  be  continuous — i.e.,  shall 
travel  from  left  to  right.  To  find  the  upper  end  of  the  jejunum,  the 
transverse  colon  is  withdrawn  from  the  wound,  together  with  the 
omentum.  By  tracing  down  the  transverse  meso-colon  to  its 
attachment  the  termination  of  the  duodenum  is  reached  as  it  crosses 
the  middle  fine  at  the  lower  border  of  the  pancreas,  and  the  coil  of 
bowel  which  emerges  on  the  left  side  is  necessarily  the  commence- 
ment of  the  jejunum.  It  is  now  possible  to  decide  finally  whether 
the  anastomosis  is  to  be  effected  to  the  anterior  or  posterior  wall  of 
the  stomach. 

(i)  The  anteyior  operation  (Fig.  478)  has  fallen  into  disrepute  of 
recent  years,  but  with  care  excellent  results  can  be  obtained  when 
the  condition  of  affairs  prevents  the  posterior  wall  from  being 
employed.  The  objections  to  it  are  twofold:  (a)  The  jejunum  is 
drawn  up  over  the  transverse  colon,  and  may  possibly  constrict  it 
and  lead  to  obstruction;  this  is  the  more  likely  to  occur  when  the 

64 


A  MANUAL  OF  SURGERY 


opening  in  the  jejunum  is  as  near  as  possible  to  the  duodenum,  a 
desirable  arrangtmcnt  from  many  other  points  of  \'itw;  and  (6)  the 
necessax}'  drag  of  the  gut  is  apt  to  bring  the  two  ends  paredlel  to  each 
other,  and  thus  proeluce  a  spur,  or  kink,  by  means  of  which  the  bile 
is  directed  into  the  stomach  instead  of  into  the  efferent  limb,  thus 
estabhshing  a  vicious  circle.  Severe  bilious  vomiting  results,  which 
may  prove  fatal.  The  actual  method  of  anastomosis  is  similar  to 
that  for  the  posterior  operation. 

(2)  In  the  posterior  o-ptxdXiow  of  Von  Hacker  the  jejunum  is  united 
to  the  posterior  wall  of  the  stomach  through  an  opening  in  the  trans- 
verse meso-colon,  the  lesser  sac  of  the  peritoneum  being  thereby 
traversed.  Long  metallic  clamps,  with  or  without  rul:)ber  guards 
over  the  blades,  are  then  applied  to  the  stomach  and  intestine  in  such 

a  way  that  they  can  be  brought 
easily  into  apposition  one  with 
the  other  (Fig.  479),  and  with 
sufficient  force  to  prevent  ex- 
travasation of  the  contents,  and 
to  control  haemorrhage.  A 
suitable  packing  of  strips  and 
abdominal  cloths  is  then  made, 
and  all  other  viscera  are  re- 
placed. Incisions,  2  inches  in 
length,  are  made  into  stomach 
and  intestine  so  as  to  corres- 
pond exactly,  and  any  fluid 
which  escapes  is  received  on 
swabs  or  gauze  strips. 

The  actual  anastomosis  is 
effected  by  simple  suturing 
without  the  aid  of  any  other 
mechanical  contrivance;  either 
sterihzed  silk  or  iodized  catgut 
may  be  employed  for  the  purpose.  The  suturing  is  undertaken 
in  four  stages.  Firstly,  a  sero-muscular  suture  secures  the 
posterior  aspects  of  the  viscera  in  apposition,  the  stitches  extending 
beyond  each  end  of  the  incision.  Then  the  mucous  membranes 
of  the  stomach  and  jejunum  are  united  by  a  continuous  suture.  T  his 
may  be  performed  in  two  sections,  back  and  front,  or  one  stitch  may 
suffice  for  the  whole  anastomosis.  Finally,  the  anterior  sero- 
muscular suture  completes  the  junction.  Occasionally  a  few  extra 
supporting  stitches  are  required  in  addition  to  the  two  rows,  and  it 
is  weh  to  secure  any  large  vessel  going  to  the  site  of  anastomosis  by 
passing  a  suture  under  and  tying  it.  The  suturing  must  be  accurate 
and  close,  as  one  depends  on  it  to  prevent  bleeding  from  the  divided 
visceral  walls. 

The  usual  peritoneal  toilette  follows :  clamps  are  removed,  blood 
is  sponged  away,  swabs  and  strips  of  gauze  are  removed  and  counted, 
the  viscera  replaced,  and  the  abdominal  incision  closed. 


Fig.   478. — Anterior    G.\stro-extero- 

STOMY. 

A,  Transverse  colon ;  B,  jejunum  dragged 
up  over  the  colon  and  omentum  (pur- 
posely omitted)  to  be  brought  into 
apposition  with  the  stomach. 


ABDOMINAL   SURGERY 


The  after-treatment  consists  in  the  adoption  of  the  sitting  posture, 
and  in  abstaining  from  stomach-feeding  for  twenty-four  to  forty- 
eight  hours,  if  practicable,  rectal  ahmentation  being  resorted  to  in  the 
interval.  Ilcemorrhage  from  the  divided  visceral  walls  is  sometimes 
troublesome,  the  patient  vomiting  blood-stained  fluid.  Ice  is  then 
applied  to  the  epigastrium,  and  a  full  dose  of  ergotin  administered 
hypodermically,  or  20  grains  of  lactate  of  calcium  by  rectum.  Not 
unfrequently  there  will  be  some  regurgitation  of  bile  into  the  stomach, 
and  this  may  lead  to  troublesome  vomiting  for  a  few  days ;  but  if  the 
junction  is  satisf actor}',  it  soon  passess  off,  especially  when  food  is 
administered  by  the  mouth,  as  may  usually  be  undertaken  on  the 
third  day,  or  earlier,  if  necessary.  At  first  only  fluid  nourishment 
should  be  permitted,  but  in  a  week's  time  soft  sohds  may  be  given. 


.^yr' 


Fig.  479. — Posterior  Gastro-enterostomy. 

Clamps  guarded  by  rubber  tubing  have  been  applied  to  the  stomach  and 
jejunum,  and  their  apposition  is  maintained  by  clipping  the  rubber 
tubing  with  Spencer  Wells  forceps  at  each  end.  The  incisions  have  been 
made,  and  the  posterior  walls  have  been  sutured  together. 

and  gradually  a  more  liberal  diet  is  ordered.  The  effect  of  the  opera- 
tion is  necessarily  only  palhative  when  cancer  is  present,  but  the 
general  condition  often  improves  considerably  for  a  time,  and  the 
final  exitus  lethalis  is  associated  with  less  suffering. 

Should  serious  biliary  vomiting  occur,  the  patient  must  sit  up  and 
the  stomach  be  washed  out.  Faihng  that,  it  may  be  necessary  to 
open  the  abdomen,  and  establish  a  fresh  opening  between  the  afferent 
and  efferent  coils.  To  prevent  the  possibihty  of  such  an  occurrence, 
Roux  has  suggested  making  a  Y-anastomosis.  The  jejunum  is  cut 
across,  the  lower  segment  being  implanted  at  right  angles  into  the 
stomach  wall,  and  the  upper  or  duodenal  end  into  a  second  opening 
in  the  gut  lower  down.  Excellent  results  have  followed  this  pro- 
cedure. 


10I2  A   MANUAL  OF  SURGERY 

Pc'pUc  Ulceration  may  occur  at  the  site  of  anastomosis  or  a  little 
below  it,  but  is  uncommon,  except  after  the  anterior  operation,  and 
even  then  only  occurs  in  2  per  cent,  of  the  cases.  It  may  determine 
pain  and  vomiting  after  food,  accompanied  perhaps  by  hiemorrhage 
or  perforation.     Treatment  is  as  for  ordinary  ulcer  of  the  stomach. 

8.  Finney's  Operation,  or  gastro-duodenostomy,  is  employed  by 
some  surgeons  as  an  alternative  to  the  gastro-jejunostomy  just 
described.  It  consists  in  an  anastomosis  between  the  second  piece 
of  the  duodenum  and  the  immediately  adjacent  stomach.  It  has 
its  advocates,  but  has  not  come  into  general  favour. 

Ulcers  of  the  Duodenum  are  very  similar  in  nature  and  origin  to 
those  of  the  stomach,  to  which  indeed  they  may  be  secondary.  They 
occur  most  frequently  in  men  thirty  to  forty  years  of  age,  and  often 
without  any  obvious  cause.  Oral  sepsis  is  not  uncommonly  present, 
as  also  hyperchlorhydria;  in  some  cases  chronic  nephritis  or  arterio- 
sclerosis has  existed,  and  in  others  the  lesion  follows  some  operation. 
The  ulceration  which  forms  a  very  occasional  sequela  of  burns  has 
been  already  alluded  to  (p.  126).  The  first  part  of  the  duodenum  is 
that  usually  affected,  and  tfie  anterior  rather  than  the  posterior  wall ; 
the  character  of  the  ulcer  is  similar  to  that  seen  in  the  stomach. 

The  Symptoms  are  tolerably  characteristic,  even  apart  from  the 
dangerous  complications,  hcemorrhage,  perforation,  and  stenosis. 
The  patient,  who  may  appear  to  be  fairly  well  nourished,  complains 
of  pain  coming  on  after  meals,  not  immediately,  but  after  an  interval 
of  two  or  three  hours,  and  often  relieved  by  taking  more  food.  Be- 
ginning with  a  sense  of  fulness  and  heat  in  the  epigastrium,  it 
develops  into  acute  pain  located  in  the  right  hypochondrium  and 
shooting  through  to  the  back.  On  examination  of  the  abdomen  a 
tender  spot  is  usually  to  be  detected  a  little  above  and  to  the  right  of 
the  umbilicus  (Fig.  480,  D).  The  patient  complains  much  of  acid 
eructations,  but  vomiting  is  not  a  very  frequent  symptom;  when 
present,  it  may  reheve  the  pain.  The  ejecta  may  contain  a  certain 
proportion  of  bile.  The  patient  is  constipated  and  loses  weight 
durhig  an  attack.  Frequently  he  has  intervals  of  complete  freedom 
from  pain,  in  which  he  can  digest  anything  and  enjoy  life.  In  a 
considerable  percentage  of  cases,  moreover,  the  condition  is  abso- 
lutely latent  and  free  from  symptoms  until  acute  manifestations  of 
perforation  or  haemorrhage  supervene. 

Perforaiion  usually  involves  the  first  part  of  the  duodenum,  and 
may  be  intra-  or  retro-peritoneal.  The  conditions  produced  are 
practically  identical  with  those  following  a  perforated  gastric  ulcer, 
but  with  slight  differences  due  to  the  change  of  situation.  Thus, 
with  the  usual  acute  intraperitoneal  perforation  the  fluid  on  escaping 
from  the  duodenum  is  guided  downwards  by  the  ascending  meso- 
colon to  the  right  iliac  fossa,  and  hence  the  symptoms  of  acute 
appendicitis  are  somewhat  simulated;  but  it  may  be  possible  to 
locate  the  primary  pain  to  the  hypochondrium.  The  mischief  soon 
spreads,  however,  to  the  general  cavity,  and  the  locahzing  symptoms 


ABDOMINAL  SURGERY 


1013 


disappear.  The  effusion  includes  the  fluid  duodenal  contents,  often 
very  abundant  and  perhaps  bile-stained,  and  usually  free  gas.  If 
the  opening  in  the  duodenum  is  small  and  the  contents  escape  slowly, 
a  subphrenic  or  subhepatic  abscess  may  form,  but  the  adhesions  are 
not  very  firm,  and  it  may  burst  secondarily  into  the  general  serous 
cavity.  A  retroperitoneal  perforation  of  the  duodenum  is  the  origin 
of  a  subacute  subphrenic  abscess,  which  is  placed  behind  the 
peritoneal  cavity,  but  always  to  the  right  side  of  the  falciform 
ligament. 

HcBinorrhage  is  evident  in  most  cases  in  the  form  either  of  hsema- 
temesis  or  melaena.  The  history  generally  given  is  that  during  a 
dyspeptic  attack  a  sensation  of 
faintness  occurs,  followed  by 
anaemia.  Part  of  the  blood  lost 
may  be  vomited,  but  the  greater 
portion  passes  down  the  intes- 
tine, giving  rise  to  melsena.  The 
patient  may  die  from  loss  of 
blood,  and  then  usually  some 
large  branch  of  the  pancreatico- 
duodenal vessels  has  been  laid 
open ;  more  frequently  it  ceases 
after  a  time,  but  may  be  repeated 
again  and  again. 

Stenosis  of  the  duodenum  re- 
sults from  the  cicatrization  of 
ulcers,  and  may  lead  to  fre- 
quently repeated  vomiting,  dys- 
pepsia of  an  intractable  type, 
a  greatly  distended  stomach,  and 
emaciation  to  an  alarming 
degree. 

Treatment. — ^If  a  diagnosis  can 
be  made  and  no  complications 
are  present,  the  same  treatment 
is  instituted  as  for  gastric  ulcer 
— viz.,  rest  in  bed  and  rectal 
alimentation.       Persistence     of 

symptoms — e.g.,  vomiting,  haemorrhage,  etc. — is  treated  by  gastro- 
jejunostomy, and  the  results  are  most  satisfactory.  Perforation, 
of  course,  needs  immediate  operation,  as  described  for  the  stomach 
(p.  994).  In  the  earlier  stages  of  a  duodenal  perforation,  the 
incision  will  probably  be  located  along  the  right  semilunar  line  for 
4  or  6  inches.  The  opening,  when  found,  should  be  stitched  up  in 
the  transverse  axis  of  the  bowel,  so  as  not  to  diminish  its  calibre. 
Stenosis  of  the  duodenum  is  treated  most  successfully  by  gastro- 
enterostomy, and  there  are  few  operations  in  surgery  which  give 
more  gratifying  results. 


Fig.  480. 


Tender  Spots  in  Abdom- 
inal Lesions. 


C,  In  ulcer  of  stomach  near  the  cardiac 
orifice;  G,  in  the  ordinary  t5rpe  of 
gastric  ulcer;  D,  in  duodenal  ulcer; 
GB,  in  affections  of  the  gall-bladder ; 
A,  in  appendicitis  (McBurney's  spot) . 


IOI4  A   MANUAL  OF  SURGERY 


Affections   of   the   Intestine. 

Bismuth  Radiography  of  the  intestines  is  often  of  great  assistance  in  the 
diagnosis  of  the  condition  and  position  of  various  lesions.  As  already  men- 
tioned (p.  989),  the  stomach  should  be  empty  in  about  four  hours,  and  about 
the  same  time  (four  and  a  half  hours)  the  bismuth  should  begin  to  enter  the 
cascum;  it  is  not  usually  possible  to  trace  the  bismuth  in  the  duodenum  or 
along  the  small  intestine.  There  is  not  uncommonly  some  hindrance  to  the 
escape  of  bismuth  through  the  ileo-caecal  valve,  and  the  bismuth  may  collect 
in  the  lower  end  of  the  ileum,  and  be  seen  in  the  pelvis.  The  hepatic  flexure 
is  generally  reached  in  five  to  eight  hours,  the  splenic  flexure  in  seven  to  four- 
teen hours,  and  the  iliac  colon  in  eight  to  sixteen  hours;  the  bismuth  normallj' 
disappears  from  the  bowel  in  from  twenty-four  to  thirty-six  hours.  Irregu- 
larities in  the  course  of  the  intestine  can  often  be  detected  by  this  means, 
such  as  strictures,  kinks,  diverticula,  etc.  The  appendix  can  occasionally 
be  recognised,  but  difficulty  in  the  escape  of  the  bismuth  from  the  small  to 
the  large  intestine  may  suggest  the  existence  of  adhesions  binding  down  the 
appendix.  Too  much  stress  must  not  be  laid  on  radiographic  reports  apart 
from  a  careful  consideration  of  the  clinical  phenomena.  Bismuth  is  heavy, 
and  a  downward  displacement  of  the  intestine  when  loaded  with  it  is  a  natural 
consequence;  it  is  also  somewhat  astringent  in  type,  and  determines  con- 
traction of  the  intestinal  wall,  so  that  the  diverticula  of  the  colon  become 
exaggerated.  Finally,  it  must  ever  be  remembered  that  radiographs  are 
shadow  pictures,  and  unless  taken  stereoscopically  it  is  possible  to  imagine  the 
existence  of  severe  kinks  due  to  the  overlapping  of  the  shadows,  when  in 
reality  nothing  of  this  type  is  present;  this  warning  especially  needs  emphasis 
in  interpreting  radiographic  representations  of  the  flexures  of  the  colon. 

Congenital  Conditions  are  occasionally  met  with  affecting  the  intes- 
tine, and  perhaps  giving  rise  to  serious  complications,  (a)  The  most 
common  of  these  consists  in  what  is  known  as  Meckel's  diverticnlwn, 
which  occurs  as  an  outgrowth  from  the  lower  end  of  the  ileum.  Tt 
may  be  patent  for  i  or  2  inches,  terminating  possibly  in  a  fibrous 
cord,  which  floats  free  among  the  intestines,  or  ma^^  contract  ad- 
hesions,  and  thus  determine  an  internal  strangulation ;  sometimes  it 
persists  as  an  open  tube  as  far  as  the  umbilicus,  giving  rise  to  a  con- 
genital faecal  fistula.  It  is  due  to  non-obliteration  ot  the  omphalo- 
mesenteric duct.  Many  forms  of  acute  abdominal  trouble  have  been 
caused  by  this  structure,  and  even  inflammatory  attacks  similar  to 
acute  appendicitis;  gallstones  or  enteroliths  have  lodged  within  it 
and  caused  perforative  peritonitis.  (&)  Congenital  stenosis  of  the 
duodenum  occurs  opposite  the  entrance  to  the  common  bile  duct, 
and  a  similar  condition  may  arise  in  the  lower  part  of  the  ileum  at  a 
spot  corresponding  to  the  site  of  Meckel's  diverticulum. 

Contusion  of  the  Intestine  may  result  from  any  serious  blow  on  the 
abdomen,  and  necessarily  varies  in  its  effects  with  the  nature  and 
force  of  the  injury,  the  amount  of  distension  of  the  gut,  and  the 
strength  and  power  of  resistance  of  the  parietes.  In  its  simplest 
form,  it  merely  produces  a  little  bruising  of  the  intestinal  wall,  fol- 
lowed by  a  subacute  or  chronic  enteritis,  from  which  with  care  the 
patient  quickly  recovers.  In  the  more  severe  cases,  an  acute  enter- 
itis ensues,  due  to  bacillary  invasion,  which  may  even  run  on  to 
ulceration  or  sloughing  of  the  coats  of  the  bowel.     The  latter  result 


A  li  DOM  IN  A  L  S  URGER  Y 


10 1 5 


BISMUTH  RADIOGRAPHY  OF  THE  INTESTINES. 


Fig.  481.  —  Slight  Downward 
Displacement  of  Transverse 
Colon. 


Fig.  482.  —  Enteroptosis  with 
Transverse  Colon  in  the  Pel- 
vis. 

The  stomach  is  occupied  by  a  bis- 
muth meal  given  two  days  after 
the  former,  part  of  which  had  not 
escaped. 


Fig.  483.  — •  Intussusception  of 
Cancer  of  C^cum  into  Trans- 
verse Colon. 

The  bismuth  does  not  extend  much 
beyond  the  hepatic  flexure;  the 
pre-operative  diagnosis  was  cancer 
of  the  transverse  colon.  For  speci- 
men removed  from  this  case,  see 
Fig.  485. 


Fig.  484. — Enteroptosis  with   Ob- 
struction IN  Transverse  Colon. 


The  bismuth  can  just  be  traced  in 
the  splenic  flexure  and  beyond;  it 
is  evidently  retained  in  caecum  and 
ascendina;  colon. 


ioi6  A   MANUAL  OF  SURGEIiY 

is  more  likely  to  follow  if  the  mesentery  has  also  been  involved  in  the 
injury  so  as  to  produce  thrombosis  of  the  mesenteric  vessels.  Under 
these  circumstances,  the  final  issue  depends  largely  upon  the  rapidity 
of  the  inflammatory  process.  If  adhesions  luu'c  had  time  to  form 
between  the  parietcs  and  the  injured  gut,  the  mischief  is  limited,  and 
the  patient  may  recover  with  a  fsecal  fistula,  the  formation  of  which 
has  been  preceded  by  a  localized  intraperitoneal  abscess,  containing 
extremely  offensive  pus,  owing  to  the  presence  of  the  B.  colt,  which 
has  migrated  through  the  intestinal  wall.  If,  however,  the  inflam- 
matory affection  is  rapid  in  its  onset,  and  adhesions  have  not  had 
time  to  develop,  acute  diffuse  peritonitis  is  almost  certain  to  follow. 
When  the  injured  portion  of  the  bowel  is  retro-peritoneal,  as  in  the 
duodenum  or  colon,  a  retro-peritoneal  abscess  may  form. 

The  Symptoms  of  intestinal  contusion  consist  primarily  of  shock 
and  pain.  The  amount  of  shock  varies  necessarily  with  the  severity 
of  the  injury  and  the  nervous  susceptibility  of  the  patient.  The  pain 
may  not  be  severe  at  first,  but  is  always  very  marked  subsequently, 
and  increased  by  examination,  movement,  or  during  violent  respira- 
tory efforts.  To  limit  such  movement,  the  abdominal  parietes  are 
maintained  in  a  state  of  firm  contraction,  and  can  be  felt  hard  and 
resistant.  Vomiting  may  be  present,  but  is  not  a  marked  feature. 
The  later  symptoms  necessarily  vary  with  the  course  taken  by  the 
case,  and  need  not  be  described  in  further  detail. 

Treatment  is  conducted  along  the  same  lines  as  that  of  contusions 
of  the  abdominal  wall  (p.  971) ;  viz.,  where  there  is  no  absolute  evi- 
dence of  rupture,  an  expectant  attitude  may  be  adopted,  but  the 
surgeon  must  be  ready  to  interfere  should  any  grave  or  suspicious 
symptoms  arise.  Acute  enteritis  induces  diarrhoea  and  the  passage 
of  blood-stained  mucus,  and  such  symptoms  will  indicate  the  use  of 
bismuth,  and  perhaps  a  little  morphia,  whilst  a  fluid  diet  or  rectal 
feeding  is  alone  permissible. 

Rupture  of  the  Intestine  folic ws  abdominal  injuries  of  a  more 
severe  character,  such  as  when  a  cart  or  cab  has  traversed  the  abdo- 
men, or  when  the  patient  has  been  tightly  squeezed  or  kicked.  The 
bowel  does  not  always  give  way  at  the  point  of  impact,  but  occasion- 
ally at  a  distance  from  it ;  under  these  circumstances  the  tear  is  more 
likely  to  be  ragged  and  irregular,  whilst  if  it  yields  at  the  point  struck, 
the  gut  may  be  cleanly  torn  across.  The  parts  most  frequently 
affected  by  this  form  of  injury  are  the  junction  of  the  moveable 
jejunum  with  the  fixed  duodenum,  and  the  lower  3  feet  of  the  ileum. 
The  fluidity  of  the  contents  of  the  small  intestine  has  a  grave 
prognostic  significance,  since  they  are  readily  diffused. 

The  early  Symptoms  consist  of  severe  and  u.-.ually  lasting  shock, 
accompanied  by  intense  abdominal  pain,  which  may  at  first  be 
localized.  If  there  is  an  abundant  escape  of  the  intestinal  contents, 
a  virulent  form  of  acute  peritonitis  follows  immediately,  frcm  which 
the  patient  rapidly  succumbs.  If,  however,  the  gut  was  empt}^  at 
the  time  of  the  accident,  the  symptoms  are  less  severe;  acute  peri- 
tonitis ensues,  but  it  is  slower  in  onset,  and  some  attempt  to  hmit  it 


ABDOMINAL  SURGERY  1017 

is  observed.  An  important  diagnostic  point  is  that  the  maximum 
tenderness  is  always  fixed  to  a  localized  area.  Free  gas  is  sometimes, 
but  not  frequently  present  in  the  peritoneal  cavity,  as  in  rupture  of 
the  stomach  In  a  few  cases  emphysema  of  the  abdominal  walls 
has  been  noted,  and  in  the  absence  of  thoracic  injuries  or  of  diffuse 
cellulitis  is  an  absolutely  certain  sign  of  rupture  of  the  intestinal 
tube.  Vomiting  occurs,  but  not  to  an  excessive  degree;  if  blood  is 
found  in  the  vomit,  it  suggests  that  either  the  stomach  or  upper  part 
of  the  intestinal  canal  has  been  injured.  Occasionally  a  blood- 
stained motion  is  passed,  but  only  late  in  the  case. 

The  Diagnosis  of  a  ruptured  intestine  is  always  a  matter  of  uncer- 
tainty in  the  absence  of  emphysema  of  the  abdominal  walls,  which  is 
very  uncommon.  Formerly  it  was  supposed  that  free  air  or  gas  in 
the  peritoneal  cavity  would  be  certain  to  find  its  way  up  between  the 
liver  and  the  abdominal  wall ;  hence  loss  of  the  liver  dulness  was  con- 
sidered an  important  sign.  It  is  by  no  means  certain,  however,  that 
the  gas  does  travel  in  this  direction,  and  a  resonant  note  over  the 
liver  is  a  common  result  of  distension  of  the  colon.  If,  however,  the 
abdominal  wall  is  retracted  and  not  distended,  the  existence  of  this 
sign  IS  suggestive.  The  amount  of  shock  is  also  an  uncertain  guide, 
as  it  varies  both  in  degree  and  duration.  The  temperature  does  not 
help  much,  although  a  secondary  fall  below  normal  after  reaction, 
especially  if  associated  with  increasing  rapidity  of  pulse  and  respira- 
tion, is  very  suggestive  of  grave  mischief.  The  presence  of  an  area 
of  deep  fixed  tenderness  and  pain  with,  perhaps,  a  rigid  abdominal 
wall  over  it,  and  the  incidence  of  early  acute  peritonitis,  are  probably 
the  only  signs  that  we  can  depend  upon  with  any  certamty.  The 
history  and  nature  of  the  accident  are  important,  and  should  be 
carefully  investigated. 

In  the  non-existence  of  any  distmct  signs  of  rupture.  Treatment  in 
the  early  stages  can  only  be  expectant,  and  directed  towards  com- 
bating the  shock  and  relieving  the  pain.  A  small  dose  of  opium 
should  be  administered  with  this  object,  and  also  to  check  peristalsis 
and  hinder  further  extravasation  of  the  intestinal  contents;  but  as 
little  as  possible  should  be  given,  since  it  tends  to  mask  symptoms. 
If  the  surgeon  has  good  grounds  for  suspecting  that  the  intestine  is 
torn,  he  ought  at  once  to  undertake  an  exploratory  laparotomy,  and 
deal  with  the  condition  found. 

Punctures  or  Stabs  involving  the  intestine  lead  to  a  similar  series  of 
phenomena ;  but  the  diagnosis  may  be  easier,  as  gas  or  fascal  material 
may  escape  through  the  external  wound.  The  direction  of  the  in- 
cision in  the  gut  is  of  importance,  since  a  longitudinal  cut  (running 
parallel  to  the  axis  of  the  bowel)  is  more  likely  to  gape  than  a  trans- 
verse one,  owing  to  the  greater  power  of  the  circular  muscle  fibres ; 
a  small  puncture  may  be  almost  closed  by  a  protrusion  of  mucous 
membrane.  Shock  is  not  necessarily  so  severe  as  when  the  intestine 
is  ruptured  by  violence  without  penetration;  abdominal  pain  is 
always  present,  and  the  phenomena  of  acute  peritonitis  may  quickly 
follow. 


iox8  A    MANUAL  OF  SURGERY 

Treatment. — Every  case  of  suspected  penetration  should  be  care- 
fully explorc'd.  The  skin  and  superlicial  parts  of  the  wound  are  first 
thoroughly  })uriried,  and  then  the  wound  is  enlarged  and  the  deeper 
parts  are  examined.  If  the  peritoneum  is  not  opened,  the  different 
layers  of  the  abdominal  wall  are  sutured  togi^ther.  If  the  peritoneum 
has  been  involved,  the  opening  in  it  should  be  enlarged,  so  as  to 
explore  the  viscera  and  determine  with  certainty  whether  or  not  the 
gut  has  been  wounded.  If  a  small  punctured  or  incised  wound  of 
the  intestine  is  present,  it  is  invaginated  and  closed  by  a  purse-string 
stitch  or  by  a  row  of  Czerny-Lembert  sutures.  If  a  more  extensive 
lesion  exists,  excision  of  the  damaged  portion  may  be  necessary;  but 
if  the  patient  is  deeply  collapsed  from  the  supervention  of  peritonitis, 
it  may  be  wiser  to  bring  the  divided  ends  to  the  abdominal  wall,  and 
form  a  temporary  artificial  anus,  which  is  subsequently  dealt  with 
when  the  patient's  general  condition  has  improved.  As  to  the  treat- 
ment of  the  resulting  peritonitis,  the  reader  is  referred  to  what  has 
been  written  concerning  rupture  of  the  stomach  (p.  990). 

For  Gunshot  Wounds  and  their  treatment,  see  pp.  248  and  249. 

Perforation  of  the  Intestine  arises  from  many  different  causes,  such 
as  the  impaction  of  a  foreign  body,  or  the  yielding  of  an  intestinal 
ulcer,  as  occurs  in  tuberculous  disease  or  typhoid  fever,  or  from  that 
form  of  enteritis  which  follows  strangulated  hernia.  The  phenomena 
resulting  from  the  perforation  of  an  ulcer  of  the  stomach  or  duo- 
denum has  been  already  discussed  (pp.  994  and  1012),  and  another 
variety  caused  by  perforation  of  the  appendix  will  be  alluded  to  sub- 
sequently (p.  1044). 

When  the  jejunum  or  upper  portion  cf  the  ileum  is  involved,  per- 
foration is  usually  due  to  the  impaction  of  a  foreign  body,  such  as  a 
fish-bone,  or  to  yielding  of  a  tuberculous  ulcer.  In  the  former  case, 
general  peritonitis  is  almost  certain  to  follow,  but  in  tuberculous 
cases  the  lesion  is  of  a  more  chronic  type,  and  then  adhesions  may 
form,  allowing  an  intraperitoneal  abscess  to  develop,  and  should  it 
open  externally,  a  faecal  fistula  follows.  In  not  a  few  cases  the 
process  of  cicatrization  may  lead  to  a  spontaneous  closure  of  the 
fistula,  and  no  operation  should  be  undertaken  until  suilicient  time 
has  elapsed  to  determine  whether  or  not  this  will  occur. 

In  the  lower  portion  of  the  ileum,  typhoid  fever  is  the  most  usual 
cause  of  perforation.  Occasionally  in  cases  of  the  so-called  '  ambula- 
tory typhoid  '  it  is  the  first  evidence  of  the  presence  of  the  disease, 
but  it  generally  occurs  about  the  end  of  the  second  or  in  the  third 
week,  and  rarely  more  than  one  perforation  is  present.  It  is  most 
commonly  seen  in  bad  cases  associated  with  meteorism  and  hcxmor- 
rhage,  but  is  not  limited  to  such.  1  he  symptoms  are  usually  those 
of  sudden  collapse,  as  indicated  by  a  falling  temperature  and  a  quick 
and  feeble  pulse,  whilst  severe  and  persistent  abdominal  pain  fol- 
lowed by  increasing  distension  indicates  the  development  of  general 
peritonitis.  Even  when  the  patient  is  already  collapsed  by  the  dis- 
ease, some  shght  fall  of  temperature  with  acceleration  of  the  pulse 
may  occur,  associated  with  al:»dominal  pain  and  meteorism.     Early 


ABDOMINAL  SURGERY  toi.j 

rigidity  of  the  belly  wall  is  an  important  diagnostic  sign,  whilst  there 
may  be  some  irritability  of  the  bladder.  The  only  treatment  which 
holds  out  an}^  prospcc^t  of  saving  the  patient  is  operation,  but  owing 
to  his  depressed  condition  the  outlook  is  not  particularly  bright. 
Obviously,  when  he  is  moribund,  it  is  useless  to  interfere;  but  the 
facts  that  of  some  300  cases  operated  on  and  reported  27  per  cent, 
have  recovered,  and  that  the  death-rate  has  gradually  fallen  from  go 
to  69  per  cent.,  indicate  that  in  cases  diagnosed  early  a  fair  propor- 
tion of  success  may  be  anticipated.  The  abdomen  should  be  opened 
in  the  middle  line  below  the  umbilicus,  or  directly  into  the  right  iliac 
fossa,  and  if  the  lesion  is  not  at  once  obvious,  the  ileum  is  sought  for 
at  its  junction  with  the  csecum,  and  the  bowel  brought  up  and  care- 
fully examined  inch  by  inch  till  the  perforation  is  found ;  it  may  then 
either  be  closed  by  sutures  introduced  so  as  to  close  the  wound  in 
the  transverse  axis  of  the  gut  and  thus  diminish  the  risks  of  a  sub- 
sequent stenosis,  or  the  edges  of  the  ulcer  stitched  to  the  margins  of 
the  wound  so  as  to  create  a  temporary  fistula.  The  peritoneum  is 
cleansed  and  drained  in  the  usual  way,  after  determining  that  no 
second  perforation  is  present  or  imminent. 

In  the  large  intestine  the  most  common  cause  of  perforation  is 
ulceration  due  to  chronic  obstruction  or  malignant  disease.  Masses 
of  faeces  accumulate  within  the  bowel,  and  bj^  their  pressure  give 
rise  to  inflammation  of  the  walls,  which  runs  on  either  to  ulceration 
or  to  actual  necrosis.  Most  usually  the  peritoneum  is  by  this  means 
laid  open,  either  just  above  the  growth,  or  as  a  consequence  of  its 
local  extension ;  sometimes,  however,  the  bowel  gives  way  at  a  higher 
level,  where  faeces  mainly  accumulate,  and  then  geneially  in  the 
csecum.  In  many  cases  acute  perforative  peritonitis  follows,  but 
occasionally  the  mischief  is  limited,  and  an  intraperitoneal  abscess 
forms,  followed  by  a  faecal  fistula. 

Foreign  Bodies  in  the  intestine  are  of  three  types : 

1.  Gallstones  give  rise  to  no  symptoms  unless  they  are  of  large 
size ;  the  smaller  ones  enter  the  canal  through  the  common  bile-duct 
after  an  attack  of  biliary  colic,  and  are  voided  in  the  stools.  Larger 
stones  usually  gain  entrance  to  the  intestine  by  ulceration  from  the 
gall-bladder  into  the  duodenum.  A  coating  of  faecal  matter  is  likely 
to  form  around  them,  and  thus  they  increase  in  size  as  they  pass 
downwards,  whilst  the  intestine  gradually  diminishes  in  calibre 
from  the  duodenum  to  the  ileum,  so  that  they  are  likely  to  become 
impacted  in  the  lower  ileum.  Women  over  hity  are  most  often  the 
subjects  of  this  condition,  and  there  may  be  only  a  history  of  some 
inflammatory  condition  in  the  region  of  the  gall-bladder,  and  none  of 
biliar}'  colic. 

2.  £"';2/erc'/i;'//s  are  of  three  classes :  [a)  CalcuH  of  phosphate  of  lime 
or  inspissated  fasces  form  around  some  foreign  body  as  a  nucleus. 
[h]  Masses  of  indigestible  vegetable  material  may  be  matted  together 
with  inspissated  faeces,  mucus,  etc. ;  they  are  said  to  be  not  uncom- 
mon in  Scotland  (the  so-called  avenolith),  consisting  largely  of  the 
husks  of  coarse  oatmeal.     They  have  also  been  known  to  consist  of 


I020  A   MANUAL  OF  SURGERY 

hair,  or  of  cocoanut  fibre  in  a  patient  engaged  in  mat-making, 
(c)  Calculi  have  been  found  consisting  of  insoluble  mineral  salts — e.g., 
carbonate  of  magnesia  or  chalk,  taken  as  medicine.  Whatever  their 
origin,  such  enteroliths  are  likely  to  become  imi)actcd  near  the  cae- 
cum, and  may  cause  acute  obstruction.  In  thin  persons  their  pres- 
ence may  be  detected  by  palpation  of  the  abdomen. 

3.  Foreign  Bodies  accidentally  or  intentionally  swallowed  occasion- 
ally pass  through  the  stomach  and  become  lodged  in  the  intestinal 
canal.  Lunatics  and  children  are  most  frequently  affected,  and  in 
the  former  the  most  astonishing  collections  arc  occasionally  found. 

I  he  Symptoms  caused  by  such  conditions  will  be  either  those  of 
intestinal  obstruction  (p.  1130)  or  of  perforation.  In  the  latter  the 
process  is  usually  gradual,  rather  than  sudden,  giving  time  for  adhe- 
sions to  form,  thereby  limiting  the  mischief.  Suppuration  follows, 
and  possibly  the  foreign  body  may  be  extruded  naturally  or  removed 
by  the  surgeon  through  the  abscess  cavity,  with  or  without  the  for- 
mation of  a  faecal  fistula. 

Small  spiculated  foreign  bodies — e.g.,  fragments  of  glass  or  metal, 
the  husks  of  cereals,  etc. — may  sometimes  lodge  in  the  pouches  of  the 
colon,  and  give  rise  to  localized  inflammatory  phenomena,  perhaps  in 
one  or  more  of  the  appendices  epiploicae.  The  symptoms  w'ill  very 
closely  resemble  those  of  a  localized  appendix  abscess,  and  similar 
operative  treatment  will  be  required.  In  other  cases  a  chronic  in- 
flammatory mass  may  be  produced  which  simulates  a  neoplasm  of 
the  intestinal  wall,  and  may  disappear  spontaneously  or  after  ex- 
ploration. The  supposed  cure  of  certain  cases  of  intestinal  cancer  by 
quack  remedies  may  be  explained  in  this  way. 

Enteritis,  or  inflammation  of  the  mucous  membrane  of  the  intes- 
tine, is  a  condition  usually  treated  by  the  physician ;  occasionally  it 
complicates  surgical  cases  and  needs  effective  treatment.  Thus  it 
may  follow  the  exposure  of  a  coil  of  intestine  in  the  depths  of  a  wound 
which  has  to  be  packed  for  drainage  purposes.  Severe  diarrhoea  may 
result,  and  the  inflammation  may  even  spread  through  the  whole 
thickness  of  the  gut  wall,  and  lead  to  the  establishment  of  a  faecal 
fistula.  Enteritis  also  occurs  as  a  post-operative  complication  of 
strangulated  hernia  (p.  1121).  Whatever  its  origin,  it  is  always 
characterized  by  diarrhoea  of  varying  type,  and  by  pain  or  abdominal 
discomfort  and  perhaps  vomiting.  Treatment  consists  in  the  use  of  a 
bland  diet- — e.g.,  milk — and  the  administration  of  soothing  astringent 
drugs,  such  as  bismuth  and  perhaps  opium.  It  must  not,  however, 
be  checked  without  ascertaining  so  far  as  possible  that  the  causative 
irritant  has  been  removed,  and  not  uncommonly  the  best  treatment 
to  start  with  is  the  administration  of  a  good  dose  of  castor  oil. 

Colitis  is  an  affection  occasionally  needing  surgical  treatment. 
The  cause  is  usually  chronic  constipation,  but  bacteria  of  various 
t^'pes  or  the  Amceha  coli  may  be  present.  In  the  simpler  cases 
{mucous  colitis)  the  patient  complains  of  griping  pains  in  the  course 
of  the  colon,  diarrhoea,  the  passage  of  mucus  in  the  stools,  perhaps 
in  membranous  flakes,  and  definite  tenderness  of  the  colon   on 


ABDOMINAL  SURGERY  ro2i 

palpation.  The  appendix  is  not  unfrequently  inflamed  at  the  same 
time,  and  one  of  the  most  tender  spots  may  be  over  this  organ. 
Ti'cahncnl  of  this  form  eonsists  in  emptying  the  bowel  by  enemata, 
Iceeping  tlie  patient  quiet  in  bed  on  a  milk  diet,  and  possibly  ordering 
bismuth  or  a  little  chlorodyne.  When  the  patient  is  convalescent 
and  all  tenderness  has  disappeared,  the  causative  chronic  constipa- 
tion must  be  treated.  Purgatives  usually  cause  irritation  and  pain, 
and  must  be  as  far  as  possible  avoided.  Abdominal  massage  and  the 
methodical  use  of  the  so-called  Swedish  exercises,  which  increase  the 
power  of  the  abdominal  muscles,  and  thereby  give  tone  to  the  re- 
laxed colon,  will  often  work  wonders  in  these  cases.  The  use  ot 
medicinal  waters  and  irrigation  of  the  colon,  as  practised  at 
Harrogate  and  Plombieres,  often  give  excellent  results.  In  a 
certain  percentage  of  cases  removal  of  the  appendix  does  good  in 
colitis,  but  before  undertaking  the  operation  the  surgeon  must  be 
careful  not  to  promise  too  much. 

The  graver  cases  [ulcerative  colitis)  are  associated  with  the  dis- 
charge of  pus  and  the  exfoliation  of  patches  of  mucous  membrane. 
The  patient's  health  may  be  profoundly  affected  in  this  disease,  pus 
of  a  most  offensive  type  pouring  out  from  the  rectum,  or  fever  of  a 
marked  hectic  character  being  present.  The  nutrition  is  necessarily 
impaired,  and  the  patient  wastes  to  a  shadow.  Under  such  circum- 
stances, and  especially  when  rectal  irrigation  has  failed,  the  surgeon 
may  be  asked  to  make  an  artificial  opening  into  the  caecum  in  order 
to  permit  of  more  thoiough  irrigation,  and  also  perhaps  to  divert  the 
intestinal  contents.  For  the  method  of  operating,  see  p.  1031.  The 
fluid  employed  for  irrigation  must  be  bland,  non-toxic,  and  unirri- 
tating.  Warm  saline  solution  should  be  first  used,  and  subsequently 
a  weak  boric  acid  solution,  or  possibly,  with  great  care,  a  i  in  5,000 
solution  of  nitrate  of  silver.  The  patient  sits  over  a  bed-pan,  and 
the  fluid  is  injected  through  the  fistula  from  an  irrigator;  distension 
of  the  bowel  must  be  avoided,  and  to  this  end  the  introduction  of  a 
rectal  speculum  to  keep  the  anus  open  during  the  irrigation  is  desir- 
able. Latterly  the  vermiform  appendix  has  been  used  for  this  pur- 
pose ;  it  is  stitched  into  the  wound  and  opened  {appendicostomy) ,  and 
the  bowel  irrigated  through  it.  The  escape  of  intestinal  contents  is 
less  than  if  the  bowel  is  opened,  and  subsequent  closure  of  the  fistula 
after  the  disease  is  cured  is  more  easily  effected.  It  is  probable  that 
some  amount  of  stenosis  of  the  bowel  may  result  from  the  cicatriza- 
tion of  the  ulcers  in  the  colon,  and  then  the  fistula  may  have  to 
remain  permanently. 

Tuberculous  Disease  of  the  Intestine  usually  occurs  in  the  ileo- 
csecal  region,  and  manifests  itself  in  two  main  varieties : 

I.  Tuberculous  Ulcers  are  generally  multiple,  though  occasionally 
single.  They  are  of  the  usual  tuberculous  type,  with  undermined 
margins  (Fig.  45,  p.  183),  and  extend  along  the  course  of  the  blood- 
vessels and  lymphatics — viz.,  around  the  gut,  so  that  if  they  heal 
stricture  is  almost  certain  to  follow.  In  their  early  stages  they  do 
not  require  surgical  assistance,  but  later  on  obstructive  phenomena 


1022  A   MANUAL  OF  SURGERY 

may  supervene,  and  these  may  be  due  not  only  to  the  stenosis,  but 
also  to  associated  peritonitis;  neighbouring  mesenteric  glands  are 
usually  infected,  and  together  with  the  bowel  and  omentum  may 
form  a  pal])able  mass,  in  the  midst  of  which  suppuration  may  occur. 
Should  the  abscess  burst  externally,  a  ftecal  listula  may  result. 
Operation  may  be  needed  for  the  relief  of  the  obstructive  phenomena, 
or  for  the  suppuration,  and  some  form  of  anastomosis,  or  even 
excision  of  the  mass,  may  be  required. 

2.  The  disease  is  sometimes  of  a  hyperplastic  type,  and  is  then 
chiefly  limited  to  the  caecum,  producing  a  well-marked  tumour, 
which  can  be  palpated  from  outside,  known  as  the  Tuberculous  Csecal 
Tumour  :  the  disease  is  liable  to  extend  along  the  ascending  colon  for 
some  distance,  and  less  frequently  along  the  ileum.  The  intestinal 
wall  is  thick,  congested,  and  infiltrated  with  a  tuberculous  deposit ; 
the  outer  coat  is  rough  and  nodulated ;  the  mucous  lining  is  ulcerated 
and  often  presents  vegetations  and  polypi  of  a  granulomatous  type ; 
the  mass  is  firm,  but  not  hard  to  the  touch.  The  neighbouring 
mesentery  is  occupied  by  enlarged  glands,  and  these  may  also  be 
found  on  the  inner  border  of  the  ascending  colon.  Adhesions  may 
be  present,  and  lead  to  kinking  or  twisting  of  loops  of  bowel,  which 
may  assist  in  producing  intestinal  obstruction.  The  sj'mptoms  vary 
a  good  deal,  but  in  the  early  stages  constipation  and  diarrhtea  may 
alternate,  whilst  later  on  obstructive  phenomena  may  supervene, 
or  even  well-marked  pyrexia  of  a  hectic  type.  The  diagnosis  from 
a  caecal  carcinoma  is  not  always  easy ;  the  chief  points  in  favour  of 
tubercle  are  the  earlier  age  (under  forty  years),  the  longer  duration 
of  symptoms  (two  or  three  years),  the  associated  pyrexia,  and  the 
presence  of  tuberculous  lesions  elsewhere.  The  diagnosis  is,  how- 
ever, not  uncommonly  made  on  the  operating-table.  Treatment 
consists  in  short  circuiting,  or  excising  the  mass.  The  latter  may 
involve  an  extensive  procedure,  but  even  when  enlarged  glands  have 
to  be  left  behind,  the  case  may  do  well. 

Stenosis  of  the  Intestine  arises  from  two  main  causes — the  contrac- 
tion of  cicatrices  or  adhesions,  and  the  development  of  tumours, 
usually  malignant. 

Simple  or  cicatricial  stricture  usually  results  (i)  from  the  healing 
of  ulcers  which  have  extended  more  or  less  circularly  around  the 
bowel,  or  have  involved  its  walls  extensively.  Hence,  tuberculous 
ulcers  lend  themselves  to  its  development  more  than  the  typhoid 
lesion,  and  it  is  a  little  doubtful  whether  it  has  ever  occurred  as  a 
sequela  of  the  latter.  Syphilitic  ulceration  is  followed  by  it,  especi- 
ally when  involving  the  rectum;  but  the  upper  part  of  the  jejunum 
is  also  occasionally  affected.  In  the  large  intestine  dysentery  is  the 
most  common  cause,  and  the  stenosis,  like  the  ulceration,  may  be 
irregular  and  extensive.  (2)  It  may  follow  strangulated  hernia  as 
the  result  of  ulceration  along  the  actual  site  of  constriction;  and, 
similarly,  it  may  develop  after  the  separation  of  an  intussusception. 
(3)  An  end-to-end  anastomosis  of  the  gut  may  lead  to  stenosis 
unless  considerable  car€  is  taken  not  to  tuck  in  too  much  of  the 


ABDOMINAL  SURGERY  1023 

gut  Willi.  (4)  The  contraction  of  adhesions  outside  the  intestine  is  by 
no  means  an  uncommon  cause;  thus  it  may  be  due  to  many  forms 
of  localized  peritonitis,  and  frequently  ensues  after  pelvic  cellulitis. 

Owing  to  the  contents  of  the  small  intestine  being  of  a  somewhat 
liquid  nature,  a  stricture  in  this  situation  often  exists  for  some  time 
before  symptoms  of  any  urgency  arise.  The  patient  may  complain 
of  a  certain  amount  of  indigestion  and  discomfort,  but  sooner  or  later 
the  narrowed  aperture  of  the  gut  becomes  blocked  either  by  a  fold 
of  mucous  membrane  or  by  a  portion  of  undigested  food,  and  thus  an 
attack  of  obstruction  is  induced.  In  the  early  stages  of  the  disease 
this  can  be  overcome  and  remedied  by  purgatives,  but  each  recur- 
rence is  likely  to  increase  in  severity,  until  finally  an  acute  attack 
supervenes,  which  kills  the  patient,  unless  relieved  by  prompt 
surgical  interference. 

In  the  large  intestine  very  similar  phenomena  appear,  but  the 
attacks  of  obstruction  are  of  a  somewhat  different  character,  since 
there  is  less  pain  and  vomiting;  and  aperients,  instead  of  relieving 
the  patient,  as  they  often  do  m  the  earlier  attacks  in  the  small  gut, 
always  aggravate  the  symptoms;  there  is  also  much  greater  dis- 
tension of  the  abdomen.  The  diagnosis  of  stricture,  though  strongly 
suggested  by  the  symptoms,  can  only  be  confirmed  absolutely  by 
an  exploratory  operation,  except  when  the  lower  part  of  the  rectum 
is  involved. 

The  Treatment  in  the  earlier  stages  consists  of  suitable  dieting,  and 
the  administration  of  purgatives  or  of  large  enemata,  and  for  a  time 
such  will  be  successful.  Sooner  or  later,  however,  a  more  than 
usually  serious  attack  of  obstruction  will  call  for  something  more 
radical,  and  readers  are  referred  to  the  chapter  on  obstruction  for 
details  of  the  treatment  to  be  adopted.  Apart  from  the  question  of 
obstruction,  a  stricture  of  the  small  intestine  is  to  be  treated  by 
enteroplasty  or  enterectomy.  For  stricture  of  the  caecum  or  ascend- 
ing colon,  some  short-circuiting  method,  whereby  the  ileum  is  im- 
planted into  the  colon  below  the  stricture  (ileo-colostomy) ,  is  per- 
haps the  best  plan  to  adopt ;  in  the  transverse  colon  excision  is  pos- 
sible, as  also  in  the  sigmoid  flexure.  Failing  any  of  these  measures, 
the  establishment  of  an  artificial  anus  will  be  required  to  give  relief. 
It  must  be  remembered,  however,  that  no  permanent  opening  of 
this  nature  can  be  permitted  in  the  small  intestine  since  the  absorp- 
tion of  nourishment  is  thereby  so  interfered  with  that  death  from 
asthenia  is  certain  to  follow  in  a  comparatively  short  time,  whilst 
the  intestinal  contents  are  fluid  and  extremely  irritating  to  the  skin. 

Tumours  of  the  Intestinal  Wall  maj^  be  simple  or  malignant, 
primary  or  secondary.  Simple  tumours  are  unusual,  and  consist  of 
papilloma,  adenoma,  myoma,  lipoma,  and  a  few  other  varieties. 
They  may  cause  irritation  and  irregular  action  of  the  gut,  resulting 
perchance  in  intussusception  (p.  1136) ;  haemorrhage,  sometimes  of  a 
serious  character,  is  associated  with  multiple  papilloma  or  adenoma ; 
and  obstruction  occasionally  ensues.  It  is  unusual  for  a  diagnosis 
to  be  made  apart  from  an  exploratory  laparotomy,  unless  the  rectum 


I024  A   MANUAL  OF  SURGERY 

is  affected.     The  treatment  is  governed  by  the  location  of  the  growth 
and  by  the  symptoms  it  causes. 

Scino))ia  of  the  intestine  is  not  common;  it  may  involve  the  ileum 
or  ciecum,  and  give  rise  to  a  localii^ed  tumour  or  diffuse  iniiltratioii. 
Obstruction  may  ensue,  or  considerable  ])eritoneal  irritation  resulting 
in  an  abundant  blood-stained  exudation  which  leads  to  al)dominal 
distension,  and  may  be  recognised  as  due  to  a  new  growth  on  taj)- 
ping.  Treatment  consists  in  removal  of  the  affected  coil  of  gut  if 
the  disease  has  not  progressed  too  far. 

Cancer  of  the  Bowel  is  almost  always  primary  in  nature,  and 
is  then  usually  a  columnar  carcinoma,  to  which  colloid  degeneration 
is  sometimes  added.  The  small  intestine  is  rarely  involved,  but  any 
part  of  the  colon  may  be  affected,  and  even  the  vermiform  appendix. 
vSecondary  growths  are  occasionally  met  with,  and  are  necessarily 
of  the  same  nature  as  the  original  tumour.  The  physical  characters 
of  the  growth  vary  considerably, but  usually  conform  to  one  of  two 
types — viz.,  (i.)  the  hypertrophic,  in  which  a  large  mass  forms, 
perhaps  occupying  the  whole  lumen  of  the  bowel  (Fig.  485).  It 
IS  a  fairly  rapid  groNvth,  and  usually  associated  with  ulceration 
and  haemorrhage,  whilst  obstructive  phenomena  are  late  in  appearing, 
(ii.)  In  the  sclerosing  form  the  tumour  develops  as  an  annular  con- 
striction around  the  bowel,  the  lumen  of  which  is  contracted  so  that  it 
may  be  almost  impossible  to  pass  a  crow's  quill  or  a  probe  through  it 
(Fig.  486).  It  is  an  astonishing  fea.ture  of  these  cases  that  the  func- 
tion of  the  bowel  is  carried  on  without  much  pain  or  difficulty  until 
the  lumen  is  almost  obliterated,  and  then  suddenly  a  serious  attack 
of  obstruction  occurs.  Sometimes  the  bowel  looks  from  outside  as  if 
a  piece  of  string  had  been  tied  round  it,  so  great  is  the  constriction. 
Above  the  gro^vth  the  bowel  is  hypertrophied  and  dilated;  the 
mucous  membrane  is  often  congested,  inflamed,  and  even  ulcerated; 
the  latter  lesion  is  usually  due  to  the  irritation  of  stagnant  faeces, 
and  the  ulcers  are  termed  '  stercoral.'  Bacteria  may  find  their 
way  into  and  through  the  intestinal  wall  from  these  foci,  and  lead 
to  peri-intestinal  suppuration,  and  as  a  sequela  a  fsecal  fistula  may 
develop.  The  bowel  below  the  growth  is  often  distended  ('  bal- 
looned ')  from  paralysis  of  its  walls,  and  the  development  of  gases 
from  the  faecal  material  which  may  accumulate  from  the  loss  of  the 
vis  a  tergo  ;  this  can  often  be  remarked  in  cancer  of  the  rectum. 

The  irritation  of  the  tumour  leads  sooner  or  later  to  the  formation 
of  adhesions,  which  may  assist  in  hampering  the  action  of  the  bowel. 
Secondary  deposits  occur  in  the  mesenteric  glands  and  omentum, 
and  less  commonly  in  the  liver  or  distant  regions ;  but  there  can  be 
no  question  that  the  growth  is  often  much  less  malignant  in  type 
than  cancer  elsewhere,  and  both  adhesions  and  secondary  deposits 
are  usually  late  developments.  On  the  other  hand,  there  is  a  con- 
siderable degree  of  permeation  by  cancer  cells,  and  this  over  an  area 
so  extensive  that  it  is  useless  to  undertake  removal  of  merely  the 
affected  portion  of  the  bowel;  a  wide  and  extensive  excision  will 
alone  suffice  to  cure. 


ABDOMINAL  SURGERY 


1025 


The  Symptoms  are  at  first  vague  in  the  extreme,  and  the  disease  is 
likely  to  ha\-c  progressed  for  some  time  before  a  diagnosis  is 
reached.  The  patient  complains  of  indigestion  of  an  intestinal 
type ;  there  may  be  some  pain  of  a  cohcky  character,  and  either 
constipation  or  diarrhrea  may  be  present;  not  unfrequently  they 
alternate,  the  constipation  being  primary,  and  the  diarrhcea  result- 
ing from  the  decomposition  of  retained  faeces,  or  a  catarrhal  enter- 
itis set  up  thereby.  A  discharge  of  mucus  or  blood  mav  be  noticed 
in  the  stools,  and  the  patient's  nutrition  begins  to  suffer,  although 
wasting  is  at  first  slow. 


Fig.  485. — Hypertrophic  Cancer  of 
the  c^cum,  invaginated  into  the 
Transverse  Colon. 

For  bismuth  radiograph  of  this  case 
see  Fig.  4S3.  This  growth  was 
successfully  removed,  and  an  ileo- 
colostomy  performed. 


Fig.    486. — Carcinoma    of   the 
Descending  Colon. 

The  growth  was  of  the  sclerosing 
type,  and  had  given  rise  to  no 
symptoms  except  a  httle  diar- 
rhoea until  the  onset  of  a  fatal 
attack  of  obstruction. 

The  conditions  which  may  require  and  justify  interference  by 
the  surgeon  are  as  follows:  (i)  Repeated  attacks  of  slight  ob- 
struction, especially  if  localized  resistance  of  the  abdominal  wall 
or  an  indefinite  sense  of  fulness  in  some  region  is  associated  there- 
with; (2)  an  acute  attack  of  obstruction,  the  nature  and  s\Tnptoms 
of  which  vary  A\ath  the  site  of  the  lesion;  (3)  the  existence  of  a 
tumour,  which,  though  at  first  readily  moveable,  becomes  fixed 
after  a  while,  owing  to  the  formation  of  adhesions ;  and  (4)  the 
development  of  a  peri-intestinal  abscess.     On  the  other  hand,  if  it 

65 


1026  A   MANUAL  OF  SURGERY 

is  evident  that  secondary  deposits  are  present  in  the  omentum  or 
elsewhere,  and  the  primary  growth  is  so  large  or  fixed  that  its 
removal  is  doubtful,  it  is  useless  to  undertake  merely  an  exploratory 
operation.  In  these  cases  it  will  suffice  to  interfere  when  obstructive 
phenomena  make  their  appearance.  The  mere  handling  of  such  a 
growth,  the  inner  surface  of  which  is  probably  ulcerated,  is  some- 
times sufficient  to  determine  increased  activity  of  the  bacteria,  and 
the  development  of  an  abscess  around  the  grow'th,  which  may  be 
followed  by  diffuse  or  localized  peritonitis,  and  even  by  a  faecal  fistula. 

The  importance  of  an  early  Diagnosis  cannot  be  over-estimated ; 
every  case  of  irregular  intestinal  function,  especially  if  associated 
with  pain,  should  be  carefully  investigated  by  abdominal  palpation, 
and  if  need  be  by  bismuth  radiography.  Sigmoidoscopy  is  also  of 
value  in  examining  the  lowest  lo  or  12  inches  of  the  bowel. 

Treatment. — Unfortunately,  cases  are  usually  left  until  the  pro- 
gress of  the  disease  has  settled  the  question  of  diagnosis,  and  then 
palliative  treatment  may  alone  be  possible.  If  found  early  enough, 
a  radical  operation  for  removal  of  the  growth  may  be  undertaken, 
and  the  intestinal  canal  restored  by  enterorrhaphy.  Affected 
mesenteric  glands  are  included  in  the  part  excised,  if  possible,  but 
the  total  removal  of  the  growth  is  quite  justifiable,  even  if  glands 
have  to  be  left,  inasmuch  as  it  restores  the  functional  activity  of 
the  tube.  It  must  be  remembered,  however,  that  unless  the  bowel 
has  been  thoroughly  emptied  previously  it  is  always  wiser  to  make 
a  temporary  artificial  anus,  and  restore  the  continuity  of  the  canal 
at  a  later  date.  Hence  excision  should  never  be  undertaken  when 
obstruction  is  present. 

Cancer  of  the  caecum  requires  removal  of  the  lower  inch  or  two  of 
the  ileum,  as  well  as  of  the  caecum  and  a  varying  portion  of  the 
ascending  colon  (possibly,  for  choice,  the  w^hole),  in  order  to  include 
the  l}Tnphatic  area;  the  ileum  is  then  united  to  the  transverse  colon. 
In  cancer  of  the  ascending  colon  or  hepatic  flexure,  the  excision 
must  extend  well  into  the  transverse,  and  it  is  then  easier  to  include 
the  caecum  in  the  scope  of  the  excision  and  unite  the  ileum  to  the 
transverse  colon  than  to  leave  it  behind.  Cancer  of  the  transverse 
colon  must  be  removed  with  a  free  hand,  and  then,  by  '  mobilizing  ' 
(p.  1038)  the  ascending  and  descending  portions  of  the  colon,  it  may 
be  possible  to  anastomose  them  effectively;  failing  this,  an  ileo- 
sigmoidostomy  must  be  performed.  Cancer  of  the  splenic  flexure 
is  often  difficult  to  remove  because  of  its  greater  fixation,  but  when 
practicable  must  include  the  left  half  of  the  transverse  colon  and  a 
portion  of  the  descending  colon.  The  continuity  of  the  intestinal 
canal  is  restored  by  uniting  the  proximal  end  of  the  transverse  to 
the  iliac  colon,  or  by  performing  an  ileo-sigmoidostomy.  Cancer 
of  the  iliac  colon  involves  removal  of  the  greater  part  of  the  descend- 
ing colon  with  it,  and  the  union  of  the  transverse  colon  to  the  pelvic 
colon  or  rectum;  in  some  cases  it  is  wiser  to  perform  an  iliac 
colostomy,  and  remove  completely  the  segment  of  bowel  below  it. 
The  same  practice  holds  good  for  many  cases  of  cancer  of  the  pelvic 


ABDOMINAL  SURGERY 


1027 


colon  or  upper  end  of  the  rectum,  where  it  is  impossible  to  restore 
the  continuit}'  of  the  canal. 

Should  excision  be  impracticable,  owing  to  the  extent  or  hxity  of 
the  tumour,  the  following  plans  of  treatment  may  be  considered, 
and  that  which  best  suits  the  requirements  of  the  particular  case 
undertaken. 

1.  The  growth  may  be  short-circuited  by  uniting  portions  of  gut 
above  and  below  it.  This  is  usually  accomplished  by  one  of  the 
forms  of  lateral  anastomosis  described  hereafter;  thus,  the  caecum 
may  be  attached  to  the  sigmoid  flexure  in  a  case  of  cancer  of  the 
transverse  colon. 

2.  The  bowel  may  be  entirely  divided  above  the  tumour,  and  the 
upper  end  implanted  into  the  gut  below  it,  the  lower  end  of  the 
divided  bowel  being  closed  (Fig.  487).  This  lateral  implantation  is 
the  best  plan  of  treatment  to  emplo^^  for  cancer  of  the  caecum  which 
cannot  be  extirpated;  the  ileum  is  divided  above  the  valve,  and  its 
upper   end  implanted  into  the 

ascending  or  transverse  colon 
well  beyond  the  growth  (ileo- 
colostomy) ,  whilst  the  lower  end 
is  totally  closed. 

3.  The  affected  coil  of  gut  has 
been  excluded  from  the  intestinal 
tube  by  dividing  the  bowel  above 
and  below,  and  uniting  the  upper 
and  lower  segments.  One  end 
of  the  diseased  coil  is  closed,  and 
the  other  is  brought  to  the  sur- 
face and  fixed  there  so  as  to 
establish  a  fistulous  track.  There 
is  always  a  certain  amount  of 
discharge  from  the  cancerous 
growlh,  and  the  mucous  mem- 
brane itself  secretes,  so  that  total 
closure  of  the  excluded  loop 
would  be  accompanied  by  danger. 

4.  Finally,  if  none  of  these 
measures  are  appHcable,  or  if  the  patient's  condition  is  such  as 
to  make  it  unwise  to  attempt  them,  and  if  the  growth  is  situated 
in  the  colon,  an  artificial  anus  may  be  established. 

Idiopathic  Dilatation  of  the  Colon  (Hirschsprung's  disease)  is  a 
rare  affection  met  \\dth  in  infancy,  but  occasionally  lasting  on  till 
young  adult  life.  The  cause  in  many  cases  is  unknown,  but  con- 
genital contraction  of  the  rectum  has  been  found  in  some.  It  is 
characterized  by  enormous  distension  of  the  colon,  and  usually  of  the 
sigmoid  flexure ;  possibly  on  opening  the  abdomen  nothing  but  the 
colon  is  seen.  The  walls  are  h5^pertrophied,  and  stercoral  ulcers  may 
be  present.  The  abdomen  is  distended,  but  soft  and  free  from 
rigidity;  the  child  does  not  complain  of  pain  and  tenderness,  and 


Fig.  487. — Lateral  Implantation  of 
Divided  End  of  Ileum  into  the 
Transverse  Colon  for  Irremove- 
ABLE  Cancer  of  the  C.a;cuM  (Ileo- 
colostomy)  . 


1028  A   MANUAL  OF  SURGERY 

vomiting  is  unusual.  The  most  prominent  symptom  is  constipation, 
and  that  generally  of  a  most  obstinate  character,  purgatives  having 
no  effect  but  to  cause  pain  and  vomiting.  Enemata  are  often  re- 
tained, and  even  gas  cannot  easily  be  passed;  the  introduction  of  a 
long  flatus-tube  is  followed  by  the  escape  of  very  putrid  gas  in  large 
quantities.  Death  results  from  cachexia,  perforative  peritonitis,  or 
obstruction.  Treatment. — Purgatives  must  be  avoided,  but  massage 
and  electricity  may  do  good,  together  with  the  routine  use  of  ene- 
mata. Excision  of  the  distended  portion,  followed  by  a  lateral 
anastomosis,  is  probably  the  best  surgical  treatment.  In  one  case, 
operated  on  by  Sir  F.  Treves,  excision  of  the  rectum,  sigmoid  flexure, 
and  descending  colon  was  performed,  and  the  transverse  colon  was 
dragged  down  and  fixed  in  the  perineal  opening. 

Enteroptosis,  or  Glenard's  disease,  is  a  condition  not  uncommonly 
met  with  in  which  there  is  a  general  displacement  downwards  of  the 
viscera.  The  small  intestine,  transverse  colon,  kidneys,  and  stomach 
are  the  organs  chiefly  involved,  but  any  of  the  viscera  may  be 
affected.  The  cause  varies  and  cannot  always  be  ascertained ;  some- 
times it  commences  after  an  acute  illness,  more  usually  it  is  chronic 
and  develops  gradually.  Ihe  relaxed  abdominal  wall  which  follows 
repeated  pregnancies  is  often  present,  and  tight-lacing  may  be  an 
important  causative  factor.  Women  are  much  more  frequently 
affected  than  men.  The  condition  per  se  is  not  necessarily  associated 
with  symptoms,  but  in  a  considerable  number  of  cases  marked 
neurasthenia  is  present,  possibly  from  the  drag  of  the  viscera  upon 
the  sympathetic  plexuses  in  the  posterior  abdominal  wall.  The 
amount  of  displacement  is  no  measure  of  the  severity  of  the  symp- 
toms. The  stomach  may  be  well  below  the  costal  arch,  and  when 
inflated  stands  out  prominently,  both  curvatures  being  visible;  it  is 
usually  distended  atonically,  and  succussion  sounds  may  be  heard. 
The  relaxation  of  the  small  intestines  is  alluded  to  in  connection 
with  the  setiology  of  hernia  (p.  1086).  The  transverse  colon  may 
sag  downwards  into  the  pelvis,  and  the  kinking  of  the  splenic  and 
hepatic  flexures  thereby  induced  may  be  an  important  element  in 
the  production  of  constipation.  For  bismuth  radiograph  of  pro- 
lapsed transverse  colon,  see  p.  10 15.  The  spleen  and  liver  may 
also  slip  downwards.  Displacement  of  the  kidneys  is  referred  to 
under  the  heading  '  Moveable  Kidney.' 

Treatment  must  be  wisely  modified  according  to  circumstances, 
and  due  allowance  made  for  the  neurasthenic  element.  A  course  of 
Weir  Mitchell  treatment  (i.e.,  rest  and  feeding)  is  often  valuable, 
both  for  its  influence  on  the  nervous  state  and  also  in  assisting  to 
increase  the  deposit  of  fat.  Electricity  and  massage  to  the  ab- 
dominal walls,  together  with  suitable  gymnastic  exercises,  help  to 
restore  their  tone  and  to  improve  the  condition  of  the  underlying 
viscera.  An  abdominal  belt  or  bandage  will  do  much  to  relieve 
symptoms,  especially  if  applied  with  the  patient  in  the  Trendelen- 
burg position.  Operation  is  not  to  be  lightly  undertaken;  but  if  a 
fair  test  has  been  given  to  the  above  measures,  it  may  be  justifiable 


ABDOMINAL  SURGERY  1029 

to  open  the  abdomen  and  stitch  up  into  place  organs  like  the  stomach, 
liver,  or  spleen,  or  to  brace  up  the  abdominal  wall  by  some  plastic 
operation,  such  as  that  suggested  on  p.  HOQ-  For  treatment  of 
moveable  kidney,  see  p.  1190.  The  question  of  removing  or  short- 
circuiting  the  kinked  colon  may  also  have  to  be  considered. 

Intestinal  Stasis  is  a  term  recently  introduced  to  indicate  a  con- 
dition of  abnormal  delay  of  the  bowel  contents  in  some  part  of  the 
intestinal  canal,  especially  the  colon.  This  delay  allows  marked 
putrefactive  changes  to  occur,  and  in  consequence  abnormal  ab- 
sorption of  toxins,  which,  circulating  in  the  blood-stream,  produce 
not  only  a  general  depreciation  of  health,  but  also  considerable 
degenerative  changes  in  many  of  the  viscera  and  tissues.  Sir  Arbuth- 
not  Lane  has  done  most  excellent  work  in  emphasizing  the  char- 
acter and  dangers  of  this  condition,  although  his  theories  and  con- 
clusions are  not  generally  accepted  by  all  surgeons.  He  attributes 
the  whole  range  of  phenomena  to  the  assumption  by  man  of  the 
erect  attitude  and  the  natural  consequential  tendency  of  the  in- 
testines to  drop.  To  counteract  this,  a  reactive  formation  of  peri- 
toneal bands  and  membranes  occurs,  producing  results  more  or  less 
similar  to  those  following  peritonitis,  and  attaching  the  intestines 
to  parietal  structures.  Thus  to  the  outer  side  of  the  ascendmg 
colon  one  often  finds  a  set  of  membranous  bands  running  down- 
wards and  inwards  from  the  parietal  peritoneum  to  lap  over  the 
intestine  and  be  attached  to  the  front  of  the  ascending  meso-colon ; 
this  thin  vascular  veil  is  sometimes  teimed  Jackson's  membrane,  and 
if  at  all  exaggerated  may  cause  interference  with  the  activity  of  the 
colon.  At  the  hepatic  and  splenic  flexures  similar  developments 
occur,  and  may  cause  such  contractions  as  to  kink  the  gut  severely. 
Even  more  importance  is  attached  by  Lane  to  a  band  of  adhesions 
running  from  under  the  surface  of  the  mesentery  to  the  anti-mesen- 
teric  border  of  the  ileum,  a  few  inches  from  the  caecum;  the  contrac- 
tion of  this  band  causes  a  kink  at  the  termination  of  the  ileum 
[Lane's  ileal  kink) ,  and  thus  determines  retention  of  the  ileal  contents. 
The  result  of  this  is  increased  sagging  of  the  small  intestine  m  the 
pelvis  and  dragging  on  the  duodeno-jejunal  flexure;  this  is  stated 
to  cause  a  reactive  formation  of  bands,  which  first  support  the 
flexure,  but,  if  excessive,  subsequently  kink  it,  causing  dilatation 
of  the  stomach  and  duodenum.  Similar  bands  and  kinks  are  de- 
scribed elsewhere.  The  whole  series  of  phenomena  is  looked  on 
as  mechanical  and  reactive,  and  not  of  an  inflammatory  nature, 
although  structures,  such  as  the  appendix  or  gall-bladder,  are  often 
involved  in  the  adhesions.  This  view  of  the  condition  is  not  uni- 
versally accepted;  many  surgeons  look  on  the  bands  as  the  result 
of  inflammatory  attacks,  and  Professor  Arthur  Keith  has  shown 
that  many  of  them  are  of  congenital  origin  and  due  to  an  exaggera- 
tion of  the  ante-natal  plastic  peritonitis  which  fixes  the  colon  in  its 
place.  The  subject,  however,  is  too  large  to  discuss  here,  and 
opinions  at  present  too  divided  to  allow  of  dogmatization. 

*  For  further  details,  see  Report  on  Discussion  on  Intestinal  Stasis,  Royal 
Society  of  Medicine,  vol.  vi.,  Nos.  5  and  7  (Supplements). 


I030  A   MANUAL  OF  SURGERY 

The  Symptoms  arising  from  intestinal  stasis  are  threefold: 
(i.)  Mechanical  results  follow  from  distension  of  various  portions  of 
the  intestinal  canal- — e.g.,  the  stomach,  duodenum,  ileum,  or  colon. 
Most  of  these  have  been  alluded  to  already,  but  one  would  especially 
emphasize  the  troubles  that  arise  from  prolapse  of  the  colon  into 
the  pelvis,  which  can  be  readily  demonstrated  by  bismuth  radio- 
graphy (Fig.  482).  The  colon  becomes  filled  with  liquid  faecal 
material  which  cannot  be  passed  on.  (ii.)  Inflammatory  phenomena 
of  various  types  follow  this  stasis- — e.g.,  gastric  and  duodenal  ulcera- 
tion, appendicitis,  colitis,  etc.  (iii.)  Toxic  results  necessarily  ensue, 
and  include  such  conditions  as  enfeebled  circulation,  cold  sweating, 
cyanosed  extremities,  facial  pigmentation,  muscular  weakness,  with 
various  nervous  and  perhaps  mental  perturbations.  The  resistance 
of  the  individual  to  bacterial  invasion  is  also  lowered,  and  sundry 
infective  diseases  may  supervene. 

Treatment. — Early  and  mild  cases  can  often  be  treated  effectively 
by  improving  the  tone  of  the  abdominal  wall  and  increasing  the 
motor  power  of  the  colon  by  a  course  of  abdominal  massage  and 
suitable  gymnastic  exercises.  Purgatives,  intestinal  antiseptics 
(such  as  liquid  paraffin),  careful  attention  to  diet,  and  a  sufficiency 
of  rest  in  the  recumbent  posture,  will  do  good;  a  relaxed  abdominal 
wall,  of  course,  requires  suitable  external  support  or  some  operative 
treatment  to  tighten  it  up.  In  the  worst  cases,  where  the  caecum 
and  transverse  colon  sag  into  the  pelvis  and  have  become  literally 
transformed  into  cesspools  filled  with  putrid  faecal  material,  ileo- 
colostomy  or  -sigmoidostomy ,  with  or  without  an  extensive  colectomy, 
according  to  the  extent  and  gravity  of  the  case,  may  be  the  only 
practicable  treatment  that  holds  out  any  prospect  of  amelioration ; 
but  it  must  not  be  undertaken  unnecessarily,  as  sometimes  the  result 
is  a  persistent  diarrhoea,  owing  to  the  loss  of  the  colon,  which  acts 
largely  as  a  drying-ground  for  the  faeces.  See  also  on  treatment  of 
Enteroptosis  (p.  1028). 

Operations  on  the  Intestines. 

1.  Enter otomy  is  a  term  which  is  only  correctly  applied  to  an  in- 
cision made  into  the  intestine  either  for  the  removal  of  a  foreign  body 
or  for  the  examination  of  its  interior.  The  wound  should  always  be 
placed  in  the  longitudinal  axis  of  the  gut,  and  along  its  anti-mesen- 
teric  border;  it  is  closed  by  a  row  of  Lembert,  Czerny-Lembert,  or 
Halstead  stitches. 

2.  Enterostomy,  or  the  formation  of  an  artificial  opening  into  the 
bowel,  may  be  undertaken  for  several  reasons,  and  any  part  of  the 
gut  may  be  opened,  {a)  The  jejunum  may  be  brought  to  the  surface 
and  opened  [jejunosfomy)  in  cases  of  cancer  of  the  stomach  where 
gastro-enterostomy  and  pylorectomy  are  impossible  and  the  patient 
is  dying  of  inanition;  he  can  subsequently  be  fed  by  the  fistula  in 
this  way  produced,  {b)  The  ileum  may  need  to  be  opened,  and 
drained  in  cases  of  obstruction  not  lower  than  the  caecum  or  ascend- 


ABDOMINAL  SURGERY 


1031 


ing  colon,  when  the  small  gut  is  much  distended  and  the  patient's 
general  condition  so  bad  that  no  prolonged  search  for  the  cause  and 
no  attempt  to  deal  chrectly  with  it,  even  if  obvious,  are  possible. 
The  abdomen  is  opened  either  in  the  middle  line  or  in  the  right  iliac 
region;  a  suitable  distended  coil  is  withdrawn  and  opened  after 
carefully  protecting  the  peritoneal  cavity  from  faecal  infection.  A 
large  trocar  and  cannula  are  first  introduced,  so  as  to  allow  the  first 
gush  of  flatus  and  fluid  contents  of  the  gut  to  escape ;  the  opening 
is  then  enlarged  and  a  rubber  drainage-tube  stitched  in,  or  a  Paul's 
(glass)  tube  tied  in  (Fig.  488)  by  means  of  a  purse-string  suture 
passing  in  and  out  through  the  whole  thickness  of  the  bowel  wall, 
and  the  affected  coil  of  intestine  fixed  to  the  abdominal  wall.  A 
thin  tube  of  rubber  is  attached  to  the  other  end  of  the  glass  tube,  and 
through  this  the  intestinal  contents  are  temporarily  allowed  to  escape 
without  contamination  of  the  peritoneal  cavity  or  of  the  wound 

If  the  patient  recovers  from  the  acute  symptoms,  a  second  opera- 
tion will  be  needed  in  order  to  re-establish  the  continuity  of  the 
intestinal  canal.  Life  is  not  likely  to  be 
of  long  duration  if  an  artificial  opening 
exists  above  the  caecum,  as  the  exclusion  of 
the  absorbing  mucous  surface  of  the  large 
intestine  seriously  hampers  nutrition.  The 
fluid  contents  of  the  small  intestine  also  act 
as  a  serious  irritant  to  the  skin  of  the 
abdominal  wall- 

(r)  Colostomy,  or,  as  it  is  more  usually 
termed,  '  colotomy,'  is  frequently  employed 
in  dealing  with  diseases  of  the  lower  bowel, 
and  is  an  extremely  successful  proceeding. 

The  character  of  the  artificial  opening 
varies  considerably  according  to  whether 
or  not  it  is  intended  to  be  a  permanent  condition, 
a  temporary  opening  is  required,  the  smaller  the 
bowel  secured  to  the  parietes  the  better,  since  the 
operation  for  its  closure  is  so  much  simpler  (Fig.  489). 
a  permanent  aperture  has  to  be  established,  the  surgeon's  aim  should 
be  to  divert  totally  the  course  of  the  faeces;  and  hence  it  is  desirable 
to  withdraw  a  portion  of  the  gut  from  the  abdominal  cavity,  and  to 
cut  away  a  complete  segment,  including  also,  if  possible,  a  portion 
of  the  mesentery.  By  this  means  the  upper  and  lower  openings  are 
brought  to  the  surface  of  the  skin,  and  separated  from  one  another 
by  an  area  of  cicatricial  tissue  representing  the  section  of  the  mesen- 
tery (Fig.  490). 

The  ascending  colon,  or  preferably  the  ccBcum,  is  occasionally 
opened  in  cases  of  membranous  or  ulcerative  colitis  where  there  is  an 
abundant  secretion  of  pus,  and  the  patient's  life  is  threatened  by 
pyrexia  and  toxic  exhaustion.  The  object  of  the  operation  is  two- 
fold— viz.,  to  prevent  the  irritation  caused  by  the  passage  of  the 
faeces  over  the  ulcerated  mucous  membrane,  and  to  permit  the  colon 


Fig.  488. — Paul's  Tubes 
(Glass),  Large  and 
Small  Sizes. 


Tf  merely 
portion  of 
subsequent 

But  where 


I032  A   MANUAL  OF  SURGERY 

to  be  irrigated.  Inasmuch  as  the  contents  of  the  bowel  at  this  level 
are  fluid  and  very  irritating,  it  is  wise  to  mal-:e  the  opening  as  small 
as  possible,  and  this  ma}'  be  done  by  stitching  lirmly  into  the  bowel  a 
piece  of  rubber  drainage-tube  as  in  Witzel's  operation  for  gastros- 
tomy (p.  1007)  and  then  fixing  the  bowel  to  the  skin  and  abdominal 
muscles.  It  is  possible,  however,  that  in  spite  of  every  precaution 
the  skin  will  become  inflamed.  If  the  opening  has  to  remain  for 
some  time,  the  patient  must  be  provided  with  an  abdominal  belt  to 
which  is  fitted  an  elastic  pad  carrying  a  solid  rubber  plug  which  fits 
into  the  aperture. 

Intestinal  obstruction  at  the  hepatic  flexure  sometimes  necessi- 
tates a  csecal  colostomy,  which  is  performed  as  for  the  small  intes- 


'  '  ^-.. 

.  ,  ■vs&^ilr 

\ 

■■! 

1         / 

4 

■"^ 

^X"- 

Fig.  489. — Diagram  of  Tempor-  Fig.  490. — Diagram  of  Permanent 
ARY  Colostomy,  showing  the  Colostomy,  showing  the  Two  Open- 
Single  Opening  on  a  Level  ings  separated  One  from  the 
with  the  Skin,  the  Passage  Other  by  a  Section  of  the  Mesen- 
To  THE  Lower  Bowel  being  tery, 

MERELY    BLOCKED     BY     A     SPUR 

OF  Mucous  Membrane. 

tines,  a  Paul's  tube  being  tied  in.  A  secondary  operation  is  usually 
required  in  order  to  excise  the  cause  of  the  obstruction,  or  to  short- 
circuit  it. 

The  transverse  colon  is  most  likely  to  need  to  be  opened  for  an  ob- 
struction located  in  the  splenic  flexure,  as  by  carcinoma  or  adhesions. 
In  all  probability  the  source  of  the  trouble  has  not  been  recognised 
prior  to  operation ;  the  abdomen  is  explored  through  an  incision  in 
the  middle  line,  and  in  order  to  relieve  the  urgent  symptom?  the  dis- 
tended transverse  colon  has  to  be  opened  at  once  and  a  Paul's  tube 
tied  in.  If  the  case  is  less  urgent,  and  yet  a  considerable  amount  of 
fsecal  material  is  present  in  the  gut,  a  small  portion  should  be  stitched 
to  the  surface,  and  after  adhesions  have  formed,  it  may  be  opened 
and  drained  for  a  few  days.  Necessarily  the  situation  is  not  a 
desirable  one  for  an  artificial  anus,  and  therefore  it  should  be  only 
of  a  temporary  character.  When  the  bowel  has  been  satisfactorily 
emptied,  the  abdomen  should  be  again  opened,  and  some  form  of 


ABDOMINAL  SURGERY  1033 

anastomosis  performed  to  short-circuit  the  obstruction  if  excision  of 
the  growth  is  impossible. 

The  descending  colon  or  sigmoid  flexure  is  the  most  frequent  situa- 
tion for  colostomy.  Two  chief  methods  have  been  employed — viz., 
the  lumbar  operation,  in  which  the  upper  part  of  the  descending 
colon  is  reached  behind  or  through  the  peritoneum,  and  the  iliac,  in 
which  the  upper  part  of  the  sigmoid  flexure  or  lower  end  of  the 
descending  colon  is  brought  to  the  surface  after  opening  the  peri- 
toneal cavity. 

Uses  of  Left  Lumbar  or  Iliac  Colostomy. — The  operation  is  required 
under  the  following  conditions:  (i)  For  congenital  absence  of  the 
rectum,  when  a  perineal  incision  has  failed  to  discover  it;  (2)  for 
chronic  obstruction  of  the  lower  end  of  the  large  intestine,  which 
cannot  be  relieved  by  enemata  or  medical  means,  such  as  that  arising 
from  simple  or  malignant  stricture,  or  from  the  pressure  of  pelvic 
tumours ;  (3)  for  carcinoma  of  the  rectum  or  sigmoid  flexure,  whether 
obstruction  is  present  or  not,  if  a  radical  operation  is  impracticable, 
or  as  a  preliminary  to  excision;  (4)  for  some  cases  of  syphilitic, 
tuberculous,  and  other  forms  of  ulceration  of  the  rectum,  which 
cannot  heal  as  long  as  they  are  irritated  by  the  passage  of  fseces: 
(5)  for  irremediable  cases  of  recto-vesical  and  recto-vaginal  fistula, 
whatever  their  origin;  (6)  for  volvulus  of  the  sigmoid  flexure,  the 
iliac  operation  being  needed  not  only  to  relieve  the  obstruction,  but 
also  to  prevent  recuirence. 

Left  Lumbar  Colostomy  (Amussat's  Operation)  has  been  niuch 
neglected  of  recent  years,  and  practically  replaced  by  its  iliac  rival. 
Performed  as  it  was  in  the  old  days  without  opening  the  peritoneal 
cavity,  this  operation  was  certainly  not  a  desirable  one;  but  if  the 
method  described  below  is  adopted,  it  will  probably  be  found  as 
eflicient  as  the  iliac  proceeding.  The  patient  lies  on  the  right  side, 
with  a  sandbag  beneath  the  loin,  so  as  to  increase  the  space  between 
the  last  rib  and  the  crest  of  the  ilium.  The  position  of  the  colon  is 
indicated  by  a  vertical  line  drawn  upwards  from  a  point  |  inch 
behind  the  centre  of  another  line,  passing  from  the  anterior  to  the 
posterior  superior  iliac  spine. 

The  centre  of  the  incision  should  correspond  to  this  line  midway 
between  the  last  rib  and  the  crest  of  the  ilium.  It  should  be  made 
parallel  to  the  last  rib,  and  for  practical  purposes  may  commence  at 
the  outer  border  of  the  erector  spina,  and  pass  outwards  for  about 
4  or  5  inches  (Fig.  534,  A,  p.  1175)  •  This  incision  is  carried  through 
the  layers  of  the  abdominal  muscles  and  the  fascia  lumborum,  and 
opens  up  the  loose  fatty  subperitoneal  tissue. 

If  the  gut  is  distended,  it  may  at  once  come  into  view;  but  if 
collapsed,  it  is  not  recognised  at  first.  In  about  20  to  30  per  cent, 
of  individuals  a  true  peritoneal  descending  meso-colon  is  present. 
Under  any  circumstances  the  peritoneum  is  opened  in  the  anterior 
portion  of  the  wound,  and  the  colon  definitely  looked  for  and 
identified.  The  highest  portion  that  can  be  reached  is  secured,  so 
that  there  shall  be  no  slack  intestine  above  the  opening  to  give  rise 


I034  A  MANUAL  OF  SURGERY 

later  on  to  prolapse;  for  choice,  one  fixes  the  end  of  the  transverse 
colon  to  the  skin. 

If  the  case  is  not  urgent,  the  loop  of  bowel  is  withdrawn  and 
secured  to  the  skin  by  sutures  through  the  sero-muscular  coats;  the 
rest  of  the  parietal  incision  is  closed.  After  a  few  days  the  bowel  is 
opened.  It  is  well  to  fix  it  as  far  back  in  the  wound  as  possible,  so 
as  not  to  leave  a  pocket  behind  in  which  discharges  can  accumulate. 
If,  however,  urgent  obstruction  is  present,  requiring  immediate 
relief,  the  bowel  is  drawn  out  of  the  wound  and  opened  with  the 
same  precautions  as  in  the  iliac  procedure.  A  trocar  and  cannula  is 
introduced  to  give  exit  to  the  first  gush  of  flatus  and  fluid  faecal 
matter,  and  then  a  Paul's  tube  is  tied  in,  the  bowel  stitched  to  the 
skin,  and  the  rest  of  the  wound  closed. 

Lumbar  colostomy  is  not  much  in  favour  at  the  present  day,  but 
there  are  surgeons  who  maintain  that  in  reality  a  lumbar  opening  is 
more  comfortable  and  convenient  than  one  in  the  iliac  fossa,  and 
that  it  is  much  easier  to  control  the  escape  of  faeces  than  in  the  latter 
proceeding. 

Iliac  Colostomy,  or  Littre's  Operation,  consists  in  opening  the  lower 
portion  of  the  colon  or  sigmoid  flexure  through  the  anterior  abdom- 
inal wall.  Various  incisions  are  used;  some  surgeons  employ  a 
vertical  incision  through  the  outer  fibres  of  the  rectus  muscle  in  the 
hope  of  gaining  some  measure  of  sphincteric  control.  Others  employ 
an  incision  2  or  3  inches  in  length,  made  at  right  angles  to  a  line 
extending  from  the  anterior  superior  spine  to  the  umbilicus,  the 
centre  of  the  incision  corresponding  to  the  junction  of  the  outer  and 
middle  thirds  (Fig.  473,  D).  The  abdominal  parietes  are  divided, 
either  in  the  line  of  the  cutaneous  incision,  or  by  McBurney's  method 
of  splitting  the  muscles  in  the  line  of  the  fibres;  the  latter  is  only 
desirable  when  there  is  but  little  distension,  and  when  it  is  not  neces- 
sary' to  make  an  extensive  exploration  of  the  viscera.  The  sigmoid 
flexure  is  sought  for,  and  recognised  by  the  presence  of  the  appen- 
dices epiploicae  and  the  longitudinal  bands  of  muscle  fibres.  It  is 
gently  drawn  out,  and  the  upper  part  is  selected  for  fixation  in  the 
wound,  so  as  to  diminish  the  risk  of  subsequent  prolapse.  Many 
different  plans  of  fixation  are  in  vogue,  (i.)  Undoubtedly  the 
best,  if  possible,  is  to  make  an  opening  through  the  meso-colon, 
and  through  this  to  draw  together  the  segments  of  the  abdominal 
wall  by  suitable  deep  stitches  and  superficial  sutures  in  the  skin 
(Fig.  491).  The  possibility  of  undertaking  this  operation  depends 
on  the  degree  of  laxity  of  the  sigmoid  flexure ;  where  the  meso-colon 
is  short,  the  peritoneum  to  its  outer  side  should  be  freely  divided, 
and  the  colon  '  mobilized  '  inwards  to  a  sufficient  extent  to  enable 
this  type  of  operation  to  be  undertaken,  (ii.)  If,  in  spite  of  its 
mobilization,  it  is  not  very  free,  it  is  better  to  make  a  hole  through 
it  and  to  introduce  a  glass  rod  which,  resting  on  the  abdominal 
wall  on  either  side,  supports  the  gut  until  suitable  adhesions  have 
formed.  It  is  wise  to  pass  one  stitch  through  the  skin  at  each  end 
of  the  rod  and  tie  the  latter  securely  to  it,  so  as  to  prevent  the  risk 


ABDOMINAL  SURGERY 


1035 


of  it  slipping  aside,  (iii.)  A  useful  and  effective  method  of  fixation 
is  to  pass  a  mattress  suture  of  strong  silk  through  the  parietes  (in- 
cluding the  skin,  muscles,  and  peritoneum)  on  either  side,  the  stitch 
traversing  the  meso-colon  en  roiUe  (Fig.  492).  By  tying  the  ends 
together,  the  parietes  are  brought  into  close  apposition  with  the 
meso-colon.  In  all  cases  a  few  additional  stitches  should  be  in- 
serted, uniting  the  skin  to  the  longitudinal  muscular  bands  at  each 
end  of  the  incision,  and  the  ends  of  the  parietal  wound  itself  should 
be  closed  as  much  as  possible,  so  as  to  prevent  subsequent  prolapse. 
If  the  bowel  does  not  need  to  be  opened  at  once,  it  is  covered  with 
purified  protective,  and  a  dressing  is  applied.  At  the  end  of  two 
or  three  days  the  gut  is  usually  opened,  and  a  glass  or  rubber  tube 
stitched  or  tied  in;  no  anaesthetic  is  required  for  this.  At  the  end 
of  three  or  four  days  these  tubes  become  loose,  and  by  the  end  of 
a  week  it  is  wise  to  '  trim  up  '  the  bowel,  removing  any  unnecessary 
redundancy,  and  separating  completely  the  upper  and  lower  ends. 


Fig.  491. — Iliac  Colostomy  fixed 
BY  suturing  Abdominal  Wall 
through  an  opening  in  the 
Meso-Sigmoid. 


Fig.  492. — Iliac  Colostomy  to 
SHOW  Fixation  Stitch  passing 
THROUGH  Mesentery  and  Ab- 
dominal Parietes. 


Should  it  be  necessary  to  open  the  gut  at  the  time  of  the  first  opera- 
tion, precautions  similar  to  those  already  suggested  for  enterostomy 
must  be  taken  in  order  to  prevent  the  peritoneum  from  being  defiled. 

When  cicatrization  of  the  wound  is  complete,  a  protective  ap- 
paratus is  required  in  order  to  keep  the  patient  clean.  This  should 
consist  of  a  hollow  oval  cup,  made  of  plated  metal,  vulcanite,  or 
celluloid,  with  a  rolled  edge,  and  kept  in  position  either  by  a  truss 
spring  or  an  abdominal  belt.  This  hollow  cup  should  be  large 
enough  to  include  a  2 -inch  margin  of  skin  all  round  the  opening,  and 
in  the  concavity  a  small  portion  of  antiseptic  dressing  is  placed. 
Such  an  apparatus  enables  the  patient  to  go  about  in  comparative 
comfort ;  the  bowels  are  encouraged  to  act  thoroughly  every  morning 
by  means  of  an  enema,  so  that  no  further  disturbance  need  occur 
during  the  day. 

Comparison  of  the  Two  Operations. — At  the  present  time  the 
methodical  and  deliberate  opening  of  the  peritoneal  cavity  obviates 
nearly  all  the  difficulties  which  were  formerly  experienced  in  con- 


1036  A   MANUAL  OF  SURGERY 

nection  with  the  lumbar  operation,  and  the  advantages  of  the  iliac 
operation  are  not  nearly  so  pronounced  as  formerly-  (a)  One  great 
advantage  is  the  closer  proximity  to  a  pelvic  grovvth,  which  can  be 
carefully  examined,  as  also  the  lymphatic  glands  in  the  meso-rectum 
or  lumbar  region,  and  valuable  indications  as  to  the  advisability  or 
not  of  excision  of  the  rectum  can  be  thereby  obtained,  {b)  An 
artificial  anus  situated  in  the  iliac  region  can  be  attended  to  by  the 
patient  himself  without  assistance,  and  is  more  easily  cleansed  and 
protected,  (c)  It  is  occasionally  possible  for  a  certain  amount  of 
sphincteric  control  to  be  developed  after  the  abdominal  operation, 
especially  if  the  gut  is  brought  out  between  the  divided  segments 
of  the  rectus. 

It  is  sometimes  desirable  to  close  a  colostomy  wound  after  a 
shorter  or  longer  interval.  The  plan  usually  adopted  at  the  present 
day  is  to  dissect  up  the  margins  of  the  wound,  freeing  the  gut  from 
its  attachments  to  surrounding  parts,  and  excising  the  affected  seg- 
ment ;  in  this  way  the  continuity  of  the  canal  can  be  restored  without 
leaving  parietal  adhesions.  Occasionally  it  may  seem  desirable  to 
close  the  opening  without  encroaching  on  the  peritoneal  cavity. 
This,  of  course,  is  only  possible  when  the  whole  circumference  of  the 
bowel  has  not  been  encroached  on,  and  the  spur  consists  of  a  valve 
or  flap  of  mucous  membrane  (Fig.  489).  It  is  then  necessary  to 
efface  or  remove  the  spur,  which  would  otherwise  hinder  the  onward 
passage  of  the  faeces.  This  may  be  effected  by  stitching  a  piece  of 
drainage-tubing  of  large  calibre  into  the  bowel  so  as  to  reach  above 
and  below  the  opening ;  the  margins  can  then  be  pared  and  closed  in 
some  suitable  way;  after  a  time  the  stitches  in  the  drainage-tube 
(catgut  by  choice)  wiU  be  absorbed,  and  it  will  pass  on  down  the 
canal.  This  latter  method  of  dealing  with  an  artificial  anus  is  ex- 
tremely unsatisfactory,  as  it  leaves  an  adherent  coil  of  intestine, which 
is  certain  to  hamper  peristalsis  and  may  cause  recurrent  colic,  or 
may  even  determine  an  attack  of  obstruction ;  the  open  operation  is 
usually  very  successful. 

3.  Enteroplasty  is  a  plan  of  treatment  which  has  been  devised  for 
dealing  with  cicatricial  strictures  of  the  intestine,  and  is  based  on  the 
same  idea  as  the  operation  of  pyloroplasty  foi  fibrous  stenosis  of  the 
pylorus  (p.  1009).  A  longitudinal  incision  is  made  through  the 
stenosed  gut  along  the  anti-mesenteric  border;  this  is  opened  out, 
and  converted  into  a  transverse  cleft,  which  is  carefully  sutured,  the 
lumen  of  the  bowel  being  thereby  considerably  increased. 

4.  Enterectomy,  or  excision  of  a  portion  of  the  bowel,  is  required 
in  the  following  conditions:  (a)  For  the  removal  of  gangrenous  gut 
after  strangulation,  whether  internal  or  external ;  [b)  in  the  treatment 
of  multiple  penetrating  wounds,  as  after  a  stab  or  gunshot  injury; 
(c)  for  the  closure  of  an  artificial  anus  or  faecal  fistula;  (d)  for  the 
removal  of  simple  or  malignant  strictures;  and  (e)  in  some  cases  of 
intussusception.  Naturally,  the  results  vary  largely  with  the  con- 
dition for  which  it  is  performed,  with  the  site  of  the  lesion,  and  with 
the  experience  and  skill  of  the  operator;  a  much  higher  rate  of 


ABDOMINAL  SURGERY  1037 

mortality  follows  when  the  excision  is  done  for  mahgnant  disease, 
for  gangrene  following  strangulation,  or  for  intussusception,  than 
when  performed  for  other  causes.  Operations  on  the  large  intestine 
are  cilso  much  less  favourable  than  those  directed  to  the  small  gut. 
Whenever  practicable,  the  bowel  should  be  thoroughly  emptied 
prior  to  operation,  and  rendered  as  sterile  as  possible  by  the  use  of 
such  drugs  as  calomel  (gr.  i.  daily),  salol,  /3-naphthol,  naphthalene, 
bismuth  subnitrate,  etc.,  for  a  few  days  previously.  Should  this  be 
impossible  and  when  the  bowel  is  distended,  it  is  usually  wise  to 
open  and  drain  it  for  a  few  days,  and  then  subsequently  perform  the 
anastomosis. 

The  abdomen  is  opened  by  any  suitable  incision,  and  the  portion 
to  be  removed  clearly  defined,  the  general  peritoneal  cavity  being 
protected  by  a  careful  packing  with  abdominal  cloths  or  gauze. 
The  bowel  rnust  then  be  clamped  on  either  side  of  the  seat  of  opera- 
tion, so  as  to  prevent  the  escape  of  intestinal  secretions  or  faeces. 
Any  of  the  forms  of  clamp  figured  in  surgical  instrument  catalogues 
will  effect  this  purpose;  but  if  they  are  not  obtainable,  the  same 
result  can  be  obtained  by  passing  a  piece  of  drainage-tube  through 
the  mesenteric  attachment,  and  tying  or  clamping  it  around  the  gut. 
The  affected  portion  is  now  removed  by  scissors,  cutting  through 
the  bowel  and  taking  away  a  V-shaped  portion  of  the  mesentery, 
after  securing  as  far  back  as  possible  the  main  nutrient  vessels  to 
the  diseased  area,  according  to  Murphy's  recommendation.  It  must 
be  remembered  that  the  terminal  vessels  run  circularly  round  the 
gut,  and  have  but  few  lateral  anastomoses,  and  therefore  it  is 
desirable  that  the  incisions  should  diverge  slightly  from  the  mesen- 
teric attachment,  otherwise  the  projecting  edge  of  the  anti-mesen- 
teric  border  is  certain  to  slough,  and  septic  peritonitis  will  result. 
Some  operators  recommend  that  the  mesentery  should  not  be  cut 
into,  but  that  the  gut  should  be  detached  from  the  mesenteric  junc- 
tion ;  such  practice  will  suffice  when  merely  a  small  segment  of  bowel 
is  to  be  removed ;  but  if  a  large  portion  needs  resection,  it  would  take 
a  much  longer  time  to  secure  all  the  bleeding-spots.  The  wound 
in  the  mesentery  is  subsequently  secured  by  sutures,  and  the 
divided  ends  of  the  bowel  united  by  either  an  end-to-end  or  a  lateral 
anastomosis. 

For  end-to-end  union  the  following  are  the  chief  plans  that  have 
been  adopted: 

A.  Entero-anastomosis  by  simple  suturing.  In  this  the  surgeon 
utilizes  no  special  apparatus,  but  trusts  to  the  deftness  of  his  fingers 
and  the  accuracy  of  his  stitches. 

The  mesenteric  and  anti-mesenteric  borders  are  first  united  by 
stitches  which  are  left  long  for  the  assistant  to  hold;  the  gut  is  there- 
by steadied  (Fig.  493).  The  mucous  membrane  is  then  sutured  by 
catgut  or  silk  stitches,  which  should  not  be  continuous  all  round  the 
junction,  as  thereby  it  might  be  drawn  in  too  closely  and  contracted; 
it  is  best  taken  up  in  two  or  three  portions.  The  sero-muscular  coats 
are. now  united  all  round  by  one  or  two  continuous  stitches  of  the 


1038 


A  MANUAL  OF  SURGERY 


Lembert  or  Gushing  type.  Extreme  care  must  be  taken  in  dealing 
with  the  mesenteric  attachment,  as  the  peritoneal  coats  separate 
there  in  order  to  enclose  the  bowel,  and  the  muscular  coat  retracts 
considerably ;  leakage  is  more  likely  to  occur  at  this  point  than  at 
any  other. 

Some  surgeons  advise  that  the  first  row  of  stitches  should  include 
the  whole  thickness  of  the  gut,  and  that  the  second  row  should  be  of 
the  Lembert  type.  This  is  unnecessary  and  undesirable  as  a  routine 
procedure,  as  it  involves  too  great  an  infolding  of  the  gut  wall,  and 
thereby  the  lumen  at  the  site  of  anastomosis  is  unduly  encroached 
on,  and  some  amount  of  stenosis  may  result. 

B.  A  vast  amount  of  ingenuity  has  been  expended  in  the  produc- 
tion of  a  variety  of  bobbins  and  buttons,  with  the  idea  of  facilitating 
entero-anastomosis  and  making  it  safer,  but  they  have  been  almost 

entirely  discarded  at  the 
present  day  in  favour  of 
simple  suturing. 

3.  Colectomy,  or  ex- 
cision of  a  larger  or 
smaller  portion  of  the 
large  intestine,  is  not 
quite  so  simple  a  matter 
as  removal  of  a  part  of 
the  small  bowel,  owing 
to  the  greater  complexity 
of  the  peritoneal  reflec- 
tions and  its  less  mobihty. 
The  latter  difficulty  can, 
however,  be  largely  over- 
come, and  the  colon 
freely  '  mobilized,'  by 
dividing  the  peritoneal 
attachments  on  the  outer 
sides  of  both  ascending 
and  descending  colon,  and 
by  detaching  the  transverse  colon  from  the  under  side  of  the 
omentum ;  the  varying  portions  of  the  bowel  can  then  be  freely  drawn 
over  to  the  middle  line  with  the  vessels,  nerves,  etc.,  being  held 
merely  by  one  layer  of  peritoneum.  By  the  assistance  of  this  pro- 
cedure, large  portions  of  the  colon  can  be  removed  without  much 
danger  or  difficulty,  and  union  of  the  upper  and  lower  segments 
can  be  readily  affected  either  by  end-to-end  anastomosis,  or  pre- 
ferably by  lateral  anastomosis,  after  closing  the  divided  ends.  One 
essential  precaution  must  be  observed  if  success  is  to  be  obtained 
— viz.,  the  colon  must  be  satisfactorily  emptied  beforehand;  in  any 
case  of  partial  or  complete  obstruction  with  retention  of  the  faecal 
contents  a  preliminary  colostomy  must  be  undertaken. 

6.  Lateral  Anastomosis  of  the  intestine  is  often  employed  in  order 
to  effect  the  short-circuiting  of  some  malignant  growth,  or  of  a 


Fig.  493.- 


-End -TO -End    Anastomosis 
Simple  Suturing. 


For  clearness'  sake,  the  first  row  of  stitches  in 
the  mucous  membrane  has  been  omitted, 
and  the  sero-muscular  sutures  of  the  Lembert 
type  are  represented  as  interrupted.  In 
practice  one  would  use  a  continuous  stitch. 


ABDOMINAL  SURGERY 


1039 


stricture  which  cannot  otherwise  be  dealt  with.  It  is  also  used 
instead  of  end-to-end  anastomosis  to  unite  divided  segments  of 
intestine.  The  open  ends  are  hrst  entirely  closed,  and  to  effect  this 
the  bowel  should  be  divided  by  the  knife  or  thermo-cautery  between 
two  pairs  of  powerful  clamp-forceps  or  enterotribes.  If  these  are  left 
in  situ  for  a  minute  or  two,  the  divided  end  of  the  bowel  will  be 
found  effectively  sealed,  and  can 
be  readily  invaginated  by  a  row  or 
two]  of  Lembert's  sutures.  The 
portions  of  bowel  are  now  made  to 
overlap,  and  the  actual  anastomosis 
is  performed  as  for  gastro-entero- 
stomy  (Fig.  494).  Robson's  or 
other  suitable  clamps  are  applied, 
and  the  coils  are  brought  into  suit- 
able apposition.  Longitudinal  in- 
cisions are  made  through  the  sero- 
muscular coats,  and  these  are  then 
unitedjpn  the  posterior  aspect  of 
the  proposed  junction.  The  seg- 
ments of  bowel  are  then  opened, 
and  any  fluid  or  solid  contents 
carefully  mopped  up  and  removed. 
A  continuous  stitch  unites  the 
mucous  membrane  all  round,  and 
finally  the  external  sero-muscular 
stitch  secures  the  anastomosis.  The 
operation  is  completed  by  securing 
the  divided  edges  of  the  overlap- 
ping segments  of  the  mesentery  so 
as  not  to  leave  an  aperture  through 
which  internal  strangulation  might 
occur. 

7.  Lateral  or  End-to-Side  Im- 
plantation is  a  procedure  not  un- 
commonly required  in  order  to 
short-circuit  a  malignant  growth 
(Fig.  487).  It  is  perhaps  employed 
most  frequently  for  irremoveable 
cancer  of  the  csecum  or  ascending 
colon;  the  ileum  is  divided  well 
above  the  growth;  the  lower  end 
is  closed,  and  the  upper  united  to 
the  transverse  colon.  The  junction  may  be  made  by  simple  suturing, 
two  rows  of  stitches  being  introduced.  It  is  probably  wiser,  how- 
ever, to  close  the  end  of  the  ileum  and  perform  a  lateral  anasto- 
mosis, as  described  above,  inasmuch  as  it  is  possible  thereby  to 
secure  a  larger  opening. 


Fig.  494. — Lateral  Anastomosis 
OF  Bowel  after  Complete 
Division. 

The  divided  ends  are  closed  by- 
sutures  and  approximated  by  a 
sero-muscular  continuous  stitch 
(A,  A') ;  the  incisions  in  the  bowel 
are  then  made,  and  the  mucous 
membranes  united  by  a  continu- 
ous stitch  (B,  B');  and,  finally, 
the  sero-muscular  suture  is  carried 
round  the  whole  opening.  Only 
the  deep  layer  of  sutures  is  shown 
here,  and  they  have  not  been 
drawn  tight,  so  as  to  indicate 
their  relative  positions. 


I040  A  MANUAL  OF  SURGERY 

Appendicitis  {Syn.  :  Perityphlitis,  Epityphlitis,  etc.). 

Appendicitis  is  an  affection  which  may  appear  at  any  time  of  life, 
but  it  is  most  common  in  young  adults,  and  the  male  sex  is  more 
frequently  attacked  than  the  female.  The  disease  is  sometimes  of 
but  slight  significance,  but  occasionally  runs  such  a  virulent  course 
as  to  destroy  life  in  a  few  hours.  Its  importance  lies  in  the  fact  that 
it  is  an  infective  process,  and  inasmuch  as  the  peritoneal  envelope  is 
generally  involved,  a  certain  degree  of  peritonitis  is  almost  neces- 
sarily a  consequence. 

etiology. — Many  different  conditions  contribute  either  directly  or 
indirectly  in  determining  an  attack  of  appendicitis,  (i)  The  appen- 
dix is  to  be  looked  on,  not  as  an  actively  functional  structure,  but  as 
a  degenerated  relic  or  remnant,  which  is  apparently  of  little  value  or 
importance.  Hence,  as  in  other  similar  structures,  it  often  has  but 
a  poor  blood-supply,  derived  from  the  posterior  ileo-cascai  branch  of 
the  ileo-colic  artery.  Ihe  main  nutrient  vessels  traverse  or  run 
along  the  free  border  of  the  meso-appendix,  but  a  second  twig  often 
runs  down  the  base  of  the  mesentery,  and  is  more  or  less  independent 
of  the  others.  Some  authorities  join  issue  with  the  above-mentioned 
view  as  to  the  inutilit}'  of  the  appendix,  and  maintain  that  it  secretes 
a  fluid  which  stimulates  the  peristalsis  of  the  Ccecum  or  colon 
(MacEwen).  This  may  be  so,  but  the  fact  remains  that  a  vast 
number  of  people  who  have  lost  their  appendixes  by  operation  get 
on  quite  well  without  them.  (2)  A  large  amount  of  l\Tnphoid  tissue 
is  present  in  the  mucous  membrane,  especially  in  young  people,  so 
much,  in  fact,  that  the  title  of  '  abdominal  tonsil '  has  been  applied 
to  it.  Ihe  lymphoid  follicles  have  a  tendency  to  atrophy  with  ad- 
vancing age.  Inflammatory  processes  are  readily  set  up  \\'ithin  its 
walls  as  a  result  of  the  absorption  of  toxins  or  organisms,  which 
are  almost  constantly  present  within  it.  It  is  interesting  to  note 
here  that  some  look  on  appendicitis  as  an  outcome  of  rheumatism, 
and  the  association  of  that  disease  with  tonsillitis  is  suggestive. 
(3)  Its  length  and  direction  vary  considerably  in  different  individuals. 
In  length  it  may  measure  anything  between  ih  and  11  or  12  inches, 
but  is  usuall}^  3  to  4  inches  long,  whilst  as  to  direction,  it  may  lie  in 
any  axis,  and  the  clinical  picture  is  largely  influenced  by  its  ana- 
tomical position  (Plate  \TII.).  The  commonest  situation  is  behind 
the  caecum  in  relation  with  the  lowest  end  of  the  mesentery,  pointing 
towards  the  spleen ;  but  it  is  not  unusual  for  it  to  lie  deeply  behind 
the  csecum,  pointing  down  towards  the  pelvis,  and  then  pelvic  com- 
plications almost  always  accompany  an  attack  of  appendicitis.  At 
other  times  the  appendix  lies  to  the  outer  side  of  the  csecum,  and 
the  inflammatory  reaction  then  may  be  more  localized.  The  posi- 
tion of  the  appendix  also  governs  the  facility-  with  which  the  intes- 
tinal contents  find  their  wa}'  into  its  lumen,  and  it  seems  probable 
that  appendicitis  is  more  commonly  met  with  where  it  is  so  placed  as 
readil}'  to  admit  material  which  is  with  difficulty  expelled — i.e., 
when  it  is  transverse,  or  directed  downwards.     A  longer  appendix 


ABDOMINAL  SURGERY  1041 


is  also  more  liable  to  become  twisted  and  kinked  on  itself.     (4)  The 
extent  to  which  the  meso -appendix  is  attached  is  also  an  important 
element,  since  the  portion  which  projects  beyond  its  free  border  is 
less  well  supplied  with  blood.     As  a  matter  of  fact,  the  mesentery 
often  does  not  extend  beyond  the  junction  of  the  middle  with  the 
distal  third,  and  perforation  not  unfrequently  occurs  about  this  spot. 
The  vessels  often  run  in  the  free  border  of  the  mesentery,  and  kink- 
ing of  the  appendix  may  result  in  thrombosis  of  the  vessels  and 
gangrene.     (5)  The  communication  with  the  caecum  is  usually  a 
small  one,  and  is  guarded  by  an  insignificant  fold  of  mucous  mem- 
brane, known  as  the  valve  of  Gerlach.     Sometimes  this  aperture 
becomes  blocked,  or  the  orifice  stenosed,  as  the  result  of  a  preceding 
attack  of  typhlitis  or  inflammation  of  the  mucous  lining  of  the 
caecum,  so  that  an  accumulation  of  mucus  occurs  within  the  appen- 
dix, leading  to  its  dilatation  into  a  cystTike  pouch.     (6)  The  contents 
of  the  normal  appendix  consists  of  a  little  mucus  and  a  certain  num- 
ber of  bacteria,  similar  to  those  found  in  the  neighbouring  intestine ; 
they  do  no  harm  unless  the  mucous  lining  is  so  damaged  as  to 
permit  them  to  invade  the  living  tissues,  and  then  they  become  viru- 
lent.    A  generalized  infection  of  the  intestinal  canal,  perhaps  the 
result  of  oral  sepsis,  will  obviously  be  a  favourable  condition  for  de- 
termining inflammation  of  the  appendix.  Foreign  bodies,  such  as  pips, 
pins,  etc.,  are  occasionally  found  within  it,  and  by  their  presence  and 
irritation  may  light  up  an  attack  of  appendicitis.    They  are  much  less 
common  than  was  formerly  imagined,  and  the  fact  that  the  opening 
into  the  intestine  is  generally  not  larger  than  to  admit  a  No.  8 
catheter  will  explain  this  rarity.     FcBcal  concretions  are  compara- 
tively common ;  they  are  oval  bodies,  varying  from  |  to  i  inch  in 
length,  and  usually  laminated,  consisting  of  dried  faecal  material 
mixed  with  myriads  of  bacteria,  and  perhaps  with  a  pip  or  foreign 
body  as  a  nucleus.     They  are  not  very  hard,  and  can  easily  be  cut 
with  a  knife,  or  even  crushed  between  the  fingers.     Occasionally 
they  can  be  recognised  in  a  radiograph  of  the  pelvis  taken  for  other 
reasons  (Fig.  495).     They  are  sometimes  the  result  of  a  preceding 
attack  which  has  left  the  tube  contracted,  and  thus  determined  stasis 
and  retention  of  its  contents,   which  have  become  inspissated. 
(7)  Appendicitis  is  not  unfrequently  associated  with  a  true  typhhtis 
or  with  a  more  generahzed  colitis,  probably  due  to  chronic  constipa- 
tion; the  continuity  of  the  mucous  lining  of  the  caecum  and  appendix 
explains  this  fact,  which  must  always  be  taken  into  consideration  in 
estimating  the  benefits  which  may  be  expected  from  removal  of  the 
appendix  in  a  quiescent  stage.     Much  disappointment  in  the  non- 
relief  of  symptoms  has  arisen  from  the  persistence  ot  a  typhlitis  or 
colitis  after  the  appendix  has  been  removed.     Dysenteric  ulceration 
may  involve  the  appendix,  or  lead  to  stenosis  of  its  orifice,  but  it  is 
rarely  imphcated  in  typhoid  fever.     (8)  Injujy  in  the  shape  of  a 
strain  or  sudden  twist  is  not  unfrequently  mentioned  as  the  cause  of 
an  outbreak,  and  probably  acts  by  displacing  a  long  appendix  m 
such  a  way  as  to  lead  to  kinking  and  possibly  to  obstruction  of  the 

66 


1042 


A   MANUAL  OF  SURGERY 


nutrient  vessels.  When  a  concretion  is  present,  it  is  easy  to  under- 
stand that  the  final  attack  is  determined  by  some  traumatism  which 
modilies  the  vascular  conditions  around  it.  When  an  appendix  is 
filled  with  muco-pus  as  a  result  of  stenosis,  either  at  the  orifice  or  in 
the  tube  itself,  a  blow  may  lead  to  its  rupture  and  cause  an  outbreak 
of  fatal  peritonitis. 

There  can  be  no  question  as  to  the  greatly  increased  frequency  of 
appendicitis  at  the  present  day,  especially  amongst  those  who  live  in 
large  towns  or  cities.     It  is  difficult  to  assign  any  one  cause  for  this, 


Fig.  495. — Radiograph  of  Right  Iliac  Fossa,  showing  the  Presence  of  an 
Elongated  F^cal  Concretion  in  the  Appendix.     (A.  D.  Reid.) 

but  possiblv  many  conditions  may  be  at  work — e.g.,  {a)  dental 
disease  and  degeneration,  and  consequent  oral  and  intestinal  sepsis; 
(b)  the  bolting  and  non-mastication  of  meals  associated  with  the 
hurry  and  scurry  of  modern  life,  leading  to  chronic  irritation  of 
stomach  and  bowel,  (c)  Chronic  constipation  is  a  most  important 
factor,  {(l)  The  presence  of  minute  foreign  bodies  in  imported  corn 
and  other  food-supplies,  and  the  chips  derived  from  enamelled 
cooking  utensils  have  been  suggested  as  causes,  but  there  has  been 
forthcoming  no  proof  of  any  connection,  (e)  The  greatestTdietctic 
change  of  recent  years  consists  in  the  increased  amount  of  meat  that 


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ABDOMINAL  SURGERY 


1043 


is  eaten.  The  cheapness  of  imported  frozen  meat  has  made  it 
generally  available,  and  it  is  quite  possible  that  meat  which  has  been 
frozen  for  some  time  is  more  putrescible  than  that  which  is  fresh, 
and  hence  intestinal  sepsis  may  be  favoured.  In  favour  of  this  idea 
is  the  fact  that  races  that  live  on  fish  or  vegetables  are  largely 
immune,  whilst  members  of  the  same  race  transported  to  other 
regions  and  put  on  a  meat  diet  develop  the  disease. 

Pathological  Anatomy. — Whatever  the  assigned  cause  may  be,  it 
must  ever  be  kept  in  mind  that  appendicitis  is  an  infective  malady, 
due  to  invasion  of  the  walls  of  the  appendix  by  organisms,  especially 
the  Streptococcus  pyogenes,  the  B.  coli,  and  other  anaerobic  intestinal 
bacteria.  These  find  an  entrance  into  the  wall 
of  the  appendix  either  through  an  eroded  area 
of  the  mucous  membrane  due  to  the  impaction 
of  a  foreign  body  or  of  a  fsecal  concretion,  or 
else  they  are  absorbed  into  the  Ijonphoid 
tissue  so  abundantly  present,  and  at  once 
commence  to  develop  and  multiply.  The 
results  may  be  best  described  under  the 
following  headings : 

(i)  Changes  in  the  Appendix  itself. — These 
vary  considerably  in  intensity  and  character 
according  to  the  cause  and  the  power  of 
resistance  of  the  individual. 

In  the  simpler  forms  a  mere  catarrh  of  the 
appendix  results.  The  organ  looks  red  and 
swollen,  and  its  peritoneal  surface  may  be 
smooth,  or  roughened  by  loss  of  endothelium 
and  deposit  of  lymph.  It  feels  stiff  from  effu- 
sion, and  has  lost  its  natural  flexibility.  The 
muscular  coats  are  often  infiltrated  with  leuco- 
cytes, and  this  is  especially  noticed  around  the 
hiatus  muscularis  through  which  the  vessels 
enter.  The  mucous  membrane  is  thickened, 
engorged,  and  infiltrated  with  polynuclear 
leucocytes,  and  here  and  there  erosion  or 
ulceration  is  present.  If  the  process  goes  no 
further,  healing  occurs  after  a  time,  and 
this  is  often  associated  with  fibrosis,  which  may  show  itself  {a)  as 
a  more  or  less  generalized  sclerosis  of  the  whole  appendix 
(Plate  VII.,  Figs,  i  and  2),  which  may  remain  stiff  and  hard,  and  is 
perhaps  twisted  on  itself  (Fig.  497) ;  or  (&)  as  a  stricture  of  the  tube 
(Fig.  496),  which  leads  to  retention  of  a  mucous  or  muco-purulent 
effusion  (hydrops  or  empyema  of  the  appendix) ;  sometimes 
a  fsecal  concretion  forms  distal  to  the  stricture,  and  in  aU  cases  there 
is  a  greater  tendency  to  recurrence,  which  is  often  of  a  severer  type 
than  the  original  attack;  or  (c)  obhteration  of  the  appendix  may 
occur  from  the  union  across  its  lumen  of  granulating  surfaces.  This 
usually  commences  at  the  tip  and  works  up  towards  the  gut,  but 


Fig.  496. — Appendix 
WITH  Stricture  at 
Proximal  End. 

The  patient  was  a  boy, 
aged  seven  years, 
who  had  had  several 
attacks  of  pain  in  the 
abdomen,  with  high 
temperature  lasting 
a  few  hours,  sickness, 
and  tenderness  in 
the  right  iliac  fossa, 
evidently  due  to  re- 
tention of  secretion. 


I044 


A   MANUAL  OF  SURGERY 


is  not  completed  until  the  patient  has  suffered  from  many  attacks. 
{(i)  Occasionally  small  diverticula  or  pouches  form  as  the  result  of  a 
nernial  protrusion  of  the  mucous  meml)rane  through  some  gap  in 
the  muscular  wall — eg'.,  the  hiatus  muscularis.  They  are  usually 
not  larger  than  a  hemp-seed,  but  are  of  importance,  since  the  thin 
walls  would  readily  give  way  as  the  result  of  any  intra-appendicular 
tension  from  effusion,  and  thereby  a  perforative  peritonitis  might 
be  lighted  up. 

\\'hen  ulceration  occur?,  the  loss  of  substance  of  the  mucous  mem- 
brane may  be  slight  or  extensive;  it  may  be  a  simple  erosion  asso- 

_^  ciated  with  a  mild  catar- 

iSHf""  rhal  attack,  or  a  deeper 
loss  of  substance  due  to 
the  presence  and  impac- 
tion of  a  faecal  concre- 
tion; or  it  may  result 
from  a  specific  infec- 
tion, as  from  typhoid 
fever  or  tuberculous  dis- 
ease. The  appendix  is 
then  likely  to  be  more 
seriously  invaded  with 
micro  -  organisms,  and 
suppuration  of  many 
types  may  ensue.  It 
may  contain  muco-pus 
in  its  lumen,  and  this 
may  increase  to  the 
point  of  determining 
rupture  of  the  appendix 
within  a  few  hours,  or 
the  whole  wall  of  the 
tube  may  be  yellow 
with  a  diffuse  purulent 
infiltration.  The  ulcer- 
ation may  gradually 
spread  through  the 
walls  and  lay  open  the  peritoneal  cavity,  giving  rise  to  a  local  or 
diffuse  suppurative  peritonitis. 

Necrosis  or  sloughing  of  the  appendix  occurs  in  the  more  severe 
forms.  It  is  due  to  an  acute  interstitial  inflammation  spreading  from 
an  impacted  concretion,  or  from  an  ulcer  of  the  mucosa;  or  results 
from  kinking  and  thrombosis  of  the  appendicular  vessels  in  the 
meso-appendix.  The  whole  appendix  may  slough,  or  merely  a 
portion  (Plate  VII.,  Figs.  3  and  4),  and  then  usually  the  tip  or 
the  part  immediately  opposite  the  distal  end  of  the  meso- 
appendix.  The  necrotic  tissue  is  soft  and  easily  torn,  of  a  blackish, 
brown,  or  green  colour,  and  usually  extremely  offensive.  It  rnay 
be  associated  with  a   perforation,  through   which  the    concretion 


Fig.  497. — Vermiform  Appkndix  tied  down 
Both  to  Caecum  and  Ileum,  and  doubled 
ON  itself  by  Old-standing  Adhesions. 

The  appearances  in  this  illustration  are  very 
characteristic  of  what  is  frequently  seen ;  but 
the  case  from  which  it  was  taken  was  a  very 
unusual  one.  It  occurred  in  a  baby  of  seven 
days,  who  was  operated  on  for  acute  obstruc- 
tion due  to  the  adhesions,  which  were  old- 
standing,  and  evidently  ante-natal.  The 
child  died,  and  the  caecum  was  subsequently 
removed. 


ABDOMINAL  SURGERY 


t045 


may  escape  (Fig.  498) .     In  all  these  cases  a  grave  peritoneal  infection 
follows. 

(2)  Changes  in  the  Csecum  often  accompany  appendicitis.  In  the 
caliinhal  \arict\-  a  geneialized  typhlo-colitis  is  often  present,  and 
perhaps  it  would  be  more  correct  to  speak  of  appendicitis  as  a  com- 
plication of  that  condition.  It  is  in  these  cases  where  the  csecum 
and  colon  are  inflamed  and  tender,  as  well  as  the  appendix,  that 
most  careful  discrimination  is  needed  in  order  to  prevent  needless 
operation  which  will  not  improve  the  patient's  condition.  In  sup- 
purative appendicitis  the  caecum  is  generally  inflamed  and  infiltrated, 
but  rather  from  the  peritoneal  aspect  than  from  within;  operative 
treatment  will  in  these  cases  be  quickly  followed  by  resolution. 
Rarely  does  the  inflammation  become  so  severe  as  to  lead  to  sup- 
puration or  necrosis  of  the  wall  of  the  csecum ;  should  this  occur,  it 
usually  involves  the  ,-rrv-— 
origin  of  the  appendix,  /"  ■'s: 
and  may  be  followed 
by  a  fsecal  fistula. 

(3)  The  Peritoneal 
Phenomena  associated 
with  appendicitis  are 
of  the  utmost  import- 
ance. 

In  the  milder  cases 
the  peritonitis  is  pro- 
tective in  type.  The 
serous  coat  of  the  ap- 
pendix becomes  in- 
flamed, sheds  its  endo- 
thelium, and  becomes 
roughened  by  a  deposit 
of  lymph,  and  this 
results    either     in     a 

thickening  of  the  wall,  or  in  a  formation  of  adhesions  which  tie 
down  the  appendix  in  various  directions  and  positions.  Most  com- 
monly it  is  simply  fixed  to  the  csecimi  along  part  of  its  length,  but 
sometimes  it  is  firmly  united  to  it  for  its  whole  extent.  iVdhesions 
may  pass  between  the  appendix  and  the  omentum,  the  mesentery, 
or  ovary,  etc. ;  in  fact,  the  appendix  may  be  united  to  almost  any  of 
the  viscera,  and  may  thereby  hamper  their  action  or  give  rise  to 
some  form  of  acute  obstruction.  It  may  also  contract  adhesions  to 
the  fasciae — e.g.,  over  the  psoas  sheath  or  iliac  vessels,  and  various 
s\miptoms  may  be  caused  thereby. 

In  the  graver  cases  an  infective  peritonitis  occurs,  and,  according 
to  the  virulence  of  the  organisms,  the  defensive  powers  of  the  patient, 
and  the  character  of  the  infection,  the  process  may  be  localized  or 
not.  A  localized  intraperitoneal  abscess  is  by  no  means  uncom- 
mon; its  extension  is  limited  by  the  formation  of  adhesions  be- 
tween the  omentum,  the  parietes,  and  neighbouring  coils  of  intestine. 


Fig.  498. — Perforation  of  the  Appendix 
FROM  AN  Impacted  Concretion,  causing  an 
Acute  Abscess  (Semi-diagrammatic). 


1046  A  MANUAL  OF  SURGERY 

Its  exact  anatomical  relations  depend  on  the  original  situation  of 
the  appendix  (see  Plate  VIII.).  Frequently  it  is  located  below  and 
behind  the  caecum;  sometimes  it  burrows  down  into  the  pelvis;  in 
other  cases  it  passes  inwards  amongst  the  intestines;  it  may  track 
up  towards  the  liver  either  on  the  inner  or  outer  side  of  the  ascending 
colon.  Ihe  abscess  may  burst  externally,  and  its  approach  to  the 
surface  will  be  heralded  by  brawny  swelling,  redness,  and  (edema; 
the  most  frequent  sites  for  external  pointing  are  the  outer  part  of 
the  iliac  fossa  and  the  lumbar  region  (Petit's  triangle).  It  may 
burst  into  any  of  the  viscera,  and  then  most  commonly  into  the 
caecum  or  bladder.  Finally,  it  may  break  through  the  peritoneal 
adhesions,  and  involve  the  general  serous  cavity,  causing  acute 
diffuse  peritonitis ;  in  other  cases  a  serous  effusion  into  the  peritoneal 
cavity  is  found,  resulting  from  the  irritation  of  the  abscess,  and  dis- 
appearing when  it  is  opened.  Ihe  pus  contained  in  the  abscess  is 
usually  of  a  stinking  character,  and  in  cases  of  sloughing  of  the 
appendix  the  foetor  may  be  intense ;  but  it  must  be  remembered  that 
the  amount  of  smell  is  no  gauge  of  the  virulence  of  the  process. 
Sometimes  the  debris  of  a  broken-down  concretion  can  be  recognised 
in  the  pus,  and  sometimes  a  portion  of  the  appendix  as  a  slough. 
Gas  is  also  present  in  some  cases,  having  escaped  from  the  bowel,  or 
been  generated  by  the  activity  of  gas-producing  organisms.  It  is 
not  always  possible  to  distinguish  the  appendix  in  these  abscesses, 
even  when  it  has  not  sloughed  off ;  it  may  be  firmly  adherent  to  the 
caecum,  and  unrecognisable  to  the  examin  n  ;  finger. 

In  the  worst  cases,  associated  with  perf  ration  or  necrosis  of  the 
appendix,  a  spreading  septic  peritonitis  is  frequently  observed,  with 
but  little  tendency  to  limitation ;  an  abundant  sero-purulent  effusion 
occurs,  due  largely  to  the  presence  of  streptococci,  and  later  to 
invasion  by  the  B.  coli.  The  line  of  diffusion  is  governed  by  the 
anatomical  relations  of  the  appendix;  most  commonly  the  effusion 
involves  the  pelvis,  and  after  filling  Douglas's  pouch,  spreads  up  on 
the  left  side  to  the  inner  aspect  of  the  sigmoid  meso-colon.  If  the 
appendix  is  situated  above  the  brim  of  the  pelvis,  the  effusion  will 
extend  to  the  right  kidney  pouch,  and  a  subphrenic  abscess  be 
thereby  detemiined.  If  it  spreads  beyond  these  limits,  the  whole 
peritoneal  cavity  will  be  affected,  and  operative  treatment  is  little 
likely  to  be  successful.  The  efiusion  in  the  first  place  is  serous,  but 
soon  becomes  turbid,  and  finally  librino-purulent  or  frankly  purulent. 
Experience  proves  that  as  long  as  the  exudate  is  serous  or  merely 
sero-purulent,  operative  treatment  holds  out  good  prospects  of  re- 
covery. In  later  stages  the  intestine  becomes  matted  together  b)^ 
lymph,  and  paralyzed,  and  a  cure  is  almost  hopeless. 

(4)  Extra-peritoneal  suppuration  occasionally  follows,  and  is  then 
usually  due  to  extension  backwards  through  adhesions  formed 
between  the  appendix  and  the  peritoneum  on  the  posterior  wall  of 
the  abdomen  or  pelvis,  thereby  leading  to  infection  of  the  retro- 
peritoneal connective  tissue.  The  pus  may  collect  in  the  iliac  fossa 
and  point  anteriorly;  or  may  track  downwards  into  the  pelvis  and 


PLATE  VIII. 


Fi^.  I. 


Fig.  2 


^k-  3- 


Fig.  4. 


Diagrammatic   representation   of  the  distribution  of  the   effusion  in  acute  ^ 
Appendicitis  according  to  the  position  of  the  Appendix  {after  Quervain). 
Fig.   I.  —Appendix  in  right  iliac  fossa ;    abscess  localized  in  fossa,  but  diffuse  effusion 
spreads  widely  up  along  the  colon  down  to  the  pelvis,  across  the  middle  line  to  the  left  side. 
Fig,  2. ^Appendix  to  outer  side  of  caecum  ;  abscess  localized. 
Fig.  Z' — Appendix  in  pelvis  (pelvic  appendicitis). 

Fig.  4. — Appendix    reaching    up    towards    the    liver    with    csecum    twisted ;     abcess 
subhepatic  and  mainly  localized  to  the  right  loin. 

Yellow — serous  or  sero-purulent  effusion.     Green — pus. 


[To  face  page  1046. 


ABDOMINAL  SURGERY  1047 

Open  into  the  roctum;  or  may  travel  along  the  psoas  tendon  and 
open  into  the  thigh;  or  burrow  upwards  into  the  loin,  forming  a 
perinephritic  collection,  or  a  retroperitoneal  subphrenic  abscess, 
and  then  may  extend  even  into  the  thorax. 

(5)  Various  complications  may  be  associated  with  any  of  these 
different  types  of  appendicitis,  (a)  The  veins  in  the  meso-appendix 
may  become  thrombosed  and  infected  with  pyogenic  organisms; 
detachment  of  emboli  may  lead  to  the  occurrence  of  pylephlebitis  and 
pyaemia.  (6)  Thrombosis  of  the  femoral  veins  may  develop ;  if  on  the 
right  side,  it  is  probably  due  to  imphcation  of  the  right  ihac  vein  in 
the  inflammatory  process ;  but  if  it  happens,  as  is  much  more  com- 
mon, on  the  left  side,  it  must  be  clue  to  general  toxic  causes;  or,  if  it 
occurs  after  operation,  to  spreading  thrombosis  from  vessels  divided 
in  the  anterior  abdominal  wall  (p.  343).  (c)  Chronic  or  subacute 
ovaritis  often  accompanies  appendicitis  in  women ;  it  is  probably  due 
to  the  position  of  the  appendix  which  hangs  over  into  the  pelvis. 
{d)  Various  renal  complications  may  supervene,  usually  from  pres- 
sure of  the  inflammatory  mass  on  the  renal  vein,  or  on  the  ureter  as 
it  crosses  the  pelvis  brim,  resulting  either  in  hsematuria  or  in  renal 
colic,  {e)  Inflammation  of  an  appendix  located  in  a  hernial  sac  is 
referred  to  hereafter  (p.  1087).  (/)  Lastly,  intestinal  obstruction 
maybe  induced  by  the  acute  inflammatory  attack  leading  to  paraly- 
sis of  the  intestinal  wall,  or  it  may  develop  subsequently  as  a  result 
of  kinking  or  strangulation  by  bands  or  adhesions. 

Clinical  History. — (i.)  The  mild  variety  of  the  disease,  known  as  a 
simple  catarrhal  appendicitis,  to  which  is  added  merely  a  localized 
plastic  peritonitis,  usually  commences  somewhat  suddenly,  the 
patient  being  seized  with  pain,  which  is  at  first  referred  to  the  um- 
bilicus or  to  any  part  of  the  abdomen,  but  at  the  end  of  twenty-four 
to  forty-eight  hours  localizes  itself  in  the  right  ihac  fossa.  It  is  often 
of  a  sharp,  cutting  character,  but  varies  much  in  intensity  and  dura- 
tion. Fever  is  usually  present,  and  the  attack  may  start  with  a 
rigor.  The  patient  may  complain  of  nausea  and  vomiting,  but  the 
latter  symptom  does  not  last  long.  Constipation  results  from  the 
intestinal  paralysis  due  to  the  inflammatory  lesion,  but  in  children 
it  is  sometimes  replaced  by  diarrhoea,  and  that  even  blood-stained, 
so  that  a  diagnosis  may  need  to  be  made  from  typhoid  fever. 

On  examination  the  abdominal  wall  is  found  to  be  more  rigid  than 
usual;  the  right  leg  is  often  drawn  up  to  relax  the  muscles,  and  in 
bad  cases  all  abdominal  respiratory  movements  are  abolished.  Even 
in  mild  cases  the  muscles  over  the  right  iliac  fossa  are  held  tense  and 
rigid  so  as  to  guard  the  underlying  structures.  Definite  tenderness 
is  noted  on  pressure,  and  the  patient  will  often,  but  by  no  means 
constantly,  refer  it  to  a  spot  about  i|  inches  from  the  anterior 
superior  iliac  spine  along  a  line  drawn  to  the  umbilicus  (McBurney's 
spot;  Fig,  480,  A).  In  many  cases,  when  the  appendix  is  directed 
backwards,  there  is  marked  tenderness  in  the  lumbar  region;  but  if 
it  points  downwards  into  the  pelvis,  the  pain  and  tenderness  may  not 
be  evident  except  on  rectal  or  vaginal  examination,  which  should 


1048  A   MANUAL  OF  SURGERY 

never  be  neglected.  A  delinite  swelling  may  sometimes  be  detected 
by  pal])ation,  usually  above  the  outer  half  of  Poupart's  ligament,  but 
varying  in  its  position  with  the  site  of  the  appendix ;  it  may  be  dull  on 
percussion,  but  is  frequently  tympanitic,  since  it  consists  of  coils  of 
intestine  and  omentum  matted  together  around  the  a])pendix.  The 
absence  of  a  dehnite  lump  is  due  to  the  non-develo})ment  of  protec- 
tive adhesions,  and  hence  is  noted  in  the  worst  cases  of  perforative 
appendicitis;  or  it  may  be  caused  by  the  inflamed  mass  lying  deep 
in  the  abdomen,  and  being  covered  o\'er  by  distended  and  uninflamed 
intestine. 

This  simple  form  of  the  disease  usually  lasts  three  or  four  days, 
and  then,  if  properly  treated,  resolves  satisfactorily  without  abscess 
formation.  It  is  exceedingly  common,  and  the  prognosis  is,  on  the 
whole,  favourable.  Tofft,  of  Copenhagen,  found  adhesions  in  the 
neighbourhood  of  the  appendix  in  35  per  cent,  of  all  bodies  subjected 
to  post-mortem  examination. 

(ii.)  The  more  serious  variety,  commonly  resulting  in  a  localized 
abscess,  may  commence  in  a  similar  way,  but  with  more  acute  symp- 
toms.    There  may  be  an  initial  rigor,  and  the  temperature  soon 
runs  up,  even  to  104°  F.     Some  general  abdominal  tenderness  and 
distension  follow ;  constipation  is  often  absolute,  and  fitcal  vomiting 
may  occur,  although  diarrhcxa  is  not  unknown,  especially  in  children. 
The  muscles  on  the  right  side  of  the  abdominal  wall  are  held  tense 
and  rigid,  and  a  well-marked  fulness  can  sometimes  be  detected  in 
the  iliac  fossa.      In  other  cases  a  distinct  swelling  can  be  seen  as 
well  as  felt,  and  is  not  necessarily  limited  to  the  right  fossa,  but 
may  be  found  in  the  middle  line  of  the  abdomen  or  elsewhere.    Under 
a  careful  regime  this  may  disappear,  and  the  symptoms  gradually 
abate  in  their  severity,  the  temperature  and  the  pulse  falling  con- 
currently; but  it  is  very  common  for  suppuration  to  ensue,  and 
this  is  indicated  by  the  temperature  persisting  at  its  original  high 
level,  or  by  the  pulse-rate  increasing  in  rapidity,  whilst  the  tempera- 
ture falls.     Fluctuation  is  rarely  to  be  detected  in  the  early  stages, 
and,  indeed,  it  is  bad  practice  to  wait  for  it  before  interfering,  since 
there  is  a  considerable  probability  that  the  tension  within  the 
abscess  may  be  sufficient  to  break  down  the  wall  of  newly-formed 
and  not  too  strong  adhesions,  and  the  general  peritoneal  cavity  may 
be  thus  infected.     The  abscess  develops  at  first  round  the  appendix, 
and  is,  of  course,  primarily  intraperitoneal.     Occasionally  it  bursts 
into  the  bowel,  and  thereby  relief  is  gained  without  the  assistance 
of  surgery;  some  authorities,  indeed,  maintain  that  this  occurs  in 
e\'ery  case  of  the  more  severe  type  w^hich  resolves.     In  other  in- 
stances it  may  point  externally,  either  through  the  anterior  ab- 
dominal \\all,  which  becomes  congested  and  cedematous  as  the  pus 
approaches  the  surface,  or  through  the  loin.     Not  unfrequently  it 
tracks  up  along  the  inner  or  outer  side  of  the  ascending  colon,  and 
then  may  get  into  relation  with  the  under  surface  of  the  liver.     In 
other  patients,  and  especially  when  the  tip  of  the  appendix  lies  over 
the  brim  of  the  pelvis,  the  pus  travels  downwards  and  forms  a 


ABDOMINAL  SURGERY  1049 

collectiuii  in  front  of  the  rectum;  the  surgeon  must  never  omit  a 
rectal  examination  in  appendicitis,  where  the  temperature  is  of  such 
a  nature  as  to  suggest  the  existence  of  an  abscess,  and  yet  no  evi- 
dence of  one  can  be  found.  Should  it  burst  into  the  peritoneal 
cavity,  all  the  phenomena  of  acute  perforative  peritonitis  with 
grave  toxcemia  supervene,  probably  indicated  by  severe  pain, 
sudden  fall  of  temperature,  rapid  collapse,  and  failure  of  the  circula- 
tion, leading  rapidly  to  a  fatal  issue,  preceded  by  increasing  ab- 
dominal distension. 

In  not  a  few  cases  the  patient's  general  symptoms  improve  after 
the  first  outbreak;  the  temperature  may  become  normal,  the  pain 
decrease,  and  the  vomiting  cease.  It  is  often  difficult  to  be  certain 
whether  this  improvement  is  merely  temporary,  or  is  the  commence- 
ment of  a  true  convalescence.  Under  the  former  circumstances— 
i.e.,  if  it  is  merely  an  interval  of  quiescence — -careful  examination  will 
probably  reveal  some  disturbing  factor;  either  the  abdominal  dis- 
tension persists,  or  perhaps  hiccough  is  present,  or  well-marked 
tenderness  continues,  perhaps  only  to  be  detected  per  rectuyn,  or  the 
pulse-rate  may  remain  unduly  high.  After  a  few  days  the  tempera- 
ture begins  to  rise  once  more,  the  focal  symptoms  become  more 
urgent,  and  a  localized  abscess  forms. 

It  is  often  by  no  means  a  simple  matter  to  make  certain  that  pus  is 
present ;  but  considerable  assistance  can  be  derived  from  a  blood 
count,  which  is  advisably  made  each  day  that  the  uncertainty  per- 
sists. Readers  are  referred  back  to  p.  62  for  a  full  consideration  of 
leucocytosis  ;  it  will  suffice  here  to  state  that  a  leucocyte  count 
under  20,000  is  merely  indicative  of  an  inflammatory  attack  well 
resisted;  if  suppuration  is  present,  the  leucocytes  are  usually  over 
20,000.  In  the  early  stages,  however,  a  high  leucocyte  count  means 
comparatively  little;  but  a  maintained  leucocytosis  is  a  valuable 
sign  of  suppuration. 

A  comphcation  likely  to  occur  in  the  more  severe  types  of  the 
disease  is  pylephlebitis,  or  infective  thrombosis  of  the  branches  of  the 
portal  vein  in  the  liver.  This  would  be  indicated  by  recurrent 
rigors,  and  possibly  by  pain  and  tenderness  in  the  hepatic  area. 
Necessarily  it  is  alinost  invariably  fatal. 

(iii.)  In  the  graver  forms  of  diffuse  or  generalized  peritonitis,  the 
onset  is  usually  sudden,  the  patient  becoming  collapsed  with  the 
severity  of  the  pain;  vomiting  often  accompanies  the  outbreak  and 
occasionally  a  rigor.  These  symptoms  sometimes  pass  over  directly 
into  those  of  generalized  peritonitis,  as  described  on  p.  975,  death 
ensuing  in  two  or  three  days ;  the  temperature  in  such  cases  may  be 
low,  and  the  absence  of  reactive  phenomena  is  indicated  by  a  leuco- 
penia.  More  frequently  the  course  is  not  quite  so  acute;  the  pain 
which  at  first  is  referred  to  the  umbilicus  becomes  localized  to  the 
right  iliac  fossa ;  the  abdominal  wall  on  that  side  is  held  rigid,  and 
the  rigidity  gradually  spreads  across  the  abdomen  to  the  left  iliac 
region  and  upwards  towards  the  liver;  vomiting  and  absolute  con- 
stipation are  present,  and  the  temperature  is  usually  raised  three  or 


I050  A   MANUAL  OF  SURGERY 

four  degrees;  the  pulse  varies  from  lOo  to  120,  and  the  amount  of 
urine  passed  is  diminished  in  quantity.  If  surgical  treatment  is  not 
undertaken  early,  the  typical  phenomena  of  acute  diffuse  peritonitis 
are  soon  developed. 

(iv.)  Relapsing  Appendicitis  is  the  term  apphcd  to  a  condition 
when  an  attack  passes  oh,  but  not  cjuite  satisfactorily.  There  may 
be  a  slight  persistent  rise  of  temperature  at  night ;  or  the  a])pendix 
remains  palpable  and  tender;  or  some  amount  of  apj^endicular  pain 
often  of  a  colicky  character  may  be  noted.  In  many  of  these 
cases  the  symptoms  are  due  to  unhealed  ulceration  of  the  mucous 
lining  or  to  stenosis  of  the  tube.  If  left  alone,  a  more  acute  outbreak 
may  supervene,  or  bacterial  invasion  of  the  vessels  in  the  meso- 
appendix  may  follow,  and  serious  consequences  develop.  If  an 
attack  of  appendicitis  has  not  cleared  up  completely  at  the  end  of  a 
week  or  ten  days,  an  operation  is  always  advisable  for  the  removal 
of  the  organ. 

(v.)  Recurrent  Appendicitis  is  characterized  by  repeated  attacks 
of  varying  gravity  in  an  individual  who  has  been  once  the  subject  of 
the  disease.  They  may  occur  only  at  prolonged  intervals,  or  be  so 
frequent  as  entirely  to  incapacitate  the  patient,  and  are  usually  asso- 
ciated with  the  presence  of  some  abnormal  adhesion  or  constriction 
of  the  appendix.  It  is  not  uncommon  for  the  appendix  to  become 
fixed  to  the  sheath  of  the  psoas  muscle,  and  then  any  excessive  move- 
ments of  the  limb  may  light  up  an  attack.  Where  stenosis  exists, 
secretions  containing  bacteria  may  be  pent  up  behind  the  constric- 
tion, and  from  time  to  time  the  patient  suffers  from  severe  pain  of  a 
colicky  nature  with  or  without  fever,  supposed  to  be  due  to  an  attempt 
to  get  rid  of  the  excess  of  mucus.  Such  attacks  have  been  named 
appendicular  colic.  In  a  few  cases  the  appendix  becomes  totally 
obliterated  after  a  time  and  incorporated  in  a  mass  of  adhesions,  a 
natural  cure  being  thus  established,  but  more  frequently,  if  these 
occurrences  are  allowed  to  continue,  the  patient  finally  develops  an 
abscess,  possibly  from  the  infection  of  some  unobliterated  portion 
of  the  tube,  or  succumbs  to  diffuse  peritonitis. 

Recurrences  are  more  common  after  the  simpler  forms  of  the 
disease,  and  it  has  been  calculated  that  over  30  per  cent,  of  the 
subjects  of  a  mild  catarrhal  attack  suffer  in  this  way.  In  the  more 
acute  forms  recurrence  is  less  common,  and  it  is  unusual  for  a  case 
to  recur  when  suppuration  has  existed;  we  have,  however,  seen  cases 
where  an  abscess  has  developed  two  and  even  three  times  in  con- 
nection with  attacks  which  were  separated  by  intervals  of  complete 
disappearance  of  symptoms. 

(vi.)  Appendicular  Gastralgia  is  the  name  applied  to  cases  in  which 
all  the  signs  and  symptoms  of  the  disease  are  referred  to  the  epi- 
gastrium, and  closely  mimic  those  of  a  gastric  or  duodenal  ulcer. 
The  patients  are  usually  women,  and  a  test-meal  examination  reveals 
a  hypersecretion  of  gastric  juice,  in  which  the  hydrochloric  acid  may 
be  increased  or  diminished.  Laparotomy  shows  no  lesion  in  the 
stomach  or  duodenum,  but  chronic  appendicitis  is  usually  present. 


ABDOMINAL  SURGERY  1051 


That  the  previous  symptoms  were  due  to  the  condition  of  the 
appendix  is  proved  by  the  reUef  to  the  symptoms  and  the  changes 
in  the  gastric  secretion  after  appendicectomy.  The  probable  ex- 
planation is  that  the  condition  of  the  appendix  causes  intestinal 
stasis,  and  this  in  turn  sets  up  a  toxaemia  which  reacts  on  the  gastric 
mucous  membrane.  The  condition  is  important  clinically,  as  it 
emphasizes  the  importance  of  hnding  definite  evidence  of  a  lesion 
in  the  stomach  or  duodenum  before  performing  gastro-enterostomy 
for  supposed  gastric  or  duodenal  ulcer.  Not  unfrequently  these 
patients  are  also  the  owners  of  a  moveable  and  tender  right  kidney. 
Diagnosis. — In  a  well-marked  case  the  symptoms  of  appendicitis 
are  so  typical  that  the  diagnosis  can  never  be  in  doubt.  The  pain, 
tenderness,  fever,  vomiting,  constipation,  abdominal  rigidity,  and 
perhaps  tumour,  constitute  a  picture  that  is  quite  characteristic. 
The  disease,  however,  often  presents  symptoms  so  varied,  and  mani- 
festations so  protean,  that  one  is  never  surprised  to  meet  with  it  in 
all  sorts  of  diverse  settings,  and  many  mistakes  of  diagnosis  are 
made,  even  by  the  most  skilled  clinicians. 

The  early  stage  of  pneumonia  is  sometimes  associated  with  severe 
pain  and  tenderness  in  the  iliac  fossa,  especially  in  children,  and  the 
resemblance  to  appendicitis  is  the  more  marked  when  the  onset  is 
sudden,  and  abdominal  rigidity  and  vomiting  are  present.  A  careful 
examination  of  the  lungs  should  never  be  omitted  in  the  case  of 
children  with  suspected  appendicitis.  Cases  which  commence  with 
diarrhoea  may  be  mistaken  for  enteric  fever,  but  the  absence  of  the 
rash  and  a  negative  Widal's  reaction  should  guard  the  practitioner 
from  error.  Recurrent  appendicular  pain  may  be  mistaken  for  that 
of  renal  colic  or  for  the  painful  attacks  associated  with  displacement 
of  a  floating  kidney  {Dietl's  crises),  or  vice  versa  ;  and  the  difficulty 
is  increased  if  hEsmaturia  or  irritation  of  the  bladder  are  caused  by 
an  appendicitic  effusion  or  abscess.  Biliary  colic  may  be  simulated, 
whilst  a  distended  and  inflamed  gall-bladder  may  closely  resemble  an 
appendix  abscess  which  has  travelled  upwards. 

Perforation  of  the  duodenum,  or  even  of  the  stomach,  may  lead  to 
symptoms  very  similar  to  those  of  appendicitis,  due  to  the  inflam- 
matorv  mischief  tracking  downwards.  The  initial  pain  will  usually 
be  referred  to  the  upper  part  of  the  abdomen,  and  there  may  be 
e\ddence  of  free  gas  in  the  peritoneal  cavity.  If  gas  escapes  from 
the  abdomen  on  operation,  and  is  free  from  odour,  the  probabihty  is 
that  the  lesion  is  gastric  or  duodenal.  Mucous  colitis  simulates 
chronic  appendicitis,  and  the  appendix  is  indeed  often  involved  m 
the  mischief.  The  distinction  is  made  by  the  tenderness  bemg 
located  over  the  whole  course  of  the  colon,  and  by  the  passage  of 
mucus  in  the  stools.  Tubal  and  ovarian  diseases  are  recognised  on 
pelvic  examination ;  but  the  fact  must  not  be  overlooked  that  chronic 
appendicitis  is  often  associated  with  inflammation  of  the  right 
ovary,  and  then  attacks  of  pain  may  occur  at  each  menstrual  period. 
A  sm^all  ovarian  dermoid  with  a  twisted  pedicle  may  resemble  appen- 
dicitis very  closely  in  the  absence  of  a  vaginal  or  rectal  examination. 


I052  A   MANUAL  OF  SURGERY 

A  considerable  swelling  in  the  right  iliac  fossa  may  result  from 
repeated  attacks  due  to  a  matting  of  the  parts  together,  and  a 
diagnosis  from  tuberculous  or  malignant  disease  is  sometimes  diffi- 
cult apart  from  operation.  1  he  history  may  be  spread  over  a  longer 
time,  however,  in  appendicitis. 

In  abdominal  abscesses  the  possibility  of  an  appeudic;ular  origin 
must  always  be  kept  in  mind,  as  they  may  occur  in  any  ])art  of  the 
abdomen ;  and  it  is  often  only  by  a  careful  exploration  of  the  cavity 
that  we  can  trace  the  cause  to  the  appendix. 

The  diagnosis  from  acute  obstruction  is  noted  hereafter  (p.  1131). 

The  Prognosis  is  never  absolutely  certain,  for,  as  has  been  well 
pointed  out  by  many  acute  observers,  the  initial  symptoms  are  fre- 
quently alike  in  all  the  varieties,  and  hence  one  can  never  know  what 
course  the  case  is  going  to  take;  as  R.  Morris,  of  New  York,  says, 
'  The  infected  appendix  is  a  cap  which  sometimes  snaps,  sometimes 
flashes,  and  sometimes  causes  an  explosion,  and  none  of  us  can  tell 
in  advance  just  what  is  going  to  happen.'  As  particularly  bad 
signs  may  be  mentioned  a  continued  high  temperature,  in  spite  of 
rest  and  careful  dietetic  measures,  or  a  fall  of  temperature  with 
increased  rate  of  the  pulse.  Persistent  hiccough  is  also  a  bad  sign. 
The  existence  of  a  swelling  in  the  iliac  fossa  is  not  a  bad  sign,  but 
rather  the  reverse.  Absence  of  a  localized  swelling  is  due  either  to  a 
defective  formation  of  protective  adhesions,  and  hence  is  likely  to  be 
noted  in  the  most  acute  cases,  or  to  the  appendix  being  placed  behind 
the  c?ecum  in  a  position  less  favourable  to  operative  measures. 

Treatment.^ — So  much  has  been  written  on  this  subject  during  the 
last  twenty  years,  that  it  is  extremely  difficult  to  compress  even  a 
brief  summary  of  the  many  facts  observed  into  a  necessarily  limited 
space.  Formerly  perityphlitis  was  the  exclusive  property  of  the 
physician;  but  a  great  change  has  occurred,  and  many  authorities 
consider  that  appendicitis  is  more  justly  within  the  realm  of  the 
surgeon,  or,  at  any  rate,  that  a  surgeon  should  always  share  the 
responsibility  of  treatment  with  the  physician.  At  any  moment 
complications  may  develop  even  in  cases  which  appear  to  be  simple, 
when  immediate  surgical  assistance  will  alone  hold  out  any  hopes 
of  saving  the  patient.  In  America  surgery  is  the  recognised  treat- 
ment for  almost  every  case  of  the  disease,  as  soon  as  it  is  diagnosed ; 
in  this  country  conservative  ideas  still  persist,  but  a  more  healthy 
opinion  is  gaining  ground,  and  surgical  interference  is  becoming 
recognised  as  the  most  appropriate  means  of  treatment  in  most 
instances. 

I.  In  the  mild  catarrhal  type  of  appendicitis,  where  the  tempera- 
ture does  not  run  above  101°  F.  and  the  symptoms  are  not  severe,  all 
that  is  required  in  the  majority  of  cases  is  to  put  the  patient  to  bed, 
and  apply  fomentations  locally ;  the  lower  bowel  should  be  emptied 
by  an  enema  after  a  rectal  examination  has  determined  that  no 
abscess  or  serious  pelvic  complication  is  present ;  if  it  seems  likely 
that  there  is  an  accumulation  of  irritating  faeces  within  the  intestine, 
one  dose  of  castor  oil  or  of  calomel  may  be  administered,  but  not 


ABDOMINAL  SURGERY  1053 

without  due  consideration.  A  fluid,  unstimulating  diet  is  all  that 
is  permitted,  and  should  there  be  much  vomiting,  rectal  alimenta- 
tion may  be  resorted  to.  Possibly  morphia  may  be  given  with 
advantage  to  quiet  the  patient  and  check  peristalsis,  thereby  facili- 
tating the  formation  of  protective  adhesions ;  but  the  less  the  better, 
since  it  tends  to  mask  symptoms. 

The  question  of  operation  for  this  mild  type  of  disease  can  be 
readily  compressed  into  the  three  following  propositions: 

{a)  If  the  condition  is  not  showing  signs  of  improvement  at  the 
end  of  forty-eight  hours — i.e.,  on  the  third  day — in  spite  of  appro- 
priate treatment,  the  case  should  be  looked  on  with  suspicion  as 
probably  one  in  which  suppuration  is  occurring,  and  operation  is 
desirable. 

[b)  If  the  appendix  remains  tender  and  palpable  after  an  attack, 
and  especially  if  the  temperature  rises  slightly  at  night,  the  organ 
should  be  removed  without  delay. 

(c)  As  soon  as  the  attack  is  really  quiescent — i.e.,  generally  in  nine 
to  ten  days — the  appendix  should  be  removed.  This  proposition 
may  not  be  generally  accepted ;  but  it  is  absolutely  logical ,  and  daily 
experience  is  emphasizing  the  conviction  as  to  its  accuracy.  In  the 
first  place,  recurrence  is  common,  and  the  figures  given  above  (viz., 
30  per  cent.)  probably  underestimate  its  frequency.  Then,  too,  it  is 
impossible  to  tell  which  cases  will  recur  and  which  escape,  whilst  the 
recurrent  attack  is  frequently  more  severe  than  the  first,  and  often 
accompanied  by  suppuration.  Moreover,  each  recurrent  attack  is 
likely  to  add  to  the  adhesions  present,  so  that  whilst  removal  after  a 
first  attack  is  an  easy  proceeding,  removal  after  many  recurrences 
may  necessitate  a  long  incision  and  a  troublesome  or  dangerous  dis- 
section, complicated,  perhaps,  by  unintentional  perforation  of  the 
bowel,  or  even  enterectomy.  Finally,  it  may  be  necessary  to  keep 
the  patient  very  quiet  and  to  limit  his  diet  and  his  activities  consider- 
ably if  recurrence  is  to  be  avoided;  and  such  practice  in  a  bread- 
winner may  be  a  serious  matter.  By  removing  the  appendix,  either 
during  or  immediately  after  the  attack,  this  period  of  disability  will 
probably  be  reduced  to  a  minimum. 

Operation  in  the  Quiescent  Period. — The  muscle-splitting  plan 
suggested  by  McBurney  may  weU  be  adopted  when  it  is  probable 
that  but  few  adhesions  are  present.  The  incision  is  an  oblique  one, 
about  2  to  3  inches  long,  crossing  McBurney's  spot  or  a  little  below 
it,  and  parallel  to  the  outer  end  of  Poupart's  ligament,  somewhat 
similar  to  that  for  ligaturing  the  external  iliac  artery  (Fig.  473,  C). 
The  external  oblique  is  exposed,  and  incised  in  the  course  of  its 
fibres ;  the  divided  segments  are  held  well  aside  by  retractors,  so  that 
about  2  inches  of  the  internal  oblique  muscle  come  into  view.  The 
exposed  fibres  of  this  muscle  run  nearl}^  in  the  same  direction  as  those 
of  the  transversalis  muscle,  and  the  two  can  be  split  together  by  a 
transverse  incision.  The  introduction  of  large  deep  retractors  will 
expose  a  square  or  diamond-shaped  area  of  subperitoneal  fat  or  peri- 
toneum about   i^  to  2  inches  in  diameter.     The  peritoneum  is 


I054  A   MANUAL  OF  SURGERY 

divided  transversely,  and  the  margins  grasped  for  identification 
purposes  by  Spencer  Wells  forceps.  The  caecum  probably  presents, 
and  is  gently  withdrawn.  The  anterior  longitudinal  muscular  band 
conducts  to  the  appendix,  which  is  freed  from  adhesions  and 
removed.  The  meso-appendix  is  first  divided  after  securing  the 
vessels  in  it  by  a  ligature.  The  serous  and  muscular  coats  are  then 
divided  by  a  circular  incision  and  peeled  back  like  a  cuff,  leaving  the 
mucous  membrane  as  a  narrow  tube.  The  retraction  is  carried  back 
so  as  to  enable  a  hgature  to  be  placed  around  the  tube  of  mucous 
membrane  flush  with  the  caecum  (Fig.  499).  The  distal  end  is 
grasped  with  Spencer  Wells  forceps,  and  cut  away  after  protecting 
the  parts  below  with  a  strip  of  sterilized  gauze.  The  protruding 
portion  of  mucous  membrane  is  carefully  curetted,  and  the  sero- 
muscular cuff  replaced  over  it.  A  purse-stiing  suture  is  then  intro- 
duced through  the  serous  and  muscular  coats  all  round  it ;  the  ap- 
pendix stump  is  gently  invaginated  into  the  csecum  by  a  pair  of 
forceps,  and  the  suture  tied ;  b}'  this  means  the  stump  of  the  appendix 
is  buried  and  covered  over  completely  with  peritoneum  (Fig.  500). 
The  site  of  detachment  of  the  meso-appendix,  or  of  the  position  from 
which  the  appendix  itself  has  been  detached,  may  require  a  few 
sutures  in  order  to  ensure  a  complete  peritoneal  coating,  and  thus 
minimize  the  risk  of  subsequent  adhesions. 

All  bleeding-points  having  been  secured,  the  ciecum,  which  has 
been  protected  during  the  operation  by  a  warm  wet  sterilized  cloth, 
is  returned  into  the  abdomen,  and  fmally  in  the  female  the  right 
ovary  and  tube  are  carefully  examined.  The  abdominal  wound  is 
then  closed,  layer  by  layer,  without  drainage. 

If,  however,  it  seems  probable  that  many  adhesions  are  present, 
the  muscle-splitting  operation  should  be  avoided,  and  the  abdominal 
parietes  divided  in  the  line  of  the  cutaneous  incision,  so  as  to  allow 
the  wound  to  be  enlarged  up  or  down  as  may  be  desired.  The 
severance  of  these  adhesions  may  be  a  most  tedious  and  troublesome 
procedure,  but  when  once  it  is  effected  the  appendix  is  amputated 
as  described  above.  In  some  of  these  more  serious  and  prolonged 
operations  it  may  be  desirable  to  drain  the  iliac  fossa  by  a  tube  or 
gauze  wick  for  a  short  time. 

In  the  more  serious  cases  the  patient  should  remain  in  bed  for  three 
weeks,  to  allow  the  bond  of  union  to  become  firm,  and  avoid  all 
needless  strain  for  some  months,  but  in  the  simpler  cases  may  be 
allowed  up  in  a  fortnight. 

2.  In  the  gravest  variety  oi  fulminating  appendicitis,  associated 
with  diffuse  septic  peritonitis,  there  can  be  no  question  that  the  only 
hope  of  recovery  lies  in  immediate  operation.  When  the  peritonitis 
is  extensive  and  the  exudate  purulent,  this  hope  is  but  slender  in  the 
extreme;  if,  however,  the  effusion  is  mainly  pelvic,  and  still  of  a  sero- 
purulent  type,  it  is  possible  that  a  considerable  percentage  of  the 
cases  may  be  saved.  Hence,  whenever  the  attack  starts  with  severe 
pain,  frequent  vomiting,  and  early  collapse,  whilst  the  abdomen 
shows  marked  signs  of  rigidity,  but  may  not  be  distended,  no  time 


ABDOMINAL  SURGERY 


1055 


should  be  lost  in  operating.  In  such  cases  the  appendix  is  either 
perforated,  and  then  every  hour  adds  to  the  mischief;  or  it  is  acutely 
distended  with  muco-pus,  and  may  perforate  at  any  moment,  giving 
rise  to  a  general  infection.  No  possible  good  can  be  derived  by 
delaying  operation  in  these  severe  cases.  The  abdomen  is  opened, 
either  through  the  middle  line  or  in  the  right  iliac  fossa ;  the  appendix 
is  looked  for  and  removed,  and  effusion,  if  present,  is  swabbed  or 
washed  away  with  sterilized  salt  solution  at  108°  F.  Drainage  may 
be  omitted  in  some  of  the  early  operations,  even  if  effusion  has  been 


Fig.  499. 


Fig.  500. 


Amputation  of  the  Appendix. 


In  Fig.  499  the  cuS  of  sero-muscular  tissue  has  been  dissected  up,  exposing  the 
tube  of  mucous  membrane,  to  which  a  pair  of  Spencer  Wells  forceps  is 
applied  distally,  whilst  a  ligature  is  placed  on  its  proximal  end.  The 
purse-string  suture  has  been  introduced  around  its  base. 

In  Fig.  500  the  purse-string  suture  has  been  tied  after  tucking  in  the  sero- 
muscular cufi,  thereby  burying  the  stump  of  the  appendix. 

present  ;  but  in  most  instances  it  is  necessary,  and  may  then  be 
provided  by  tubes  or  gauze  wicks. 

3.  When  an  abscess  is  evidently  present,  being  indicated  either 
by  fluctuation  or  by  a  commencing  oedema  of  the  abdominal  wall, 
there  should  be  no  hesitation  in  cutting  down.  An  incision  is  made 
over  the  oedematous  spot,  and  deepened  carefully,  since  the  tissues 
are  probably  matted  together,  and  cut  like  bacon  or  brawn.  The 
knife  or  index-finger  may  suddenly  sink  into  the  abscess  cavity,  and 
a  gush  of  foetid  pus  follows.     The  cavity  is  gently  explored,  so  as 


1056  A   MANUAL  OF  SURGERY 

to  ascertain  whether  or  not  the  appendix  can  be  felt;  no  undue  force 
should  be  used,  for  fear  of  breaking  down  adhesions  and  thus  open- 
ing the  general  peritoneal  sac.  If  the  appendix  cannot  be  readily 
found,  it  is  best  left  alone;  the  abscess  may  be  gently  irrigated, 
drainage  is  provided  for,  and  the  incision  partly  closed.  Probably 
the  case  will  go  on  well,  the  discharge  losing  its  smell  about  the 
third  day,  and  the  remaining  sinus  will  gradually  heal  by  granula- 
tion. Should  the  appendix,  howe\-er,  present  itself,  it  should  be 
removed. 

4.  There  is  still,  however,  a  large  group  of  cases  in  which  none 
of  the  above  conditions  is  manifest,  and  yet  the  symptoms,  botli 
local  and  general,  indicate  that  a  lesion  of  considerable  gravity  is 
present.  The  attack  may  have  commenced  more  or  less  acutely,  but 
has  progressed  steadily.  Much  difference  of  opinion  has  existed  as 
to  the  desirability  of  operation  in  these  cases,  and  especially  as  to  the 
most  favourable  time  for  such  a  procedure.  It  must  be  admitted 
that  in  many  instances  conservative  or  medical  treatment  will  suffice 
to  bring  about  a  satisfactory  result,  but  this  can  never  be  depended 
on,  and,  unfortunately,  the  experience  of  all  surgeons  is  that  only  too 
frequently  have  they  been  called  in  to  operate  on  patients  who  have 
been  brought  into  the  gravest  jeopardy  of  their  lives  through  undue 
delay.  Either  they  are  suffering  from  generalized  peritonitis,  or  are 
profoundly  toxaemic  by  absorption  from  a  large  abscess,  or  exhausted 
by  previous  suffering ;  possibly  other  complications  have  arisen  due 
to  extension  of  thrombosis  or  dissemination  of  emboli.  Operation 
under  such  circumstances  is  alw^ays  risky,  and  even  if  the  local 
conditions  are  effectively  dealt  with,  the  patient  may  subsequently 
succumb  to  toxaemia,  septicaemia,  pulmonary  embolus,  or  other 
manifestations  of  blood-poisoning,  perhaps  aggravated  by  the 
operation. 

The  objections  usually  raised  to  early  operation  are  that  it  involves 
the  removal  of  the  appendix  from  a  certain  number  of  people  who 
might  get  well  without  operation,  and  that  it  is  not  the  best  time  to 
operate  when  inflammatory  phenomena  are  present.  The  answer  to 
these  objections  is  quite  obvious,  viz.,  that  the  prognosis  in  any  case 
is  so  hopelessly  uncertain  that  the  risks  involved  in  waiting  for  a 
quiescent  interval  on  the  one  hand,  or  for  the  development  of  un- 
doubted indications  of  the  presence  of  pus  on  the  other,  are  much 
greater  than  those  of  an  operation  undertaken  at  an  early  date  by  a 
skilful  surgeon.  Moreover,  an  appendix  that  has  once  been  inflamed 
is  of  no  service,  and  may  be  a  source  of  grave  danger  to  its  possessor, 
and  the  sooner  he  is  rid  of  it  the  better.  Extensive  experience  of  the 
early  operation  proves  that  pus  is  frequently  present  at  quite  an 
early  stage  of  the  affection — i.e.,  within  twenty-four  hours  or  less — 
and  one  rarely  operates  on  ainy  case  where  the  symptoms  are  at  all 
severe  without  finding  cause  for  gratification  that  delay  had  not  been 
counselled.  Moreover,  statistics  prove  that  the  mortality  associated 
with  operation  during  the  infIammator\'  attack  is  much  less  when  it 
is  undertaken  on  the  first  da}'  (12  per  cent.)  than  on  any  of  the 


ABDOMINAL  SURGERY  1057 

successive  days  up  to  the  sixth  or  seventh.*  The  chief  advantages 
of  an  early  operation  may  be  indicated  as  follows:  {a)  That  the 
patient  is  not  in  a  state  of  collapse  from  toxaemia,  and  hence  can 
easily  stand  the  shock  of  an  intraperitoneal  exploration;  {b)  that 
the  amount  of  effusion  likely  to  be  present  is  small,  and  hence  can 
be  easily  dealt  with  and  safely  removed  with  but  little  risk  of  infect- 
ing the  general  peritoneal  cavity  or  the  abdominal  wall ;  (c)  that  the 
appendix  can  usually  be  found,  isolated,  and  removed  without  much 
difficulty ;  in  the  later  stages  where  a  large  abscess  exists  this  may  be 
impracticable,  and  a  second  operation  for  its  removal  may  be  re- 
quired later  on,  and  then  the  appendix  may  have  to  be  '  dug  out  '  of 
a  mass  of  adhesions,  and  serious  risks  taken;  and  (d)  that  a  smaller 
incision  will  be  required,  and  hence  there  will  be  less  likelihood  of  the 
subsequent  development  of  a  hernia.  One  would  therefore  claim 
that  the  following  rule  is  both  reasonable  and  justifiable,  and  that  its 
observance  will  be  beneficial,  viz.,  that  in  cases  of  moderate  severity 
if  in  spite  of  suitable  rest  and  medical  treatment  the  symptoms,  both 
general  and  local,  are  not  commencing  to  abate  at  the  end  of  forty-eight 
hours,  operation  shoiild  be  undertaken,  and  still  more  so  if  any  of  the 
following  conditions,  indicative  of  the  formation  of  an  intraperitoneal 
abscess  are  existent,  viz.,  a  steady  rise  in  the  leucocyte  count,  or  one 
above  20,000,  especially  if  maintained  for  twenty-four  hours;  per- 
sistent distension  of  the  abdomen,  a  maintained  high  temperature, 
hiccough,  or  a  continued  high  pulse  rate,  in  spite  of  a  falling  tempera- 
ture. Of  course,  a  localized  swelling  which  persists  or  increases  in 
size  and  becomes  more  tender,  will  also  indicate  operation. 

5.  Not  a  few  cases  will  be  observed  in  which  the  initial  symptoms 
quiet  down  at  the  end  of  twenty-four  or  forty-eight  hours,  but 
after  an  interval  of  quiescence  of  varying  length  the  phenomena 
suggestive  of  suppuration  show  themselves.  In  such  patients  opera- 
tion should  be  advised  immediately,  as  an  abscess  is  obviously 
developing. 

Operation  for  Suppurative  Appendicitis. — Ether  should  always  be 
the  anaesthetic,  if  possible ;  the  mortality  after  operation  when  chloro- 
form is  employed  is  decidedly  higher.  The  incision  will  vary  with 
the  physical  signs  and  the  site  of  maximum  tenderness.  The  whole 
thickness  of  the  abdominal  wall  is  divided,  and  it  is  well  to  make  a 
sufficiently  large  opening ;  an  extra  inch  of  incision  may  make  all  the 
difference  between  blindly  groping  in  the  dark  and  seeing  clearly 
what  one  is  doing.  The  general  arrangement  of  the  parts  is  noted, 
and  the  peritoneal  cavity  protected  from  purulent  infection  by  pack- 
ing in  sterilized  gauze ;  one  strip  is  usually  passed  upwards  along  the 
ascending  colon,  one  downwards  into  the  pelvis,  and  one  internally 
to  protect  the  small  intestines  and  general  serous  cavity.  The 
caecum  is  then  gently  lifted  from  its  bed,  and  the  abscess  will 
usually  be  found  behind  it.  Every  effort  must,  of  course,  be  made 
to  prevent  soiling  of  the  unaffected  peritonermi.     Whenever  pos- 

*  See  Hugh  Lett,  '  The  Present  Position  of  Acute  Appendicitis,'  Lancet, 
January  31,  1914. 

67 


1058  A  MANUAL  OF  SURGERY 

sible,  the  appendix  should  be  removed,  but  not  unfrequently  a 
formal  amputation  is  impracticable.  A  ligature,  and  preferably  of 
catgut,  which  can  be  absorbed,  is  then  tied  around  the  base  about 
I  inch  from  the  csecum,  and  the  appendix  cut  away;  the  stump  is 
guarded  by  a  gauze  strip  passed  down  to  it  from  the  wound  and  used 
for  drainage.  Not  unfrequently,  however,  the  appendix  does  not 
appear,  and  then  it  may  be  better  to  leave  it  alone ;  in  many  cases, 
however,  an  experienced  surgeon  will  be  able  to  detach  and  remove 
it.  The  cavity  is  emptied  of  pus  by  swabbing  it  out,  and  a  careful 
but  thorough  exploration  of  the  pelvis  and  right  kidney  pouch  made 
to  ensure  that  pus  is  not  shut  up  in  these  regions.  Finally,  the 
cavity  is  packed  in  such  a  way  as  to  drain  it  thoroughly,  and  yet  to 
protect  the  surroundmg  parts.  The  abdominal  incision  is  partially 
closed. 

The  packing  is  gradually  removed  in  the  next  two  or  three  days, 
and  after  the  general  cavity  has  been  shut  off  by  the  development 
of  adhesions,  irrigation  with  salt  solution  or  peroxide  of  hydrogen  is 
permissible.  The  wound  heals  by  granulation,  and  when  nearly  flush 
with  the  surface  may  be  drawn  together  by  strapping,  so  as  to  limit 
the  chances  of  development  of  a  ventral  hernia. 

Sequelae." — A  F cecal  Fistula  may  result  from  a  perforative  appendi- 
citis when  the  abscess  has  been  merely  opened,  and  no  radical 
treatment  undertaken  at  the  same  time,  or  it  may  follow  an  amputa- 
tion of  the  appendix  from  sloughing  or  yielding  of  the  stump.  It 
is  usually  small  in  size,  and  sinuous  in  its  course,  and  in  the  majorit}' 
of  cases  closes  of  itself.  Occasionally  it  is  necessary  to  deal  with  it 
by  laying  bare  the  csecum  in  the  iliac  fossa,  and  removing  the 
appendix  or  suturing  the  opening.  Failing  that,  it  may  be  neces- 
sary to  short-circuit  the  caecum. 

A  Ventral  Hernia  sometimes  follows  from  the  yielding  of  the 
cicatrix  in  the  abdominal  wall  after  an  abscess  has  been  opened  and 
drained.  Both  omentum  and  bowel,  perhaps  matted  together  and 
adherent  to  the  cicatrix,  are  found  in  the  protrusion.  In  some 
cases  it  may  suffice  to  protect  and  restrain  it  wath  a  truss,  but  in 
others  operation  is  required;  adhesions  must  be  divided  or  broken 
down,  and  often  the  opportunity  can  be  taken  for  removing  the 
appendix,  if  this  has  not  already  been  accomplished.  The  margins 
of  the  divided  muscles  are  then  sought  for,  and  united  by  a  row  of 
buried  sutures  in  the  ordinary  way,  or  overlapped  as  described  in 
discussing  the  subject  of  ventral  hernia  (p.  1109). 

Tuberculosis  of  the  Appendix  is  found  not  uncommonly  in  patients 
who  have  died  of  other  manifestations  of  the  disease,  especially 
phthisis  (30  per  cent.,  Keen) ;  it  is  not  often  seen  as  an  independent 
condition,  but  most  frequently  comes  under  observation  in  men 
between  the  ages  of  twenty  and  forty,  who  are  the  subject  of  urino- 
genital  tuberculous  disease.  The  affection  may  develop  as  an 
ulceration  of  the  mucous  membrane,  which  slowly  spreads  from  the 
tip  and  destroj's  the  walls  of  the  organ,  giving  rise  finally  to  a  large 
pericsecal  abscess,  which  opens  into  the  bowel  or  discharges  exter- 


ABDOMINAL  SURGERY  1059 

nally.  In  other  cases  the  condition  is  merely  an  element  in  the 
e\-olution  of  the  hyperplastic  tuberculous  growth  of  the  cajcum 
described  elsewhere  (p.  1022).  Occasionally  the  appendix  is  in- 
vol\-ed  in  a  tuberculous  peritonitis,  and  then  the  trouble  may  either 
ha\-e  started  in  the  appendix,  or  have  reached  it  secondarily  from 
the  serous  coat.  The  symptoms  of  these  conditions  are  in  no  ways 
peculiar,  and  correspond  to  those  of  a  chronic  appendicitis. 

Actinomycosis  attacks  the  appendix  more  frequently  than  any 
other  abdominal  organ.  The  disease  originates  usuall\-  from  the 
ingestion  of  infected  material,  and  the  result  is  the  production  of  a 
hard,  slowh'-enlarging  mass,  infiltrating  the  tissues  in  the  right  iliac 
fossa.  Sooner  or  later  the  skin  gives  way,  and  then  the  discharge  of 
glairy  pus  and  of  the  yellow  sulphur-like  granules,  together  with  the 
musty  smell,  is  pathognomonic.  Pyococcal  infection  of  the  sinuses 
is  only  too  likely  to  follow,  sometimes  originating  from  within  the 
bowel,  and  the  case  then  becomes  complicated  by  a  suppurating 
element  which  has  an  important  bearing  on  the  result.  Secondary 
foci  are  common,  especially  in  the  hver  (p.  1067).  Treatment 
consists  in  the  excision  of  the  appendix  and  even  of  the  csecum,  if 
such  be  practicable,  or  in  the  exhibition  of  large  doses  of  iodide 
of  potassium  with  curettage  and  drainage;  but  even  when  the 
organisms  have  been  destroyed  by  the  drug,  the  discharge  of  pus 
may  continue,  and  the  affection  may  prove  fatal. 

Primary  Carcinoma  of  the  appendix  is  noteworthy  on  account  of 
its  slight  malignancy.  The  case  presents  the  history  of  a  chronic 
appendicitis,  in  no  ways  peculiar,  and  on  operation  the  growiih  is 
discovered.  Removal  is  usually  followed  by  freedom  from  recur- 
rence. The  condition  is,  however,  very  uncommon.  Sarcoma  has 
also  been  known  to  occur  in  connection  with  the  appendix,  but  the 
prognosis  is  less  favourable. 

Affections  of  the  Liver. 

Displacements  of  the  Liver  are  obviously  not  likely  to  be  common, 
since  the  organ  is  well  supported,  both  by  ligaments  and  attach- 
ments to  deep  structures,  and  by  the  intra-abdominal  pressure. 
Should,  however,  the  abdominal  parietes  be  relaxed  and  the  intra- 
abdominal pressure  lessened,  it  is  possible  for  the  liver  to  sink,  and 
thus  hepatoptosis  becomes  an  element  in  the  syndrome  known  as 
Glenard's  disease  (p.  1028) .  The  displaced  liver  is  rotated  fonvards 
so  that  its  upper  wall  presents  anteriorly,  with  obvious  resulting 
physical  signs.  An  enlarged  liver  may  manifest  somewhat  similar 
phenomena,  but  dulness  is  then  found  over  the  normal  hepatic 
area;  in  hepatoptosis  the  normal  site  is  resonant.  Some  amount 
of  dragging  pain  and  discomfort  may  be  complained  of,  but  this  is 
not  generally  great  enough  to  demand  treatment  other  than  the 
support  of  a  belt,  together  with  such  measures  as  shall  assist  in  the 
restoration  of  the  abdominal  wall  to  a  state  of  normal  tonicity.  In 
the  worst  cases  it  is  justifiable  to  expose  the  liver  by  an  incision 


io6o  A   MANUAL  OF  SURGERY 

parallel  to  the  costal  margin,  and  fix  it  to  the  parietal  peritoneum 
by  sutures.  The  operation  is  conducted  in  the  Trendelenburg 
position,  and  the  patient  must  remain  with  the  lower  end  of  the  bed 
raised  for  some  weeks  after  operation. 

Riedel's  lobe  is  the  name  applied  to  a  linguiform  enlargement  of 
the  right  lol)c,  which  projects  downwards  into  the  loin,  and  is  likely 
to  be  mistaken  for  a  floating  kidney.  It  is  sometimes  stated  to  be 
the  result  of  tight  lacing,  but  this  is  not  invariable,  and  more  fre- 
quently it  is  associated  with  an  enlarged  gall-l)ladder,  probably 
containing  stones,  which  is  covered  in  by  the  projection,  llie  lobe 
may  have  a  broad  base  of  attachment  to  the  liver,  or  may  be  almost 
severed  from  it,  and  then  its  mobility  is  considerable,  and  may  be 
independent  of  the  liver.  A  little  care  in  examination  should  enable 
the  surgeon  to  differentiate  between  this  condition  and  a  floating 
kidney;  if  the  patient  be  laid  over  on  the  left  side,  the  examining 
hand  can  be  insinuated  between  the  lobe  and  the  kidney.  Treat- 
ment is  not  required,  except,  perhaps,  for  the  condition  of  the  gall- 
bladder. 

Rupture  o£  the  Liver  is  produced  by  injuries  to  the  abdominal 
walls,  such  as  blows,  kicks,  or  crushes,  or  it  may  be  torn  by  the 
broken  end  of  a  rib.  Penetrating  injuries  also  occur,  as  from  sword 
or  dagger  thrusts,  and  the  organ  may  be  involved  in  a  gunshot 
wound.  The  resulting  lesion  varies  considerably;  the  gland  may  be 
merely  torn  or  contused  from  a  non-penetrating  blow,  or  freely 
incised  by  a  sharp-cutting  implement,  in  which  case  some  of  the 
larger  venous  trunks  are  likely  to  be  divided ;  a  bullet  sometimes 
produces  almost  total  disorganization.  The  amount  of  injury 
depends,  to  some  extent,  on  the  condition  of  the  organ ;  if  it  is  firm 
and  sclerosed,  it  may  receive  little  damage  from  a  blow  which  would 
otherwise  do  it  considerable  harm,  whilst  if  it  is  enlarged  and  fatty, 
it  is  readily  torn. 

The  chief  Symptoms  are  shock,  which  is  often  not  very  excessive, 
pain  and  tenderness  in  the  right  hypochondrium,  and  the  evidences 
of  loss  of  blood.  The  last  is,  perhaps,  the  most  important,  and 
upon  its  severity  depends  to  a  large  extent  the  result.  vShould  the 
capsule  remain  intact,  there  is  considerable  intraglandular  ecchy- 
mosis  and  laceration,  but  no  free  blood  escapes  into  the  peritoneal 
cavity.  Such  a  lesion  is  not  unlikely  to  be  followed  by  an  abscess 
of  the  liver.  When  the  capsule  is  torn,  intraperitoneal  haemorrhage 
is  sure  to  ensue;  if  slight,  the  patient,  though  suffering  from  all 
the  phenomena  characteristic  of  loss  of  blood,  may  recover,  the 
blood  being  absorbed,  and  the  wound  in  the  liver  cicatrizing.  This 
process  is  usually  attended  by  a  certain  amount  of  jaundice  and 
some  vomiting,  whilst  the  urine  is  also  tinged  with  bile-pigment. 
Well-marked  pyrexia  may  follow  the  initial  shock,  and  the  abdom- 
inal wall  is  held  rigid.  In  other  cases,  the  blood  collects  at  first 
in  the  upper  part  of  the  abdomen,  but  gradually  extends  downwards ; 
if  the  bowel  is  uninjured,  recovery  may  ensue,  but  not  uncommonly 
there  is  some  associated  contusion  of  the  gut  wall,  through  which 


ABDOMINAL  SURGERY  1061 

intestinal  bacteria  find  their  way,  giving  rise  to  a  localized  or  general 
peritonitis.  Of  course,  in  the  more  severe  lesions,  where  perhaps 
the  left  lobe  is  entirely  torn  off  or  a  portion  hopelessly  contused, 
death  from  haemorrhage  is  almost  certain  to  ensue  in  a  very  short 
time. 

The  Diagnosis  of  hepatic  rupture  turns  mainly  on  the  history  of 
the  accident,  the  situation  of  the  blow,  and  the  resulting  symptoms. 
Evidences  of  intraperitoneal  bleeding,  associated  with  pain  in  the 
right  side,  are  extremely  suggestive.  It  must  not,  however,  be  for- 
gotten that  the  passage  of  a  hansom  cab  or  other  vehicle  over  the 
body  may  give  rise  to  much  shock,  and  to  considerable  local  pain 
and  tenderness,  and  yet  no  serious  mischief  need  have  happened 
to  the  liver. 

The  Treatment  in  the  more  simple  cases  consists  merely  in  careful 
expectancy,  the  surgeon  holding  himself  in  readiness  to  interfere 
should  any  untoward  symptoms  supervene.  The  patient  is  kept 
quietly  in  bed;  ice  may,  if  necessary,  be  applied  to  the  side,  the  diet 
is  limited  to  fluids,  and  the  bowels  emptied  by  enemata.  In  the 
more  serious  cases,  where  the  diagnosis  of  ruptured  liver  is  tolerably 
certain,  an  exploratory  laparotomy  should  be  undertaken,  and  an 
attempt  made  to  deal  with  the  wound.  Possibly  a  median  incision  is 
as  good  as  any,  since  the  left  half  of  the  liver  often  bears  the  brunt 
of  the  injury.  Outlying  ragged  portions  of  the  gland  may  be  totally 
removed,  preferably  by  the  cautery,  though  one  usually  has  to  de- 
pend upon  plugging  the  wound  with  gauze  in  order  to  effect  hsemo- 
stasis.  Clean  linear  cuts  may  be  sutured  with  silk,  but  there  is 
considerable  difficulty  in  preventing  the  stitches  from  tearing  out 
of  the  friable  hepatic  tissue;  it  is  wise  to  insert  all  the  stitches  first, 
taking  up  a  wide  margin  of  the  gland  substance  before  attempting 
to  tie  any.  The  wound  is  then  carefully  closed  by  the  fingers,  and 
the  sutures  slowly  and  gently  tightened.  Very  shallow  wounds 
which  it  is  impossible  to  stitch  or  plug  satisfactorily  may  be  seared 
with  the  cautery  so  as  to  stop  bleeding,  and  then  a  gauze  drain  is 
placed  over  them,  and  brought  out  of  the  external  wound. 

Abscess  of  the  Liver  is  due  to  a  variety  of  causes. 

1.  Multiple  Abscesses  develop  in  cases  of  pyaemia,  whether  the 
emboli  are  carried  by  the  hepatic  artery  or  by  the  portal  vein.  In 
the  former  case,  the  condition  arises  as  a  comphcation  of  general 
pysemia  of  systemic  origin;  in  the  latter,  the  originating  focus  of 
mischief  is  located  in  the  area  of  distribution  of  the  portal  vein— i.e., 
in  the  intestinal  canal.  Thus,  pylephlebitis,  as  it  is  termed,  is  not 
uncommonly  met  with  in  appendicitis,  and  sometimes  in  typhoid 
fever,  whilst  suppurating  piles  may  also  lead  to  it.  It  is  character- 
ized clinically  by  high  fever,  rigors,  vomiting  and  abdominal  disten- 
sion ;  the  liver  is  enlarged  and  tender,  and  the  spleen  may  also  be 
engorged  with  blood. 

2.  Suppurative  Cholangitis  is  another  cause  of  multiple  abscess  of 
the  liver.  It  consists  of  an  inflammatory  affection  of  the  biliary 
duct  and  passages,  and  is  due  to  the  spread  of  organisms  from  the 


io62  A   MANUAL  OF  SURGERY 

intestine,  or  occasionally  from  the  gall-bladder  after  an  operation. 
The  biliary  ducts  in  the  liver  become  enormously  dilated,  and  tilled 
with  a  mixture  of  bile  and  pus  which  closely  resembles  yellow  ochre. 
It  is  accompanied  by  pain  over  the  gland  and  the  general  phenomena 
of  pyrexia,  but  rigors  are  not  present.  The  patient  is  not  usually 
jaundiced,  but  bile  may  be  found  in  the  urine.  Treatment  is  of  little 
avail,  but  if  a  diagnosis  can  be  made,  and  the  gall-bladder  has  not 
been  already  incised,  it  may  relieve  tension  to  open  and  drain  it. 

3.  Hydatid  cysts  may  suppurate,  and  require  treatment  as  for  an 
abscess  of  the  liver. 

4.  The  more  important  abscesses,  from  a  surgical  standpoint,  are 
those  which,  from  their  size,  demand  operative  treatment.  They 
may  result  from  traumatism  in  the  way  stated  above,  or  may  arise 
in  connection  with  hydatid  cysts,  but  more  commonly  are  of  the  type 
known  as  tropical  abscess.  The  latter  usually  occurs  in  men  who 
have  travelled  in  the  tropics,  and  75  per  cent,  of  the  cases  are  attri- 
buted to  dysentery.  It  is  probable  that  unwise  indulgence  in  alcohol 
is  a  predisposing  factor,  and  that  the  abscess  itself  is  embolic  in 
origin.  A  large  proportion  of  the  cases  are  stated  (by  Dr.  Leonard 
Rogers*)  to  be  free  from  ordinary  pyogenic  organisms  when  first 
opened,  but  to  contain  in  abundance  the  A  mceha  coli,  which  is  looked 
on  as  being  an  important  factor  in  the  aetiology  of  dysentery.  In  the 
less  acute  cases  the  pus  becomes  sterile  after  a  time,  the  organisms 
apparently  dying.  It  is  probable  that  in  the  more  acute  cases 
ordinary  pyogenic  cocci  are  usually  to  be  found.  A  tropical  abscess 
is  most  frequently  situated  at  the  back  of  the  right  lobe,  but,  of 
course,  any  part  of  the  viscus  may  be  involved.  Though  often 
single,  the  cavity  is  generally  loculated,  indicating  that  several 
original  foci  of  suppuration  have  united  together.  1  he  abscess  wall 
consists  of  disintegrating  hepatic  tissue  in  acute  cases,  but  may  have 
a  fibro-cicatricial  wall  in  the  more  chronic  forms,  and  in  an  old- 
standing  abscess  the  limiting  membrane  may  be  as  tough  as  leather. 
The  pus  is  sometimes  of  the  ordinary  type,  but  not  uncommonly 
reddish-brown  in  colour,  somewhat  like  chocolate,  and  of  a  most 
nauseating  odour. 

The  Symptoms  are  in  some  instances  extremely  slight,  the  patient 
perhaps  dying  of  peritonitis  due  to  its  rupture  without  its  presence 
having  ever  been  suspected,  or  retaining  the  pus  encapsuled  for 
years.  The  individual  usually  complains  of  a  sense  of  pain  and 
fulness  in  the  right  h^^^ochondrium,  and  in  the  more  acute  cases  this 
may  be  accompanied  by  severe  pain  and  localized  tenderness  over 
the  whole  hepatic  region,  the  pain  being  also  referred  to  the  right 
shoulder.  When  the  pus  encroaches  on  the  upper  surface  of  the 
liver,  a  cough  on  taking  a  deep  breath  is  rather  characteristic.  A 
certain  amount  of  febrile  disturbance  occurs,  the  degree  of  which 
depends  on  the  rapidity  of  formation  of  the  abscess;  in  the  more 
acute  forms  the  temperature  is  high  and  rigors  may  be  present ;  in 
the  more  chronic  variety  there  is  some  fever  in  the  evening,  and 

*  British  Medical  Journal,  June  16,  1906? 


ABDOMINAL  SURGERY  1063 

night  sweats  occur.  The  pyrexial  phenomena  are  associated  with 
loss  of  appetite,  rapid  and  well-marked  emaciation,  and  perhaps  a 
slight  amount  of  icterus.  On  physical  examination  a  more  or  less 
e\ident  enlargement  of  the  liver  will  be  detected;  but  there  is 
neither  fluctuation  nor  a  sense  of  elastic  tension  unless  the  abscess  is 
very  superficial.  The  dulness  often  extends  up  towards  the  thorax 
rather  than  downwards,  though  the  contrary  obtains  when  the 
abscess  is  situated  not  far  from  the  free  margin  of  the  liver. 

Left  to  itself,  several  distinct  courses  are  open  for  the  abscess  to 
follow :  it  may  become  adherent  to  the  anterior  abdominal  wall  and 
point  in  the  epigastrium,  its  onward  passage  being  indicated  by  con- 
gestion and  cedema  of  the  parietes ;  it  may  open  into  the  peritoneal 
cavity,  or  into  one  of  the  hollow  viscera,  such  as  the  colon  or  duo- 
denum; or,  again,  it  may  travel  upwards,  burrowing  through  the 
diaphragm,  and  either  bursting  into  the  lung,  its  contents  being 
expectorated,  or  into  the  pleural  cavity,  leading  to  an  empyema. 
Occasionally  it  remains  passive  as  a  chronic  encysted  abscess,  and 
then  the  walls  become  very  thick,  as  in  a  case  operated  on  by  one 
of  us,  which  had  been  diagnosed  by  an  exploring  needle  twelve 
years  previously,  and  left  alone.     It  contained  about  2  pints  of  pus, 
and  the  walls  were  fully  h  inch  thick.     The  patient  came  under 
observation  because  the  swelling  was  becoming  more  prominent,  as 
the  result  of  increased  intra-abdominal  pressure,  due  to  pregnancy. 
In  many  cases  the  diagnosis  of  suppuration  is  by  no  means  easy, 
and  mistakes  are  likely  to  be  made,  the  condition  being  looked  on  as 
one  of  hepatitis.     A  blood  count  may  be  of  some  assistance,  and 
especially  a  diferential  count;  but  sometimes  it  is  of  little  value, 
since  a  le.ucoc\i:e  count  of  20,000  or  more  can  occur  without  suppura- 
tion.    A  marked  increase  in  the  polynuclear  leucoc\i;es  and  a  dimi- 
nution in  the  small  lymphocj' tes  is  always  suggestive  of  the  presence 
of  pus,  due  to  pyogenic  organisms ;  in  a  pure  amoebic  abscess,  leuco- 
cytosis  occurs  with  a  comparatively  small  increase  of  polynuclears. 
A  doubtful  diagnosis  can  sometimes  be  confirmed  by  the  aspirator 
or  exploring  syringe,  but  this  should  not  be  utilized  unless  one  is  fully 
prepared  for  immediate  operation  in  the  case  of  pus  being  found. 
Manson  directs  that  the  aspirator  needle  should  be  introduced  in 
the  following  situations :  (i)  In  the  right  axillary  line  through  the 
seventh  or  eighth  costal  interspace;  (2)  just  below  the  ribs  m  the 
right  nipple  line ;   (3)  immediately  below  the  lung  in  the  line  drawn 
downwards  from  the  angle  of  the  right  scapula. 

Treatment. — It  is  unnecessary  to  discuss  the  medical  treatment  of 
cases  of  suspected  abscess  of  the  liver ;  but  we  must  refer  in  passing 
to  the  diagnostic  and  curative  value  of  ipecacuanha  in  the  hepatitis 
that  accompanies  amoebic  dysentery  when  pus  is  not  present.  Doses 
of  20  to  40  grains  are  administered  once  or  twice  a  day  tw^enty 
minutes  after  a  small  dose  of  tincture  of  opium,  and  if  suppuration 
is  absent  the  s\Tnptoms  usually  yield  rapidly.  When  an  abscess  is 
present,  operative  treatment  'is'  of  course  necessary.  Aspiration, 
repeated  once  or  twice,  has  been  frequently  employed,  but  is  of  little 


1064  A  MANUAL  OF  SURGERY 

value,  and  not  a  few  cases  are  on  record  in  which  septic  peritonitis 
or  pleurisy  followed  the  introduction  of  the  needle  from  the  front  or 
side  respectively.  The  practice  usually  followed  is  in  accordance  with 
the  surgical  law  of  treating  suppuration — viz.,  that  the  abscess 
should  be  opened  and  drained.  If  pointing  in  front  and  adherent  to 
the  parietes,  there  is  no  difficulty  or  danger  in  making  an  incision 
over  the  most  prominent  spot  and  laying  the  cavity  open;  it  is 
then  well  flushed  out  and  a  drainage-tube  inserted.  If  on  dividing 
the  abdominal  parietes  it  is  found  that  the  liver  is  not  yet  adherent, 
it  was  formerly  thought  best  to  plug  the  wound  with  sterilized  or 
antiseptic  gauze,  or  to  introduce  sutures  between  the  liver  and  the 
parietal  peritoneum  so  as  to  determine  the  formation  of  adhesions 
to  such  an  extent  as  to  shut  off  the  general  peritoneal  cavity;  in 
a  few  days  the  abscess  could  then  be  opened  with  safety.  At  the 
present  time  the  operation  is  usually  done  at  one  sitting,  with  pre- 
cautions similar  to  those  taken  in  dealing  with  an  intraperitoneal 
abscess  connected  with  appendicitis.  The  general  serous  cavity 
must  be  carefully  protected  by  sterilized  gauze  before  letting  out 
the  pus,  w^hich  is  of  course  done  slowl3%  and  the  assistant  must  keep 
the  parietes  in  close  contact  with  the  hepatic  tissue.  It  may  be 
possible  to  insert  a  few  stitches  through  the  liver  substance, 
securing  it  thus  to  the  parietal  peritoneum;  otherwise  one  must 
trust  to  careful  packing.  After  opening  the  abscess,  it  is  usually 
advisable  to  wash  it  out,  and  this  may  with  advantage  be  repeated 
subsequently.  A  large  drainage-tube  is  inserted,  and  packed 
around  with  gauze  to  prevent  purulent  extravasation. 

When  the  abscess  is  in  its  most  common  situation,  viz.,  the  back 
of  the  right  lobe,  it  is  often  most  satisfactory  to  open  it  from  the 
side ;  a  similar  proceeding  is  sometimes  needed  when  an  abscess  has 
been  opened  from  the  front,  and  does  not  drain  properly.  An 
incision  is  made  a  little  behind  the  mid-axillary  line  through  the 
ninth  or  tenth  intercostal  space,  and  a  portion  of  one  of  the  adjacent 
ribs  removed.  The  pleural  cavity  is  opened,  and  the  costal  pleura 
stitched  carefully  to  that  portion  which  covers  the  diaphragm;  it 
will  be  found  that  this  structure  lies  nearly  vertical  in  this  position, 
and  but  little  difficult}^  is  experienced  in  shutting  off  the  general 
pleural  cavity.  The  diaphragm  is  then  divided,  and  not  unfre- 
quently  the  peritoneal  cavity  is  opened;  it  must  be  carefully  pro- 
tected by  gauze  packing,  and  then  the  liver  incised ;  less  commonly 
adhesions  may  have  already  formed,  or  a  bare  area  of  the  liver  may 
be  found,  through  which  the  pus  can  be  withdrawn  and  the  abscess 
opened. 

Recently,  however,  some  doubt  has  been  thrown  on  this  practice 
by  Dr.  Leonard  Rogers,*  who  finds  that  the  Amwha  coli  is  easily 
killed  by  comparatively  weak  solutions  of  quinine,  and  hence  has 
suggested  that  in  amrebic  abscesses  all  that  is  needed  is  to  empty 
the  cavity  by  aspiration,  introduce  30  or  40  grains  of  bi-hydro- 
chlorate  of  quinine,  and  employ  no  drainage.    The  results  hitherto 

*  Op.  cit. 


ABDOMINAL  SURGERY  1065 

reported  have  been  most  encouraging.     A  rapid  microscopic  ex 
amination  of  the  pus  must  of  course  be  made  at  the  time,  and  if 
pyogenic  organisms  other  than  the  amreba  are  found,  the  ordinary 
operation  can  be  carried  out. 

Hydatid  Cysts  occur  in  the  liver  more  frequently  than  m  any  other 
part  of  the  body.  For  general  details  as  to  the  life-history  of  the 
TcBnia  echinococcus  and  the  structure  of  hydatid  cysts,  see  p.  233. 
They  produce  a  localized  painless  enlargement  of  the  liver,  the  cysts 
varying  in  size  from  a  small  marble  to  a  child's  head;  the  outline  is 
well  defined  if  superficial,  but  not  so  if  placed  deeply ;  the  cavity  is 
usually  filled  with  fluid  and  daughter-cells.  Fluctuation  may  be  dis- 
tinguished, and  a  hydatid  fremitus  or  thrill  (arising  from  the  concus- 
sion of  the  contained  daughter-cysts)  may,  it  is  said,  be  elicited  on 
palpation.  The  diagnosis  is  easily  made  if  the  cyst  projects  from  the 
lower  border,  but  when  deeply  embedded  in  the  organ  it  may  be 
exceedingly  difficult,  and  the  tumour  can  only  be  distinguished  with 
certainty  from  carcinoma  or  syphilis  by  the  use  of  the  aspirator,  or 
preferably  by  an  open  exploration.  The  character  of  the  fluid  with- 
drawn from  a  hydatid  cyst  is  at  once  conclusive,  as  it  is  of  low  specific 
g^a^^ty,  viz.,  1007  to  loog,  slightly  opalescent,  with  no  albumen, 
and  a  trace  of  salt;  the  presence  of  scolices  or  booklets  is  the 
pathognomonic  feature. 

Terminations. — The  cyst  may  remain  latent  and  innocuous,  or 
maj-  actually  dry  up  and  form  a  mass  somewhat  like  wet  mortar, 
owing  to  the  death  of  the  organism ;  or  it  may  burst  and  be  evacuated 
in  different  directions,  with  or  wdthout  suppuration.  Thus,  it  may 
open  externally  through  the  abdominal  parietes,  or  into  the  peri- 
toneal cavity,  causing  fatal  shock  and  in  many  cases  peritonitis ;  or 
into  the  stomach  or  intestines,  spontaneous  cure  usually  resulting; 
or  it  may  penetrate  the  diaphragm,  and  the  contents  be  expector- 
ated, or  set  free  in  the  pleural  cavity,  causing  a  rapidly  fatal  pleurisy. 
It  has  been  known  to  open  into  the  pericardium,  or  even  into  the 
hepatic  veins,  the  contents  then  being  impacted  in  the  right  auricle ; 
in  both  cases  immediate  death  resulted. 

Treatment. — The  best  plan  of  dealing  with  a  hydatid  cyst  is  to  lay 
it  open  either  through  the  anterior  abdominal  wall,  or  through  the 
costal  parietes  and  diaphragm,  to  empty  it  of  its  contents,  and  if 
possible  to  enucleate  the  lining  wall  or  endocyst,  which  is  often  but 
loosely  connected  to  the  fibrous  ectocyst.  This  is  usually  accom- 
plished at  one  sitting.  Similar  precautions  as  to  protecting  the  peri- 
tonemn  are  taken  as  for  an  abscess.  When  the  surface  of  the  liver 
is  exposed,  it  is  advisable  to  puncture  the  cyst  first  with  a  trocar  and 
cannula,  so  as  to  reduce  the  tension  within  it.  It  is  then  incised 
freely  and  the  loose  daughter-cysts  removed.  This  is  facilitated  by 
flushing  out  the  cavity  with  sterilized  salt  solution.  The  endocyst  is 
removed  either  by  enucleation  wdth  the  fingers  or  a  blunt  dissector, 
or  it  may  be  possible  to  detach  it  by  irrigation,  the  nozzle  of  the 
irrigator  being  inserted  beneath  it.  If  enucleation  is  completely 
successful,  the  lesion  in  the  liver  may  be  closed,  and  the  abdominal 


io66  A   MANUAL  OF  SURGERY 

wound  sutured  in  the  ordinary  way  without  drainage  (Hamilton 
Russell),  dependence  being  placed  on  the  aseptic  organization  of  the 
blood-clot  which  fills  up  the  cavity  in  the  liver.  If  for  any  reason 
this  seems  undesirable,  a  gauze  packing  is  introduced  into  the  cavity, 
and  healing  by  granulation  is  allowed  to  proceed.  If,  however,  part 
of  the  lining  wall  is  left,  a  drainage-tube  must  also  be  introduced, 
and  the  cavity  subsequently  irrigated  at  each  dressing. 

No  attempt  should  be  made  to  remove  the  fibrous  ectocyst,  as  it  is 
closely  connected  with  the  liver  substance,  and  grave  haemorrhage 
might  follow  any  interference  with  it. 

Formerly  aspiration  and  electrolysis  were  largely  employed  in  the 
treatment  of  this  affection.  It  has  been  found,  however,  that 
although  a  considerable  percentage  of  cases  could  be  cured  in  this 
way  (more  than  a  half),  yet  it  was  not  unaccompanied  by  risk  of 
peritonitis,  and  that  recurrence  was  often  observed.  Moreover, 
some  of  the  fluid  not  unfrequently  leaked  into  the  peritoneal  cavity, 
and  probably  from  the  absorption  of  some  toxic  product  present  led 
to  urticaria,  and  sometimes  to  even  graver  phenomena  of  poisoning. 
Electrolysis  merely  acts  by  producing  a  puncture  of  the  cyst  wall 
and  consequent  leakage.  Both  of  these  methods  should  be  entirely 
discontinued. 

A  suppurating  hydatid  cyst  is  dealt  with  according  to  the  same 
rules  of  treatment  as  hold  good  for  abscess  of  the  liver. 

Tumours  of  the  Liver  are  rarely  primary.  Angiomata,  adenomata, 
and  simple  cysts  have  been  described,  but  primary  gro\\i:hs  are  more 
often  carcinomatous  in  nature,  and  develop  either  as  a  large  well- 
defined  infiltrating  mass,  or  as  a  small  central  tumour,  with  secondary 
nodules  scattered  around.  Sarcomata  are  rare.  Secondary  tumours 
of  the  liver  are  common,  and  either  arise  by  direct  extension  from 
the  gall-bladder,  or  follow  a  carcinoma  of  the  intestinal  canal, 
especially  of  the  stomach  or  large  intestine,  or  perhaps  may  be  a 
sequel  of  cancer  of  the  ovary,  uterus,  or  breast.  The  liver  is  also 
involved  secondarily  in  melanotic  disease  of  the  skin  or  retina.  In 
all  these  cases  the  organ  becomes  enlarged  and  its  surface  irregular, 
due  to  the  projection  of  nodular  masses  of  the  growth;  in  cancer 
they  are  frequently  more  or  less  umbilicated.  The  simple  growths 
are  occasionally  pedunculated,  and  may  arise  from  the  left  lobe,  and 
thus  become  amenable  to  surgical  treatment.  Pain  is  not  generally 
a  prominent  symptom,  but  ascites  and  jaundice  develop  in  malignant 
cases  from  pressure  on  the  portal  vein  and  biliary  ducts  in  the  portal 
fissure,  and  oedema  of  the  legs  may  be  caused  by  compression  of  the 
inferior  vena  cava. 

Gummata  are  developed  in  inherited  and  acquired  syphilis,  and  are 
of  sufficient  size  to  need  careful  diagnosis  from  the  more  serious 
growths  which  develop  in  the  liver.  They  are  single  or  multiple,  and 
occur  in  the  form  of  rounded  yellowish  avascular  masses,  tending 
to  caseate,  and  surrounded  by  much  fibrous  tissue.  Absorption  is 
followed  by  considerable  cicatrization,  which  leads  to  deformity. 
The  diagnosis  from  secondary  carcinoma  is  not  always  easy.     The 


ABDOMINAL  SURGERY  1067 

history  of  the  patient  must  be  carefully  considered,  and  if  any  doubt 
arise  the  W'assermann  reaction  is  tested.  Carcinomatous  growths 
have  a  hard  umbilicated  surface,  if  it  can  be  felt,  enlarge  rapidly  with 
marked  cachexia,  and  early  produce  jaundice  and  ascites.  Gummata 
are  slower  in  their  progress,  do  not  generally  affect  the  structures 
in  the  portal  fissure,  and  may  be  associated  \vith  an  enlarged  spleen 
from  lardaceous  or  gummatous  disease.  A  course  of  antisyphilitic 
medicme  will  necessarily  influence  the  case  verv  decidedly. 

Actinomycosis  of  the  liver  is  usually  secondary  to  an  affection  of 
the  alimentary  canal,  particularly  the"  appenchx  or  transverse  colon, 
or  may  be  due  to  a  direct  spread  of  the  infection.  The  liver  is 
enlarged,  and  may  be  covered  with  adhesions.  On  section  the 
affected  area  presents  a  trabeculated  honeycombed  appearance, 
which  has  been  compared  to  a  sponge  soaked  in  pus.  There  is  much 
fibrosis  around,  and  the  trabeculae  are  markedly  fibrous.  The  pus 
contains  the  characteristic  granules  of  the  fungus.  The  clinical 
history  is  that  of  an  hepatic  abscess,  and  the  prognosis  is  bad. 
Treatment  is  as  for  the  disease  elsewhere  (p.  193). 

Affections  of  the  Gail-Bladder  and  Bihary  Passages. 

The  Gail-Bladder  (Fig.  501,  GB)  is  a  pear-shaped  sac  lying  under  cover  of 
the  liver  and  proj  ecting  into  the  peritoneal  ca\ity.  Its  average  length  is  about 
3  to  4  inches,  and  it  is  normally  capable  of  holding  about  an  ounce  of  fluid. 
\Mien  one  remembers  that  the  liver  secretes  about  an  ounce  of  bile  every  hour, 
it  is  ob%-ious  that  its  function  as  a  biliary  reservoir  must  be  verv  limited ;  in 
fact,  it  is  possible  that  in  a  state  of  health  it  does  not  contain  bile  at  all,  and 
that  it  merely  acts  as  a  pressure-gauge  regulating  the  flow  of  bile  into  the 
intestine  or  secretes  a  mucoid  fluid  which  dilutes  the  bile.  An  enlarged  gall- 
bladder projects  do^\-n wards  and  towards  the  umbiHcus,  constituting  a  rounded 
swelling  which  moves  with  respiration,  and  is  almost  always  in  close  relation 
^\-ith  the  anterior  abdominal  wall;  it  is  freely  mobile  from  side  to  side,  and  has 
attained  such  dimensions  that  it  has  been  operated  on  in  mistake  for  an 
ovarian  cyst.  It  is  attached  to  the  liver  by  reflections  of  the  peritoneum, 
which  vary  somewhat  in  their  insertion;  as  a  rule,  about  a  fiith  of  the  circum- 
ference of  the  gall-bladder  is  in  contact  -with  the  liver.  The  attachment  is 
loose,  and  when  once  the  right  layer  has  been  reached,  it  is  easy  to  strip  the 
gall-bladder  from  the  liver.  The  cystic  arterv'  reaches  it  at  some  distance 
from  the  fundus.  In  a  few  cases  the  gall-bladder  has  a  complete  peritoneal 
investment,  swinging  loose  from  the  Uver  on  a  mesentery,  and  in  two  cases  one 
has  seen  serious  colic  develop  apparently  from  this  lax  attachment,  much  in 
the  same  way  as  a  long  appendix  can  cause  appendicular  cohc.  Removal  of 
the  gall-bladder  demonstrated  the  absence  of  stones  and  cured  the  condition. 
Such  a  condition  may  be  termed  Gall-Bladder  Colic,  to  distinguish  it  from  the 
biliary  colic  produced  by  gall-stones. 

The  Cystic  Duct  (Fig.  501 ,  CD)  is  about  2  inches  in  length,  or  rather  less,  and 
is  arranged  more  or  less  in  a  spiral  fashion  by  the  attachment  of  the  peritoneum. 
It  will  ordinarily  permit  of  the  introduction  of  a  Xo.  5  catheter,  but  probablv  in 
a  healthy  state  the  mucous  membrane  is  in  such  folds  that  a  probe  cannot  be 
passed  along  it.  The  Hepatic  Duct  [HD)  is  2  inches  in  length,  and  is  formed  by 
the  junction  of  the  right  and  left  ducts  which  issue  from  the  liver  at  either  end 
of  the  transverse  fissure  and  unite  together  at  a  verv  obtuse  angle.  The  duct 
passes  down  with  the  hepatic  artery,  and  a  httle  above  the  upper  border  of  the 
first  piece  of  the  duodenum  is  joined  at  a  very  acute  angle  bv  the  cystic  duct. 
The  Common  Bile  Duct  {CBD)  is  about  3  inches  in  length,  and  takes  a  Xo.  7 
catheter;  one  inch  or  more  of  it  is  to  be  found  above  the  duodenal  border,  and 


io68 


A   MANUAL  OF  SURGERY 


then  it  dips  bcliind  the  viscus;  and  after  lying  between  the  inner  bonier  of  the 
gut  and  the  head  of  the  pancreas,  it  perforates  the  bowel  obliquely  (A'),  some- 
times being  distended  just  before  its  termination  to  constitute  the  ampulla  of 
Vater,  and  into  this  the  duct  or  ducts  of  the  pancreas  also  open. 

Rupture  or  Perforation  of  the  Gall-bladder  results  from  such 
injuries  as  blows,  crushes,  kicks,  etc.,  whilst  it  may  also  be  produced 
by  penetrating  wounds  or  bullets ;  occasionally  it  may  follow  ulcera- 
tion from  within,  as  from  a  large  impacted  gall-stone.  Blood  and 
bile  are  in  consequence  extravasated  into  the  peritoneal  cavity. 
Pure  bile  is  sterile,  but  if  any  inflammation  of  the  bihary  passages 
has  been  present,  organisms  are  sure  to  have  found  their  way  into 
the  gall-bladder,  and  thus  complications  may  readily  ensue.     If  a 


DTV 


Fig.  501. — Diagram  of  the  Biliary  Passages  and  their  Relation  to  the 
Duodenum,  which  has  been  laid  open,  and  Pancreas. 

GB,  Gall-bladder;  CD,  cystic  duct;  HD,  hepatic  duct;  CBD,  common  bile- 
duct;  DS,  duct  of  Santorini;  DW ,  duct  of  Wirsung;  A',  opening  of 
common  bile-duct  and  duct  of  Wirsung  in  the  duodenum;  A,  aorta; 
SA,  splenic  artery;  SM,  superior  mesenteric  vessels. 

considerable  quantity  of  bile  escapes  suddenly  into  the  peritoneal 
sac,  acute  peritonitis  is  certain  to  follow  sooner  or  later,  whether 
organisms  are  present  or  not;  slight  jaundice  arises  from  absorption 
by  the  peritoneum  of  bile,  which  may  also  be  found  in  the  urine. 
A  more  gradual  escape  of  the  secretion  will  probably  lead  to  the 
formation  of  a  localized  intraperitoneal  abscess  or  collection  of  fluid, 
associated  with  jaundice  and  probably  clay-coloured  stools.  In  a 
penetrating  wound  bile  and  blood  will  escape  on  the  surface,  and 
septic  peritonitis  is  almost  sure  to  follow. 

The  immediate  Symptoms  are  those  of  shock  and  severe  liy])o- 
chondriac  pain,  and  this  will  be  succeeded  either  by  acute  peritonitis 
or  b}^  the  formation  of  a  localized  intraperitoneal  swelling,  together 
with  mild  jaundice.     When  the  existence  of  such  a  lesion  is  sus- 


ABDOMINAL  SURGERY  1069 

pected,  Treatment  always  consists  in  an  exploratory  laparotomy. 
The  fluid  within  the  abdomen  is  removed  with  swabs  or  washed  away, 
and  the  gall-bladder  carefully  examined.  Should  only  a  small  injury 
be  found,  it  is  perfectly  feasible  to  close  it  by  sutures;  a  gauze  wick 
should,  however,  be  passed  down  to  the  lesion  for  a  few  days,  so  as  to 
provide  a  means  of  drainage,  should  leakage  occur.  A  more  serious 
rupture  will  necessitate  removal  of  the  gall-bladder.  Should  the 
common  bile-duct  be  entirely  divided,  the  ends  should  be  closed  by 
sutures  and  a  cholecystenterostomy  undertaken ;  a  small  wound  in 
the  duct  may  be  sutured. 

Inflammation  of  the  Biliary  Passages  is  of  frequent  occurrence,  and 
generally  arises  as  a  sequela  of  a  gastro-duodenal  catarrh.  The 
affection  is  similar  in  nature  to  that  commonly  seen  in  other  tracks 
lined  with  mucous  membrane,  and  may  be  limited  to  the  main  bile- 
ducts  and  their  extensions  into  the  liver  {cholangitis),  or  may  also 
involve  the  gall-bladder  [cholecystitis).  The  catarrh  is  determined 
by  the  presence  of  micro-organisms,  and  streptococci,  staphylococci, 
or  the  B.  coli,  are  most  frequently  present;  the  condition  may  be 
limited  to  a  simple  catarrh,  or  suppuration  may  follow. 

Catarrhal  Cholangitis  is  more  of  medical  than  of  surgical  interest, 
but  its  frequency  and  its  setiological  connection  with  the  develop- 
ment of  gall-stones  warrants  its  introduction  into  a  surgical  text- 
book. In  the  acute  form  it  is  common  in  young  people,  arising  from 
over-eating  or  injudicious  food,  combined  perhaps  with  exposure 
to  cold  and  wet.  The  patient  feels  ill,  perhaps  shivers,  looks  a  little 
sallow,  or  maybe  is  actually  yellow  [catarrhal  jaundice) .  Abstinence 
from  all  but  fluid  food,  and  the  administration  of  mild  purgatives, 
especially  of  the  saline  type,  will  generally  free  the  patient  from  his 
symptoms  in  a  very  short  time. 

Sometimes  the  condition  is  of  a  more  chronic  type,  occurring  then 
in  people  of  middle  hfe,  who  are  the  subjects  of  persistent  dyspepsia, 
often  caused  by  late  hours,  irregular  and  injudicious  meals,  constipa- 
tion, and  perhaps  mental  and  nervous  tension.  Indulgence  in 
alcohol  adds  to  the  trouble.  Such  people  are  frequently '  livery, '  and 
look  more  or  less  sallow,  but  are  not  actually  jaundiced;  they  lose 
weight,  and  are  irritable  to  a  degree ;  but  none  of  the  graver  symp- 
toms of  malignant  disease  are  to  be  found.  The  liver  is  probably  a 
little  enlarged  and  may  be  tender,  and  the  gall-bladder  may  be 
palpable.  It  is  this  type  of  patient  in  whom  gall-stones  are  liable  to 
develop,  and  for  whom  courses  of  waters  do  so  much  good,  as  at 
Carlsbad  or  Harrogate,  where  hydro-therapeutic  measures  are  com- 
bined with  a  rigid  dietary.  The  essential  elements  of  the  treatment 
can  be  quite  well  carried  out  at  home  if  the  patients  will  submit  to 
the  restrictions  that  must  be  enforced. 

Infective  Cholangitis  is  a  much  more  serious  affection,  and  may  lead 
to  a  fatal  issue.  It  is  usually  due  to  the  presence  of  a  stone  or 
stones  in  the  common  bile-duct,  but  may  arise  from  other  causes,  e.g., 
ascarides  or  hydatid  cysts  which  have  escaped  into  the  biliary 
passages,  from  malignant  disease,  or  it  may  spread  backwards  into 


I070  A   MANUAL  OF  SURGERY 

the  liver  from  a  suppurating  gall-bladder.  The  general  phenomena 
which  follow  an  attack  of  biliary  colic,  due  to  the  attempted  or 
successful  passage  of  a  gall-stone,  are  due  to  this  cause,  and  hence 
fever  with  or  without  a  shivering  fit,  a  certain  amount  of  jaundice 
(which  is  easily  comprehended  when  one  remembers  the  low  pressure 
at  which  the  bile  is  secreted),  enlargement  and  tenderness  of  the  liver 
are  to  be  looked  on  as  the  characteristic  features  of  a  mild  attack. 
Treatment  necessarily  consists  in  removal  of  the  cause,  if  possible,  or, 
faihng  that,  in  drainmg  the  biliary  passages  by  cholecystostomy.  It 
must  not  be  forgotten  that  the  persistent  presence  of  such  a  condition 
may  lead  not  only  to  mischief  in  the  liver,  but  also  to  chronic 
pancreatitis,  and  to  adhesive  peritonitis,  which  may  complicate 
future  operative  procedures,  and  therefore  in  any  patient  with  well- 
marked  symptoms  operation  should  never  be  delayed  too  long. 

In  the  more  serious  types  of  this  affection  suppuration  may  ex- 
tend up  the  passages  and  lead  to  multiple  abscesses  in  the  liver, 
a  condition  already  noted  at  p.  1061.  Drainage  of  the  gall-bladder 
and  removal  of  the  causative  stones  is  the  only  hope  of  cure,  but  the 
prognosis  is  very  grave. 

Cholecystitis,  or  inflammation  of  the  gall-bladder,  is  most  com- 
monly the  result  of  the  presence  of  stones  in  that  cavity,  but  may 
also  arise  as  a  sequela  of  typhoid  fever.  Indeed,  the  B.  typhosus 
seems  to  have  a  special  predilection  for  this  viscus,  and  may  reside 
there  for  years  after  the  primary  attack,  the  individual  or  typhoid 
carrier  being  thus  a  danger  to  the  community  from  his  ability  to 
discharge  living  organisms  at  intervals.  Streptococci  or  staphylo- 
cocci are  present  in  the  other  cases,  with  or  without  the  B.  coli. 

There  is  nothing  specially  noticeable  about  the  pathological 
phenomena,  except  that  the  viscus  is  intraperitoneal,  and  that  there 
is  some  analogy  between  the  troubles  arising  here  and  in  the 
appendix.  There  is,  however,  less  tendency  for  the  peritoneum  to 
be  seriously  involved  owing  to  the  greater  thickness  of  the  wall,  and 
its  greater  capacity  for  stretching ;  thus  a  distended  gall-bladder  may 
contain  a  large  quantity  of  muco-pus  without  giving  way,  and  the 
viscus  has  even  been  opened  in  the  pelvis  or  through  the  sac  of  a 
hernia.  Protective  adhesions  frequently  develop  between  the  gall- 
bladder and  the  stomach,  duodenum  or  transverse  colon,  and  not  a 
few  of  the  uncomfortable  symptoms  produced  by  gall-stones  are  due 
to  their  existence. 

The  clinical  history  varies  according  to  whether  the  condition  is 
chronic  or  acute.  In  the  chronic  variety  produced  b}'  gall-stones,  the 
symptoms  are  part  of  the  syndrome  characteristic  of  that  condition, 
and  are  but  little  noticeable  in  themselves.  The  gall-bladder  may  be 
enlarged,  and  a  little  tender  on  pressure ;  should  the  cystic  duct  be 
blocked,  it  will  be  distended  with  mucus  or  muco-pus  according  to 
the  degree  of  irritation  present.  The  acute  form  is  evidenced  by 
marked  pain  and  tenderness  in  the  right  hvpochondrium,  together 
with  vomiting,  constipation,  and  fever.  The  constipation  may  be 
very  marked,  as  it  is  due  to  paralysis  of  neighbouring  coils  of  intes- 


ABDOMINAL  SURGERY  1071 

tine,  and  especiall}-  the  transverse  colon.  The  abdominal  wall  is 
held  rigid,  and  the  right  rectus  is  very  tense;  but  the  enlarged  gall- 
bladder can  usually  be  detected  beneath  it.  In  one  case  it  was  as 
large  as  a  cocoa-nut,  and  on  exposure  was  of  a  brilliant  red  colour, 
and  contained  about  8  ounces  of  muco-pus;  it  was  absolutely  free 
from  adhesions  and  contained  two  gall-stones,  one  of  them  embedded 
in  the  cedematous  wall  and  near  the  point  of  perforation.  As  a 
rule,  a  sufticienc\-  of  adhesions  forms  to  protect  the  general  cavity 
of  the  peritoneum,  and  then  the  abscess,  if  unrelieved  by  art,  may 
burst  into  the  bowel,  or  ma\-  open  externally  and  discharge  itself. 
In  the  most  severe  forms  sloughing  and  gangrene  of  the  wall  follow 
{phlegmonous  or  gangrenous  cholecystitis),  and  then  general  peritoneal 
infection  may  ensue.  In  the  milder  forms  the  inflammation  may  in 
time  subside,  the  gall-bladder  emptying  itself  per  vias  naturales  ;  but 
adhesions  of  a  more  or  less  severe  character  are  likely  to  be  left  and 
may  cause  much  trouble,  whilst  the  gall-bladder  itself  may  shrink 
and  atrophv. 

Treatment  consists  in  dealing  with  the  cause,  if  such  be  gall-stones. 
In  the  acute  variety  of  suppurative  inflammation,  the  gall-bladder 
should  be  removed  without  dela}',  just  as  one  removes  an  inflamed 
appendix.  There  are  frequently  many  newly  formed  omental 
adhesions,  but  it  is  not  difficult  as  a  rule  to  clear  the  gall-bladder 
and  excise  it  completely.  Only  if  there  are  dense  adhesions  of  old 
standing  is  it  necessary  to  open  it,  remove  the  contained  stones,  and 
drain  it.  The  operations  are  described  below,  and  need  no  special 
reference. 

Cholelithiasis  is  the  term  applied  to  the  presence  in  the  gall-bladder 
or  biliary  passages  of  Gall-stones.  These  consist  mainly  of  crystals 
of  cholesterine,  held  together  by  mucus  and  coloured  by  the  bile- 
pigment;  they  are  soluble  in  chloroform.  When  first  passed  and 
moist,  their  specific  gra\'ity  is  a  little  higher  than  that  of  water,  and 
hence  when  immersed  in  it  they  sink;  after  dr^-ing,  however,  they 
are  found  to  float.  The  number  present  varies  immensely;  some- 
times a  single  large  one  exists,  which  is  more  or  less  barrel-shaped 
(Plate  IX.) ;  more  frequently  they  are  multiple,  scores  or  hundreds 
being  present,  and  are  then  usually  faceted,  and  with  a  satin-like 
yellowish  lustre.  If  they  have  lain  long  in  the  gaU-bladder,  they  are 
usually  of  a  deep  brown  or  almost  blackish  colour. 

The  Origin  of  gall-stones  is  not  yet  fuUy  understood,  but  there 
seems  no  doubt  that  they  are  primarily  due  to  a  chronic  catarrhal 
aftection  of  the  gall-bladder  or  biliary  passages,  the  cholesterine  being 
formed  bv  the  lining  epithelium.  Ihe  original  trouble  is  probably  a 
gastro-duodenal  catarrh,  and  the  inflammation  spreads  upwards  from 
the  bowel  to  the  gall-bladder.  Gall-stones  usuall}^  develop  in  the 
gall-bladder  or  the  lower  biliary  passages,  but  they  can  also  form  in 
the  ducts  ^^^thin  the  liver,  especially  in  cases  where  the  hepatic 
derangement  has  been  of  long  standing.  Ihey  occur  most  com- 
monly in  women  who  have  suffered  from  dyspepsia  and  constipation, 
and  mav  be  associated  with  cancer,  either  as  cause  or  eftect.     In  one 


I072  A   MANUAL  OF  SURGERY 

case  the  origin  of  the  trouble  seems  to  have  been  the  swallowing  of  a 
pin  many  years  previously,  which  worked  its  way  into  the  gall- 
bladder, set  up  an  inflammation,  which  resulted  in  the  formation  of 
calculi,  and  only  appeared  again  after  a  successful  operation,  when 
sixty-six  stones  had  been  removed. 

The  fact  that  gall-stones  are  frequently  found  unexpectedly  on  the 
operating-table  or  in  the  post-mortem  room  suggests  that  they  may 
remain  quiescent  for  years,  and  only  cause  trouble  when  attempting 
to  escape,  or  if  associated  with  some  inflammatory  disturbance. 
Thus  the  first  evidence  of  their  presence  may  be  an  attack  of  acute 
suppurative  cholecystitis,  and  then,  unless  prompt  attention  is  given, 
diffuse  peritonitis  may  result.  Sometimes  they  cause  chronic 
irritation  of  the  gall-bladder,  resulting  in  the  walls"  becoming  thick- 
ened and  hypersemic  at  first,  but  subsequently  white  and  opaque; 
and  in  time  a  process  of  sclerosis  supervenes,  which  may  lead  to  con- 
traction of  the  wall  upon  the  stones  which  are  thereby  encapsuled, 
and  all  attempts  to  displace  them  come  to  an  end ;  cancer  may  also 
supervene.  Adhesions  also  form  between  the  gall-bladder  and 
surrounding  tissues,  and  thereby  the  movements  of  the  pylorus 
or  transverse  colon  may  be  hampered.  More  frequently  the  gall- 
bladder contains  enough  fluid  to  keep  its  walls  distended,  and  then 
efforts  to  expel  the  stones  follow,  giving  rise  to  definite  painful 
symptoms.  Sometimes  the  stones  slip  back ;  at  others  they  pass  on 
and  may  escape  into  the  bowel,  or  may  be  blocked  in  the  cystic  or 
the  common  bile-duct,  and  find  it  impossible  to  progress  further. 
Such  stones  may  ulcerate  through  into  various  viscera,  such  as  the 
stomach,  duodenum,  or  colon,  and  thereby  relief  be  given  to  the 
symptoms,  or  they  may  escape  into  the  general  peritoneal  cavity  and 
cause  peritonitis. 

The  Clinical  History  of  a  case  of  cholelithiasis  is  obviousl}^  very 
variable  according  to  the  exact  location  and  condition  present. 

1.  In  what  has  been  termed  the  Prodromal  Stage,  when  the  stones 
are  free  in  the  gall-bladder,  and  not  doing  much  harm,  the  symptoms 
are  referable  rather  to  the  stomach  than  to  the  hypochondrium. 
The  patient  complains  of  a  sense  of  weight  and  fulness  in  the 
epigastrium,  particularly  after  meals,  accompanied  by  fleitulent 
distension,  which  is  relieved  by  belching,  or  entirely  removed  by 
vomiting.  This  may  have  lasted  for  years,  and  is  usually  accom- 
panied by  constipation.  vSometimes  the  discomfort  amounts  to  acute 
pain,  which  doubles  up  the  patient,  and  may  be  more  severe  on 
taking  a  deep  inspiration.  With  these  phenomena  there  may  be  a 
sense  of  chilliness  scarcely  amounting  to  a  rigor,  and  when  the 
pain  passes  the  patient  may  perspire.  He  is  often  a  little  sallow, 
especially  on  days  when  he  feels  bilious,  and  there  is  some  tender- 
ness over  the  gall-bladder;  but  the  diagnosis  of  gall-stones  is  scarcely 
warranted  unless  the  pain  is  very  acute.  Unfortunately,  radio- 
graphy does  not  often  help  in  the  diagnosis. 

2.  When  the  gall-stones  are  loose  in  the  bladder  and  attempting  to 
escape,  more  definite  and  distinct  phenomena  result.  Pain  is  perhaps 


PLATE  IX. 


# 


'^SB^ 


Various  types  of  Gallstones  (natural  size) 


In 
lirmly 


I  is  a  large  bairel- shaped  slone  removed  with  ihe  gall-bladder,  in  which  it  was 
held.  Fig.  2. — An  ordinary  gallstone  of  moderate  size.  Fig.  3. — Dark 
gallstones,  evidently  old  inhabitants  of  the  gall-bladder,  and  deeply  stained  with  bile- 
pigment.  Fng.  4. — More  recently-formed  gallstones  with  but  little  bile-pigment,  and 
one  on  section  showing  laraination.     Fig.   5. — Bright  brownish  stones  with  facets. 


[  To  face  page  1072. 


ABDOMINAL  SURGERY  1073 

the  most  marked  feature,  and  may  be  of  various  types,  {a)  There  is 
the  locahzed  pain,  due  to  the  irritation  of  the  gall-bladder  itself, 
which  is  rather  a  dull  ache  referred  to  the  right  hypochondrium, 
shooting  through  to  the  back  about  the  level  of  the  tenth  rib,  and 
perhaps  up  to  the  right  shoulder ;  this  form  is  usually  increased  on 
mowment.  [b]  Pain  is  also  complained  of,  due  to  the  adhesions 
which  form  about  the  gall-bladder,  and  hamper  the  movements  of 
the  stomach  or  intestine ;  this  is  often  epigastric  in  location,  and  may 
be  of  a  colickv  nature,  especially  after  meals,  (c)  The  worst  pain  is 
the  typical  biliary  colic,  due  to  the  efforts  of  Nature  to  expel  the 
stones.  This  is  often  of  an  excruciating  character,  starting  suddenly, 
continuing  for  a  while,  and  often  ceasing  as  suddenly  as  it  com- 
menced when  the  stone  passes  on  or  slips  back ;  the  patient  may  be 
collapsed  owing  to  its  severity.  It  radiates  from  the  right  hypo- 
chondrium, shooting  over  the  scapular  region  and  into  the  back ;  the 
gall-bladder  mav  be  enlarged  and  tense  during  the  attack,  and  the 
liver  somewhat  swollen.  Vomiting  occurs  during  or  after  an  attack 
of  biliarv  colic,  especially  when  adhesions  to  the  stomach  or 
duodenum  are  present.  Jaundice  is  not  usual  except  after  an  attack 
of  biharv  colic,  and  is  then  due  to  the  swelling  of  the  mucous  lining 
of  the  biliarv  passages,  preventing  the  escape  of  bile ;  if  the  stone 
slips  back,  it  is  not  so  likely  to  occur.  The  presence  of  many  loose 
gall-stones  usually  determines  an  enlargement  of  the  gall-bladder, 
which  can  be  felt  from  the  outside. 

3.  Impaction  of  a  stone  in  the  cystic  duct  is  characterized  by  pain, 
which  is  more  or  less  persistent,  but  wdth  paroxysmal  exacerbations, 
and  the  gall-bladder  becomes  distended  with  its  own  mucoid  secre- 
tion [kvdrops),  until  it  mav  attain  a  considerable  size.  Jaundice  is 
usuaUv  absent.  Not  uncommonly  acute  inflammatory  phenomena 
follow" (acute  suppurative  cholecystitis),  and  this  may  lead  to  ulcera- 
tion or  perforation.  Less  frequently  chronic  suppuration  occurs, 
constituting  an  empyema  of  the  gall-bladder. 

4.  Occasionallv  a  stone  becomes  lodged  at  the  junction  of  the 
cystic  and  the  hepatic  ducts,  and  then  the  manifestations  of  obstruc- 
tion are  verv  severe,  and  the  pain  may  be  very  acute.  Icterus  is 
intense,  but" the  gall-bladder  may  be  empty;  the  liver  is  certain  to 
be  much  enlarged. 

5.  The  presence  of  gall-stones  in  the  common  duct  may  give  rise  to 
s\Tnptoms  of  the  most  diverse  tvpe;  a  small  stone  may  originate 
ver^-  severe  phenomena,  whilst  a  much  larger  stone  may  cause  less 
trouble.  Frequentlv  several  stones  are  present,  and  sometimes  they 
are  embedded  in  a  mass  of  soft  '  biliary  mud,'  consisting  of  inspis- 
sated bile  salts.  Their  location,  too,  varies  considerably;  a  single 
stone  is  perhaps  found  most  frequently  in  the  lower  part  of  the  duct, 
whilst  multiple  stones  involve  its  whole  length.  The  sjmiptoms 
caused  are  pain  of  a  paroxvsmal  character  accompanied  by  vomiting, 
and  jaundice,  sometimes  of  a  severe  type,  occasionally  less  marked, 
but  rarelv  as  persistent  as  the  jaundice  due  to  mahgnant  disease. 
The  stone  is  more  or  less  moveable,  and  acts  as  a  ball- valve,  at  times 

68 


I074  A   MANUAL  OF  SURGERY 

allowing  a  certain  amount  of  bile  to  pass.  In  malignant  disease  the 
obstruction  is  absolute,  and  the  jaundice  is  thereby  maintained.  The 
Hver  is  enlarged  owing  to  back  pressure  of  bile,  l)ut  the  gall-l)Iadder 
does  not  participate  in  this  distension,  whereas  in  malignant  disease 
or  other  causes  of  persistent  jaundice  it  is  often  dilated  to  a  consider- 
able degree  (Courvoisier's  law).  If  the  stone  is  located  in  the 
ampulla  of  Vater,  it  is  easy  to  understand  that  pancreatic  troubles 
are  likely  to  be  associated  with  the  jaundice,  but  it  may  ulcerate  into 
the  duodenum  without  much  difficulty.  Should  a  perforation  form 
posteriorly,  the  retroperitoneal  cellular  tissue  becomes  involved,  and 
a  subphrenic  abscess  may  result. 

The  Treatment  of  gall-stones  is,  in  the  first  place,  medical  in 
character,  and  consists  in  a  rigid  attention  to  the  diet  which  should  be 
simple  and  easily  digestible ;  this  is  accompanied  by  regular  exercise 
and  the  use  of  alkaline  purgatives  of  a  saline  character  and  an 
abundance  of  pure  water.  This  is  best  carried  out  at  a  spa  such  as 
Harrogate  or  Carlsbad,  but  can  be  arranged  for  at  home,  if  the 
patient  will  submit  to  the  necessary  regulations.  Biliary  cohc  is 
treated  by  fomentations,  and  if  need  be  by  an  injection  of  morphia; 
it  is  perhaps  wise  to  administer  salol  or  some  other  intestinal 
antiseptic,  whilst  salicylate  of  soda  assists  in  increasing  the  fluidity 
of  the  bile.  It  is  quite  an  arguable  question  as  to  what  happens  in 
such  cures,  whether  the  stones  are  softened  and  passed,  or  whether 
they  become  acclimatized  in  the  gall-bladder  and  cease  to  cause 
trouble.  At  any  rate,  it  is  important  not  to  waste  too  much  time  in 
this  direction,  should  the  s}Tnptoms  persist.  It  has  been  already 
pointed  out  that  gall-stones  are  not  to  be  looked  on  as  perfectly 
innocuous;  inflammatory  troubles  of  a  serious  character  and  even 
malignant  disease  may  be  caused  by  them,  and  therefore  the  per- 
sistence of  symptoms,  and  especially  their  aggravation,  indicates  the 
necessity  for  surgical  interference.  The  proceedings  required  vary 
somewhat  according  to  the  location  of  the  stones,  and  different 
operative  measures  have  been  devised  in  order  to  deal  effectively 
with  these  varied  conditions. 

It  must  be  remembered  that  the  existence  of  gall-stones  is  an 
evidence  of  chronic  inflammation  of  the  lining  mucous  membrane  of 
the  gall-bladder,  and  that  the  mere  presence  of  the  stones  maintains 
and  increases  this  irritation  so  that  the  walls  are  usually  in  a  sclerosed 
or  thickened  condition.  The  simple  removal  of  the  gall-stones  does 
not  necessarily  cure  the  inflammatory  trouble,  and  hence  recurrence 
is  by  no  means  uncommon ;  moreover,  the  sclerosed  wall  of  the  gall- 
bladder freed  from  irritation  often  contracts  down,  and  the  result  is 
that  the  organ  becomes  shrunken  and  functionally  useless.  Hence  in 
a  large  percentage  of  cases  it  is  useless  to  attempt  to  save  the  gall- 
bladder, and  the  general  rule  of  treatment  is  that  when  it  is  probable 
that  recurrence  of  gall-stones  may  be  expected  or  the  functional 
value  of  the  gall-bladder  destroyed,  complete  excision  of  the  organ 
and  of  the  contained  stones  should  be  undertaken.  Cholecystectomy 
is  also  indicated  when  a  stone  has  been  firmly  impacted  in  the  cystic 


ABDOMINAL  SURGERY  1075 

duct;  a  stricture  in  that  position  is  almost  certain  to  follow  the 
removal  of  the  stone,  and  hydrops  or  empyema  of  the  gall- 
bladder will  result.  In  acute  cholecystitis  of  calculous  origin, 
excision  is  usually  desirable,  as  also  in  the  more  chronic  suppurating 
cases. 

Incision  with  removal  of  the  stones  and  subsequent  suture  of  the 
gall-bladder  {cholecystendysis)  is  occasionally  permissible,  but  only 
when  the  calculous  history  is  insignificant,  or  when  a  gall-stone  is 
discovered  by  accident  during  an  abdominal  operation.  Drainage 
is  probably  unnecessary  in  the  majority  of  cases  where  the  gall- 
bladder wall  is  tolerably  healthy. 

In  cases  where  the  symptoms  have  not  been  very  severe,  but  the 
patient  has  suffered  for  some  time  from  pain  and  recurring  '  bilious  ' 
attacks,  and  looks  sallow  and  slightly  jaundiced,  and  yet  on  explora- 
tion the  gall-bladder  is  free  from  adhesions  and  not  much  altered  in 
its  structure,  it  may  be  wise  to  drain  it  for  a  while  after  removing  the 
stones  [cholecystostomy)  rather  than  to  excise  it.  The  flow  of  bile 
relieves  the  hepatic  congestion,  and  improves  the  condition  of  the 
patient.  Moreover,  calculi  in  such  cases  sometimes  develop  in  the 
biliary  passages  higher  up,  and  an  opportunity  for  the  escape  of  these 
is  thereby  afforded.  A  drainage-tube  is  placed  in  the  fundus  of  the 
gall-bladder  and  secured  by  catgut  stitches,  which  are  dissolved  in 
about  a  week  and  set  the  tube  free.  The  flow  of  bile  usually  persists 
for  another  week  or  two  and  then  ceases,  the  wound  in  the  gall- 
bladder closing  by  granulation  when  the  wound  is  packed.  Should 
it,  however,  continue  for  any  length  of  time,  further  operative 
measures  in  the  direction  of  closing  the  opening  in  the  gall- 
bladder by  invagination  of  the  margin  and  over-stitching  will  be 
required,  or  the  organ  is  removed  completely  and  the  cystic  duct 
ligatured. 

Impaction  of  a  calculus  in  the  cystic  duct  usually  necessitates 
excision  of  the  gall-bladder,  inasmuch  as  a  stricture  of  the  duct  is 
almost  certain  to  follow  incision  and  removal  of  the  stone.  Should 
it,  however,  be  fixed  close  to  its  junction  with  the  common  bile-duct, 
it  may  be  better  to  free  the  gall-bladder  and  remove  it  by  dividing 
the  C3/stic  duct  on  the  distal  side  of  the  stone,  which  is  then  extruded 
by  digital  pressure  or  delivered  by  a  scoop.  The  biliary  passage 
may  then  be  drained  for  a  while,  or  the  duct  closed  by  ligature  or 
suture. 

A  stone  in  the  common  bile-duct  is  removed  by  exposing  and 
incising  the  duct  {choledochotomy) .  There  is  but  little  difficulty  in 
effecting  this  if  the  stone  is  in  the  upper  part  above  the  duodenum ; 
the  stone  is  localized  and  fixed,  and  the  duct  incised  longitudinally 
over  it.  The  peritoneum  is  guarded  by  suitable  swabs,  and  the 
stone  is  then  removed.  Careful  examination  should  be  made  both 
upwards  to  the  liver  and  down  to  the  intestine  by  a  probe  to  make 
certain  that  no  further  stones  are  present.  If  a  stone  is  lodged 
behind  the  second  piece  of  the  duodenum,  it  may  be  possible  to 
manipulate  it  up,  and  make  it  accessible  above  the  intestine;  but 


1076  A   MANUAL  OF  SURGERY 

otherwise  the  duodenum  must  be  mobilized  by  dividing  the  peji- 
toneum  on  its  outer  edge.  It  can  then  be  displaced  inwards  suffi- 
ciently to  enable  the  dilated  duct  and  stone  to  be  reached  from  the 
outer  side.  In  both  of  these  operations  an  effort  may  be  made  to 
close  the  ducts  with  sutures  which  do  not  encroach  on  the  mucous 
membrane;  but  it  is  probably  wiser  to  introduce  a  drainage-tube 
into  and  up  the  duct  for  a  few  days  so  as  to  relieve  the  engorgement 
of  the  liver,  which  is  certain  to  be  present.  These  wounds  usually 
heal  quite  satisfactorily. 

In  a  few  cases,  when  the  stone  is  lodged  in  the  lowest  portion  of  the 
duct,  it  may  be  necessary  to  incise  the  duodenum  longitudinally 
front  and  back,  and,  after  extracting  the  stone,  to  make  a  listula 
between  the  duct  and  the  posterior  wall  of  the  intestine  [internal 
choledocho-duodenostomy).  An  impacted  stone  should  never  be  left 
in  sihi,  as,  although  it  may  pass  at  the  end  of  a  few  days  or  weeks,  it 
will  cause  much  pain,  and  before  becoming  dislodged  it  may  do  much 
harm,  not  only  to  the  biliary  apparatus,  but  also  to  the  pancreas. 

Operations  on  the  Biliary  Passages. — No  special  preparation  of  the  patient 
is  required,  although  some  surgeons  recommend  that  in  cases  which  have  been 
long  jaundiced  it  is  wise  to  give  20  or  30  grains  of  lactate  of  calcium  per  rectum 
once  or  twice  previously,  so  as  to  lessen  the  bleeding,  which  has  a  tendency 
to  persist;  one's  own  personal  experience  does  not  confirm  this  statement. 

It  is  wise  in  all  operations  on  the  biliary  passages  to  introduce  a  firm  sand- 
bag horizontally  beneath  the  patient's  back,  so  as  to  throw  the  liver  forwards, 
and  thereby  gain  better  access  to  the  deeper  parts. 

The  incisions  suggested  vary  somewhat,  but  that  usually  employed  is  a 
vertical  one,  3  or  4  inches  in  length,  to  the  outer  margin  or  through  the  sub- 
stance of  the  rectus;  this  would  suffice  if  the  gall-bladder  is  merely  to  be 
emptied  of  stones,  and  is  easily  accessible.  But  when  it  is  tied  down  by 
adhesions  to  the  under  surface  of  the  liver,  or  has  to  be  completely  excised,  or 
when  the  common  bile-duct  has  to  be  explored  or  opened,  a  more  extensive 
approach  will  be  required,  and  this  is  gained  by  carrying  the  vertical  incision 
inwards  parallel  to  the  costal  margin  and  about  i^  inches  from  it,  extending 
across  the  rectus  muscle  to  the  middle  line  if  necessary  (Fig.  473,  B).  It  has 
recently  been  recommended  by  Perthes*  that  the  incision  should  be  made 
close  to  the  middle  line,  extending  from  the  ensiform  cartilage  nearly  to  the 
umbilicus,  and  then  crossing  the  rectus  horizontally  outwards  to  the  margin 
of  the  ribs.  The  fibres  of  the  rectus  muscle  are  secured  by  mattre.ss  sutures 
to  the  anterior  layer  of  the  sheath  above  and  below  before  being  divided  so  as 
to  prevent  retraction,  and  the  rectangular  flap  of  skin  and  muscle  is  then 
dissected  up  off  the  posterior  layer  of  the  sheath  and  peritoneum,  which  are 
divided  by  an  obhque  incision.  The  main  object  of  this  procedure,  which 
gives  an  admirable  approach  to  the  biliary  passages,  is  to  avoid  division  of 
the  nerves  supplying  the  rectus  muscle.  It  may  be  employed  with  advantage 
except  in  cases  where  drainage  is  likely  to  be  necessary. 

The  peritoneum  being  opened,  the  liver  is  drawn  upwards  and  outwards, 
and  the  intestines,  stomach,  and  omentum  downwards  and  inwards  after 
protecting  them  by  abdominal  cloths.  In  the  absence  of  adhesions,  the  object 
of  the  operation  can  usually  be  attained  without  much  difhculty,  but  not 
unfrequently  the  presence  of  adhesions  complicates  matters  considerably; 
they  must  be  carefully  divided  with  a  view  to  preventing  subsequent  haemor- 
rhage. If  the  gall-bladder  is  much  distended,  it  is  sometimes  necessary  to 
tap  it  and  empty  out  its  contents  before  a  decision  as  to  diagnosis  or  treat- 
ment can  be  reached.     Care  must  be  taken  not  to  allow  the  peritoneum  to 


M.  W.  Gray,  British  Medical  Journal  of  Surgery,  October,  1913,  p.  200. 


ABDOMINAL  SURGERY  1077 

be  soiled  by  the  escape  of  bile,  mucus,  pus,  or  stones,  which  are  almost  always 
infecteil. 

For  cholecystendysis,  the  trocar  puncture  is  enlarged  by  the  knife,  and  the 
stone  or  stones  rcmoxeil  by  forceps,  scoop,  or  by  digital  extrusion,  and  then 
the  opening  is  closed  by  sutures  which  do  not  encroach  on  the  mucous  mem- 
brane. One  or  two  rows  of  stitches  may  be  employed  according  to  the  con- 
ilition  of  tlie  gall-bladder  wall,  and  it  may  be  wise  to  strengthen  the  site  of 
union  by  an  omental  graft.  For  cholecystostomy,  a  medium-sized  drainage- 
tube  without  lateral  openings  is  stitched  into  the  gall-bladder  by  catgut 
sutures,  which  should  last  about  a  week.  The  gall-bladder  is  then  fixed  to 
the  parietal  peritoneum,  and  the  remainder  of  the  wound  closed.  It  is  often 
wise  to  protect  the  abdominal  cavity  from  leakage  by  packing  off  the  gall- 
bladder area.  The  outer  end  of  the  tube  is  passed  into  a  bottle  lying  by  the 
patient's  side,  in  which  the  bile  collects.  When  the  tube  becomes  loose,  the 
wound  IS  lightly  packed  with  gauze,  and  for  a  time  the  patient's  condition  is 
uncomfortable,  as  the  bile  escapes  into  the  dressings,  which  must  be  fre- 
quently changed.  As,  however,  the  wound  granulates,  it  becomes  more 
diflicult  for  the  bile  to  escape  externally,  and  more  easy  for  it  to  follow  its 
natural  course,  and  hence  after  two  or  three  weeks  the  external  flow  usually 
ceases,  and  the  wound  may  be  allowed  to  close.  Should,  however,  the  escape 
of  bile  persist,  further  treatment  becomes  necessary.  If  the  presence  of  a 
certain  amount  of  bile  in  the  motions  indicates  that  the  common  bile  duct 
is  free  from  obstruction,  the  opening  in  the  gall-bladder  may  be  completely 
closed  by  sutures  after  freeing  it  from  adhesions.  The  absence  of  bile  in  the 
stools,  however,  suggests  the  presence  of  some  stricture  or  obstruction  in  the 
bile-duct,  and  if  this  cannot  be  dealt  with,  cholecystenterostomy  must  be 
undertaken. 

Cholecystectomy,  as  already  mentioned,  is  the  operation  of  choice  in  the 
majority  of  cases  of  gall-stones.  It  is  usually  not  a  difficult  proceduie.  and 
the  mortality  is  small.  The  serous  coat  is  divided  on  either  side  and  over 
the  fundus  about  a  centimetre  from  its  reflexion  from  the  liver,  and  a  line  of 
cleavage  is  generally  found  w'ithout  difficulty  between  the  capsule  of  Ghsson 
and  the  body  of  the  viscus.  It  is  then  easy  to  separate  it  from  the  liver: 
the  cystic  vessels  are  secured  by  ligature,  and  finally  the  cystic  duct  is  tied 
and  divided.  If  possible,  the  peritoneal  coat  is  drawn  together  over  the  gap 
left  by  the  removal  of  the  gall-bladder,  but  it  is  usually  necessary  to  pack 
this  space  with  gauze  for  a  few  days. 

Cholecystenterostomy,  or  the  formation  of  an  artificial  communication 
between  the  gall-bladder  and  the  bowel,  is  required  in  cases  where  jaundice 
persists,  owing  to  absolute  stenosis  of  the  common  duct.  It  has  also  been 
undertaken  for  the  relief  of  jaundice  due  to  malignant  disease,  either  of  the 
common  bile-duct,  the  head  of  the  pancreas,  or  of  the  intestine;  the  relief 
given  under  these  circumstances  is,  of  course,  only  temporary.  The  parts  are 
exposed  as  described  above,  the  gall-bladder  and  duodenum  are  brought  into 
contact,  and  a  lateral  anastomosis  made  by  simple  suturing  by  a  technique 
similar  to  that  employed  for  a  lateral  anastomosis  of  the  intestine. 

Tumours  of  the  Gall-bladder  and  Biliary  Passages  are  usually 
malignant,  and  of  a  columnar  carcinomatous  type ;  benign  tumours 
are  very  rare,  and  merely  of  pathological  interest.  Cancer  is  com- 
paratively common,  and  is  so  constantly  associated  with  gall-stones 
(some  authorities  state  that  go  to  95  per  cent,  of  such  cases  also  have 
gall-stones)  as  to  suggest  that  the  irritation  of  the  latter  may  induce 
the  neoplastic  formation.  The  disease  is  about  three  times  as 
common  in  women  as  in  men.  Cancer  of  the  gall-bladder  usually 
commences  near  the  fundus  and  spreads  upwards.  The  s\'mptoms 
and  signs  are  those  of  a  hard,  painless  swelling  in  the  region  of  the 
gall-bladder,  with  progressive  loss  of  weight,  and  later  on  jaundice 


1078  A   MANUAL  OF  SURGERY 

and  ascites.  Primary  cancer  of  the  common  l:)ilc-duct  is  rarer,  and 
causes  jaundice,  without  pain,  as  an  early  symptom,  together  with 
distension  of  the  gall-bladder.  The  jaundice  is  persistent,  and 
gradually  increases  in  severity.  Gastric  symptoms  from  pressure  of 
the  growth  on  the  pylorus  or  duodenum  may  follow,  and  extension 
in  various  directions  may  determine  different  manifestations.  In 
either  of  these  affections  lymphatic  dissemination  along  the  falci- 
form ligament  may  lead  to  the  appearance  of  a  secondary  nodule  in 
the  region  of  the  umbilicus,  which  may  be  of  diagnostic  import. 

Treatment  is  rarely  practicable,  as  the  disease  is  usually  recognised 
too  late.  Excision  of  the  gall-bladder,  and,  if  need  be,  of  the  neigh- 
bouring portion  of  the  liver,  may  be  practicable  in  a  few  cases;  for 
tumours  of  the  common  bile-duct,  excision  is  usually  impossible,  but 
cholec\'stenterostomy  may  relieve  the  intense  jaundice  and  add  to 
the  patient's  comfort. 

Affections  of  the  Pancreas. 

The  pancreas  is  a  glandular  organ  which  secretes  an  active 
digestive  juice,  which  escapes  into  the  intestine  through  the  duct  of 
Wirsung  (Fig.  501,  DW),  which  traverses  the  whole  length  of  the 
gland,  and  opens  with  the  common  bile-duct  into  the  ampulla  of 
Vater ;  a  small  accessory  duct  of  Santorini  (DS)  opens  into  the  bowel 
about  an  inch  higher  up.  The  pancreas  has  only  recently  received 
much  attention  from  surgeons;  its  depth  and  anatomical  relations 
explain  the  neglect  with  which  it  was  treated  for  so  long.  At  the 
present  time  its  affections  are  being  studied  with  a  keen  interest,  and 
considerable  operative  activity  is  being  directed  towards  it.  There 
are  two  chief  methods  of  approaching  it:  (i)  The  transperitoneal,  in 
which  the  abdomen  is  opened  in  the  middle  line  above  the  umbilicus ; 
the  gland  is  reached  either  above  the  stomach  by  dividing  the  small 
omentum,  or  by  traversing  the  great  omentum  just  below  the  great 
curvature  of  the  stomach,  or  by  opening  through  the  transverse 
meso-colon.  (2)  The  retroperitoneal  method  consists  in  an  incision 
below  the  last  rib  in  the  lumbar  region,  but  only  the  head  or  the  tail 
is  exposed  b}^  this  procedure. 

There  are  two  chief  risks  associated  with  pancreatic  lesions  or 
operations:  (i.)  The  organ  is  very  freely  supplied  with  blood,  and 
it  is  extremely  difficult  to  ensure  haemostasis.  Ligature  of  the 
pancreatic  tissue  causes  necrosis,  and  from  the  necrotic  tissue 
ferments  are  set  free  which  act  injuriously  on  the  tissues  around, 
and  predispose  to  further  haemorrhage.  Deep  stitches  and  effective 
tamponade  can  alone  be  relied  on  in  this  direction,  (ii.)  The  leakage 
of  pancreatic  juice  is  a  serious  danger  to  the  patient  in  that  it  is 
likely  to  determine  necrosis  of  fat  wherever  it  spreads;  hence  foci  of 
fat  necrosis  may  be  found  scattered  extensively  through  the  omen- 
tum and  mesentery  in  all  acute  pancreatic  lesions.  Moreover,  it  acts 
most  prejudicially  on  the  peritoneum,  and  induces  either  an  aseptic 
peritonitis  and  intestinal  paralysis  which  may  prove  fatal,  or  deter- 
mines an  infective  peritonitis  if  bacteria  are  present. 


ABDOMINAL  SURGERY  1079 

Wounds  of  the  Pancreas  are  due  to  direct  violence  applied  to  the 
ci)igastrium,  and  may  result  from  penetrating  or  non-penetrating 
injuries.  They  are  usually  accompanied  by  lesions  of  other  viscera, 
such  as  the  stomach  or  duodenum,  and  surgeons  should  remember 
the  necessity  for  examining  this  viscus  in  any  traumatic  condition 
hi  the  neighbourhood.  Deep  sutures  and  tamponade  must  be  used 
in  all  cases  where  solution  of  continuity  has  occurred,  the  latter  being 
needed  not  only  as  a  haemostatic  agent,  but  also  in  order  to  drain 
away  any  leakage  of  pancreatic  fluid.  Prolapse  through  an  abdom- 
inal wound  has  been  recorded  in  a  few  cases,  the  organ  having  been 
almost  entirely  separated  from  its  connections ;  however  bruised  or 
damaged,  its  total  extirpation  must  never  be  resorted  to,  since 
diabetes  is  certain  to  follow;  it  should  therefore  be  carefully  purified 
and  replaced. 

Acute  Pancreatitis  is  a  grave  affection,  frequently  fatal,  and  not 
uncommonly  mistaken  for  acute  obstruction  until  diagnosed  on  the 
operating  or  post-mortem  table.  It  may  follow  an  injury,  and  is 
then  due  to  an  interstitial  haemorrhage,  which  gradually  increases ;  a 
similar  hemorrhage  sometimes  appears  spontaneously  in  alcohohc 
subjects,  and  is  termed  a  '  pancreatic  '  apoplexy;  it  is  quite  possible 
for  such  cases  to  run  an  acute  course  and  even  prove  fatal  without 
infection.  More  usually  the  condition  is  infective,  the  bacteria 
reaching  the  gland  from  the  intestine,  or  is  determined  by  regurgita- 
tion of  bile  owing  to  the  impaction  of  a  bihary  calculus  in  the  ampulla 
of  Vater.  Pancreatic  calculi  also  occur,  and  may  light  up  an  attack 
of  acute  pancreatitis;  they  are  usually  small  and  elongated,  consist- 
ing mostly  of  carbonate  of  lime,  fhe  organ  becomes  enlarged, 
thickened,  and  congested;  purulent  foci  are  scattered  here  and  there 
through  it,  and  in  and  around  it  are  found  necrotic  spots  due  to  the 
action  of  the  pancreatic  secretion.  Sometimes  the  whole  gland  or 
a  large  portion  of  it  has  been  known  to  slough.  An  inflammatory 
effusion  develops  in  front,  which  is  usually  purulent  and  sometimes 
haemorrhagic ;  it  may  be  limited  to  the  lesser  sac  of  the  peritoneum, 
then  following  the  lines  of  a  subphrenic  abscess,  or  it  may  involve 
the  general  peritoneal  cavity. 

The  Symptoms  vary  much,  but  usually  start  suddenly  with  acute 
epigastric  pain,  which  soon  becomes  excruciating.  This  is  accom- 
panied by  nausea  and  sickness,  by  constipation  and  abdominal 
distension,  and  by  a  serious  collapse  which  may  quickly  prove  fatal. 
The  pain  is  due  to  the  swollen  organ  pressing  on  the  coeliac  plexus 
of  nerves.  The  swelling  of  the  abdomen  commences  in  the  epigas- 
trium, and  may  for  a  time  be  limited  to  that  region,  but  subsequently 
the  phenomena  of  acute  diffuse  peritonitis  may  supervene.  Occa- 
sionally the  trouble  quiets  down  at  the  end  of  a  few  days,  but  much 
more  frequently  it  is  fatal.  The  Diagnosis  usually  made  is  that  of 
acute  obstruction,  or  acute  generalized  peritonitis,  and  the  true  nature 
of  the  case  is  only  recognised  on  opening  the  abdomen.  Treatment 
consists  in  laparotomy  and  giving  an  exit  to  the  inflammatory 
exudate.  If  diffuse  peritonitis  is  present,  the  abdominal  cavity 
must  be  opened  above  and  below  and  irrigated,  and  the  local  trouble 


io8o  A   MANUAL  OF  SURGERY 

exposed;  dead  pancreatic  tissue  should  be  removed,  and  effective 
drainage  provided.  If  a  localized  abscess  forms,  the  greatest  care 
must  be  taken  to  guard  against  a  generalized  infection.  Posterior 
drainage  is  advisable  in  all  these  cases. 

Chronic  Pancreatitis  is  not  to  be  looked  on  as  a  very  uncommon 
lesion.  It  is  frequently  associated  with  gall-stones  and  inflammation 
of  the  biliary  passages,  and  may  follow  gastro-duodenal  catarrh  or 
ulceration.  The  organ  becomes  harder  than  usual,  or  is  shrunken 
and  sclerosed.  It  may  produce  a  swelling  in  the  epigastrium  which 
is  likely  to  be  mistaken  for  a  pancreatic  carcinoma,  or  the  symptoms 
may  be  mainly  of  a  dyspeptic  type.  Fixed  epigastric  pain  is  often 
present,  and  a  tender  spot  a  little  above  the  umbilicus.  Diabetes 
may  arise  in  certain  forms  of  chronic  inflammation ;  offensive  diar- 
rhoea with  undigested  fat  in  the  stools  and  rapid  wasting  are  also 
suggestive  symptoms.  Operative  treatment  may  be  of  value,  since 
pancreatic  or  bihary  calculi  may  be  found  obstructing  the  duct; 
apart  from  this,  benefit  has  certainly  been  derived  by  cholecysto- 
stomy  and  drainage  of  the  biliary  passages. 

Cysts  of  the  Pancreas  have  been  observed  and  treated  in  so  many 
cases  since  1887  that  their  characters  are  pretty  clearly  known. 
Simple  complete  obstruction  to  the  duct  has  been  proved  experi- 
mentally not  to  be  a  sufficient  cause  for  the  disease;  some  patho- 
logical condition  of  the  epithelium  must  also  be  present,  preventing 
the  re-absorption  of  the  retained  secretion.  Slight  traumatism  is 
not  an  uncommon  cause,  and  a  cyst  may  develop  as  a  sequela  of  an 
attack  of  inflammation  which  has  quieted  down.  The  fluid  within  is 
usually  turbid,  and  brownish  from  admixture  with  blood,  odourless, 
and  with  a  fairly  high  specific  gravity;  it  is  of  an  alkaline  or  neutral 
reaction,  and  contains  albumen,  but  no  urea  or  bile;  it  is  capable  of 
peptonizing  albumen,  of  emulsif3ang  fat,  and  of  converting  starch 
into  sugar.  The  cyst  can  be  felt  as  a  rounded,  tense,  fluctuatmg  or 
elastic  swelling,  placed  deeply  in  the  abdomen,  immoveable,  and 
perhaps  transmitting  the  aortic  pulsation.  The  relations  of  a  cyst 
to  the  stomach  and  transverse  colon  vary  (Figs.  502-504) ;  the  cyst 
primarily  forms  behind  the  stomach,  but  when  it  attains  any  con- 
siderable size  it  projects  anteriorly,  and  then  most  commonly 
approaches  the  abdominal  wall  below^  the  stomach  and  above  the 
transverse  colon  (Fig.  503).  More  rarely  it  presents  above  the 
stomach  (Fig.  502),  or  below  the  transverse  colon  (Fig.  504).  Pan- 
creatic C3^sts  usualh'  develop  in  middle  life,  occurring  most  frequently 
in  men.  Emaciation  is  sometimes  marked,  since  a  good  proportion 
of  the  fatty  food  passes  away  in  the  motions;  the  skin  is  often  dirty, 
earth}-,  and  unhealthy-looking. 

Treatment  consists  in  laying  the  cyst  bare,  the  surgeon  usually 
finding  his  way  to  it  between  the  stomach  and  transverse  colon. 
Its  contents  are  then  drawn  off  by  trocar  and  cannula,  and  arrange- 
ments made  for  drainage.  A  large  tube  is  inserted,  either  through 
the  front,  or  from  the  back  by  the  side  of  the  vertebrse.  The  skin 
around  usually  becomes  irritated  by  the  discharge,  owing  to  a 
process  of  digestion.     The  prognosis  with  such  treatment  is  good, 


ABDOMINAL  SURGERY 


1081 


although  healing  may  be  slow,  and  a  permanent  fistula  may  develop. 
Kortc  collected  loi  cases  operated  on,  and  of  these  5  died,  4  from  the 
the  direct  result  of  the  operation,  i  from  infection  of  the  fistula. 

Carcinoma  of  the  Pancreas  is  met  with  cither  as  a  primary  growth 
of  a  spheroidal-celled  type,  usually  scirrhus,  or  is  secondary  to  a 
similar  disease  of  the  stomach  or  pylorus.  The  condition  is  not 
necessarily  painful  in  the  early  stages,  and  produces  an  ovoid  or 
oblong  mass  at  the  junction  of  the  epigastric  and  right  hypochondriac 
regions.  As  it  develops,  it  becomes  more  painful,  and  the  patient 
quickly  wastes  and  loses  appetite  and  energy.  Jaundice  gradually 
supervenes,  and  becomes  absolute,  with  an  enlarged  gall-bladder; 
the  abdomen  is  distended  with  fluid  from  pressure  on  the  portal 


Fig.  502. 


Fig.  503. 


Fig.  504. 


Figs.  502-504.— Diagrams  to  represent  the  Varying  Relations  of 
Pancreatic  Cysts. 

In  Fi^^  502  the  cyst  (P)  projects  forwards  between  the  stomach  (5)  and  liver 
into  the  lesser  peritoneal  sac,  presenting  through  the  lesser  omentum. 
In  Fio-  503  the  cyst  is  located  below  the  stomach,  projectmg  forwards 
between  the  stomach  and  the  transverse  colon  (C).  In  Fig.  504. the  cyst 
lies  lower,  between  the  transverse  colon  above  and  the  small  mtestme 
with  its  mesentery. 

vein,  and  the  legs  may  become  cedematous  from  involvement  of  the 
inferior  vena  cava;  whilst  the  gro\\i:h  may  lead  to  distension  of  the 
stomach  from  pressure  on  and  constriction  of  the  pylorus.  In  one 
or  two  cases  removal  has  been  undertaken  with  success,  although  an 
exact  diagnosis  was  not  arrived  at  before  the  operation.  Sarcomata 
and  other  tumours  are  very  rare. 

Affections  of  the  Spleen. 
Rupture  of  the  Spleen  occurs  as  a  result  of  injury,  causing  great 
shock,  pain  in  the  left  hypochondrium,  and  internal  ^haemorrhage, 
usually  to  such  an  extent  as  to  prove  rapidly  fatal. 


In  less  severe 


io82  A   MANUAL  OF  SURGERY 

cases  the  l^lood  collects  in  the  left  loin,  and  gravitates  towards  the 
pelvis,  the  right  loin  being  often  kept  clear  by  the  position  of  the 
mesenter}'.  l.aparotomy  should  be  undertaken  whenever  practic- 
able, and,  if  much  damaged,  the  organ  is  removed,  the  splenic 
vessels  being  secured  by  ligature;  the  results  of  such  treatment  have 
been  most  satisfactory.  In  a  few  cast^  it  has  been  possible  to  stop 
the  bleeding  by  suturing  the  spleen,  or  by  inserting  a  gauze  tampon, 
which  is  removed  in  a  few  days. 

Abscess  o£  the  Spleen  may  develop  in  the  course  of  pycemia,  or 
follow  an  injury,  especially  if  associated  with  a  lesion  of  a  neighbour- 
ing coil  of  intestine.  The  symptoms  are  merely  those  of  deep 
suppuration  in  the  left  hypochondrium,  and  the  abscess  either  hnds 
its  way  externally,  or  bursts  into  the  peritoneal  cavity.  It  may  be 
opened  and  drained  with  the  same  precautions  as  for  any  other  intra- 
peritoneal collection  of  matter,  and  the  results  hitherto  obtained 
have  been  encouraging.  In  pyaemia  the  disease  is  often  fatal  before 
the  local  phenomena  are  recognised. 

Floating  Spleen  is  occasionally  congenital,  but  more  commonly 
acquired,  in  consequence  of  tight-lacing,  injuries,  or  the  presence  of 
tumours.  It  is  characterized  by  the  existence  of  a  moveable  intra- 
abdominal swelling,  whose  shape  is  that  of  the  spleen,  and  having  a 
notch  in  its  anterior  border;  its  size  increases  after  meals.  It  may 
be  so  displaced  as  to  lie  in  the  right  iliac  fossa,  or  even  in  the  pelvis, 
and  then  has  a  long  narrow  pedicle  which  has,  in  a  few  cases,  led  to 
its  torsion  and  strangulation.  Splenectomy  was  formerly  the  only 
treatment,  if  the  displaced  organ  caused  discomfort  or  pain;  it  has 
been  found  possible,  however,  to  fix  it,  and  several  successful  cases 
have  now  been  recorded.  Splenopexy,  as  the  operation  is  termed,  is 
best  undertaken  by  preparing  a  bed  for  the  organ  outside  the  peri- 
toneum in  the  loose  cellular  tissue  beneath  the  floating  ribs  on  the 
left  side.  The  spleen  is  then  shpped  through  a  small  hole  specially 
made  for  the  purpose  in  the  parietal  peritoneum,  and  secured  by 
stitches,  which  pass  through  its  capsule  and  anchor  it  to  the  under 
surface  of  the  diaphragm. 

Enlargement  of  the  Spleen  is  not  uncommon,  and  is  due  to  many 
different  causes.  It  is  characterized  by  a  swelling  which  extends 
downwards  from  the  left  hypochondrium  towards  the  umbilicus,  the 
notch,  perhaps,  being  felt  in  front ;  it  hugs  the  anterior  abdominal 
wall,  so  that  intestine  is  not  found  in  front  of  it,  whilst  a  resonant 
note  is  obtained  in  the  flank.  It  is  usually  moveable  with  respira- 
tion, and  occasionally  increases  in  size  after  meals. 

The  commonest  causes  of  this  condition  are  as  follows:  i.  Certain 
general  diseases,  such  as  malaria,  inherited  syphilis,  rickets,  lardace- 
ous  disease,  lymphadenoma,  or  generalized  tuberculosis.  2.  Passive 
hypersemia,  as  the  result  of  back-pressure  from  the  heart,  lungs,  or 
liver;  thus  it  occurs  in  chronic  valvular  disease  of  the  heart,  chronic 
pulmonar}/  disease,  and  cirrhosis  of  the  liver.  3.  It  is  also  met  with 
in  certain  blood  conditions,  such  as  spleno-medullary  leukaemia  (for 
blood-count,  see  p.  67) ;  splenic  anaemia,  in  which  the  splenic  enlarge- 
ment is  associated  with  a  chlorotic  type  of  anaemia,  and  is  followed 


ABDOMINAL  SURGERY  1083 

by  cirrhosis  of  the  liver,  leucocytosis  being  noticeably  absent,  the 
syndrome  constituting  what  is  known  as  Banti's  disease;  and 
polycytluemia,  in  which  there  is  an  increase  of  the  erythrocytes  and 
an  augmented  iKemoglobin  content  accompanying  the  enlargement 
of  the  spleen.  4.  A  simple  splenomegaly  or  hypertrophy  of  the 
spleen  exists,  in  which  the  swelling  is  accompanied  by  no  charac- 
teristic blood  changes.  5.  Tumours  and  cysts  of  the  spleen  also  lead 
to  its  enlargement :  the  former  are  usually  secondary  and  malignant 
in  nature;  the  latter  may  be  due  to  hydatid  disease,  or  be  of  the 
nature  of* a  simple  serous  cyst. 

The  differential  diagnosis  of  these  conditions  cannot  be  discussed 
here,  but  it  must  suffice  to  point  out  that  the  chief  reliance  must  be 
placed  on  a  careful  and  thorough  examination  of  the  blood,  together 
with  a  complete  investigation  of  the  condition  of  the  other  organs  of 
the  body. 

Treatment  necessarily  varies  with  the  cause,  but  if  medicine  is  of 
no  avail,  the  question  of  splenectomy  will  have  to  be  considered. 
This  operation  has  been  performed  for  many  different  affections,  and 
its  value  and  position  as  a  surgical  procedure  are  now  fairly  well 
established.  For  traumatic  lesions  it  is  both  safe  and  justifiable. 
For  splenomegaly  and  for  malarial  enlargement  it  may  be  performed, 
if  serious  discomfort  is  being  caused  and  cannot  be  otherwise 
remedied.  If  drainage  fails  to  cure  a  cyst,  or  if  a  primary  growth  is 
discovered  in  a  sufficiently  early  stage,  excision  may  be  undertaken. 
Splenectomy  for  leucocythsemia  is  absolutely  unjustifiable,  all  the 
cases  operated  on  having  died.  In  splenic  ansemia  excellent  results 
have  followed  removal  of  the  organ  in  the  few  cases  in  which  it  has 
been  attempted;  the  red  cells  subsequently  increased  rapidly  in 
numbers,  as  also  their  haemoglobin  content,  whilst  the  leucocyte 
count  remained  much  the  same.  Such  a  result  indicates  that 
possibly  the  condition  is  due  to  an  increased  destruction  of  erythro- 
cytes in  the  spleen,  which  is  brought  to  an  end  by  removing  the 
organ. 

The  operation  itself  is  performed  through  any  suitable  incision  of 
sufficient  length;  probably  one  in  the  linea  semilunaris  is  the  best. 
The  peritoneum  having  been  opened,  the  organ  is  carefully  examined 
to  ascertain  in  particular  whether  or  not  adhesions  are  present,  as,  if 
extensive,  any  attempt  to  break  them  down  might  result  in  fatal 
hsemorrhage.  If  the  organ  is  freely  mobile,  it  is  carefuhy  drawn  out 
of  the  abdomen,  and  the  anterior  layer  of  the  gastro-splenic  omentum 
divided  so  as  to  expose  the  vessels.  Care  is  taken  not  to  secure  the 
main  trunk  at  a  distance,  but  the  smaller  branches  as  they  enter  the 
hilum.  The  lieno-renal  and  lieno-phrenic  ligaments  are  divided,  and 
the  organ  thus  set  free  is  removed.  Gastric  hemorrhage  has  been 
known  to  occur  after  this  operation,  but  is  probably  due  to  absence 
of  care  in  securing  the  vessels  close  to  the  hilum,  as  if  the  splenic 
vein  is  tied  so  as  to  include  the  veins  returning  from  the  cardiac  end 
of  the  stomach  (vasa  brevia)  congestion  of  this  part  of  the  gastric 
wall  will  result,  and  may  cause  hsemorrhage. 


CHAPTER  XXXVI. 

HERNIA. 

By  the  term  Hernia  is  meant  the  protrusion  of  some  viscus  from  its 
normal  situation  through  an  opening  in  the  walls  of  the  cavity  within 
which  it  is  contained.  This  may  affect  not  only  the  abdominal 
viscera,  but  also  the  brain  and  lungs,  giving  rise  to  conditions  which 
have  been  already  described.  The  present  chapter  is  limited  to 
hernia  as  met  with  in  connection  with  the  abdomen. 

The  most  common  Situations  at  which  hernia  occurs  are  those 
spots  where  the  parietes  are  weakened  by  the  transmission  of  such 
structures  as  the  spermatic  cord  and  round  ligament  (inguinal 
hernia),  or  at  the  entrance  of  the  crural  canal,  where  the  main  vessels 
of  the  leg  pass  under  Poupart's  ligament  (femoral  hernia),  or  at  the 
umbilicus  (umbilical  hernia).  Hernial  protrusions  may,  however, 
develop  through  the  obturator  foramen,  sciatic  notch,  the  diaphragm, 
and  in  various  other  situations. 

^tiology.^ — A  great  many  conditions  may  be  associated,  directly  or 
indirectly,  with  the  production  of  a  hernia.  They  may,  however,  be 
described  for  practical  purposes  under  two  main  headings — the  con- 
genital and  the  acquired. 

Congenital  Causes  are  rather  predisposing  than  exciting  in  nature, 
and  must  be  looked  for  amongst  the  many  malformations  and  con- 
ditions of  imperfect  development  to  which  the  abdominal  parietes 
and  contents  are  liable.  The  follo^\^ng  are  the  most  important  of 
these:  (a)  The  non-obliteration  of  the  funicular  process  of  peri- 
tonemn,  which  in  the  male  precedes  and  accompanies  the  testicle  on 
its  progress  downwards  from  the  abdominal  cavity  to  the  scrotum, 
and  in  the  female  passes  along  the  round  ligament.  The  so-called 
congenital  inguinal  hernia  results  from  this,  although  it  must  be  re- 
membered that  the  rupture  does  not  necessarily  show  itself  at  birth, 
and,  indeed,  may  not  appear  till  after  puberty.  It  is  probable  that 
incomplete  obliteration  of  this  process  is  the  cause  of  a  great  majority 
of  the  cases  of  oblique  inguinal  hernia,  a  small  pouch  being  left  at  the 
upper  end.  It  is  often  possible  to  demonstrate  the  existence  of  this 
in  patients  with  weak,  bulging  groins,  but  with  no  actual  hernia.  In 
females  under  the  age  of  twenty-five,  hernia  into  the  canal  of  Xuck, 
as  this  peritoneal  tube  is  called,  is  the  most  frequent  variety  met  with. 

1084 


HERNIA  1085 

{b)  The  late  descent  of  the  testis,  whether  it  finds  its  way  into  the 
scrotum  or  not,  is  usually  associated  with  the  formation  of  an 
inguinal  hernia  of  the  congenital  type,  or  of  some  form  01  mterstitial 
hernia,  {c)  Inherited  weakness  of  the  abdominal  muscles  and 
parietes,  with  unusual  patency  of  the  rings,  will  certainly  predispose 
to  this  condition,  and,  moreover,  there  is  no  doubt  as  to  the  tendency 
of  hernia  to  run  in  f  amihes.  {d)  Abnormal  length  of  the  mesentery 
or  omentum  has  also  been  looked  on  as  a  causative  factor;  but, 
although  it  may  have  some  influence  when  other  conditions  are 
present,  it  can  per  se  have  but  little  effect,  {e)  Congenital  phimosis, 
by  inducing  forcible  acts  of  micturition,  acts  as  an  excitmg  cause. 
(/)  Congenital  apertures  occur  in  the  linea  alba  or  linea  semilunaris, 
especially  opposite  one  of  the  tendinous  intersections  in  the  rectus, 
and  through  these  one  form  of  ventral  hernia  may  develop,  (g)  The 
umbilicus  is  sometimes  imperfectly  developed  at  birth,  permitting 
the  viscera  to  protrude  into  the  base  of  the  umbilical  cord  (con- 
genital umbilical  hernia).  (A)  The  diaphragm  is  also  occasionally 
defective,  allowing  the  stomach  or  other  viscera  to  find  their  way 
into  the  thoracic  cavity. 

Acquired  Cawses.— Hernia  may  result  from  any  condition  whicli 
tends  either  to  weaken  the  abdominal  parietes,  or  to  increase  the 
intra-abdominal  pressure.  Thus  (i)  it  may  be  post-operative,  result- 
ing from  the  imperfect  development  of  a  cicatrix  after  a  laparotomy. 
(2)  It  may  be  the  outcome  of  direct  traumatisfn,  and  is  then  just  as 
likely  to  occur  away  from  the  hernial  regions.  If  seen  early,  the 
affected  area  \vill  probably  show  signs  of  injury,  such  as  tender- 
ness, swelHng,  and  ecchymosis,  but  a  hernia  is  by  no  means  a  neces- 
sary consequence.  It  is  unusual  for  an  ordinary  complete  hernia 
to  develop  after  injury  or  severe  strain,  unless  a  pre-formed  sac  is 
present,  and  then  immediate  strangulation  is  not  an  uncommon 
sequence;  apart  from  this,  the  hernia,  if  seen  soon  after  the  aUeged 
accident,  is  imperf ectlv  developed,  and  in  the  bubonocele  stage.  1  he 
fact  that  compensation  may  be  required  for  the  development  of  a 
hernia  should  make  practitioners  cautious  in  giving  opinions  as  to 
ffitiology.  (3)  Much  more  frequently  hernia  is  due  to  chronic  strain, 
such  as  occupations  which  involve  hfting  heavy  weights,  and  the 
more  so  if  the  individual  is  forced  to  maintain  the  upright  position, 
or  wears  tight  bands  or  girths  round  the  abdomen.  Prolonged  and 
severe  bronchitis,  and  frequent  straining  to  pass  water  m  cases  of 
enlarged  prostate  or  stricture,  may  determine  the  development  of  a 
hernia;  whilst  chronic  constipation  is  a  frequent  factor  m  its  pro- 
duction, especiallv  if  the  patient  makes  use  of  a  closet  with  a  high 
seat,  whereby  the'inguinal  canals  are  left  unprotected;  a  patient  with 
weak  and  bulging  inguinal  regions  may  with  advantage  use  a  low 
commode.  (4)  Relaxation  of  the  abdominal  parietes  also  favours 
hernia,  especiallv  if  associated  with  or  followed  by  severe  straining^ 
Thus  pregnancy  brings  about  a  stretching  of  the  wall,  especially  if 
frequentlv  repeated  and  followed  by  imperfect  involution;  and  par- 
turition determines  the  development  of  hernia,  either  m  the  crural 


io86  A  MANUAL  OF  SURGERY 

region  or  through  the  linea  alba.  Similarly  the  relaxed  and  atonic 
abdominal  wall,  which  bulges  down  in  the  hypogastric  region  in  old 
people,  favours  the  occurrence  of  a  direct  inguinal  hernia,  should  the 
patient  have  a  bad  cough  or  an  enlarged  prostate.  In  old  and 
weakly  people  an  additional  cause  may  be  found  in  the  slipping 
downwards  of  the  mesenteric  attachment,  causing  the  intestines  to 
occupy  the  lower  part  of  the  abdomen  rather  than  the  upper,  so  that 
the  former  bulges  out  over  the  pelvic  brim.  This  is  possibly  due  to 
weakening  or  relaxation  of  the  unstriped  muscular  tissue  which 
normally  exists  behind  the  peritoneum,  passing  from  the  posterior 
abdominal  wall  to  the  base  of  the  mesentery ;  it  is  sometimes  called 
the  muscle  of  Treifz.  (5)  Obesity  is  also  a  predisposing  factor  to 
hernia,  the  accumulated  fat  being  deposited  in  the  omentum,  mesen- 
tery, and  subperitoneal  tissue,  thus  increasing  the  intra-abdominal 
tension. 

Structure. — A  hernia  consists  of  a  sac  and  its  contents,  the  sac 
being  formed  of  peritoneum,  perhaps  thickened  by  additional  cover- 
ings, derived  from  the  abdominal  paiietes,  and  the  contents  being 
the  protruded  viscera. 

The  sac,  or  peritoneal  investment  of  an  acquired  hernia,  is  in  the 
early  stages  funnel-shaped,  small,  and  thin,  being  derived  from  that 
portion  of  the  serous  membrane  which  normally  lies  over  the  hernial 
aperture.  As  the  rupture  increases  in  size,  the  sac  becomes  larger, 
partly  by  stretching,  and  partly  by  the  drawing  down  of  fresh  mem- 
brane from  the  neighbourhood.  Occasionally  it  stretches  irregularly 
and  becomes  sacculated,  and  sometimes  the  sac  becomes  hour-glass- 
shaped,  probably  as  the  result  of  inflammation.  The  sac  is  described 
as  consisting  of  two  portions — the  neck  and  the  fundus.  The  neck, 
sometimes  large  and  open  at  first,  gradually  becomes  narrowed, 
and  is  generally  thickened  from  the  irritation  to  which  it  has  been 
exposed,  either  from  the  wearing  of  a  truss  or  from  the  pressure  of 
the  contained  viscera.  The  body,  or  fundus,  varies  much  in  size  and 
shape,  and  may  undergo  considerable  alterations  in  structure. 

{a)  The  sac  soon  becomes  adherent  to  surrounding  parts ;  and  with 
increasing  irritation,  as  by  a  truss,  these  adhesions  become  more 
definite,  [b)  Inflammation  may  occur  as  the  result  of  injury  or 
pressure,  constituting  a  form  of  localized  peritonitis.  If  this  is  of 
a  chronic  type,  the  sac  becomes  thickened  and  opaque,  with  dilated 
vessels  coursing  over  it,  as  seen  especially  in  old  irreducible  hernite. 
Acute  or  subacute  inflammation  is  also  met  with,  resulting  in  the 
formation  of  adhesions  between  the  inner  wall  and  the  contained 
viscera,  or  between  the  opposite  sides  of  the  sac,  if  no  other  structures 
interpose.  Natural  cure  of  a  hernia  may  occasionally  be  produced 
in  this  way  by  adhesions  forming  across  the  neck  of  the  sac,  or 
by  an  adherent  plug  of  omentum,  thus  occluding  the  communication 
with  the  peritoneal  cavity.  The  lower  portion  of  the  sac  may  in 
a  similar  way  be  shut  off  from  the  upper,  either  by  a  band  of  ad- 
hesions or  by  a  septum  of  adherent  omentum;  this  isolated  cavity 
is  sometimes  the  seat  of  a  serous  effusion,  known  as  a  hydrocele  of  a 


HERNIA  1087 

hernial  sac.  {c)  Hcemorrhage  into  the  sac  wall  may  result  from 
violence,  and  will  cause  it  to  become  much  thickened,  and  even 
pigmented  or  leathery  in  appearance. 

The  coverings  of  the  sac  are  indurated  in  old-standing  cases,  and 
matted  together  in  such  a  manner  as  to  make  it  difficult  to  recognise 
the  constituent  parts.  This  is  specially  noticeable  at  the  neck  of  the 
sac,  where  their  union  with  surrounding  structures  is  often  such  as 
to  constitute  an  important  predisposing  element  in  the  production 
of  strangulation.  The  opening  through  which  the  hernia  protrudes 
loses  its  characteristic  features  and  shape,  being  enlarged,  more  or 
less  circular,  and  displaced,  so  that  an  oblique  passage,  such  as  the 
inguinal  canal,  becomes  straight,  the  internal  abdominal  ring  lying 
almost  immediately  behind  the  external. 

Contents.^ — Any  viscus  in  the  abdomen  may  be  found  in  the  sac  of 
a  hernia,  except,  perhaps,  the  pancreas;  as  a  rule,  however,  one  finds 
only  small  intestine  or  omentum. 

An  enterocele  is  the  name  given  to  a  hernia  containing  some  portion 
of  the  bowel.  It  is  at  first  reducible ;  but  if  the  gut  becomes  adherent, 
either  to  the  sac  or  to  some  other  contained  structure,  it  is  rendered 
irreducible.  It  may  also  participate  in  an  inflammatory  condition  of 
the  sac ;  whilst,  if  irreducible,  obstruction  may  ensue  from  impaction 
of  its  contents,  and  if  its  vessels  are  constricted  strangulation  super- 
venes. For  a  description  of  these  conditions,  see  p.  mo.  The  small 
intestine  is  much  more  frequently  involved  than  the  large  gut.  The 
amount  of  bowel  protruded  varies  from  a  few  inches  to  several  feet. 

If  omentum  is  found  in  a  hernial  sac,  the  condition  is  known  as  an 
epiplocele.  As  long  as  it  remains  reducible,  it  is  likely  to  retain  its 
normal  texture;  but  when  large  in  amount,  and  especially  if  irre- 
ducible, it  becomes  thickened,  brawny,  and  matted  together  to  such 
an  extent  as  almost  to  constitute  a  solid  tumour ;  it  is  often  the  seat 
of  an  excessive  deposit  of  fat,  and  in  consequence  of  this  overgrowth 
it  may  become  irreducible,  even  when  no  adhesions  are  present. 
Serous  cysts  sometimes  develop  within  it  as  a  result  of  effusion  be- 
tween opposed  surfaces.  In  some  cases  openings  are  found  in  it  of 
sufficient  size  to  allow  the  gut  to  pass  through  and  become  strangu- 
lated. When  omentum  and  bowel  are  present  in  the  same  sac,  the 
condition  is  known  as  an  enter o-epiplocele. 

The  CcBctim  sometimes  occupies  a  hernial  sac,  either  in  aggravated 
and  large  hernise,  or  in  children  with  congenital  hernia;  it  has 
even  been  found  in  a  hernia  on  the  left  side.  Since  the  c^cum  ha,s 
generally  a  complete  serous  covering  and  usually  a  mesentery,  it  is 
freely  moveable,  and  may  pass  into  a  hernial  sac  in  the  same  way  as 
any  other  moveable  part  of  the  intestine.  On  the  other  hand,  a  few 
indisputable  cases  have  been  related  in  which  the  serous  envelope 
was  incomplete  in  a  so-called  '  csecocele.' 

The  Vermiform  A  ppendix  is  occasionally  found  in  a  hernial  sac  on 
the  right  side.  It  is  rarely  free,  but  generally  fixed  by  adhesions  and 
irreducible.  The  hernia  is  more  painful  than  usual,  and  on  palpation 
the  appendix  can  sometimes  be  felt  enlarged  and  tender,  pressure 


io88  A   MANUAL  OF  SURGERY 

causing  pain  referred  to  the  umbilicus.  The  patient  is  Hkely  to  give 
a  history  of  recurrent  attacks  of  inflammation  in  the  sac. 

The  Bladder  may  be  associated  with  a  hernial  sac  in  two  distinct 
ways,  and  usually  in  the  inguinal  region,  (a)  The  fundus  may  be 
dragged  downwards  by  the  traction  of  the  peritoneum,  when  the 
hernia  has  attained  a  colossal  size.  'Ihere  is  then  only  a  partial 
peritoneal  investment,  the  bladder  lying  outside  the  sac,  and  being 
adherent  to  it.  Considerable  irritability  of  the  viscus  is  induced, 
and,  owing  to  stagnation  of  urine  in  the  displaced  part,  a  phosphatic 
concretion  may  form  therein,  and  such  has  even  been  removed  by 
incision  through  the  scrotum,  {b)  Occasionally  a  saccule  of  the  outer 
wall  of  the  bladder  becomes  adherent  to  the  peritoneum,  and  is 
drawn  down  by  it  into  the  inguinal  canal ;  its  presence  may  be  sus- 
pected if  a  small  hernia  is  associated  with  much  vesical  irritability. 
The  saccule  consists  merely  of  thickened  mucous  membrane  and 
submucous  tissue,  and  is  devoid  of  muscular  fibres ;  it  is  very  liable 
to  be  laid  open  when  an  operation  for  the  radical  cure  is  under- 
taken. If  such  an  accident  happens,  the  saccule  should  be  excised, 
and  the  opening  at  once  closed  by  sutures,  which  should  not  pene- 
trate the  mucous  membrane.  Failure  to  recognise  this  accident  is 
followed  by  urinary  extravasation,  possibly  intraperitoneal,  and  will 
require  prompt  treatment  if  a  fatal  issue  is  to  be  avoided.  Ihe 
wound  must  be  re-opened,  the  gap  in  the  bladder  wall  found  and 
closed,  and  effective  drainage  provided. 

The  Ovary  and  Fallopian  Tube  are  occasionally  found  in  an 
inguinal  hernia,  more  often  in  a  child  than  in  an  adult,  and  give  rise 
to  an  irreducible  swelling,  pressure  on  which  causes  a  sickening  pain. 

Loose  foreign  bodies,  somewhat  resembling  marbles  in  size,  are  occa- 
sionally, but  very  rarely,  met  with  in  hernial  sacs.  They  are  derived 
from  the  detachment  of  one  or  more  of  the  appendices  epiploicse, 
which  subsequently  become  enlarged  from  a  deposit  of  fibrin  induced 
by  movement  in  the  peritoneal  cavity,  and  may  even  calcify. 

Signs  and  Symptoms.^ — The  characteristic  features  whereby  a 
hernial  protrusion  is  recognised  consist  in  the  presence  of  a  rounded 
or  pyriform  swelhng,  in  one  of  the  normal  or  abnormal  situations 
already  mentioned,  which  increases  in  size  when  the  patient  stands, 
coughs,  or  strains,  having,  as  it  is  termed,  '  an  impulse  on  coughing.' 
If  intestine  is  present,  it  may  be  possible  to  obtain  a  tympanitic  note 
on  percussion,  whilst  the  tumour  is  tense  and  rounded,  and  on  pres- 
sure slips  back  into  the  abdomen  with  a  distinct  gurgle.  An  entero- 
cele  often  gives  rise  to  dyspeptic  phenomena,  and  perhaps  to  colicky 
pains.  An  omental  hernia  feels  soft  and  doughy,  has  a  less  distinct 
impulse,  or  even  none,  on  coughing,  and  is  replaced  without  a  gurgle ; 
it  is  dull  on  percussion.  When  allowed  to  reappear,  it  does  so  slowly 
without  any  sudden  impulse,  the  omentum  insinuating  itself  gently 
down  the  inguinal  canal,  and  gradually  distending  the  sac. 

The  Treatment  of  hernia,  whether  palhative  by  means  of  trusses, 
or  radical  by  means  of  operation,  differs  so  greatly  in  the  various 
forms,  that  it  will  be  better  to  discuss  each  one  separately. 


HERNIA 


Special  Forms  of  Hernia. 

Inguinal  Hernia. — The  term  inguinal  hernia  is  limited  to  those 
conditions  in  which  a  protrusion  occurs  into  the  inguinal  canal,  and, 
if  allowed  to  progress,  finally  makes  its  way  through  the  external 
abdominal  ring.  If  it  extends  into  the  scrotum,  it  is  termed  complete, 
or  scrotal ;  whilst  if  it  does  not  pass  beyond  the  external  abdominal 
ring,  it  is  known  as  a  bubonocele,  or  incomplete  inguinal  hernia.  The 
neck  is  always  in  relation  with  the  deep  epigastric  artery,  and  the 
structures  of  the  cord  are  either  spread  out  over  the  sac  or  are  in 
close  proximity  to  it.     In  the  early  stages,  the  pubic  spine  can  be  felt 

to  the  outer  side  of  the 
neck  of  the  sac ;  but  as 
it  increases  in  size,  it  lies 
over  the  spine,  which 
can  only  be  felt  after 
pushing  the  hernia  up- 
wards and  inwards. 


Fig.  505. — Oblique  Inguinal  Hernia. 


Fig.  506. — Diagram  of 
Acquired  Inguinal 
Hernia,  showing  Se- 
rous Sac  with  Intes- 
tine coming  down  to 
THE  Top  of  the  Testis. 


Two  main  varieties  of  inguinal  hernia  are  described,  viz.,  the 
oblique  and  the  direct. 

An  Oblique  Inguinal  Hernia  (Fig.  505)  is  one  which  passes  down 
the  whole  length  of  the  inguinal  canal,  entering  at  the  internal  and 
emerging  at  the  external  abdominal  ring ;  the  deep  epigastric  artery 
is  thus  placed  to  the  inner  side  of  the  neck.  During  its  passage 
through  the  canal  every  form  of  oblique  hernia  pushes  before  it  and 
becomes  covered  by  structures  representing  the  various  layers  of  the 
abdominal  parietes.  Hence  in  cutting  down  on  such  a  sac,  the 
surgeon  will  divide,  in  addition  to  the  skin  and  subcutaneous  tissues, 
[a)  the  intercolumnar  fascia,  derived  from  the  transverse  fibres  of 
the  external  oblique  which  pass  across  the  external  abdominal  ring ; 

69 


logo 


A   MANUAL  OF  SURGERY 


{b)  the  cremasteric  muscle  and  fascia,  representing  and  extending 
from  the  internal  oblique;  (c)  the  infundibuliform  fascia  derived  from 
the  fascia  transversalis ;  and  {d)  finall}',  a  laver  of  subserous  tissue 
varying  in  thickness,  and  closely  surrounding  the  peritoneal  sac. 
Probably  the  surgeon  will  only  recognise  the  muscular  fibres  of  the 
cremaster,  which  serve  as  a  useful  landmark. 

There  are  three  different  forms  of  oblique  inguinal  hernia,  viz.,  the 
acquired,  the  congenital,  and  the  infantile  oi  encysted. 

I.  An  Acquired  Inguinal  Hernia  (Fig.  506)  is  one  in  which  the  sac 
consists  entirely  of  peritoneum  protruded  from  within  the  abdomen. 
It  gradualh'  increases  in  size,  and  finds  its  way  along  the  cord  to  the 
scrotum.  The  sac  usually  extends  as  far  as  the  head  of  the  epididy- 
mis, but  if  of  a  large  size  it  may  overlap  the  testicle,  which  lies 
behind  it.  The  structuies  of  the  cord  are  frequently  spread  out 
over  the  sac.  In  old-standing  cases  the  internal  ring  is  dragged 
downwards  and  inwards,  and  often  lies  behind  the  outer,  and  thus  it 


Fig.  507. — Congenital  Inguinal  Hernia. 
A,  Vaginal  variety;  B,  funicular  t^^pe. 

may  be  difficult,  apart  from  operation,  to  determine  whether  any 
particular  hernia  is  direct  or  obhque.  Even  in  early  cases  the  sac 
is  distinctly  flask-shaped,  suggesting  that  the  condition  is  due  to  the 
non-closure  of  the  uppermost  part  of  the  funicular  process. 

2.  Congenital  Inguinal  H srnia  (Fig.  507)  is  due  to  non-closure  of  the 
funicular  process  of  peritoneum,  which  passes  down  to  the  scrotum 
with  the  testicle,  and  is  usually  obhtc  rated  completely  except  below, 
where  it  forms  the  tunica  vaginalis.  As  already  mentioned,  the 
hernia  does  not  necessarily  appear  in  infancy,  its  occurrence  being 
often  delayed  until  puberty,  or  when  the  patient  has  to  undertake 
heavy  work.  This  form  of  hernia  is  much  more  frequently  met  with 
on  the  right  side  of  the  body,  owing  to  the  fact  that  the  right  testicle 
descends  into  the  scrotum  at  a  later  date  than  the  left.  It  is  always 
characterized  by  becoming  complete  at  once,  and  its  development 
may  be  immediately  followed  by  acute  strangulation. 

When  the  non-obliteration  is  complete  and  the  patent  funicular 
process  is  continuous  with  the  tunica  vaginalis,  the  protruded  viscera 


HERNIA 


1091 


lie  in  contact  with  the  testis,  and  somewhat  obscure  it ;  this  is  known 
as  a  congenital  vaginal  hernia  (Fig.  507,  A).  Less  frequently  the 
funicular  process  is  patent  only  as  far  as  the  head  of  the  epididymis, 
being  shut  off  from  the  tunica  vaginalis.  The  hernia  under  such 
circumstances  exactly  resembles  the  acquired  variety,  being  unrecog- 
nisable from  it  except  by  the  fact  that  it  becomes  complete  at 
once.     It  is  termed  a  congenital  fiinicular  hernia  (Fig.  507,  B). 

In  congenital  hernia  the  structures  of  the  cord  are  usually  more 
intimately  adherent  to  it  than  in  the  acquired  form.  Phimosis  is 
often  associated  with  this  condition  in  young  boys. 

3.  Ihe  Infantile  or  Encysted  Hernia  is  one  occurring  in  individuals 
in  whom  the  funicular  process,  although  shut  off  from  the  abdominal 
cavity  above,  remains  patent  below,  communicating  with  the  tunica 
vaginalis,  which  cavitv  extends,  in  consequence,  as  high  as  the  in- 
guinal canal  (Fig.  508,  A).     The  hernia  has  a  distinct  sac,  which 


Fig.  508. — Infantile  Inguinal  Hernia. 

A,  Prehernial  condition  with  tunica  vaginalis  extending  upwards  to  inguinal 
canal;  B,  hernial  sac  coming  down  behind  tunica;  C,  sac  invaginating  the 
tunica  vaginalis. 

passes  down  behind  the  open  process,  or  invaginates  it  (Fig.  508, 
B  and  C).  It  cannot  be  recognised  except  on  operation,  when  the 
surgeon  is  apt  to  open  the  tunica  vaginalis,  which,  though  reaching 
upwards,  does  not  communicate  with  the  general  peritoneal  cavity; 
on  removing  or  displacing  this,  the  true  sac  of  the  hernia  is  found 
behind  it.  This  does  not  often  occur  at  the  present  day,  when  the 
high  incision  is  made. 

A  Direct  Inguinal  Hernia  (Fig.  509)  is  one  which,  though  passing 
through  the  external  abdominal  ring,  has  only  travelled  through  a 
portion  of  the  inguinal  canal;  it  is  never  congenital,  and  usually 
smaller  than  the  oblique  type,  not  becoming  scrotal.  The  neck  lies 
to  the  inner  side  of  the  epigastric  artery,  which  is  often  arched  very 
distinctly  over  it,  passing  also  along  its  upper  wall.  1  he  hernia  thus 
escapes  through  the  lowest  portion  of  the  linea  semilunaris,  and 
traverses  the  space  known  as  Hesselbach's  triangle,  which  is 
bounded  internally  by  the  outer  border  of  the  rectus  muscle,  by  the 


I092 


A   MANUAL  OF  SURGERY 


deep  epigastric  artery  externally,  and  by  Poupart's  ligament  below 
(Fig.  510).  'Ihe  obliterated  hypogastric  artery  passes  across  the 
space  in  a  direction  parallel  to  its  outer  border,  dividing  it  into  two 
parts,  and  according  to  whether  the  hernia  protrudes  through  the 
outer  or  inner  segment,  it  is  known  as  an  external  or  internal  direct 
hernia  (Fig.  510,  2  and  3).  The  spermatic  cord  usually  lies  to  the 
outer  side  of  a  direct  hernia,  and  its  constituent  elements  are  never 
spread  out  over  the  sac  as  in  the  oblique  form.  A  direct  hernia  is 
rarely  found  in  young  people,  and  there  is  often  a  considerable 
amount  of  subperitoneal  fatty  tissue  around  the  sac.     The  coverings 

are  practically  the 
same  as  in  the  oblique 
variety,  although  the 
cremasteric  invest- 
ment may  be  less  com- 
plete. 

Interstitial  Hernia  is 
the  name  given  to  an 
inguinal  hernia  which 
develops  in  some  ab- 
normal relation  to  the 
abdominal  wall.  Three 
varieties  are  described : 
{a)  Where  a  sac  exists 
between  the  transver- 
salis  fascia  and  the  per- 
itoneum {intraparietal 
form,  or  properitoneal 
hernia),  either  with  or 
without  a  hernia  in  the 
usual  position;  in  the 
former  instance  one 
form  of  '  hernia  en  bis- 
sac  '  is  produced.  This 
abnormal  pocket  of  the  sac  is  found  either  between  the  sj^mphysis 
pubis  and  the  bladder  (hernia  inguinalis  ante-vesicalis),  or  it  extends 
outwards  towards  the  iliac  fossa  (hernia  inguinalis  intra-iliaca).  As 
no  external  swelling  is  caused  by  this  condition,  it  is  usually  im- 
possible to  recognise  its  existence  prior  to  operation ;  'occasionally 
it  is  the  cause  of  a  continuation  of  the  symptoms  of  strangulation, 
when  apparently  successful  taxis  has  been  performed,  owing  to  the 
strangled  bowel  having  been  pushed  backwards  from  the  superficial 
into  the  deeper  portion  of  the  sac.  {h)  An  abnormal  expansion 
of  the  sac  is  situated  between  the  internal  and  external  oblique 
muscles  [interparietal  form).  A  swelling  is  thus  produced  in  the 
region  of  the  inguinal  canal,  covered  by",  the  external  oblique 
aponeurosis,  and  gradually  spreading  upwards  and  outwards  parallel 
with  Poupart's  ligament.  It  may  be  associated  with  late  descent 
of  the  testis,   the  external  abdominal  ring  being  closed  so  that 


i'lG.  509. — Direct  Inguinal  Hernia. 


HERNIA 


1093 


the  organ,  and  with  it  a  hernia,  has  to  travel  beneath  the  external 
oblique  aponeurosis.  Sometimes  the  condition  is  due  to  the  exist- 
ence of  a  more  or  less  complete  septum  at  the  level  of  the  external 
abdominal  ring,  formed  either  by  adhesions  or  by  a  mass  of  adherent 
omentum.  The  sac  is  then  shaped  hke  an  hour-glass,  and  as  the 
usual  downward  course  of  the  hernial  contents  is  prevented,  the 
upper  part  of  the  sac  yields  laterally  above  the  site  of  the  obstruc- 
tion, and  passes  between  the  muscles,  (c)  The  hernia  escapes  as 
usual  from  the  external  abdominal  ring,  but  travels  outwards  along 
Poupart's  ligament,  somewhat  simulating  a  femoral  hernia  [extra- 
pariefal  variety) .  This  form  is  generally  associated  with  late  descent 
of  the  testis,  and  a  contracted  state  of  the  scrotum,  so  that  it  is  easier 


Fig.  510.— Abdominal  Wall  from  Within,  to  show  Hernial  Apertures. 
A    V    External  iliac  artery  and  vein;  SV,  spermatic  vessels;  PL,  Poupart's 

ligament;  VD,  vas  deferens;  E,  epigastric  vessels;  R,  rectus  abdominis; 

H,  obliterated  hypogastric  artery;   i,  internal  abdominal  ring;  2  and  3, 

sites  of  direct  hernia  in  Hesselbach's  triangle;  4,  crural  ring  for  femoral 

hernia;  5,  obturator  foramen  and  vessels. 

for  the  hernia,  which  is  always  of  a  congenital  type,  to  pass  into  the 
thigh,  and  be  guided  by  the  fascia  in  the  direction  indicated;  in  a 
case  of  this  character  operated  upon  some  years  back,  the  testicle 
was  found  lying  close  to  the  anterior  superior  iliac  spine.  There  is 
no  difficulty  in  recognising  such  a  condition. 

The  Signs  of  an  inguinal  hernia  do  not  require  much  special  notice 
here,  as  we  have  already  described  the  general  cHnical  features  of  a 
rupture  (p.  1088).  In  the  early  stages,  where  merely  a  bubonocele 
exists,  a  fulness  is  noted  in  the  course  of  the  inguinal  canal,  which 
increases  when  the  patient  coughs;  it  is  best  detected  by  a  finger 
passed  through  the  external  ring  into  the  canal.  When  it  descends 
into  the  scrotum,  the  swelling  increases  in  size  from  above  down- 


I094  A   MANUAL  OF  SURGERY 

wards,  and  in  the  oblique  variety  is  continuous  with  the  fulness  in 
the  inguinal  canal.  'Ihe  structures  of  the  cord  are  masked  by  the 
presence  of  the  hernia,  but  the  testicle  is  to  be  felt  more  or  less  dis- 
tinctly at  the  lower  and  back  part  of  the  swelling.  When  of  the 
direct  variety,  the  cord  lies  to  the  outer  side,  and  although  the  hernia 
can  be  felt  projecting  from  the  external  ring,  it  passes  directly  back- 
wards, and  there  is  no  fulness  along  the  course  of  the  canal. 

Inguinal  hernia  is  usually  met  with  in  the  male  sex,  the  oblique 
variety  being  more  common  in  the  young,  and  the  direct  in  elderly 
patients.  In  the  female  sex  it  is  not  unfrequent,  however,  in  girls 
and  young  nulliparous  women;  in  such  cases  it  is  almost  always 
congenital,  passing  into  the  labium  along  the  canal  of  Nuck,  but 
rarely  attains  any  considerable  size. 

The  Diagnosis  of  an  inguinal  hernia  is  a  tolerably  simple  matter  if 
it  is  uncomplicated  by  any  other  condition;  it  may,  however,  be 
difficult,  and  in  old-standing  cases  it  is  often  impossible  to  distinguish 
the  oblique  variety  from  the  direct.  The  conditions  for  which  it  may 
be  mistaken  are  best  considered  in  two  groups. 

I.  Whilst  the  hernia  is  still  incomplete  and  in  the  bubonocele  stage, 
it  has  to  be  distinguished  from  the  following :  (a)  Encysted  hydrocele 
of  the  cord,  which  is  recognised  by  its  smooth  globular  outline  and 
tense  walls;  the  impulse  on  coughing  is  less  distinct,  and,  although 
freely  moveable  in  the  canal,  the  hydrocele  cannot  always  be  entirely 
reduced  into  the  abdomen,  whilst  the  characteristic  gurgle  of  a  hernia 
is  absent;  traction  on  the  testis,  moreover,  fixes  the  tumour,  and 
renders  it  immobile.  The  exact  limitation  of  the  upper  end  of  the 
swelling,  if  it  can  be  reached,  is  very  characteristic  of  a  hydrocele. 
(6)  A  chronic  abscess  originating  in  the  abdominal  parietes,  or  within 
the  abdomen  or  pelvis,  will  sometimes  point  through  the  external 
abdominal  ring.  In  such  cases,  although  there  is  a  distinct  im- 
pulse on  coughing,  and  although  the  swelling  is  reducible,  it  has  not 
the  definite  outline  and  characteristic  sensation  of  a  hernia,  being 
usually  soft  and  fluctuant.  Other  evidences  pointing  to  the  exist- 
ence of  the  original  disease  may  also  assist  in  determining  the  nature 
of  the  swelling,  (c)  Enlarged  glands  in  the  groin  which  have  become 
adherent  to  the  external  oblique  are  sometimes  mistaken  for  a 
hernia,  owing  to  the  fact  that  on  coughing  a  distinct  impulse  is  com- 
municated to  them;  it  is,  however,  merely  heaving  in  nature,  and 
not  expansile,  whilst  on  digital  exploration  of  the  inguinal  canal  the 
absence  of  a  hernia  may  be  readily  ascertained,  {d)  A  testicle  retained 
in  the  inguinal  canal  is  recognised  by  that  side  of  the  scrotum  being 
empty,  and  on  pressing  the  swelling  testicular  sensation  may  be 
elicited.  The  rounded  upper  end  of  the  testis  can  otten  be  detected. 
[e)  Tumours  consisting  of  fat  or  other  tissues  are  occasional!}^  seen  in 
the  inguinal  canal,  but  are  characterized  by  the  strict  hmitation  of 
their  upper  border,  and  usually  by  the  absence  of  a  distinct  impulse 
on  coughing.  On  the  other  hand,  as  described  elsewhere,  a  mass  of 
fat  simulating  a  lipoma  is  often  present,  resulting  from  a  protrusion 
of  the  subperitoneal  tissue,  a  hernial  sac  being  sometimes  found 


HERNIA  1095 

embedded  within  it.  (/)  Hcemaiocele  of  the  cord  is  recognised  by  a 
history  of  injury,  the  presence  of  pain  and  ecchymosis,  and  the 
absence  of  an  impulse  on  coughing,  whilst  reduction  is  impracticable. 
2.  When  the  hernia  extends  into  the  scrotum,  less  difficulty  is  ex- 
perienced in  its  diagnosis.  By  examination  of  the  cord  immediately 
outside  the  external  abdominal  ring,  all  purely  scrotal  swellings, 
such  as  hydrocele  or  sarcocele,  are  readily  eliminated,  since  in  them 
the  cord  can,  in  the  early  stages,  be  felt  perfectly  free.  A  varicocele 
can  also  be  similarly  recognised  from  an  omental  hernia  by  the  con- 
dition of  the  cord  in  its  upper  region;  moreover,  if  the  patient  is 
made  to  assume  the  recumbent  posture,  the  swelling  disappears  in 
each  instance,  but  if  a  finger  is  placed  firmly  over  the  inguinal  canal 
so  as  to  prevent  any  protrusion  of  omentum,  and  he  is  then  directed 
to  stand  up,  the  swelhng  immediately  reappears  if  it  is  venous  in 
character.  To  the  practised  hand,  the  diagnosis  is  never  a  matter 
of  difficulty,  since  the  enlarged  veins  of  a  varicocele  and  omentum 
are  not  at  all  alike  to  the  touch,  the  veins  moving  freely  under  the 
finger  '  like  worms  in  a  bag.'     When  a  hernia  is  associated  with  a 

hydrocele  or  sarcocele,  a  little  ^ ______^ 

more  care  is  necessary  in  order      ^— ^<:^^^^^^^s^S^^^^^:ss:^^ 
to  distinguish  between  the  two     r^^'^sX  "^"^^^^^i^ 

The   Treatment   of   inguinal     ^^====,y^^  ^^ss?^ 

hernia  is  either  palliative   by       "^'"'^'''^^^^  ®    1\ f^^^^^^^^^^^^'^ 

means  of  trusses,  or  radical.        ^\  //yi^^J-^^'^^=^^^^^^''''^^^ 

Palliative      Treatment.  —  A      vV^-Ty/^^^^^'^^^ 
truss  is  an  appliance  which  is        Vc:::^/^/^/^ 

worn  around  the  body  with  the     Fig.  511.— Inguinal    Truss.      (Down 
object  of  preventing  by  pres-  Brothers.) 

sure  the  descent  of  the  hernia. 

No  one  form  is  capable  of  dealing  with  every  case,  and  hence  the 
truss  must  be  selected  with  care,  so  as  to  suit  the  special  needs 
of  the  particular  patient.  A  good  truss  consists  of  a  pad  kept  in 
position  over  the  hernial  aperture  by  a  steel  spring  (Fig.  511), 
which  fits  the  patient  accurately,  resting  behind  on  the  middle 
piece  of  the  sacrum,  and  passing  laterally  midway  between  the  crest 
of  the  ilium  and  the  top  of  the  great  trochanter.  If  the  hernia 
is  unilateral,  the  spring  ends  on  the  sound  side  just  behind  the 
anterior  superior  spine,  and  is  prolonged  anteriorly  into  a  leather 
thong  or  cross-strap,  which  is  secured  to  a  stud  on  the  pad.  To 
prevent  it  from  slipping  up,  an  under-strap  passes  from  the  affected 
side  close  behind  the  anterior  superior  spine  along  the  fold  of  the 
nates  to  the  inner  side  of  the  thigh,  being  fixed  finally  to  a  second 
stud  on  the  pad.  The  pad  may  be  rounded  or  oval  in  shape,  and 
usually  consists  of  soft  iron  protected  by  cork,  but  polished  vulcanite, 
wood,  or  an  indiarubber  cushion  filled  with  air,  water,  or  glycerine, 
may  be  employed  instead;  it  should  be  well  covered  with  leather, 
and  the  strength  of  the  spring  must  be  so  adjusted  as  to  retain  the 
hernia  under  all  conditions  of  strain  to  which  it  may  be  subjected, 


ro96 


A    MANUAL  OF  SURGERY 


but  without  the  use  of  undue  force.  In  ordering  a  truss  from  an 
instrument-maker,  the  only  measurement  required  is  that  around 
the  body,  following  the  line  taken  by  the  truss,  and  reaching  in  front 
to  the  symphysis  pubis;  it  is  also  advisable  to  indicate  the  size  of  the 
hernia,  and  whether  the  opening  in  the  abdominal  parietcs  is  large 
or  small.  In  the  earlier  cases  of  obhque  hernia,  the  pad  should  rest 
rather  over  the  inguinal  canal  than  over  the  external  abdominal 
ring,  the  object  being  to  restore  the  valve-like  action  of  the  canal  by 
approximating  its  sides.  In  a  direct  hernia  the  pad  must  be  applied 
directly  over  the  opening.  If  such  an  apparatus  is  properly  adjusted 
and  continuously  worn,  a  cure  is  sometimes  established  in  the  course 
of  a  year  or  two ;  and  in  the  congenital  hernia  of  children  a  cure  may 
be  confidently  expected  if  the  mother  or  attendants  of  the  child 
conscientiously  carry  out  the  necessary  details.     If  the  hernia  is 


Fig.  512.  —  Wool  Truss  for 
Treatment  of  Left  Inguinal 
Hernia  in  an  Infant. 


Fig.  513. — Indiarubber  Band  Truss, 
WITH  Air-pads,  for  Infants. 

The  air-pads  fit  around  the  root  of  the 
penis,  and  are  inflated  through  the 
tube  tied  up  in  front.  The  under- 
straps  fit  round  the  child's  thighs. 


once  allowed  to  slip  down,  even  after  six  or  twelve  months'  treat- 
ment, all  the  previous  good  will  have  been  undone. 

In  infants,  an  efficient  support  is  afforded  by  a  skein  of  wool 
(specially  known  as  '  lingering  '),  divided  at  one  end,  so  that  when 
placed  round  the  body  the  cut  ends  of  the  skein  can  be  passed 
through  the  loop,  forming  a  knot  over  the  inguinal  canal,  which 
acts  as  the  pad  of  a  truss.  The  cut  ends  are  now  passed  under  the 
perineum,  and  tied  to  the  transverse  portion  behind  (Fig.  512).  This 
apparatus  is  changed  night  and  morning  when  the  child  is  bathed, 
and  also,  if  need  be,  at  shorter  intervals,  the  mother  being  previously 
instructed  as  to  how  to  support  the  hernia  whilst  the  apparatus  is 
being  removed.  In  cases  of  double  rupture  in  infants,  an  indiarubber 
band  with  two  pneumatic  air-pads  (Fig.  513),  arranged  so  as  to  fit 
over  the  inguinal  canals,  and  with  suitable  straps  and  studs,  will 
often  suffice,  and  is  certainly  more  comfortable  than  a  spring  truss. 
In  addition  to  such  pressure,  it  is  important  to  remove  all  causes  of 


HERNIA  1097 

iutra-iibdominal   tension,    as  by   circumcision,   where   phimosis   is 
present,  or  by  regulating  the  bowels. 

The  Radical  Cure  of  inguinal  hernia  is  an  operation  to  which  much 
attention  has  been  directed  of  late  years,  since  its  value  was  brought 
prominently  before  the  profession  by  the  late  Professor  John  Wood 
and  others.  It  is  very  largely  employed  at  the  present  day,  and  may 
be  expected  to  give  excellent  results  if  the  cases  are  carefully  selected, 
if  the  technique  is  satisfactory,  and  if  the  after-treatment  is  efficient. 
The  mortality  is  very  small,  and  in  a  series  of  7,419  cases  collected 
by  Sultan,  it  did  not  exceed  o"48  per  cent.* 

The  selection  of  cases  for  an  operation  of  this  type,  which  is  not  an 
essential,  but  only  a  desirable  means  of  treatment  (or,  as  it  is  sortie- 
times  termed,  an  operation  de  complaisance),  is  a  matter  requiring 
considerable  judgement  and  discrimination.    In  an  individual  whose 
occupation  does  not  subject  him  to  heavy  strain  or  exertion,  and  who 
possesses  a  hernia  which,  under  ordinary  circumstances,  is  easily 
commanded  by  a  suitably  applied  truss,  no  operation  is  absolutely 
necessary;  although  one  is  perfectly  justified  in  urging  him  to  submit 
to  it,  since  he  will  be  thereby  freed  from  the  irksomeness  of  wearing 
a  truss,  and  from  the  possible  occurrence  of  strangulation.     If,  how- 
ever, the  subject  is  a  labouring  man,  exposed  to  injury  and  strain, 
and  who  may  find  it  difficult  to  provide  a  suitable  series  of  trusses, 
the  operation  should  always  be  undertaken  unless  distinctly  contra- 
indicated  (i)   by  a  general  inherited  weakness  of  the  abdominal 
muscles;  (2)  by  a  relaxed  and  atonic  condition  of  the  abdominal 
parietes,   which   is   commonly   associated  in   elderly   people   with 
slipping  downwards  of  the  mesenteric  attachment  of  the  intestine 
(enteroptosis),  so  that  the  hypogastrium  obviously  bulges;  or  (3)  by 
such  constitutional  disease  as  precludes  all  unnecessary  operative 
interference.     (4)  Again,  in  cases  of  extensive  irreducible  hernia,  the 
return  of  large  masses  of  intestine  which  have  lain  for  year?  in  the 
hernial  sac  so  increases  the  intra-abdominal  tension  as  frequently  to 
determine  recurrence  locally  or  elsewhere,  and  therefore  operative 
interference,  though  very  desirable  owing  to  the  great  risk  of  strangu- 
lation incurred  by  the  patient,  is  often  followed  by  very  bad  results, 
unless  the  patient  has  previously  been  put  through  a  course  of  serni- 
starvation  and  persistent  taxis  in  order  to  reduce  gradually  the  size 
of  the  protrusion. 

As  to  the  best  age  at  which  to  operate,  statistics  definitely  prove 
that  it  is  essentially  an  operation  of  adolescence,  the  results  gradually 
getting  worse  as  the  age  increases.  Young  children  should  not  be 
touched  until  careful  truss  pressure  for  a  year  has  failed,  or  unless  it 
is  impossible  to  keep  up  the  hernia  by  such  treatment.  In  any  case 
it  is  perhaps  wiser  to  delay  it  until  the  age  of  three,  or  even  later, 
owing  to  the  risk  of  infection  of  the  wound  from  the  constant  satura- 
tion of  the  dressings  with  urine. 

Very  many  different  operations  have  been  described  and  practised 
by  various  surgeons.     One  of  the  most  satisfactory  is  that  known  as 
*  Munch.  Med.  Wochens.,  February  3,  1903. 


log  A   MANUAL  OF  SURGERY 

Bassini's,  which  has  now  been  extensively  employed,  and  has  been 
followed  by  a  large  measure  of  success.  The  operation  may  be 
described  in  the  following  stages:  (i)  Ihe  pubic  region  having  been 
previously  shaved  and  thoroughly  purified,  an  incision  is  made  in  the 
direction  of  the  inguinal  canal  and  cord,  about  2|  inches  in  length, 
its  centre  being  a  little  above  the  external  abdominal  ring.  Ihis  is 
carried  through  the  skin  and  subcutaneous  tissues  until  the  structures 
of  the  cord  are  reached,  the  superficial  external  pudic  artery  being 
necessarily  divided  en  route  ;  the  pillars  of  the  ring  are  clearly  defined, 
and  the  external  oblique  aponeurosis  slit  up  in  the  direction  of  the 
cord.  (2)  Ihe  sac  has  now  to  be  identified;  if  the  hernia  is  one  of 
old  standing,  or  contains  adherent  omentum  or  intestine,  it  is  easily 
recognised;  but  if  it  is  thin,  empty,  and  of  recent  formation,  and 
especially  in  the  case  of  a  bubonocele,  its  identification  may  be  a 
matter  of  some  difficulty.  The  cremaster  and  other  coverings  of  the 
cord  are  incised  longitudinally,  and  the  sac  looked  for  and  isolated 
with  as  little  handling  and  disturbance  of  the  parts  as  possible. 
Enlarged  veins  may  be  removed,  as  also  fatty  protrusions  from  the 
subperitoneal  tissues.  It  is  sometimes  necessary  to  lift  up  the  struc- 
tures of  the  cord  in  order  to  define  the  sac,  which  is  often  recognised 
by  the  white  convex  border  of  the  fundus.  (3)  If  the  sac  is  empty, 
it  is  freed  from  its  connection  wdth  the  structures  of  the  cord  without 
opening  it,  and  isolated  as  far  as  or  beyond  the  internal  abdominal 
ring,  as  indicated  by  a  collar  of  fatty  subperitoneal  tissue  surrounding 
the  neck.  If  the  hernia  is  irreducible,  the  sac  is  laid  open,  its  con- 
tents freed  from  adhesions,  and  the  intestine  returned  into  the  abdo- 
men, whilst  omental  tissue  is  removed  and  the  stump  replaced. 
Adhesions  are  carefully  divided  either  by  the  finger  or  between 
ligatures;  if  the  gut  is  closely  adherent  to  the  sac,  it  may  be  necessary 
to  leave  a  small  portion  of  this  attached  to  the  intestine,  which  is 
then  returned.  Omentum,  whether  adherent  or  not,  should  be 
removed,  as  the  elongated  fringes  are  very  liable  to  contract  ad- 
hesions to  the  abdominal  parietes,  which  subsequently  produce 
mischief.  In  removing  omentum,  it  is  not  advisable  to  encircle  a 
large  mass  with  a  single  hgature,  as  it  is  then  more  difficult  to  replace, 
the  vessels  are  less  securely  commanded,  and  a  pocket  or  pucker 
may  be  produced,  possibly  leading  to  internal  strangulation  at  a 
later  date.  Small  portions,  including  one  or  more  of  the  larger 
vessels,  should  be  taken  up  one  after  another,  and  tied  separately 
and  with  advantage  at  different  levels,  so  as  to  assist  in  the  subse- 
quent return  of  the  stump.  The  protruded  mass  is  then  cut  away 
below  the  ligatures,  and  the  stump  replaced  after  seeing  that  no 
bleeding-point  remains  unsecured.  The  sac,  being  now  emptied,  is 
isolated  as  far  as  the  internal  ring.  (4)  The  neck  is  transfixed  as 
high  as  possible,  and  ligatured  with  sterihzed  silk,  and  the  sac  cut 
off  below  the  ligature,  the  stump  retracting  well  above  the  internal 
ring,  and  presenting  a  flush  surface  towards  the  intestines.  (5)  The 
opening  in  the  abdominal  parietes  is  closed  by  a  row  of  sutures 
passing  through  the  arched  fibres  of  the  internal  oblique  and  trans- 


HERNIA 


logg 


versalis  muscles  or  through  the  conjoined  tendon  on  the  inner  side, 
and  through  Poupart's  hgament  on  the  outer,  the  stitches  being  all 
placed  behind  the  cord.  To  effect  this,  the  cord  is  drawn  up  out  of 
the  wound  and  held  aside  by  a  retractor  (Fig.  514.  C),  whilst  the 
divided  margins  of  the  external  oblique  aponeurosis  are  grasped  by 
pressure  forceps  iK,  A').  Gentle  traction  on  the  lower  pair  enables 
the  deepest  portion  of  Poupart's  ligament  to  be  defined  and  seen. 
The  stitches  must  secure  a  good  hold  of  the  tissues,  but  should  not 
include  the  external  oblique  aponeurosis,  and  when  dealing  with 
Poupart's  ligament  the  proximity  of  the  iliac  vessels  must  not  be 


Fig.  514. — Bassini's  Operation  for  Radical  Cure  of  Hernia. 

A,  A',  Spencer  Wells  forceps,  holding  aside  the  divided  portions  of  external 
obUque  aponeurosis;  B,  arched  fibres  of  internal  oblique,  continuous  on 
the  inner  side  with  the  conjoined  tendon;  C,  hook  or  retractor  holding 
aside  the  spermatic  cord;  D,  D,  D,  D,  deep  silk  stitches  passed  behind  the 
cord  through  the  deepest  fibres  of  Poupart's  ligament  on  the  outer  side, 
and  conjoined  tendon  on  the  inner.  (The  cutaneous  incision  and  the 
incision  through  the  external  oblique  are  here  shown  much  greater  than 
would  actually  be  undertaken,  in  order  to  demonstrate  clearly  the  deeper 
parts.) 

forgotten.  Either  interrupted  or  looped  mattress  sutures  may  be 
used,  but  if  the  latter,  they  must  not  be  tied  too  tightty,  as  they  may 
strangle  the  portions  of  tissue  included  in  their  grasp  and  cause 
necrosis.  The  opening  in  the  abdominal  parietes  is  in  this  way 
commanded  as  far  down  as  the  pubic  spine,  but  sufiicent  room  must 
be  left  at  the  upper  end  for  the  passage  of  the  cord,  undue  constric- 
tion of  which  would  cause  atroph}'  of  the  testis;  sometimes  it  is 
desirable  to  introduce  a  stitch  above  the  cord,  in  order  to  command 
a  spot  where  recurrence  is  not  uncommon.  When  the  three  or  four 
needful  stitches  have  been  introduced  and  tightened,  the  cord  is 
replaced,  and  the  divided  portions  of  the  external  oblique  are  sutured 


iioo  A   MANUAL  OF  SURGERY 

together  over  it.     (6)  The  wound  in  the  skin  is  closed  by  a  continuous 
suture,  and  usually  no  drainage-tube  is  needed. 

After-Treatment. — The  patient  is  placed  in  bed  with  the  knees 
slightly  flexed  over  a  pillow.  1  he  wound,  as  a  rule,  does  not  require 
dressing  for  seven  or  eight  days,  when,  on  removal  of  the  stitches,  it 
should  be  found  completely  healed,  if  asepsis  has  been  maintained. 
The  patient  should  turn  to  the  opposite  side  in  order  to  pass  water, 
and  the  greatest  care  must  be  taken  to  prevent  the  dressing  be- 
coming soiled.  Occasionally  retention  of  urine  follows  this  opera- 
tion, necessitating  the  use  of  a  catheter.  In  the  case  of  children,  it 
is  well  to  employ  the  open  method  of  treatment  suggested  on  p.  281. 

The  recumbent  posture  should  be  maintained  for  three  weeks,  and 
nothing  but  the  slightest  work  undertaken  for  at  least  six  weeks,  and 
no  violent  effort  until  six  months  after  the  operation.  Under  such 
circumstances  the  use  of  a  truss  is  unnecessary,  and,  indeed,  un- 
desirable, as  its  pressure  is  liable  to  produce  atrophy  of  the  newly- 
formed  cicatricial  tissue.  When,  however,  the  abdominal  walls  are 
congenitally  weak,  or  if,  unfortunately,  the  wound  has  suppurated, 
the  deep  stitches  coming  away,  it  is  advisable  to  use  a  light  truss  for 
a  time. 

The  treatment  of  congenital  hernia  differs  in  no  particular  from  that 
already  described,  except  that  the  sac  must  be  divided  below  as  well 
as  above,  and  the  lower  opening  secured  by  suture  or  ligature,  so  as 
to  close  the  cavity  of  the  tunica  vaginalis.  The  operation  often 
proves  difficult  owing  to  the  intimate  adhesions  between  the  sac  and 
the  structures  of  the  cord,  and  it  is  sometimes  impracticable  to 
isolate  completely  the  neck  of  the  sac. 

The  other  operations  which  require  to  be  mentioned  are  as 
follows : 

(fl)  In  Banks'  Operation,  the  sac  is  isolated  and  removed  as  high 
as  the  internal  ring  without  any  division  of  the  external  oblique. 
Stitches  are  then  introduced  through  the  conjoined  tendon  and 
Poupart's  ligament  respectively,  including  the  external  oblique  in 
their  grasp,  and  passing  in  front  o/the  cord.  It  is  ob\dous  that  by 
such  a  plan  the  deep  ring  cannot  be  closed  as  accurately  as  in 
Bassini's  operation.  It  may  suffice,  however,  in  a  few  of  the  simpler 
congenital  cases. 

{b)  In  Maceiven's  Method  the  aponeurosis  of  the  external  oblique  is 
most  carefully  maintained  intact,  and  the  inguinal  canal  is  explored 
through  the  external  abdominal  ring.  The  sac  is  freed  from  its 
surroundings,  and  this  liberation  goes  on  for  about  an  inch  all  round 
the  internal  abdominal  ring.  A  silk  suture  is  then  tied  to  the  fundus 
of  the  sac,  and  is  carried  by  a  curved  needle  through  the  centre  of  the 
sac  from  above  downwards,  and  again  through  the  neck  of  the  sac 
from  below  upwards.  The  needle  is  then  introduced  through  the 
inguinal  canal  under  the  loosened  abdominal  parietes,  and  is  made 
to  emerge  through  the  abdominal  muscles  a  little  above  the  inguinal 
canal;  the  silk  thread  is  carried  through  this,  and  by  a  little  traction 
the  sac  is  carried  in,  doubled  up,  and  implanted  as  a  pad  across  the 


HERNIA 


internal  ring.     Ihis  thread  is  held  by  an  assistant  during  the  next 

step  of  the  operation.     This  consists  in  closing  the  canal  by  one  or 

more  looped  sutures,  passed  in  such  a  way  as  to  draw  up  Poupart's 

ligament  over  the  arched  fibres  of  the  internal  oblique  in  front  of  the 

cord.     Finally,  the  thread  used  for  the  fixation  of  the  sac  is  drawn 

tight,  and  its  free  end  employed  to  close  the  external  abdominal  ring 

to  a  sufficient  extent.     The  results  of  this  proceeding  are  very  good, 

but  it  is  a  more  difficult  operation  than  Bassini's,  and  one  loses  the 

advantage  of  opening  the 

canal,    and   thereby    ex-  ;^ 

ploring  the  structures  of 

the  cord.     Subperitoneal 

lipomata  are    frequently 

found  in   the  canal,  and 

these  would  inevitably  be 

left,  and  would  possibly 

lead  to  a  recurrence  of 

the  hernia,  if  the   canal 

had  not  been  opened  up. 

(c)  In  Halstead's*oipeTa.- 
tion  the  inguinal  canal  is 
opened  up  as  in  Bassini's 
method,  and  the  cre- 
master  divided  longi- 
tudinally along  the  upper 
border  of  the  cord,  and 
dissected  back,  so  as  to 
enable  the  sac  and  any  Fig.  515. 
enlarged  veins,  etc.,  to 
be  removed.  The  lower 
border  of  the  internal 
oblique  is  defined,  and 
the  upper  edge  of  the  cre- 
master  is  sutured  to  the 
under  surface  by  a  series 
of  mattress  stitches.  The 
lower  edge  of  the  internal 
oblique     and     conjoined 


Operation  for  Inguinal  Hernia 
(Carless.) 

The  inguinal  canal  is  opened  up,  and  the  sac  re- 
moved as  high  as  possible.  The  cord  and 
cremaster  (not  represented  here)  are  pressed 
back  and  covered  over  by  approximating  the 
internal  oblique  and  transversalis  to  the  under 
surface  of  Poupart's  ligament  by  mattress 
sutures,  which  are  introduced  as  indicated 
above,  and  tied  on  the  outer  aspect  of  the 
ligament.  The  divided  segments  of  the  ex- 
ternal oblique  are  then  overlapped  and 
sutured . 


tendon  is  then  sutured  in 
front  of  the  cord  to  the  under  surface  of  Poupart's  ligament,  and 
finally  the  divided  portions  cf  the  external  oblique  closed  by  over- 
lapping. If  there  is  much  tension  in  the  deeper  stitches,  a  longi- 
tudinal incision  through  the  sheath  of  the  rectus  muscle  will  give 
suitable  relaxation.  Excellent  results  have  followed  this  procedure. 
(d)  For  the  last  few  years  extensive  employment  of  a  somewhat 
similar  proceeding  has  given  most  satisfactory  results.  The  canal  is 
opened  in  the  same  way,  and  the  sac  excised,  the  ligature  being 
placed  as  high  as  possible.  The  fibres  of  the  internal  oblique  are 
*   Johns  Hopkins  Bulletin,  August,  1903. 


II02  A   MANUAL  OF  SURGERY 

then  exposed  by  thorough  retraction  of  the  divided  external;  and 
mattress  sutures  are  introduced  through  the  internal  oblique  and 
transversalis,  or  edge  of  the  rectus  sheath,  carried  across  in  front  of 
the  cord  through  Poupart's  ligament,  and  tied  on  its  outer  surface 
(Fig.  515).  This  constitutes  a  firm  muscular  barrier  across  the 
canal;  one  or  two  such  sutures  usually  suffice.  The  lower  or  outer 
segment  of  the  external  oblique  is  then  carried  up  and  stitched  down 
to  the  internal  oblique  well  above  the  mattress  sutures;  the  inner 
segment  of  the  divided  external  oblique  is  then  made  to  overlap  the 
outer,  and  stitched  down  to  Poupart's  ligament;  the  deep  layer  of 
fascia  is  also  carefully  secured  by  sutures,  and  the  wound  closed. 
Healing  almost  invariably  occurs  without  suppuration;  and  even 
should  this  happen,  the  stitches  are  easily  removed,  as  the  knots  are 
on  the  outer  side  of  Poupart's  ligament,  and  not  on  the  inner,  as  in 
Bassini's  and  Halstead's  methods.  In  all  these  three  methods 
epididymitis  and  hydrocele  occasionally  develop  as  sequelae. 

The  treatment  of  direct  inguinal  hernia  is  somewhat  different  at 
times,  in  that  the  condition  usually  occurs  in  elderly  men.  In  many 
it  is  wise  to  order  a  double  truss  and  avoid  operation ;  but  in  some 
operation  is  permissible.  The  prognosis  is  never  so  good  as  in  the 
oblique  variety- — [a)  because  it  occurs  in  older  subjects,  and  is  often 
predisposed  to  by  chronic  obesity,  cough,  or  difficulty  in  mictuiition; 
and  {b)  because  the  chief  weakness  is  at  the  lower,  and  not  at  the 
upper,  end  of  the  canal,  and  hence  the  deep  ring  lies  almost  directly 
behind  the  opening  in  the  external  obhquc.  In  these  cases  ex- 
perience has  taught  one  that  the  best  plan  to  adopt  is  to  displace 
the  cord  entirely,  bringing  it  out  through  the  muscles  opposite  the 
interna]  abdominal  ring,  and  closing  up  the  rest  of  the  canal  com- 
pletely as  in  a  woman.  The  more  superficial  position  of  the  cord 
does  not  seem  to  affect  it  injuriously. 

Recurrence  after  Operation  is  much  less  common  than  formerly, 
and  statistics  go  to  prove  that  in  experienced  hands  less  than  10  per 
cent,  of  the  cases  recur,  and  that  rarely  after  the  first  twelve  months. 
As  already  stated,  it  may  be  due  partly  to  an  injudicious  selection  of 
cases,  partly  to  errors  of  technique,  and  in  part  to  a  faulty  after- 
treatment,  the  patient  being  given  too  much  liberty  at  too  early  a 
date.  In  connection  with  this  we  would  especially  emphasize  the 
necessity  for  isolating  the  sac  as  far  as  possible,  since  otherwise  the 
infundibuhf orm  opening  at  the  top  of  the  closed  peritoneal  canal  is  cer- 
tain to  persist.  Another,  and  that  perhaps  the  most  common,  cause 
of  recurrence  is  pyogenic  contamination  of  the  wound ;  if  the  deep 
stitches  are  not  involved,  no  great  harm  is  done,  but  whenever  they 
have  been  removed  or  come  away  it  is  wise  to  use  a  light  truss  for  a 
time  as  a  precautionary  measure.  Again,  the  mere  restoration  of  a 
mass  of  intestine  or  omentum  into  the  abdominal  cavity  may  suffice 
to  raise  the  intra-abdominal  pressure,  and  thus  predispose  to  a  re- 
currence ;  hence  the  importance  of  removing  as  much  omental  tissue 
as  possible  in  all  bad  cases.  Relapses  may  also  be  due  to  splitting 
or  tearing  of  the  tendinous  structures  around,  either  by  the  mere 


HERNIA 


1103 


passage  of  the  needle,  or  by  the  traction  induced  by  tightening  the 
sutures;  indeed,  it  is  often  the  case  that  a  hernia  originally  oblique 
may  after  operation  be  followed  by  one  that  is  direct,  and  probably 
from  this  cause. 

Whenever  it  appears  likely  that  recurrence  may  occur,  a  truss 
should  be  ordered.  If,  however,  a  hernia  has  developed,  a  second 
operation  may  be  performed,  if  the  condition  of  the  abdominal 
parietes  warrants  it.    ''^ 

Femoral  Hernia. — A  femoral  hernia  is  one  which,  travelling  down 
the  crural  canal,  presents  at  the  inner  and  upper  part  of  the  thigh 
through  the  saphenous  opening.  It  occurs  most  commonly  in  women 
on  account  of  the  greater  expansion  of  the  iliac  crests  allowing  in- 
creased space  beneath  Poupart's  ligament,  and  especially  in  those 
who  have  borne  children.  During  parturition  the  inguinal  regions 
are  in  a  measure  protected,  and  hence  inguinal  hernia  is  rarely  caused 
in  this  way.  In  young  people,  however,  it  is  more  common  in  the 
male  sex. 

The  crural  canal  constitutes  the  inner  compartment  of  the  femoral 
sheath,  a  space  usually  occupied  by  fatty  cellular  tissue,  lymphatic 
vessels,  and  perhaps  a  lymphatic  gland.     It  is  about  |  inch  in  length 
anteriorly,  and  i^  inches  along  its  posterior  wall;  it  is  closed  above 
by  a  thickened  portion  of  the  subserous  cellular  tissue  known  as  the 
septum  crurale,  and  its  lower  end  is  formed  by  the  saphenous  open- 
ing, and  closed  by  the  cribriform  fascia.     Hence  a  femoral  hernia, 
as  it  passes  downwards,  receives  the  following  coverings:  (a)  peri- 
toneum; ih)  subserous  cellular  tissue,  including  the  septum  crurale, 
a  layer  sometimes  known  as  the  fascia  propria,  and  occasionally 
represented  by  a  thick  fatty  envelope;  (cj  the  anterior  layer  of  the 
femoral  sheath,  derived  from  the  fascia  transversalis ;  [d)  cribriform 
fascia;  {e)  subcutaneous  tissue;  and  (/)  skin.     In  its  passage  through 
the  canal  it  is  situated  immediately  internal  to  the  femoral  vein,  and 
pressure  upon  this  may  produce  oedema  of  the  leg,  whilst  Gimbernat's 
ligament  lies  to  the  inner  side.    The  spermatic  cord  or  round  ligament 
is  placed  just  above  and  internal  to  it,  but  on  a  superficial  plane, 
whilst  the  epigastric  artery  is  not  very  far  from  the  outer  side  of 
the  neck.     Occasionally  the  obturator  artery  arises  from  this  latter 
vessel  (once  in  three  and  a  half  subjects) ;  it  may  pass  to  the  inner 
side  of  the  neck  of  the  sac  along  the  border  of  Gimbernat's  ligament 
(once  in  seventy-five  times) ,  but  more  commonly  runs  between  the 
neck  and  the  femoral  vein.     When  once  it  has  emerged  from  the 
saphenous  opening,  a  femoral  hernia  usually  travels  upwards  and 
outwards  along  Poupart's  ligament  towards  the  anterior  superior 
iliac  spine,  being  guided  by  the  attachment  of  the  deep  layer  of  the 
superficial  fascia;  when  of  large  size,  it  may  extend  considerably 
above  the  level  of  Poupart's  ligament.     Femoral  hernia  are  less 
likely  to  contain  omentum  than  the  inguinal  variety:  a  portion  of 
the  ileum  is  most  often  present,   but  occasionally  the  ovary  or 
Fallopian  tube  may  be  found  in  the  sac. 

The  Signs  of  a  femoral  hernia  are  very  characteristic.     A  rounded 


II04 


A   MANUAL  OF  SURGERY 


swelling  with  an  impulse  on  coughing,  and  more  or  less  reducible, 
forms  on  the  inner  side  of  the  thigh,  its  neck  or  aperture  of  com- 
munication with  the  abdomen  lying  to  the  inner  side  of  the  femoral 
vessels,  and  to  the  outer  side  of  the  pubic  spine,  which  can  always 
be  easily  felt  (Fig.  516).  There  is  usually  but  little  difficulty  in 
making  a  diagnosis,  although  occasional!}^  some  care  is  needed. 
{a)  An  inguinal  hernia  is  recognised  by  the  fact  that  its  neck  occupies 
the  mguinal  canal,  the  saphenous  opening  being  free;  whilst  it  is 
also  above  and  internal  to  the  pubic  spme,  and  above  Poupart's 
ligament  at  its  point  of  exit;  it  tends  to  pass  downwards  into  the 
scrotum,  or  in  females  into  the  labium.  Femoral  hernia,  on  the 
other  hand,  usually  (but  not  invariably)  occurs  in  women  over 
twenty- five  years  of  age ;  the  inguinal  canal  is  free,  whilst  the  neck 
is  in  the  situation  of  the  crural  canal,  below  and  external  to  the 
pubic  spine,  and  below  Poupart's  ligament;  moreover,  it  travels 
upwards  and  outwards,  the  labium  being  unaffected,    {b)  An  enlarged 

lymphatic  gland  over  the  saphenous 
opening  may  simulate  this  condi- 
tion very  closely;  but  the  absence 
of  impulse  on  coughing  and  of  the 
usual  hernial  signs  is  generally  suffi- 
cient to  distinguish  it ;  when,  how- 
ever, the  hernia  is  purely  omental 
and  irreducible,  the  impulse  is  so 
slightly  marked  that  correct  diag- 
nosis in  a  stout  woman  is  often  diffi- 
cult without  an  exploratory  incision, 
(c)  A  small  lipoma  in  the  canal 
somewhat  resembles  a  hernia,  but 
the  limitation  of  the  tumour,  its 
greater  mobility,  and  the  absence 
of  an  impulse  on  coughing,  should 
suffice  to  prevent  a  mistake,  {d)  A 
psoas  abscess  pointing  at  the  saphenous  opening  resembles  a  hernia  in 
the  existence  of  a  reducible  swelling  with  an  expansile  impulse  on 
coughing.  It  is  distinguished  from  it  by  the  facts  that  there  is  no 
gurgle  on  reduction;  that  the  abscess,  as  it  passes  under  Poupart's 
ligament,  lies  to  the  outer  side  of  and  behind  the  vessels;  and  that 
distinct  fluctuation  occurs  between  the  swelling  in  the  saphenous 
opening  and  the  tumour,  which  can  always  be  felt  in  the  iliac  fossa; 
the  characteristic  signs  of  spinal  caries  are  also  usually  present. 
[e]  In  varix  of  the  saphena,  if  a  pouch  or  ampulla  forms  close  to  its 
entrance  into  the  femoral  vein,  it  may  be  mistaken  for  a  femoral 
hernia  on  account  of  the  marked  impulse  on  coughing,  and  because 
the  swelling  disappears  on  assuming  the  recumbent  position.  It  is, 
however,  usually  associated  with  the  signs  of  varix  below,  and  by 
the  fact  that,  although  pressure  is  maintained  over  the  upper  part 
of  the  crural  canal  after  the  vein  has  been  emptied,  the  swelling 
regains  its  ordinary  size  when  the  patient  stands  up.     The  impulse 


Fig.  516. — Femoral  Hernia. 


HERNIA 


1105 


is  of  a  different  character  to  that  of  a  hernia ;  the  blood  can  be  felt 
to  be  driven  past  the  examining  finger  with  a  thrill,  instead  of  there 
merely  being  an  expansile  bulge. 

Treatment. — When  reducible  and  of  small  size,  a  femoral  hernia 
may  be  treated  by  the  use  of  a  truss,  similar  in  nature  to  that  used  for 
an  inguinal  hernia,  except  that  the  pad  extends  somewhat  lower,  so 
as  to  maintain  pressure  along  the  course  of  the  canal.  A  badly- 
fitting  truss  may  compress  the  femoral  vein,  and  lead  to  oedema  of 
the  leg. 

Operative  Treatment  is  undertaken  either  for  the  relief  of  strangu- 
lation, or,  if  a  radical  cure  is  desired,  as  an  operation  de  complaisance. 
The  remarks  already  made  as  regards  the  cure  of  inguinal  hernia, 
and  the  general  princi- 
ples there  enunciated, 
apply  also  to  this 
variety.  The  apposi- 
tion of  the  anterior  and 
posterior  walls  of  the 
crural  canal  is  the  essen- 
tial element  in  the  opera- 
tion, and  this  practically 
resolves  itself  into  the 
fixation  of  the  inner 
end  of  Poupart's  hga- 
ment  to  the  horizontal 
ramus  of  the  pubis  or 
the  structures  overlying 
it.  The  sac  is  exposed  by 
a  vertical  incision  along 
the  course  of  the  crural 
canal  (Fig.  473,  G), 
cleared  of  its  fatty 
covering,  which  is  often 
thick  and  abundant, 
emptied  of  its  contents 

by  reduction,  and  then  cut  away  after  transfixing  and  tying  the  neck. 
Some  surgeons,  however,  retain  the  sac,  pushing  it  back  into  the 
abdomen,  and  using  it  as  a  pad  across  the  upper  opening  of  the 
canal.  The  fatty  covering  of  the  sac  must  be  dealt  with  in  a  similar 
way.  The  deep  ring  is  then  commanded  by  one  of  the  following 
methods:  (i)  In  the  great  majority  of  cases  it  will  suffice  to  introduce 
stitches  through  the  inner  end  of  Poupart's  hgament  (Fig.  517), 
and  deeply  through  the  horizontal  fibres  of  Cooper's  hgament, 
which  he  in  close  apposition  to  the  horizontal  ramus  of  the  pubis. 
There  are  but  few  cases  where  this  manoeuvre,  if  effectively  carried 
out,  is  not  sufficient  to  determine  closure  of  the  canal;  but  for  this 
purpose  the  hernia  needle  must  be  carried  down  to  the  bone,  and  not 
merely  through  the  fascia  over  the  pectineus.  (2)  In  a  few  cases, 
perhaps,  where  the  opening  is  larger,  it  may  be  desirable  to  approxi- 

70 


Fig.    5 17. ^Diagram    of    the    Radical    Cure 
FOR  Femoral  Hernia. 

The  position  of  the  femoral  vein  and  artery  is 
indicated,  and  the  internal  saphena  vein  passes 
up  through  the  saphenous  ring  to  join  the 
former.  The  spermatic  cord  is  seen  above,  and 
the  situation  of  the  suture  to  close  the  crural 
canal. 


iio6  A  MANUAL  OF  SURGERY 

mate  Poupart's  ligament  to  the  horizontal  ramus  by  some  other 
method,  and  for  this  purpose  Roux  has  advised  the  use  of  a  f| -shaped 
metal  staple,  which  traverses  the  ligament,  and  the  free  ends  of 
which  are  driven  into  the  bone.  This  plan  appears  to  us  undesir- 
able, since  the  staple  occasionally  works  loose,  and  then  the  prox- 
imity of  the  femoral  vein  makes  it  an  unwelcome  neighbour.  (3)  A 
good  substitute  for  this  plan  has  been  practised  by  Nicoll*  of 
Glasgow,  who  drills  the  horizontal  ramus  from  below  upwards  in 
two  spots,  and  then  b}^  passing  a  mattress  suture  through  Poupart's 
ligament  and  the  free  ends  through  these  drill-holes,  t\ang  them 
below,  the  ligament  is  safely  approximated  to  the  inner  and  upper 
aspect  of  the  pubis. 

Umbilical  Hernia.- — Ihree  different  forms  of  umbilical  hernia  are 
described. 

1.  Congenital  Umbilical  Hernia,  or  Exomphalos,  is  an  exceedingly 
rare  condition,  due  to  imperfect  closure  of  the  abdominal  walls,  as 
a  result  of  which  part  of  the  intestine  is  found  at  birth  in  a  cavity  at 
the  base  of  the  umbilical  cord,  which  is  bulbous  and  enlarged.  If 
the  condition  is  overlooked,  it  may  be  included  in  the  ligature  with 
which  the  cord  is  tied,  and  fatal  strangulation,  or  at  the  best  a  faecal 
fistula,  will  result.  If  left  untreated  until  the  cord  has  separated,  the 
peritoneal  cavity  will  be  laid  open,  and  septic  peritonitis  ensue.  The 
only  treatment  is  immediate  laparotomy,  reduction  of  the  gut,  and 
closure  of  the  umbilical  opening  by  sutures,  if  such  be  possible. 

2.  The  Umbilical  Hernia  of  Infants  and  Young  People,  or,  as  it  is 
commonly  called,  '  starting  of  the  navel,'  is  due  to  weakness  of  the 
umbilical  cicatrix,  which  yields  before  the  intra-abdominal  pressure. 
Its  occurrence  is  often  determined  by  chronic  constipation  or 
phimosis,  necessitating  continual  straining  in  order  to  evacuate  the 
bowels  or  bladder.  The  condition  rarely  persists  till  adult  life,  as  it  is 
easily  cured.  Treatment  consists  in  regulating  the  bowels  and  in  the 
performance  of  circimicision,  if  necessary,  whilst  the  local  condition 
is  dealt  with  by  strapping  the  abdominal  wall  in  such  a  way  as  to 
tuck  the  umbilical  cicatrix  inwards;  no  pad  is  required.  In  per- 
sistent cases  it  may  be  necessary  to  lay  the  sac  open  and  remove  it, 
suturing  the  parts  together,  as  described  in  detail  below.  In  these 
cases  the  opening  is  often  a  transverse  chink  rather  than  a  round 
hole,  and  it  is  sometimes  advisable  to  introduce  the  sutures  in  a 
vertical  direction,  thereby  securing  transverse  apposition. 

3.  The  so-called  Umbilical  Hernia  of  Adults  is  usually  due  to  a  pro- 
trusion of  omentum  or  intestine  through  an  opening  in  the  linea  alba, 
either  immediately  above  or  below  the  umbilicus,  the  former  being 
the  more  common.  It  occurs  most  frequenth^  in  women  who  have 
borne  children,  being  sometimes  due  to  actual  rupture  of  the  linea 
alba  and  separation  of  the  recti  muscles.  A  peritoneal  sac  is 
present,  but  in  old-standing  cases  it  is  extremely  attenuated,  and 
so  adherent  to  surrounding  parts  as  to  be  unrecognisable,  whilst 
the  contents  may  be  matted  together  in  an  almost  inextricable 

*  Scottish  Med.  and  Surg.  Journ.,  December,  1903. 


HERNIA  1 107 

confusion.  Under  such  circumstances  obstruction  is  very  liable 
to  ensue,  and  if  combined,  as  is  not- uncommon,  with  a  subacute 
form  of  inflammation,  it  may  even  run  on  to  strangulation.  More- 
over, the  skin  over  the  tumour  becomes  stretched,  atrophic,  and 
not  unfrequently  ulcerated,  so  that  perforation  may  threaten.  The 
hernia  is  often  lobulated  in  character,  and  a  considerable  deposit  of 
fat  may  sometimes  surround  it. 

Treatment. — When  of  large  size,  and  occurring  in  stout  individuals, 
it  should  be  supported  by  a  bag  truss,  whilst  the  patient  is  placed  on 
such  dietetic  and  hygienic  measures  as  shall  assist  in  the  reduction  of 
excessive  corpulency.  In  favourable  cases  operative  treatment  can 
be  undertaken.  A  vertical  incision  is  made  over  the  site  of  the 
tumour,  and  to  effect  this  without  wounding  the  subjacent  gut,  it 
may  be  advisable  to  pinch  up  the  skin  on  either  side,  and  divide  it  by 
transfixion.  The  sac  is  then  opened,  the  incision  being  enlarged,  if 
necessary,  so  as  to  allow  the  contents  to  be  drawn  aside  and  the 
opening  in  the  abdominal  wall  exposed.  When  the  intestine  has 
been  reduced  and  omentum  removed,  the  sac  is  dissected  up  to  the 
margins  of  the  opening  into  the  abdomen,  which  is  usually  small  in 
size  and  circular  in  shape,  whilst  the  edges  are  firm  and  thickened. 
The  sac  may  now  be  cut  away  close  to  the  opening,  and  all  bleeding- 
points  secured.  The  aperture  is  then  closed  in  the  following  way : 
Several  deep  transverse  sutures  are  passed  through  the  whole  thick- 
ness of  the  abdominal  wall  on  each  side  and  tightened,  after  a  row  of 
interrupted  sutures  has  drawn  the  peritoneal  surfaces  into  contact. 
By  this  means  the  circular  aperture  is  obliterated  and  the  margins 
united  in  the  median  line.  The  external  wound  may  now  be  closed, 
any  redundant  skin  being  cut  away ;  it  is  usually  safer  to  insert  a 
drainage-tube  in  the  more  extensive  cases. 

Most  surgeons  have  discovered  by  experience  that  such  a  pro- 
cedure is  insufficient  in  any  but  the  slighter  cases,  and  that  a  much 
more  radical  operation  is  required  when  the  hernia  is  large  and  irre- 
ducible, and  the  patient  at  all  inclined  to  corpulence,  (i)  The  early 
steps  of  the  operation  are  identical,  but  it  will  be  found  advantageous 
to  place  the  cutaneous  incision  to  one  side  of  the  tumour  rather  than 
over  its  centre.  The  freeing  of  the  omentum  may  be  a  matter  of 
great  difficulty,  as  it  is  often  adherent  to  the  margins  of  the  opening. 
(2)  It  will  then  be  found  that  the  anterior  layer  of  the  sheath  of  the 
rectus  is  prolonged  over,  and  soon  lost  on  the  sac.  An  incision  is 
made  all  round  the  neck  of  the  sac  through  this  aponeurotic  covering 
to  reach  down  to  the  subperitoneal  tissue;  stitches  are  now  intro- 
duced across  the  opening  through  the  peritoneum  and  this  detached 
ring  of  aponeurotic  tissue  in  order  to  effect  its  closure  (Fig.  518) ;  all 
redundant  sac  is  clipped  away  with  scissors,  bleeding-points  being 
secured.  (3)  The  recti  muscles  are  now  laid  bare  on  either  side,  and 
their  posterior  surfaces  and  edges  loosened  so  that  they,  together 
with  the  anterior  layer  of  their  sheaths,  can  be  brought  into  apposi- 
tion over  the  closed  neck  of  the  sac,  which  is  thereby  buried.  To  do 
this  effectively  the  incisions  may  have  to  be  prolonged  up  and  down 


iio8 


A   MANUAL  OF  SURGERY 


the  abdominal  wall  for  some  distance,  since  the  recti  are  usually 
displaced  outwards  some  way  above  and  below  the  opening.  Silk- 
worm gut  may  be  advisably  used  to  bring  the  margins  together. 
Redundant  skin  is  now  cut  away  with  a  free  hand,  so  that  the 
abdominal  integument  may  not  be  unduly  lax,  but  shall  just  cover 
the  muscles  comfortably.  In  stout  patients  this  may  involve  the  re- 
moval of  considerable  masses  of  fat. 
An  operation  of  this  type  is  a 
severe  one,  and  not  to  be  lightly 
entered  upon;  but  if  it  is  carefully 
conducted,  the  results  in  many  cases 
are  most  successful.  Of  course  it  is 
very  desirable  that  the  abdominal 
wall  should  afterwards  be  supported 
by  firm  strapping  for  some  time, 
and  that  no  undue  strain  should  be 
placed  upon  it. 

A  Ventral  Hernia  is  the  term 
used  in  describing  any  protrusion 
occurring  at  some  spot  in  the  an- 
terior abdominal  wall  other  than 
those  already  mentioned.  Several 
forms  may  be  met  with : 

I.  It  consists  not  uncommonly  of 
a   protrusion    of    subserous,    fatty 
tissue    through    a    congenital    or 
acquired  opening  in  the  linea  alba, 
lineae  semilunares,  or  lineae  trans- 
versae,  especially  at  the  junctions  of 
Fig.  518. — Diagrammatic  Repre-  the  last  with  the  former.     1  hey  are 
sENTATioN  OF  THE  Radical  Cure  j^^^e   common   above    than  below 
OF  AN  Umbilical  Hernia  WHERE    ,-,  -,  ■,■  ■,  -r  x        x  , 

THE  Recti  Muscles   are    con-   ^^e  umbihcus,  and  if,  as  not  unfre- 
siDERABLY  DISPLACED.  qucutly  happcns,  the  fatty  tissue 

The  short  cross-hnes  represent  the  proliferates,  a  localized  tumour 
sutures.which  close  the  opening  in  resembhng  a  lipoma  IS  produced, 
the  peritoneum;  the  long  ones,  which  goes  by  the  name  of  a 
the  sutures  needed  for  apposing  y^/zy  hernia    of   the    linea   alba.      A 

S:atSo°  wafiroMhT^Sf.  P«rt.on    of    peritoneum  is  drawn 

through  the  opening  into  the  centre 
of  these  masses  when  they  have  persisted  for  some  little  time,  and  a 
tnie  hernia  is  thus  induced.  A  similar  condition  is  met  with  in  the 
inguinal  and  crural  regions,  and  probably  most  of  the  cases  described 
as  lipomata  in  these  parts  are  of  this  nature.  Considerable  pain  and 
abdominal  disturbance  (vomiting,  colic,  etc.)  accompany  almost 
every  movement  of  the  body,  being  caused  partly  by  the  traction  of 
the  peritoneum,  partly  by  the  constriction  of  the  neck  of  the  sac 
against  the  sharp  edges  of  the  small  opening.  Treatment  consists 
in  the  removal  of  the  projecting  mass,  care  being  taken  not  to 
include  any  viscera  in  the  suture  with  which  the  base  is  surrounded. 


HERNIA  nog 

The  stump  is  pushed  back  into  the  abdomen,  and  the  opening  closed 
by^deep  sutures. 

.  2.  After  operations  involving  the  .'division  of  the  abdominal 
parietes,  ventral  hernia  may  be  caused  by  the  yielding  of  the  cica- 
trix, especially  if  the  wound  suppurates,  and  the  deep  stitches  come 
away  or  are  removed,  or  if  the  opening  is  left  patent  for  the  purpose 
of  draining  an  intra-abdominal  abscess.  Treatment  of  such  cases 
consists  in  dividing  the  skin  and  subjacent  fibrous  tissues,  defining 
and  refreshing  the  edges  of  the  parietal  wound,  and  drawing  them 
together  with  buried  sutures.  Whenever  possible,  however,  the 
object  of  the  operation  should  be  to  overlap  the  margins  of  the  open- 
ing by  the  use  of  mattress  sutures,  bringing  surface  to  surface  rather 
than  merely  edge  to  edge.  A  little  more  manipulation  and  freeing 
of  the  parts  is  necessary,  but  it  is  astonishing  to  note  what  extensive 
gaps  in  the  abdominal  wall  can  be  effectively  cured  in  this  way. 
Sometimes,  however,  the  defect  is  too  extensive  for  treatment  in  this 
manner,  and  then  the  surgeon  may  advisably  utilize  a  silver  filigree, 
which  is  implanted  across  the  opening  on  a  level  with  the  sub- 
peritoneal tissue.  Of  course  it  is  effectively  sterilized  before  use, 
and  forms  a  permanent  barrier  against  further  hernial  protrusions.* 

3.  In  women  who  have  borne  children  the  linea  alba  often  stretches 
and  yields,  allowing  considerable  separation  of  the  recti  muscles  for 
almost  their  whole  length.  If  placed  in  the  recumbent  posture,  and 
told  to  raise  their  head  and  shoulders  from  the  bed  without  using 
their  elbows  for  support,  the  linea  protrudes  as  a  longitudinal  ridge  of 
considerable  breadth.  Much  discomfort  and  dyspepsia  arises  from 
this  cau^e,  owing  to  the  inefficient  support  given  to  the  intestines.  A 
firm  abdominal  belt  may  be  used  as  a  palhative  measuie,  but  opera- 
tion is  very  desirable.  The  thinned  linea  alba  is  spht  down  the 
middle  from  top  to  bottom  if  need  be ;  on  one  side — say,  the  right — 
it,  together  with  the  neighbouring  rectus  muscle,  is  separated  from 
the  subcutaneous  tissues  and  tucked  under  the  rectus  on  the  left  side, 
its  free  end  being  secured  by  a  row  of  mattress  sutures  passing 
through  its  edge  and  the  left  hnea  semilunaris,  and  being  tied  super- 
ficially. The  left  free  edge  is  subsequently  secured  to  the  right  linea 
semilunaris  by  a  row  of  stitches.  Redundant  fat  and  skin  is 
removed,  and  the  wound  closed  by  sutures.  In  this  way  the 
abdominal  wall  is  drawn  together  like  a  double-breasted  coat,  and 
excellent  results  follow. 

A  Lumbar  Hernia  is  a  condition  of  considerable  rarity,  in  which  the 
abdominal  viscera  protrude  by  the  side  of  the  erector  spiuce,  coming 
to  the  surface  between  the  latissimus  dorsi  and  the  external  obUque, 
in  the  space  known  as  Petit's  triangle.  It  is  perhaps  seen  most 
frequently  after  operations  upon  the  kidney  where  suppuration  has 
occurred,  and  the  deep  stitches  have  had  to  be  removed.  The 
ordinary  signs  of  hernia  are  present,  and  with  a  little  care  the  condi- 
tion is  readily  distinguished  from  a  lumbar  abscess.  Treatment  may 
be  c  onducted  along  the  same  lines  as  for  a  ventral  hernia. 
*  MacGavin,  Practitioner  August,  1906. 


iiio  A   MANUAL  OF  SURGERY 

A  Diaphragmatic  Hernia  is  rarely  recognised  ante-mortem.  A  few 
cases  of  strangulation  have,  however,  been  diagnosed.  It  is  usually 
congenital  in  origin,  arising  from  imperfect  development  of  one  or 
both  halves  of  the  diaphragm,  and  is  most  common  on  the  left  side, 
It  may,  however,  result  from  traumatic  lesions,  such  as  stabs, 
involving  the  diaphragm.  The  transverse  colon  or  stomach  generally 
protrudes  into  the  thorax,  and  there  is  usually  no  peritoneal  sac. 
Treatment  is  impracticable  in  the  majority  of  instances,  although  one 
or  two  cases  of  traumatic  hernia  have  been  successfully  operated  on 
through  the  chest  wall  and  pleural  cavity,  thus  permitting  the 
closure  of  the  hole  in  the  diaphragm. 

Obturator  Hernia  consists  in  a  protrusion  of  intestine  through  the 
upper  part  of  the  thyroid  foramen,  and  has  usually  been  observed  in 
elderly  females.  It  is  not  often  recognised  in  the  living,  except  when 
strangulated,  and  even  then  it  is  more  likely  to  be  discovered  from 
the  abdominal  aspect  during  a  laparotomy  for  acute  obstruction  than 
diagnosed  apart  from  operation.  In  a  few  cases,  however,  it  has 
been  noted  that,  in  addition  to  the  general  signs  of  strangulation, 
there  was  a  sense  of  deep  resistance  and  of  fulness  close  to  the  origin 
of  the  adductor  muscles ;  whilst  pain  was  referred  down  the  obturator 
nerve  to  the  inner  side  of  the  knee.  Rectal  or  vaginal  examination 
may  throw  some  light  on  the  nature  of  the  case.  Treatment  has 
generally  been  confined  to  cases  of  strangulation,  and  in  these  an 
incision  is  made  over  the  inner  aspect  of  Scarpa's  triangle,  and  the 
pectineus  divided  or  displaced.  The  sac  when  found  should  be 
opened,  and  strangulation  relieved  by  cutting  upwards,  the  obturator 
vessels  being  usually  situated  below  the  neck  of  the  sac.  If  found 
during  a  laparotomy  for  obstruction,  the  same  precautions  must  be 
taken  as  for  a  Richter  hernia  in  the  femoral  region  when  discovered 
in  the  same  way  (p.  1123). 

Other  forms  of  hernia — e.g.,  pudic,  pudendal,  vaginal,  sciatic,  etc. — 
have  been  described,  but  are  so  uncommon  that  they  need  no  special 
mention. 

Abnormal  Conditions  of  Hernise. 

Irreducibility  of  a  Hernia  is  generally  due  to  the  presence  of 
adhesions,  either  between  the  contents  and  the  sac,  or  between  the 
contents  themselves,  which  are  thus  united  into  a  mass  too  large  to 
pass  through  the  aperture  of  communication  with  the  abdomen.  This 
is  often  associated  with  contraction  of  the  neck  of  the  sac,  which 
arises  either  from  the  pressure  of  an  ill-fitting  truss  or  the  constant 
drag  of  the  contents.  Overgrowth  or  an  excessive  deposit  of  fat  in 
the  omentum  may  result  in  irreducibility,  whilst  cysts  may  occa- 
sionally form,  as  already  described. 

The  local  signs  of  this  condition  are  very  evident,  whilst  dyspepsia, 
colicky  pains,  and  a  sense  of  dragging  are  among  the  most  prominent 
symptoms. 

Treatment. — i.  It  may  sometimes  be  remedied  by  forcible  taxis 
applied  at  intervals,  between  which  the  patient  is  kept  in  bed,  and  an 


HERNIA  III  I 

icebag fipplied SO  as  to  contract  the  parts;  moreover,  the  patient,  if 
fat,  should  be  carefully  dieted.  It  is  most  important  not  to  operate 
on  large  hernije  of  this  nature  until  some  such  preliminary  treatment 
has  been  undertaken;  the  sudden  reduction  of  a  large  amount  of 
intestine  into  the  abdominal  ca\'ity  has  been  responsible  for  several 
deaths  from  interference  with  the  heart's  action.  2.  Another  plan 
consists  in  the  use  of  what  is  known  as  the  hinged-cup  truss  ;  the 
hernia  is  supported  in  a  suitable  leather  bag  hinged  to  the  lower  part 
of  a  truss,  upward  pressure  being  maintained  by  means  of  an  elastic 
spring.  By  the  use  of  one  or  other  of  these  plans  reduction  may 
after  a  time  be  accomplished ;  but  we  are  not  in  favour  of  any  such 
proceedings,  except  in  very  large  hernice.  3.  In  healthy  indi\aduals, 
and  if  the  rupture  is  not  too  large,  operation  is  preferable  and  much 
more  satisfactory,  omentum  being  removed  and  adhesions  di\dded, 
as  already  described.  4.  In  a  few  very  aggravated  cases,  it  is  only 
possible  to  support  the  hernia  by  an  elastic  bag. 

Inflamed  Hernia  is  one  characterized  b\^  the  existence]of  a  localized 
peritonitis  in\-olving  the  sac,  and  perhaps  also  the  contents.  It 
usually  arises  from  injury,  such  as  ill-directed  taxis,  or  from  in- 
judicious truss  pressure.  The  S}Tmptoms  are  those  of  a  local  inflam- 
mation, the  part  becoming  hot,  painful,  tender,  and  swollen,  and 
perhaps  the  skin  over  it  congested;  this  is  associated  with  general 
fe^'er,  malaise,  nausea,  and  vomiting,  whilst  constipation  is  generally 
present.  A  condition  is  thus  induced  somewhat  resembling  strangu- 
lation ;  but  it  is  distinguished  from  the  latter  by  the  presence  of  fever 
instead  of  shock,  the  absence  of  tension  in  the  sac,  and  the  character 
of  the  vomiting,  which  is  not  faecal.  The  hernia  is  irreducible,  at 
any  rate  for  a  time,  probabh'  more  on  account  of  the  pain,  which 
prevents  taxis,  than  from  any  mechanical  reason,  except  in  old- 
standing  cases  where  pre\'iously  formed  adhesions  exist.  Lymph  is 
deposited  on  the  serous  surfaces,  and  this  usually  leads  to  the  forma- 
tion of  adhesions.  Occasionally,  where  omentimi  is  alone  present, 
an  attack  of  this  type  may  result  in  a  natural  cure,  especially  in  the 
umbilical  variety. 

The  Treatment  consists  in  putting  the  patient  to  bed  and  restricting 
his  diet  to  fluids,  whilst  fomentations  are  applied  to  the  part.  A 
little  opium  may  also  be  administered  to  allay  the  pain,  and  the 
lower  bowel  is  emptied  by  an  enema.  Should  the  condition  persist 
in  spite  of  treatment,  it  will  be  wise  to  operate,  as  otherwise  strangu- 
lation might  foUow. 

Obstructed  Hernia  is  a  condition  in  which  the  onward  passage  of 
fseces  through  the  gut  contained  in  a  hernial  sac  is  prevented.  It  is 
most  frequently  seen  in  the  umbilical  variety,  and,  of  course,  only  in- 
volves the  large  gut .  It  is  due  to  an  accumul  ation  of  undigested  food 
or  faeces,  the  condition  being  aggravated  by  the  presence  of  flatus 
derived  from  the  decomposition  of  the  contents  of  the  bowel.  Nausea 
and  vomiting  are  induced,  the  latter,  however,  rarely  becoming  faecu- 
lent,  whilst  constipation  is  usuall}^  present,  although  the  lower  bowel 
may  empty  itself  and  flatus  may  pass.     Locally,  the  trunour  becomes 


III2  A  MANUAL  OF  SURGERY 

irreducible  and  distended,  but  not  tense  as  in  strangulation,  and  a 
doughy  mass,  which  can  be  moulded  and  indented  by  the  fingers, 
is  fell  within  the  sac.  There  is  no  tenderness,  but  the  patient  com- 
plains of  a  good  deal  of  intermittent  colicky  pain.  If  unrelieved,  a 
subacute  form  of  inflammation  may  supervene,  and  this  may  pass  on 
to  strangulation,  and  even  death. 

Treatment  consists  in  the  use  of  copious  enemata,  and  the  applica- 
tion of  an  icebag  to  the  hernia,  followed  by  carefully-applied  taxis, 
so  as  to  assist  the  onward  passage  of  the  impacted  contents.  As 
soon  as  the  obstruction  is  overcome,  a  brisk  purge  should  be  adminis- 
tered. 

Strangulated  Hernia. 

A  hernia  is  said  to  be  strangulated  when  the  contents  are  con- 
stricted in  such  a  way  as  to  obstruct  and  ultimately  to  arrest  the 
flow  of  blood  in  the  vessels  contained  therein.  Interference  with 
the  passage  of  faeces  is  not  an  essential  in  this  condition,  since  omen- 
tum alone  may  be  involved,  or  the  intestine,  if  present,  may  only 
have  a  portion  of  its  lumen  constricted,  as  in  the  form  known  as 
Riehter's  hernia  (Fig.  519),  whilst  in  Littre's  hernia  a  diverticulum  is 
similarly  affected. 

Two  chief  varieties  of  strangulation  are  described:  those  occur- 
ring within  the  abdomen,  which  are  dealt  with  more  fully  in 
Chapter  XXXVII.,  and  those  which  are  extra-abdominal;  it  is  only 
the  latter  to  which  we  shall  now  direct  attention. 

External  Strangulated  Hernia  arises  in  one  of  two  ways:  {a)  The 
hernia  becomes  strangled  immediately  after  its  formation;  this  is 
most  frequently  seen  in  children  or  adolescents,  the  hernia  being 
then  of  the  congenital  type,  and  having  a  long  narrow  sac.  {b)  In 
adults  it  more  frequently  results  from  extrusion  of  an  additional 
amount  of  the  abdominal  contents  into  the  sac,  as  the  outcome  of 
some  sudden  violent  effort.  This  condition  usually  obtains  in  old- 
standing  herniae,  the  neck  of  the  sac  having  previously  become 
thickened  and  contracted,  either  by  the  pressure  of  a  truss  or  the 
irritation  of  the  protruded  viscera.  The  former  of  these  two  con- 
ditions is  generally  acute  in  character,  the  latter  more  often  subacute. 

The  site  of  the  constriction  is  either  at  the  neck  of  the  sac,  or  in 
the  dense  tissues  external  to  it  (Plate  X.),  but  occasionally  it  exists 
elsewhere.  Most  frequently  the  active  agent  in  the  strangulation  is 
the  thickened  sac  wall  itself;  but  in  femoral  and  umbilical  herniae 
structures  outside  the  sac,  such  as  Gimbernat's  hgament  or  the  linea 
alba,  may  be  the  actual  cause  of  the  constriction,  whilst  it  may  also 
be  produced  by  the  passage  of  a  coil  of  intestine  under  a  tight  adhe- 
sion or  through  a  sht  or  aperture  in  the  omentum  contained  in  the 
sac.  In  those  herniae  which  become  strangulated  immediately  after 
their  protrusion,  the  constricting  cause  is  invariably  the  resistance  of 
the  tissues  surrounding  the  opening  in  the  abdominal  parietes. 

Pathological  Phenomena. — ^The  effects  of  strangulation  vary  some- 
what with  the  tightness  of  the  constriction.    The  circulation  is  seldom 


PLATE  X. 


Strangulated  Hernia. 


[  To  face  page  1 1 1 2. 


HERNIA  1 113 


arrested  entirely  at  the  onset  of  the  symptoms;  but  the  pressure 
affects  first,  and,  more  especially,  the  veins,  and  later,  by  the  con- 
gestion and  exudation  thus  produced,  the  flow  in  the  arteries  is 
brought  to  a  standstill.  Hence  the  constricted  tissues  are  congested 
to  begin  with,  and  then,  partly  as  a  result  of  the  deficient  supply  of 
arterial  blood,  mainly  in  consequence  of  bacterial  invasion,  gangrene 
ensues,  with  or  without  an  intervening  period  of  inflammation. 

When  a  portion  of  intestine  is  strangulated,  it  ftrst  becomes  of  a 
dusky  red,  chocolate,  or  claret  colour,  owing  to  vascular  congestion; 
it  is  thickened  and  stiff  from  exudation  into  its  walls,  and  distended 
bv  the  formation  of  gas  within  its  lumen,  owing  to  the  arrest  of 
peristalsis  and  the  putrefaction  of  its  contents.     The  surface  for  a 
time  remains  smooth  and  shiny,  but  as  the  exudation  into  the  sac 
increases,  the  endothehum  is  shed.     Occasionally  some  of  the  super- 
ficial capillaries  rupture,  giving  rise  to  ecchymoses,  whilst  in  rarer 
instances,  and  possibly  as  the  result  of  injudicious  taxis,  the  con- 
gested vessels  completely  empty  themselves  into  the  sac,  which  is 
thus  filled  with  clotted  blood,  the  intestine  in  consequence  becoming 
lax  and  vellowish-grey  in  colour.     When  the  strangulation  is  re- 
lieved in  this  early  stage,  the  bowel  soon  regains  its  former  healthy 
appearance.     If  inflammation  occurs,  the  surface  becomes  rough 
from  the  deposit  of  h^mph,  and  entirely  loses  its  shiny  and  polished 
aspect.     Gangrene  results  partlv  from  the  prolonged  stagnation  of 
blood,  and  partly  from  the  invasion  of  the  intestinal  wall  by  the 
B.  coli  and  other 'anaerobic  inhabitants  of  the  gut,  which,  as  soon  as 
the  vitality  of  the  intestinal  wall  is  sufficiently  impaired,  migrate 
through  it,  and  by  their  development  produce  toxic  bodies  which  still 
further  assist  the'^gangrenous  process.     As  soon  as  it  is  established, 
the  intestine  turns  an  ashy  grey  or  black  colour,  usually  at  one  or 
more  spots  which  gradually  spread,  lose  all  lustre  and  polish,  and 
after  a  time  become  soft,  lacerable,  and  offensive.     Gangrene*  3s 
much  more  common  in  the  femoral  and  umbiHcal  forms  of  hernia 
than  in  the  inguinal;  it  is  generally  developed  in  two  or  three  days, 
but  occasionally  may  supervene  in  less  than  twenty-four  hours  from 
the  onset  of  the  strangulation.     It  is  more  often  seen  in  small  herniffi 
of  recent  origin  than  in  large  old-standing  ones.     At  the  point ^  of 
strangulation  the  gut  is  completely  anaemic  and  liable  to  ulceration 
or  gangrene,  which  may  subsequently  result  in  perforation;  adhe- 
sions may,  however,  form  between  it  and  the  neck  of  the  sac,  thus 
preventing  contamination  of  the  general  peritoneal  cavity.     The 
intestine   above  the  site   of  strangulation  becomes  paralyzed,   and 
peristalsis  is  entirely  arrested,  even  in  a  Richter's  hernia.     Fsecal 
material,  accumulating  and  undergoing  decomposition,  gives  rise  to 
a  catarrhal  enteritis,  and  even  occasionally  to  stercoral  ulcers,  which 
may  perforate  and  cause  general  peritonitis;  this,  however,  is  not 
very  common  in  external  strangulation,  since  the  small  intestine  is 
usually  involved,  and  soHd  faces  are  absent.     In  more  chronic  cases 

*  For  a  valuable  paper  on  '  Gangrene  in  Strangulated  Hernia,'  see  Comer, 
St.  Thomas's  Hospital  Reports,  vol.  xxix. 


III4  A   MANUAL  OF  SURGERY 

gangrene  of  the  gut  may  be  induced  by  the  pressure  of  the  accumu- 
lated contents  and  the  action  of  the  B.  coli.  The  portion  of  the 
bowel  below  the  constriction  may  be  affected  in  a  similar  manner, 
owing  to  the  arrest  of  the  peristalsis,  but  to  a  slighter  degree. 

Omentum,  when  strangled,  is  at  first  congested  and  of  a  dark  red  or 
purphsh  colour,  and  later  on  infiltrated  and  matted  together.  If, 
however,  it  has  contracted  adhesions  to  the  sac,  and  no  gut  is  present, 
the  trouble  may  subside,  since  its  vitality  may  be  maintained  through 
the  adhesions,  and  a  natural  cure  of  the  hernia  may  result.  Where 
such  a  condition  is  not  present,  gangrene  supervenes,  and  the 
omentum  then  becomes  ashy  gray  or  brown  in  colour,  and  is  pulta- 
ceous  and  friable.  It  does  not  become  offensive  unless  associated 
with  intestine,  since  it  does  not  contain  any  intrinsic  source  of 
putrefaction. 

The  sac  is  usually  distended  with  fluid,  which  at  the  commence- 
ment is  serous  in  character,  and  perhaps  blood-stained,  whilst  subse- 
quently it  becomes  turbid  and  mixed  with  lymph ;  finally,  it  is  dark 
brown  or  yellowish-green,  with  a  marked  and  most  objectionable 
odour.  Sometimes  there  is  but  little  or  no  effusion  of  fluid,  a  con- 
dition generally  due  to  complete  strangulation  of  arteries  and  veins 
simultaneously,  and  often  the  precursor  of  earty  gangrene.  The 
serous  lining  of  the  sac  is  but  slightly  affected  in  the  early  stages;  as, 
however,  the  case  progresses  to  inflammation  or  death  of  the  con- 
tents, it  also  becomes  inflamed,  and  ultimately  gangrenous  from  the 
activity  of  bacteria,  which  by  this  time  have  penetrated  to  the  turbid 
serum  contained  within  it.  Ihe  skin  and  surrounding  tissues  become 
cedematous,  congested,  and  crepitant,  and,  finally,  a  natural  cure 
may  be  determined  by  sloughing  and  the  establishment  of  an  arti- 
ficial anus. 

After  the  relief  of  strangulation,  even  if  no  gangrene  has  occurred, 
the  patient  is  not  free  from  risk,  owing  to  changes  which  may 
possibly  follow  the  temporary  arrest  of  the  circulation,  since  the 
prolonged  blood-stasis  in  the  bowel  may  be  followed  by  inflamma- 
tion, owing  to  the  damage  done  to  the  vessel  walls,  or  by  gangrene, 
owing  to  the  diminished  vitality  of  the  bowel  wall  rendering  it  more 
vulnerable  to  the  attacks  oi  the  intestinal  bacteria. 

The  Clinical  History  of  a  case  of  strangulation  is  usually  so  char- 
acteristic that  there  can  be  but  little  uncertainty  as  to  the  diagnosis. 
The  general  symptoms  are  similar  to  those  described  at  p.  1127,  as 
occurring  in  all  cases  of  acute  intestinal  obstruction.  Ihe  patient 
during  some  sudden  effort  notices  a  severe  pain,  localized  at  first  to 
one  of  the  hernial  regions,  or  referred  to  the  umbiHcus ;  this  is  accom- 
panied by  the  usual  evidences  of  shock — i.e.,  he  feels  faint,  the  pulse 
becomes  slow  and  weak,  the  temperature  falls,  and  the  surface  is 
covered  by  a  cold,  clammy  sweat.  1  his  shock  is  often  not  very  pro- 
longed, and  is  associated  with  or  quickly  followed  by  vomiting,  at 
first  gastric,  then  bilious,  and  finally  stercoraceous  or  faecal.  As  this 
continues,  the  pain  increases  in  severity,  and  radiates  over  the  whole 
of  the   abdomen,   which  becomes  tense,  tender,   and  tympanitic. 


HERNIA 


1115 


Symptoms  of  exhaustion  supervene,  caused  partly  by  the  pain  and 
vomiting,  and  partly  by  the  inability  to  take  food;  probably  the 
absolution  of  toxic  material  from  the  intestines  also  assists  in  its  pro- 
duction. Complete  constipation  is  usually  present,  but  the  patient 
may  pass  flatus  or  faces  from  the  lower  part  of  the  intestine.  The 
onset  of  gangrene  is  geneially  accompanied  by  a  sudden  fall  of  tem- 
perature and  a  cessation  of  pain,  whilst  the  pulse  becomes  weak, 
rapid,  and  intermittent,  the  surface  is  covered  by  a  cold  sweat,  the 
countenance  becomes  shrunken  and  drawn  (the  so-called  fades 
Hippocratica),  hiccough  follows,  and  finally  the  patient  dies,  usually 
as  a  result  of  toxaemia  due  to  the  absorption  of  products  developed 
either  in  the  bowel  wall  or  sac,  or  in  consequence  of  acute  generalized 
peritonitis. 

Locally,  a  tumour  is  found  in  one  of  the  usual  sites  of  a  hernia,  or 
if  alreadV  the  subject  of  this  condition,  the  patient  may  notice  that 
his  rupture  has  suddenly  become  larger. 
'Ihe  swelling  is  irreducible,  tense,  ex- 
tremely tender  and  painful,  and  without 
impulse  on  coughing.  It  is  hard  and 
rounded  if  bowel  is  involved,  softer  and 
more  doughy  to  the  touch,  if  omentum. 
When  gangrene  ensues,  the  tension 
wnthin  the  sac  is  reduced,  pain  and 
tenderness  cease,  whilst  the  skin  over 
the  tumour  becomes  dusky,  inflamed, 
and  oedematous;  finally,  evidences  of 
gangrene  show  themselves  externally, 
the  parts  becoming  dark  in  appearance, 
and  soft  and  emphysematous  to  the 
touch.  If  the  patient  survive,  the 
necrotic  tissues  separate,  and  an  artifi- 
cial anus  is  produced  either  naturally  or 


through  the  intervention  of  the  surgeon. 


Fig.  519. — Richter's  Hernia. 
(Diagrammatic.) 


Suppuration  within  thesac  is  uncommon. 

Occasionally,  however,  cases  are  met 
wath  in  which  the  above-described  signs  are  considerably  modified, 
and  gangrene  of  the  gut  may  occur  without  the  exaggerated  pheno- 
mena of  a  serious  toxsemic  type  indicated  above.  In  one  case  the 
patient  complained  of  no  inconvenience  beyond  slight  pain,  although 
incipient  gangrene  was  present ;  he  walked  into  hospital  saying  that 
he  never  felt  better  in  his  life. 

The  early  s\miptoms  arising  from  strangulation  of  a  portion  of  the 
lumen  of  the  intestine  [Richter's  hernia,  Fig.  519)  are  sometimes  less 
marked  than  when  a  complete  loop  is  constricted,  but  the  later 
phenomena  are  always  verj^  severe.  It  is  usually  of  the  femoral 
variety,  and  the  ileum  is  most  frequently  involved.  If  less  than  half 
the  circumference  of  the  bowel  is  constricted,  the  obstruction  is  not 
alwa3's  complete  at  first,  flatus  and  faeces  being  sometimes  passed; 
but  w^here  more  than  half  the  circumference  of  the  bowel  is  engaged, 


Ili6  A   MANUAL  OF  SURGERY 

complete  obstruction  from  kinking  or  paralysis  of  the  gut  ensues. 
The  vomiting  is  less  marked  than  in  other  cases,  and  is  not  so 
commonly  faeculent.  The  tumour  produced  is  small  in  size,  but 
tense  and  tender.  It  is  quite  possible,  however,  for  it  to  be  over- 
looked, even  when  the  groin  is  examined,  and  the  diagnosis  is  then 
likely  to  be  made  either  on  the  operating  or  post-mortem  table.  The 
prognosis  in  these  cases  is  always  grave,  partly  from  the  difficulty  ex- 
perienced in  diagnosis,  partly  from  the  tightness  of  the  constriction ; 
death  usually  results  from  perforative  peritonitis,  which  is  occasion- 
ally due  to  wounding  of  the  gut  by  the  hernia  knife.  The  mortality 
in  these  cases  is  calculated  at  62  per  cent.,  which  is  in  marked  con- 
trast with  that  of  about  35  per  cent.,  which  is  usually  said  to  be 
characteristic  of  strangulated  hernia.  The  mortality  for  all  cases  of 
strangulated  hernia  admitted  to  King's  College  Hospital  during  the 
years  1892  to  1897  only  amounted  to  i6-6  per  cent. 

The  occurrence  o'f  strangulation  in  a  pure  epiplocele  is  very  rare ;  the 
symptoms  are  vague  in  character,  and  the  diagnosis  is  often  difficult. 
The  presence  of  a  soft,  doughy,  tender  swelling  in  any  of  the  hernial 
regions,  combined  with  pain,  bilious  vomiting,  and  possibly  constipa- 
tion, is  always  a  significant  feature.  So  long  as  no  kinking  of  the 
bowel  is  caused  thereby,  the  symptoms  may  remain  indefinite,  the 
vomiting  never  becoming  faecal;  but  as  tmie  goes  on,  arrest  of 
peristalsis  may  lead  to  true  obstruction,  or  even  general  peritonitis. 
As  already  mentioned,  strangulated  omentum  does  not  per  se  be- 
come offensive;  but  occasionally  a  neighbouring  coil  of  intestine 
may  be  dragged  upon,  and  its  circulation  disturbed  sufficiently  to 
enable  the  B.  c.oli  to  escape,  and  then  it  may  find  its  way  into  the  sac, 
and  an  infective  inflammation  may  result. 

The  Treatment  of  a  strangulated  heinia  consists  in  reducing  the 
contents  by  taxis,  or  by  operaiton. 

Taxis  is  the  term  employed  for  the  manipulation  by  means  of 
which  a  hernia  is  reduced.  In  cases  of  strangulation,  it  must  be 
used  with  gentleness  and  great  care,  since  the  involved  portion  of 
intestine  is  congested  and  easily  torn.  The  patient  is  laid  on  a 
couch  with  the  head  supported  and  the  thighs  slightly  flexed,  so  as 
to  relax  the  abdominal  muscles.  The  fundus  of  the  tumour  is  then 
grasped  with  one  hand,  and  steady  pressure  employed,  having  for  its 
object  the  emptying  of  the  congested  bloodvessels,  and  consequently 
a  diminution  in  the  size  of  the  hernia;  the  fingers  of  the  other  hand 
manipulate  the  neck  of  the  sac,  in  order  that  the  part  which  has  most 
recently  been  protruded  may  be  first  returned.  The  direction  in 
which  taxis  is  made  varies  in  different  cases.  In  inguinal  hernia,  it 
should  be  directed  upwards  outwards,  and  backwards.  In  a 
femoral  hernia  which  has  extended  beyond  the  saphenous  opening, 
taxis  is  first  employed  downwards  and  inwards  in  order  to  make  the 
gut  re-enter  the  crural  canal,  and  then  finally  backwards  and  up- 
wards, the  margins  of  the  saphenous  opening  being  relaxed  by 
flexing  and  slightly  inverting  the  thigh.  In  umbilical  hernia,  the 
pressure  is  mainly  directed  backwards. 


HERNIA  1 117 

It  must  be  admitted  that  in  the  past  taxis  has  often  been  used 
injudiciously  and  in  cases  where  it  could  not  be  expected  to  do  any 
good ;  the  bowel  has  sometimes  been  ruptured  or  its  wall  bruised, 
the  mesenter}^  torn,  and  other  serious  results  have  followed.  At  the 
present  day  operative  treatment  for  hernia  is  eminently  successful, 
and  open  exploration  of  the  sac  enables  one  to  judge  of  the  condition 
of  the  gut  and  prevents  the  likelihood  of  returning  to  the  abdomen 
an  infected  and  even  gangrenous  focus.  Hence  it  may  be  stated  that 
taxis  is  permissihle  when  the  hernia  is  of  large  size,  particularly  if 
inguinal,  when  the  symptoms  have  a  mild  onset  and  do  not  become 
severe,  and  especially  if  taxis  has  been  successful  on  former  occa- 
sions. It  may  also  be  employed  in  old  people  with  diabetes  or  albu- 
minuria, or  in  insanitary  surroundings.  Taxis  is  objectionable,  and 
if  emplo^-ed  at  all  should  be  used  very  cautiously,  when  the  hernia 
is  small  and  tense,  and  particularly  if  femoral;  when  the  onset  is 
acute  and  sudden ;  when  the  sj^inptoms  are  well  marked,  and  especially 
if  they  become  so  in  the  early  stages  of  the  case ;  if  strangulation 
follows  on  the  first  development  of  the  hernia;  and  of  course  if  the 
case  has  lasted  for  some  time  and  fsecal  vomiting  is  present.  A  final 
attempt  may  always  be  made  before  operation  when  the  patient  is 
anesthetized. 

In  some  of  the  slighter  and  earlier  conditions  of  strangulation,  and 
especially  if  the  patient  has  had  similar  attacks  before  which  have 
been  relieved  without  operation,  reposition  may  be  assisted  by 
applying  fomentations  for  half  an  hour,  followed  by  the  use  of  an 
icebag,  reduction  sometimes  taking  place  spontaneously  or  being 
brought  about  bj^  taxis.  Ihe  heat  relaxes  the  tissues  around  the 
neck  of  the  sac,  and  the  effect  of  the  cold  is  not  only  to  constrict 
these  tissues,  but  also  to  induce  contraction  of  the  intestinal  blood- 
vessels and  muscles. 

Persistence  of  Symptoms  after  Apparently  Successful  Taxis. — It 
happens  occasionally  that  although  the  surgeon  may  have  apparently 
reduced  the  hernia  satisfactorily,  the  symptoms  of  strangulation — 
viz.,  pain,  vomiting,  and  constipation — persist.  Such  may  be  due  to 
a  variety  of  conditions,  and  considerable  judgment  is  needed  in 
coming  to  a  correct  decision  in  any  particular  case,  (i.)  Infective 
gangrene  may  involve  the  released  coil  of  gut  and  spread  to  the 
portion  above  it,  causing  death  from  peritonitis  and  toxaemia, 
(ii.)  Ulceration  and  perforation  may  occur  along  the  '  constriction 
groove.'  (iii.)  The  rupture  reduced  may  not  be  the  one  which  has 
given  rise  to  the  symptoms,  an  internal  hernia,  or  one  in  some  other 
region,  co-existing,  (iv.)  The  strangulation  may  have  been  caused, 
not  by  the  neck  of  the  sac,  but  by  a  slit  in  the  omentum  contained 
in  the  sac.  Reduction  in  such  a  case  would  not  relieve  the  symp- 
toms, the  whole  mass  being  returned  into  the  abdomen,  (v.)  A 
volvulus  may  have  been  present,  either  wholly  or  partly  in  the  sac, 
and  may  have  been  reduced  untwisted.  Occasionally  a  volvulus  is 
produced  by  the  manipulations  of  reduction,  especially  when  the 
mesentery  has  been  lengthened  in  long-standing  hernia  and  the 


iii8  A   MANUAL  OF  SURGERY 

bowel  paralyzed  by  the  strangulation,  (vi.)  The  hernial  sac  may 
have  a  diverticulum  or  pocket  communicating  with  it  at  its  upper 
end  (intraparietal  interstitial  hernia),  or  it  may  be  shaped  like  an 
hour-glass.  It  is  possible  to  reduce  the  intestine  from  the  lower 
portion  of  this  so-called  hernia  en  bissac  into  the  upper  pocket,  and 
then  of  course  the  symptoms  persist,  (vii.)  Reduction  en  bloc  or 
en  masse  ought  never  to  be  seen,  as  it  can  only  occur  when  con- 
siderable, and  therefore  an  unjustifiable  amount  of  force  has  been 
employed.  The  sac  and  its  contents  are  together  reduced  from 
their  superficial  position  to  the  deep  aspect  of  the  abdominal  parietes, 
the  hernia  then  lying  between  the  muscular  planes  or  in  the  sub- 
serous areolar  tissue,  and  the  constriction  remaining.  The  hernia 
gradually  disappears,  but  without  the  characteristic  gurgle.  In 
such  a  case  the  sac  sometimes  gives  way,  the  intestine  and  the 
portion  of  the  neck  which  compresses  it  being  pushed  upwards. 
When  occurring  in  the  inguinal  region  it  is  recognised  by  the  per- 
sistence of  symptoms,  and  by  the  fact  that  a  finger  inserted  into  the 
canal,  which  is  unduly  patent,  detects  a  tense  rounded  swelling  at 
its  upper  end.  It  also  happens,  but  less  commonly,  in  the  femoral 
region,  and  in  either  variety  the  hernia  may  slip  down  again  a  short 
time  after  its  apparent  reduction. 

In  any  case  where,  after  an  apparently  successful  taxis,  the 
s'VTnptoms  of  strangulation  are  still  present,  a  most  careful  investiga- 
tion is  needed  in  order  to  ascertain,  if  possible,  the  cause.  Thus,  the 
character  and  frequency  of  the  vomiting  must  be  considered,  since 
it  may  be  due  to  the  anaesthetic,  but  then  loses  its  faecal  character, 
and  is  less  severe.  If  the  vomiting  is  associated  with  a  certain  amount 
of  local  pain,  and  possibly  with  some  blood-stained  diarrhoea  or  the 
passage  of  mucus,  the  probability  is  that  the  coil  of  gut  has  been  in 
reality  reduced,  but  has  subsequently  become  inflamed.  Apart  from 
such  indications  the  affected  region  must  be  thoroughl}'  explored  with 
the  finger,  so  as  to  ascertain  whether  any  tumour  can  be  felt  at  the 
upper  or  deeper  end,  as  occurs  in  reduction  en  masse.  Should  this 
throw  no  light  upon  the  case,  the  other  hernial  apertures  must  each 
in  turn  be  examined,  and  finally  an  incision  is  made  over  the  sup- 
posed site  of  strangulation,  and  an  exhaustive  search  made  for  the 
sac.  If  no  help  is  thus  obtained,  the  abdomen  must  be  opened,  and 
some  internal  complication  sought  for.  In  the  inguinal  region,  all 
that  is  needed  is  to  prolong  the  first  incision  upwards  and  outwards ; 
in  a  femoral  hernia,  it  is  perhaps  wiser  to  make  a  separate  abdo- 
minal incision  in  the  middle  line,  so  as  to  avoid  the  division  of 
Poupart's  ligament;  whilst  in  the  umbilical  variety,  the  require- 
ments of  the  case  are  met  by  simply  increasing  the  size  of  the 
communication  between  the  sac  and  the  abdominal  cavity. 

The  Operative  Treatment  of  strangulated  hernia  should  always  be 
undertaken  at  as  early  a  date  as  possible,  when  once  it  is  certain 
that  the  bowel  is  constricted.  Nothing  can  be  gained  by  waiting, 
whilst  even  the  delay  of  an  hour  may  make  it  doubtful  whether  the 
result  will  be  successful  or  not.     There  is  always  sufficient  time  to 


HERNIA  1 1 19 

permit  of  efficient  purification  of  the  parts,  and  it  may  be  desirable  to 
empty  the  lower  bowel  by  an  enema,  or  if  there  is  much  vomiting 
to  wash  out  the  stomach.  T he  administration  of  an  anaesthetic  needs 
care,  and  in  the  worst  cases  local  anaesthesia  or  spinal  analgesia 
must  be  depended  on.  A  suitable  incision  is  then  made  down 
to  the  sac,  which  should  be  recognised  by  its  tense  and  rounded  out- 
line. It  is  isolated  as  far  as  possible  from  surrounding  structures,  and 
then  carefully  opened.  The  amount  of  fluid  varies  much,  and  is 
sometimes  very  small,  so  that  the  possibility  of  injuring  the  bowel 
must  be  kept  in  mind.  Having  given  exit  to  the  fluid  from  the  sac 
and  noted  its  characters,  the  surgeon  carefully  examines  the  bowel  or 
omentum.  The  cause  of  strangulation  is  then  looked  for  and  divided 
by  a  special  hernia  knife,  which  practically  consists  of  a  curved 
blunt-ended  bistoury,  the  cutting  blade  being  limited  to  an  extent  of 
about  I  inch  from  the  blunt  end.  If  such  is  not  to  hand,  an  ordinary 
blunt-ended  curved  bistoury  will  suffice.  The  index-finger  is  em- 
ployed to  repress  and  guard  the  mtestine,  and  acts  better  than  a 
director,  since  intestine  is  likely  to  curl  up  on  either  side  of  the  instru- 
ment, and  may  thus  be  injured.  The  knife  is  then  slipped  on  the 
flat  under  the  constriction,  and  turned  so  as  to  divide  it;  it  is  better 
to  nick  it  slightly  in  two  or  three  places  than  to  incise  it  by  one 
deep  cut. 

The  gut  is  carefully  drawn  down  into  the  wound,  and  its  condition 
at  the  site  of  strangulation  examined;  it  is  sometimes  a  matter  of 
difficulty  to  decide  whether  it  should  be  returned  or  not.  Of  course 
when  gangrene  is  obviously  present  further  treatment  is  necessary ; 
but  in  many  cases  the  condition  of  the  bowel  is  doubtful.  It  is  then 
well  to  delay  action  for  a  few  minutes,  and  perhaps  douche  the  parts 
with  warm  salt  solution.  A  gradual  change  of  colour  from  a  deep 
claret  to  a  more  definite  red  indicates  that  the  circulation  is  still 
active;  occasionally,  however,  it  will  be  found  that  no  change  occurs 
in  spite  of  division  of  the  constriction,  or  that  the  admittance  of  the 
circulation  brings  into  evidence  here  and  there  patches  that  remain 
unaltered ;  these  are  probably  gangrenous,  and  it  is  wise  to  deal  with 
them  as  such.  Omentum,  if  smaU  in  amount  and  recently  pro- 
lapsed, may  be  reduced,  but  it  is  better  practice  to  remove  any  con- 
gested portion,  or  that  which  has  evidently  been  in  the  sac  for  some 
time.  The  method  of  its  removal  has  been  already  described 
(p.  1098). 

According  to  the  condition  of  the  intestine,  the  further  steps  of  the 
operation  are  modified  as  follows : 

I.  If  the  gut,  though  congested,  shows  no  sign  of  gangrene  or  per- 
foration, it  may  be  safely  reduced.  This  is  not  always  a  matter  of 
ease,  owing  to  the  fact  that  the  effusion  into  its  walls  has  made  it 
stiff  and  fiim.  Prolonged  and  steady  pressure  with  the  fingers  will, 
however,  sufficiently  remove  the  exudation  to  permit  of  its  reposition 
into  the  abdomen.  All  manipulation  directed  to  the  intestine  must, 
of  course,  be  of  the  gentlest  nature,  since  its  congested  state  makes 
it  more  friable  than  usual. 


II20  A   MANUAL  OF  SURGERY 

2.  If  the  gut  has  been  tightly  strangled  and  gangrene  is  threaten- 
ing, it  is  advisable  to  resect  it  at  once,  the  incisions  being  made  well 
above  and  below  the  sites  of  constriction ;  the  divided  ends  are  united 
by  one  of  the  plans  detailed  at  p.  1037.  If,  however,  the  bowel  is  in  a 
doubtful  condition,  but  recovery  thought  possible,  it  is  gently  re- 
placed just  inside  the  abdomen,  after  freely  dividing  the  constriction, 
and  a  large  drainage-tube  is  inserted  down  to  it.  There  is  no  need  to 
fix  the  bowel;  it  is  already  inflamed  and  paralyzed,  and  hence  will 
not  change  its  position,  especially  if  a  small  dose  of  opium  is  subse- 
quently administered.  In  this  way,  even  if  gangrene  or  perforation 
occurs,  a  track  is  left  for  the  escape  of  the  contents,  while  a  localized 
plastic  inflammation  will  shut  off  the  general  peritoneal  cavity.  A 
faecal  fistula  may  thus  be  formed,  but  it  often  closes  spontaneously  at 
a  later  date. 

3.  If  the  gut  at  the  time  of  operation  is  evidently  gangrenous,  the 
ideal  treatment  consists  in  [a]  total  removal  of  the  affected  coil,  and  of 
some  inches  below  and  above  it,  especially  the  latter,  so  as  to  be  well 
clear  of  the  infected  focus.  The  ends  are  united  together  in  the 
usual  way,  and  a  considerable  degree  of  success  may  be  expected  in 
patients  who  have  not  been  left  too  long.  The  intestinal  canal  is  at 
once  restored  to  functional  utility,  so  that  the  fluid  and  offensive 
fsecal  material  can  pass  onwards,  whilst  the  absorption  of  toxins 
from  the  stinking  gangrenous  gut  wall  is  stopped,  [b)  In  only  too 
many  cf  these  cases,  however,  the  general  condition  is  almost  hope- 
lessly bad  through  delay,  and  primary  enterectomy,  even  in  expert 
hands,  takes  some  time.  It  is  then  necessary  to  open  the  bowel  and 
make  an  artificial  anus.  It  is  essential  that  a  free  passage  should  be 
made  under  the  constriction  into  the  gut  above,  but  if  possible 
without  detaching  or  loosening  adhesions  at  the  neck  of  the  sac, 
whereby  peritoneal  infection  is  prevented.  Ihe  introduction  of  the 
finger  up  the  bowel  may  be  followed  by  a  free  flow  of  faeces ;  but  if 
not,  then  the  constriction  may  be  dilated  from  inside  the  bowel  b}^ 
dressing-forceps  and  a  large  drainage-tube  introduced;  or  the  con- 
striction at  the  neck  may  be  carefully  divided  from  outside,  and 
either  a  Paul's  tube  or  a  large  drainage-tube  inserted.  Of  course  one 
should  cut  away  as  much  of  the  stinking  gut  as  practicable.  An 
artificial  anus  is  thus  formed,  through  which  for  a  time  the  patient 
can  discharge  the  intestinal  contents,  and  unless  this  desideratum  is 
at  once  attained,  failure  is  very  likely  to  follow  the  operation.  The 
wound  is  left  open  and  a  suitable  dressing  apphed,  into  which  the 
faeces  can  be  received ;  possibly  the  best  application  is  a  layer  of  pro- 
tective with  a  sufficient  hole  in  the  centre  to  allow  the  faeces  to  pass, 
and  then  over  it  a  thick  layer  of  tenax. 

The  relative  value  of  the  two  methods  cannot  be  fairly  measured 
by  statistics,  since  so  many  of  the  cases  treated  by  the  formation 
of  an  artificial  anus  are  hopeless  from  the  beginning.  There  can  be 
no  question  that,  with  our  prerent  methods  of  intestinal  suture,  a 
large  measure  of  success  may  be  expected  from  the  adoption  of 
primary  resection  in  the  majority  of  cases. 


HERNIA  1 12 1 

Having  thus  dealt  with  the  hernial  contents,  it  is  always  advisable 
to  perform  a  radical  cure  in  uncomplicated  cases,  so  as  to  prevent  any 
recurrence  of  the  condition.  This  is  undertaken  according  to  the 
methods  already  described,  and  the  external  wound  subsequently 
closed  and  drained. 

ihe  After- Treatment  in  cases  of  strangulated  hernia  is  of  the 
greatest  importance.  The  patient  is  placed  in  bed,  and  absolute 
quiet  is  maintained,  no  food  being  allcwed  for  twenty-four  hours, 
although  a  little  ice  may  be  sucked  or  hot  water  sipped  in  order  to 
relieve  thirst.  If  there  is  no  pain,  opium  need  not  be  administered, 
as  it  helps  to  maintain  the  paralyzed  condition  of  the  bowel;  severe 
pain  may,  however,  call  for  the  hypodermic  injection  of  a  small  dose 
of  heroin.  Liquid  food  can  usually  be  taken  at  the  end  of  twenty - 
four  hours,  and,  if  the  patient's  condition  remains  satisfactory,  it  is 
unnecessar}-  to  administer  any  purgative,  the  bowels  often  acting 
naturally;  if  they  remain  unreheved  for  five  or  six  days,  a  dose  of 
castor  oil  should  be  given. 

\"arious  Complications  may  arise  after  the  operation,  needing 
special  notice,  (i)  Vomiting  may  persist  for  a  time  as  a  result  of 
the  anaesthetic.  It  loses,  however,  its  fseculent  character,  and  may 
generally  be  stopped  b\'  washing  out  the  stomach  or  by  the  hypoder- 
mic injection  of  morphia.  (2)  The  Paralytic  condition  of  the  gut 
may  remain  for  some  considerable  time,  causing  prolonged  constipa- 
tion. If  there  is  no  evidence  of  inflammatory  mischief,  it  is  best 
treated  by  the  administration  of  a  purgative  or  by  a  turpentine 
enema.  (3)  Aci.te  Enteritis  may  arise  either  in  the  portion  of  strangu- 
lated gut  or  just  above.  This  is  usually  indicated  by  localized  pain, 
and  perhaps  the  passage  of  mucus,  w^hich  may  be  so  abundant  as  to 
amount  to  diarrhoea;  the  vomiting,  moreover,  persists,  but  is  no 
longer  stercoraceous.  It  is  best  treated  by  the  administration  of  bis- 
muth combined  with  chlorodyne,  whilst  all  solid  food  is  interdicted. 
(4)  It  is  possible  that,  although  the  gut  looked  healthy  at  the  time 
of  operation,  its  walls  were  in  reality  already  infected,  and  in 
spite  of  the  relief  of  the  constriction,  infeitive  gangrene  may  follow, 
causing  death  from  peritonitis.  (5)  Occasionally  acute  septic  peri- 
tonitis results  from  a  localized  perforation,  either  of  a  small  gan- 
grenous patch  or  from  ulceration  along  the  '  constriction  groove.' 
Treatment. — The  condition  is  obviously  one  of  the  gravest  import, 
and  must  be  dealt  with  actively  if  the  patient  is  to  be  saved.  The 
abdomen  must  be  opened,  the  affected  coil  identified,  and  if  need  be 
resected,  or  fixed  in  the  wound  and  opened  for  drainage  purposes. 
The  peritoneal  cavity  itself  is  dealt  with  according  to  the  rules 
alread\'  given.  (6)  Localized  Peritonitis  may  be  looked  on  as  a 
conservative  measure,  whereby  Nature  isolates  some  focus  of  danger 
from  the  general  peritoneal  ca\aty.  Occasionally  localized  sup- 
puration follows  as  the  result  of  a  limited  ulceration  or  perforation 
of  the  gut;  the  pus  must  then  be  let  out  at  the  earliest  possible 
moment,  but  a  fsecal  fistula  is  very  likely  to  follow. 

It  is  impossible  to  describe  in  detail  every  form  of  strangulated 

7t 


II22  A   MANUAL  OF  SURGERY 

hernia.  A  few  facts,  however,  must  be  stated  about  tlie  more 
important  varieties.  In  Strangulated  Inguinal  Hernia  the  constric- 
tion most  commonly  occurs  at  the  neck  of  the  sac,  usiiaUy  close  to 
the  external  abdominal  ring,  as  a  result  of  the  condensation  of  the 
surrounding  tissues.  The  signs  are  generally  very  characteristic,  and 
the  condition  can  rarely  be  mistaken.  Some  difficulty  may  be  ex- 
perienced in  distinguishing  it  from  inflammation  of  an  undescended 
testis  ;  in  this,  however,  there  is  no  persistent  vomiting  or  constipa- 
tion, whilst  the  absence  of  the  testis  below,  and  the  existence  of  the 
peculiar  testicular  sensation,  when  the  swelling  in  the  canal  is  com- 
pressed, should  clear  up  the  case.  Occasionally  the  two  conditions 
co-exist,  and  then  a  correct  diagnosis,  apart  from  an  open  explora- 
tion, may  be  almost  impossible.  Torsion  of  the  testis,  and  subse- 
quent strangulation  of  the  organ,  give  rise  to  a  swelling  not  at  all 
unlike  a  strangulated  hernia,  but  the  absence  of  constipation  and 
faecal  vomiting  should  prevent  mistakes. 

Division  of  the  stricture  in  the  course  of  the  operation  is  performed 
in  a  vertical  direction,  the  surgeon  cutting  directly  upwards,  the 
reason  being  that  it  is  impossible  in  old-standing  cases  to  be  certain 
whether  the  hernia  is  oblique  or  direct,  and  thus  the  liability  to  injury 
of  the  epigastric  artery  is  diminished.  If,  however,  the  modern 
method  of  operation  is  followed,  and  the  external  oblique  aponeu- 
rosis exposed  and  freely  divided,  it  will  often  be  found  that  the  con- 
striction is  relieved  by  this  means  alone,  and  reduction  becomes 
possible.  The  sac,  however,  should  always  be  opened,  and  the 
condition  of  the  bowel  examined. 

In  Strangulated  Femoral  Hernia  it  is  more  common  to  find  bowel 
than  omentum,  and  it  is  in  this  situation  that  partial  hernia 
(Richter's)  are  most  frequently  met  with.  A  tense  painful  swelling 
is  felt,  situated  in  the  neighbourhood  of  the  saphenous  opening, 
and  the  diagnosis  from  inflamed  lymphatic  glands  and  phlebitis  of 
a  varicose  saphena  vein  may  not  be  altogether  easy,  particularly  if 
omentum  alone  is  present.  The  histor}'  of  the  case,  and  a  careful 
consideration  of  the  physical  signs  and  symptoms,  should  generally 
be  sufficient  to  clear  up  the  diagnosis.  The  constriction  is  usually 
met  with  opposite  Gimbernat's  ligament,  and  to  divide  it  the  surgeon 
must  cut  directly  inwards,  so  as  to  incise  that  structure.  The  plan 
already  mentioned  of  nicking  it  in  two  or  three  places,  rather  than 
freely  dividing  it,  is  especially  useful  in  this  situation,  on  account  of 
the  occasional  abnormal  course  of  the  obturator  artery,  which  is 
stated  to  be  wounded  once  in  ever}-  150  cases.  The  accident  would 
be  recognised  by  the  occurrence  of  free  haemorrhage  alter  the  use 
of  the  hernia  knife.  In  such  a  case,  the  rupture  is  first  reduced,  the 
wound  enlarged  upwards,  and  both  ends  of  the  divided  vessel  secured, 
if  possible ;  failing  this,  carefully  adjusted  pressure  may  be  employed. 
Where  the  constriction  is  very  tight,  so  that  it  is  almost  impossible 
to  pass  a  director  between  Gimbernat's  ligament  and  the  intestine, 
the  plan  already  mentioned  of  dividing  the  constriction  from  without 
may  be  utilized  with  advantage. 


HERNIA  1 1 23 

Gangrene  is  more  than  twice  as  common  in  femoral  hernia  as  in 
inguinal  (icj'S  per  cent,  in  femoral  against  O'l  per  cent,  in  inguinal). 
Where  entcrectomy  is  feasibJe,  it  will  often  be  necessary  to  open 
the  abdomen  by  an  additional  incision  above  the  pelvic  brim,  and 
then,  having  divided  the  constriction  at  the  neck  of  the  sac,  the 
affected  coil  must  be  slipped  back  and  pulled  out  of  the  upper 
wound,  the  greatest  care  being  taken  not  to  contaminate  other  coils 
of  intestine.  The  shortness  of  the  mesentery  renders  it  impossible  to 
perform  the  necessary  manipulations  through  the  wound  in  the  groin. 

It  is  quite  possible  to  overlook  the  existence  of  a  small  Richter's 
hernia,  and  only  to  ascertain  its  presence  during  a  laparotomy  for  an 
acute  attack  of  obstruction.  Under  these  circumstances  the  greatest 
gentleness  must  be  exercised  in  any  attempts  to  withdraw  the  bowel 
from  the  sac,  for  fear  of  tearing  the  gut  and  flooding  the  peritoneal 
cavity  with  fluid  faeces.  It  is  usually  well  to  cut  down  on  the  hernia 
from  outside,  open  the  sac,  and  divide  the  constriction;  and  then 
partly  from  without,  partly  from  within,  to  reduce  the  strangled 
portion  of  bowel,  which  is  brought  to  the  surface  and  carefuUy 
examined.  In  many  such  cases  drainage  of  the  gut  by  a  Paul's  tube 
will  be  required,  and  a  subsequent  enterectomy. 

Seguelse  of  Strangulated  Hernia. — (i)  Artificial  Anus  may  arise  from  the 
sloughing  of  the  intestine  and  overlying  skin  apart  from  operation;  or  from  the 
surgeon's  interference,  either  by  his  opening  the  gut  in  mistake  for  the  sac,  or 
b}^  his  incising  it  when  gangrenous ;  or  it  may  slough  subsequently,  if  left  in  situ 
when  gangrene  is  threatening.  After  a  time  the  surrounding  parts  settle  down 
and  heal  over,  the  diversion  of  the  fasces  from  their  natural  course  becoming 
more  and  more  complete,  owing  to  the  formation  of  a  spur  of  mucous  mem- 
brane, which  lies  across  and  blocks  the  entrance  to  the  lower  portion  of  the 
bowel.  This  spur  arises  partly  as  a  result  of  the  kinking  of  the  gut,  partly 
from  the  intra-abdominal  pressure,  which  pushes  the  exposed  inner  wall  of  the 
intestine  forwards.  The  effects  produced  by  an  artificial  anus  on  the  indi- 
vidual vary  with  the  portion  of  the  bowel  involved.  If  the  jejunum  or  upper 
part  of  the  ileum  is  thus  opened,  the  patient  soon  loses  ground  and  becomes 
emaciated,  owing  to  the  escape  of  the  intestinal  contents  before  the  nutritive 
elements  of  the  food  have  been  absorbed.  Eczema  of  the  skin  in  the  neigh- 
bourhood is  usually  produced,  resulting  from  the  irritation  of  the  faeces.  For 
treatment,  see  p.  1036. 

(2)  Faecal  Fistula  occasionally  results  from  a  strangulated  hernia,  owing  to  a 
perforative  inflammation  of  the  gut  after  the  relief  of  strangulation,  whether  at 
the  site  of  constriction,  or  above  or  below  it,  in  the  latter  case  arising  from  a 
stercoral  ulcer.  Though  the  lesion  may  be  intraperitoneal,  it  by  no  means 
follows  that  general  peritonitis  need  result,  since  sufficient  plastic  material  may 
be  formed  around  it  to  shut  off  the  general  peritoneal  ca\'it3^  and  to  allow  the 
extravasated  contents  of  the  bowel  to  find  their  way  outwards  through  a 
sinuous  track  to  the  external  wound.  It  may  be  some  days  before  any  evi- 
dence of  the  existence  of  this  condition  appears.  Not  uncommonly  the  opening 
will  close  naturally  as  a  result  of  cicatricial  contraction,  and  hence  no  steps 
need  be  taken  to  deal  with  it  until  all  hopes  of  such  a  result  have  faded. 
Where,  however,  it  persists,  attempts  may  be  made  to  effect  this  purpose  by 
injecting  stimulating  lotions,  or  by  applying  the  actual  cautery  to  the  interior 
of  the  fistula;  but  more  frequently  an  operation  to  expose,  if  practicable,  the 
wound  in  the  gut,  and  to  close  it  by  suture,  or  to  remove  the  affected  segment, 
will  be  necessary. 

(3)  Stenosis  of  the  gut  at  the  site  of  strangulation  may  ensue,  giving  rise  to 
the  symptoms  already  indicated  (p.  1022),  which  may  appear  weeks  or  months 
later. 


CHAPTER  XXXVII. 

INTESTINAL  OBSTRUCTION. 

By  Intestinal  Obstruction,*  or  Ileus,  is  meant  a  condition  in  which 
the  onward  passage  of  faeces  is  prevented.  It  is  often  associated 
with  vascular  phenomena,  due  to  strangulation  or  kinking  of  the  gut, 
which  result  in  a  deficient  supply  of  arterial  blood  reaching  the  part, 
thereby  predisposing  to  gangrene. 

Various  elements  enter  into  the  picture  provided  by  a  classical 
case  of  obstruction,  and  of  these  the  most  marked  are: 

I.  Coprostasis,  or  retention  of  faeces.  The  fact  that  simple  con- 
stipation may  last  for  a  week  or  more  at  a  time,  and  do  no  harm  to 
the  patient  beyond  a  certain  slight  degree  of  toxic  poisoning,  demon- 
strates that  this  is  not  the  only  element  in  cases  of  obstruction,  and 
indeed  is  often  an  almost  insignificant  factor  in  acute  cases.  Yet  it 
colours  the  whole  picture,  and  has  very  marked  results  in  the  clinical 
manifestations.  Retention  of  the  intestinal  contents  is  certain  to  be 
followed  by  their  decomposition  and  liquefaction,  and  this  causes  the 
intestinal  canal  to  be  filled  with  a  quantity  of  offensive  fluid  material, 
partly  due  to  bacterial  activity,  partly  to  the  pouring  out  of  a  con- 
siderable quantity  of  secretion  from  the  congested  gut  wall.  If  the 
obstruction  is  only  partial,  this  liquefaction  of  the  bowel  contents 
may  enable  them  to  pass  on,  and  the  patient's  attack  of  partial 
obstruction  is  followed  by  one  of  diarrhcea,  whereb}'  relief  is  ob- 
tained. If  the  obstruction,  however,  is  complete,  the  intestine  above 
the  block  is  gradually  filled  with  this  decomposing  material,  from 
which  toxins  may  be  absorbed,  the  patient  being  thereby  poisoned. 

A  second  result  of  this  decomposition  of  the  retained  faeces  is  the 
development  of  gas,  which  ma}^  be  so  marked  as  to  lead  to  great 
abdominal  distension,  or  meteorism.  Whilst  present  in  almost  every 
case  to  a  certain  degree,  it  is  most  marked  when  there  is  considerable 
involvement  of  the  mesentery,  and  experiments  on  animals  indicate 
that  constriction  of  the  nerves  contained  therein  is  the  chief  factor 
in  its  production. 

*  For  much  of  the  material  incorporated  in  this  chapter  we  beg  to  acknow- 
ledge our  indebtedness  to  Sir  Frederick  Treves'  classical  text-book  on  the 
subject  (published  by  Cassell  and  Co.),  than  which  nothing  better  has  ap 
peared,  and  which  we  have  freely  utilized. 

1124 


INTESTINAL  OBSTRUCTION  1125 

2.  Increased  peristalsis,  with  the  object  of  forcing  the  intestinal 
contents  past  the  block,  is  often  an  important  feature  in  the  case, 
leading  to  severe  pain  of  a  colicky  character.  So  violent  may  these 
efforts  become  that  the  bowel,  weakened  by  distension  and  inflamma- 
tion, is  finally  torn,  and  perforative  peritonitis  rapidly  ends  the  case. 

J.  Regurgitant  vomiting  is  always  a  prominent  element.  At  first 
the  gastric  contents  alone  are  ejected,  but  later  the  vomit  becomes 
bilious,  and  even  stercoraceous  or  faecal.  The  origin  of  this  pheno- 
menon is  still  a  little  dubious.  Some  have  considered  it  due  to  anti- 
peristalsis  ;  others  maintain  that  the  ordinary  onward  movements  of 
the  bowel  are  quite  sufficient  to  explain  it.  The  intestinal  contents 
are  urged  forward  against  the  face  of  the  obstruction,  and,  being 
unable  to  pass,  an  axial  regurgitant  stream  is  produced.  It  is  a  little 
difficult  to  see  how  this  could  occur  when  the  lower  end  of  the  colon 
is  the  part  affected.  Whatever  the  mechanical  explanation,  there  is 
no  question  as  to  the  influence  of  the  nervous  system  in  its  produc- 
tion, or  as  to  its  being  chiefly  reflex  in  character,  which  is  evident 
from  the  fact  that  it  occurs  whether  omentum  or  bowel  is  strangled. 
Hence,  it  is  easy  to  understand  that  it  commences  early  in  children 
and  sensitive  women,  on  account  of  the  greater  irritability  of  their 
nervous  centres,  whilst  it  is  also  more  marked  when  the  small 
intestine  is  involved.  Anything  that  increases  peristalsis  naturally 
intensifies  its  occurrence. 

4.  Nervous  phenomena  also  add  their  peculiar  features  to  the 
picture.  The  affected  coil  of  bowel  is  directly  paralyzed  by  the 
lesion,  but,  in  addition,  various  reflex  manifestations  occur.  Thus, 
in  acute  cases  the  patient  suffers  almost  at  once  from  shock,  which 
passes  off  after  a  time,  and  from  collapse  due  to  toxaemia  at  a  later 
date;  vomiting  and  perhaps  hiccough  develop  reflexly,  and  the  latter 
sign  is  always  to  be  looked  on  with  grave  suspicion  and  as  an  omen 
of  bad  import.  In  the  latest  stages  intestinal  paralysis  from  the 
onset  of  peritonitis  may  dominate  the  scene. 

5.  Infective  phenomena  are  likely  to  follow  sooner  or  later,  the 
bowel  walls  being  attacked  by  the  virulent  organisms  contained 
within  them.  Complete  paralysis  and  want  of  blood-supply  pre- 
dispose them  to  bacterial  invasion,  and  hence  the  more  acute  forms 
of  infective  gangrene  are  chiefly  seen  in  conditions  of  the  strangula- 
tion type;  when  mere  obstruction  is  present  without  vascular 
changes,  microbic  invasion  rarely  produces  more  than  a  patchy 
necrosis,  or,  more  commonly,  perforative  ulceration.  Of  course, 
when  infective  gangrene  is  present,  virulent  toxins  develop  in  the 
walls  of  the  gut,  and  a  rapid  depreciation  of  the  patient's  general 
condition  follows  from  their  absorption. 

6.  Finally,  death  is  almost  certain  to  ensue  apart  from  surgical 
assistance,  although  a  few  cases  may  recover  spontaneously.  The 
final  event  is  due  either  to  perforative  peritonitis,  or  to  simple 
exhaustion,  the  result  of  toxic  absorption  from  the  retained  fceces  or 
from  the  necrotic  intestinal  wall,  of  constant  pain  and  vomiting, 
want  of  nutrition,  and  general  dehydration  of  the  tissues. 


II26  A   MANUAL  OF  SURGERY 

Causes.- — Much  elaborate  work  has  been  undertaken  to  produce  a 
satisfactory  classification  of  the  many  diverse  causes  of  intestinal 
obstruction ;  and  when  one  mentions  the  fact  that  a  recent  attempt 
included  eighty  distinct  causative  lesions,  it  is  ob\-ious  that  there  is  an 
abundant  field  for  this  type  of  ingenuity.  It  must  suffice  here  to  state 
that  there  are  two  great  divisions — the  dynamic  and  the  mechanical. 

(i)  Dynamic  ileus  is  due  to  some  paralytic  or  spasmodic  condition 
of  the  intestinal  wall,  which  results  in  interference  with  its  power  of 
transmitting  onwards  its  contents.  Paralysis  of  the  bowel  results 
from:  [a)  Diffuse  or  localized  acute  infective  inflammation,  as  in 
septic  peritonitis  or  acute  appendicitis;  ih)  torsion  of  intra-abdominal 
viscera,  such  as  the  spleen  or  omentum,  or  of  tumours — e.g.,  ovarian 
cysts,  leading  to  the  so-called  '  aseptic  '  peritonitis;  (c)  embolus  or 
thrombosis  of  the  mesenteric  vessels,  leading  to  necrosis;  (d)  nervous 
lesions,  which  may  involve  the  spinal  cord  itself,  or  more  frequently 
the  peripheral  nerves — e.g.,  a  tumour  at  the  root  of  the  mesentery. 
Spasm  of  the  gut,  as  by  chronic  lead-poisoning,  may  also  determine 
obstructive  phenomena. 

(2)  Mechanical  ileus  is  the  variety  most  commonly  seen,  {a)  The 
gut  may  be  strangled  by  bands  or  through  apertures,  causing  internal 
strangulation,  (h)  It  may  be  kinked  over  bands,  thereby  determining 
not  only  occlusion  of  the  lumen,  but  also  a  marked  interference  with 
the  vascular  supply,  [c]  The  intestine  may  be  twisted  on  its  own  axis, 
giving  rise  to  a  condition  known  as  volvulus,  {d)  One  portion  of  the 
bowel  may  be  invaginaied  into  a  neighbouring  portion,  constituting 
an  intussusception,  {e)  The  lumen  of  the  bowel  may  be  blocked  by 
foreign  bodies  or  accumulations  of  faeces  (obturation).  (/)  The 
onward  passages  of  the  faeces  may  be  rendered  difficult  or  impossible 
by  the  gut  becoming  narrowed,  as  from  cicatricial  or  cancerous 
stenosis,  or  the  pressure  of  external  tumours. 

The  most  useful  division  is,  however,  the  clinical,  grouping  to- 
gether those  cases  which  present  a  similarity  of  sxTuptoms;  and  this 
method  will  be  employed  here,  the  subject  being  discussed  under 
the  three  headings^ — Acute  Obstruction,  Chronic  Obstruction,  and 
Intussusception. 

Acute  Intestinal  Obstruction. 

ihe  following  are  the  chief  Causes  which  give  rise  to  this  con- 
dition : 

1.  Strangulation  by  bands  or  adhesions,  or  through  apertures,  etc. 

2.  Volvulus. 

3.  The  impaction  of  foreign  bodies. 

4  Strangulation  over  a  band  or'acute  kinking''of,'^the  gut,  both 
very  rare  conditions. 

5.  Acute  intussusception. 

6.  It  may  be  the  termination  of  a  chronic  obstruction. 

7.  Acute  localized  paralysis  of  the  gut  due  to  an  infective  inflam 
mation — e.g.,  acute  suppurative  appendicitis. 

8.  Acute  enterospasm. 


INTESTINAL  OBSTRUCTION 


1127 


It  will  be  noted  that  in  the  lirst  five  of  these  causes,  where  the 
ileus  is  primary,  there  is  a  definite  vascular  lesion  in  addition  to  the 
obstruction,  which  threatens  the  patient  at  an  early  date  with  per- 
forative ulceration  or  gangrene,  and  it  is  mainly  on  the  presence  of 
this  element  that  the  acuteness  of  the  case  depends. 

The  General  Symptoms  of  acute  obstruction  are  practically  iden- 
tical with  those  of  a  strangulated  hernia.  The  patient  is  suddenly 
seized  with  severe  abdominal  pain  somewhat  of  the  nature  of  colic, 
and  perhaps  referred  to  the  umbihcus,  coming  on  sometimes  during 
some  special  effort — e.g.,  lifting  a  heavy  weight,  or  sometimes  when 
lying  quietly  in  bed.  At  the  same  time  he  suffers  from  shock,  as 
evidenced  by  a  weak  pulse,  pale  face,  and  cold,  clammy  sweat,  the 


Fig.  520. — Strangulation  of  a  Coil  of  the  Lower  End  of  the  Ileum  by 
A  Band  developed  in  the  Neighbourhood  of  the  Vermiform  Ap- 
pendix.    (King's  College  Hospital  Museum.) 

temperature  of  the  body  falling  below  the  normal.  The  shock  is 
usually  more  or  less  recovered  from,  but  the  pain  persists,  and  is 
liable  to  exacerbation  and  intermissions,  soon  becoming  continuous. 
Vomiting  ensues,  being  at  first  limited  to  the  contents  of  the  stomach, 
but  quickly  changes  to  a  bilious,  stercoraceous,  or  even  fsecal  char- 
acter. Distension  of  the  abdomen  is  generaUy  present,  but  its 
amount  and  characters  vary  with  the  site  of  the  lesion.  Signs  of 
constitutional  depression  and  exhaustion  follow  in  a  short  time,  the 
pulse  becoming  weak,  rapid,  and  thready,  the  temperature  remain- 
ing subnormal  (except  occasionally  after  the  supervention  of  perito- 
nitis, when  it  may  rise  a  few  degrees),  the  face  looking  drawn  [facies 
Hippocratica),  and  the  abdomen  being  distended  and  painful. 
Finally,  if  unrelieved  by  treatment,  the  patient  dies,  and  usually 


1  [28 


A   MANUAL  OF  SURGERY 


within  seven  to  ten  days  from  the  onset,  owing  to  exhaustion  or 
perforative  peritonitis.  Constipation  may  be  absolute  from  the 
hrst,  not  even  flatus  being  passed,  but  at  any  time  the  lower  bowel 
may  empty  itself,  and  raise  false  hopes  as  to  the  pnjgnosis. 

The  Special  Forms  of  Acute  Obstruction  must  now  be  considered 
serial  im. 

I.  Strangulation  by  Bands  or  Adhesions,  through  Apertures,  etc. — 
Causes.--(a)  Isolated  peritoneal  hands  and  adhesions  arc  usually  the 
result  of  old  plastic  peritonitis  of  a  localized  and  chronic  character. 
The  greatest  variety  is  met  with  in  the  appearance  and  situation  of 
these  adhesions;  most  frequently  they  are 
single  and  cord-like;  sometimes  they  are  broad 
and  membranous,  constituting  a  false  liga- 
ment; or,  again,  they  may  be  multiple.  A 
common  situation  is  between  different  parts  of 
the  mesentery,  or  between  the  mesentery  and 
some  other  viscus,  the  cause  being  either  dis- 
ease of  that  viscus  (usually  a  pelvic  organ, 
the  caecum,  or  the  appendix),  or  inflammation 
of  a  mesenteric  gland  with  localized  perito- 
nitis. Whatever  the  exact  cause,  the  mischief 
is  most  frequently  found  either  in  the  right 
iliac  fossa  or  in  the  pelvis.  Two  methods  of 
producing  strangulation  exist :  either  the 
bowel  passes  under  the  arch  or  loop  formed  by 
a  short  constricting  band,  and  cannot  return 
(Fig.  520) ;  or,  if  the  band  is  long,  it  may  form 
a  loop  or  noose  through  which  the  bowel  passes,  and  so  becomes 
strangled  (Fig.  521).  (b)  Cords  formed  by  the  omentum  result  from 
union  between  its  fimbriated  extremities  and  some  part  of  the 
viscera  or  parietes,  forming  at  first  a  broad  band-like  adhesion, 
which  is  gradually  moulded  into  a  rounded  cord  by  the  constant 
dragging  and  puliing  to  which  it  is  subjected.  They  are  usually 
coarser  and  thicker  than  those  due  to  peritonitis.  The  mechanism 
of  strangulation  is  identical,  the  noose  form  being  perhaps  the  more 
common,  since  the  adhesions  are  likely  to  be  longer,  (c)  Meckel's 
diverticulum  (p.  10 14)  is  liable  to  cause  strangulation  when  its  free 
end  becomes  adherent  either  to  the  parietes  or  to  the  viscera;  it  is 
attached  most  frequently  to  the  mesentery  of  the  ileum,  and  after 
that  to  the  neighbourhood  of  the  umbilicus.  Occasionally  the 
diverticulum  ends  in  a  fibrous  cord,  which  mav  remain  fixed  to  the 
umbilicus,  or  floats  free  in  the  abdominal  cavitv,  and  subsequently 
becomes  adherent  to  some  other  structure,  thus  producing  a  fibrous 
cord.  Strangulation  may  be  effected  by  bowel  passing  under  the 
loop  formed  by  the  adherent  diverticulum,  [d)  The  vermiform 
appendix,  appendices  epiploic  a,  or  Fallopian  tubes  may  contract  ab- 
normal attachments,  and  thus  form  arches  or  loops  under  which 
bowel  may  pass  and  become  strangled,  {e)  Slits,  pouches,  and 
apertures  in  the  peritoneal  investment,  whether  normal  or  abnormal 


Fig.  521.  —  Strangu- 
lation BY  Band. 


INTESTINAL  OBSTRUCTION  1129 

may  lead  to  strangulation.  All  external  herni^e  may  be  grouped 
under  tliio  lieading,  as  also  those  conditions  known  as  internal 
hernia,  in  which  the  abdominal  contents  find  their  way  into  pouches 
in  the  posterior  wall  of  the  peritoneum — e.g.,  into  the  lesser  sac  of 
the  omentum,  the  fossa  duodeno-jejunalis,  or  into  some  of  the  retro- 
csecal  fossje.  Slits  may  also  be  found  in  the  omentum  or  mesentery, 
either  congenital,  traumatic,  or  the  result  of  operations. 

Phenomena.- — This  form  of  obstruction  usually  occurs  in  young 
people,  and  is  rare  after  forty ;  it  constitutes  more  than  a  fourth  of 
all  the  forms  of  internal  obstruction,  and  the  lower  2  feet  of  the  ileum 
are  most  frequently  involved.  There  may  be  a  previous  history  of 
peritonitis,  but  that  may  have  been  overlooked  or  forgotten;  the 
onset  is  usually  sudden,  and  the  symptoms  of  strangulation,  as 
detailed  above,  are  of  a  typical  character.  The  abdomen  is  flaccid 
at  first,  and  not  tender  until  peritonitis  ensues,  on  about  the  third  or 
fourth  day.  There  is  generally  no  obvious  tumour,  and  no  peri- 
stalsis or  dilated  coils  of  intestine  are  to  be  seen.  Occasionally  an 
area  of  locahzed  fulness  or  of  fixed  and  limited  tenderness  may 
indicate  the  site  of  the  lesion.  The  average  duration  is  about  five 
to  seven  days,  the  patients  dying  of  exhaustion  or  toxaemia  following 
peritonitis. 

2.  Volvulus  is  the  most  common  cause  of  acute  primary  obstruc- 
tion of  the  large  intestine.  By  it  is  meant  a  rotation  of  the  gut 
upon  its  own  mesenteric  axis  in  such  a  way  as  to  interfere  not  only 
with  the  passage  of  the  intestinal  contents,  but  also  sooner  or  later 
with  the  circulation,  determining  a  condition  of  strangulation. 
Occasionally  a  similar  result  is  brought  about  by  the  intertwining  of 
one  coil,  usually  of  small  intestine,  with  another.  The  sigmoid 
flexure  is  the  part  generally  affected,  although  it  occurs  in  the  caecum 
when  there  is  a  definite  meso-csecum,  or  in  the  small  intestine.  In 
the  former  situation  it  is  predisposed  to  by  a  long  narrow  sigmoid 
meso-colon,  so  that  the  two  ends  of  the  loop  are  brought  closely 
together ;  this  condition  may  be  of  congenital  origin,  but  is  usually 
due  to  the  traction  induced  by  prolonged  chronic  constipation  ;  a 
distended  sigmoid  hanging  into  the  pelvic  cavity  drags  upon  and 
elongates  the  meso-colon,  tending  to  approximate  the  two  ends  of 
the  loop,  and  necessarily  causing  a  slight  obstruction  at  these  spots. 
Some  irregular  movement  of  the  gut  or  of  the  abdominal  walls 
suffices  to  cause  rotation  of  the  pedicle,  and  thus  brings  about  the 
volvulus.  When  once  present,  plastic  peritonitis  soon  fixes  the  coil, 
whilst  the  pressure  on  the  vessels  causes  venous  congestion  and  such 
obstruction  to  the  arterial  supply  of  the  gut  as  almost  certainly  to 
end  in  its  death.  Distension  of  the  coil  with  gas  from  decomposition 
of  the  retained  faeces  also  aggravates  the  condition. 

Symptoms. — Volvulus  is  rare  before  the  age  of  forty,  and  appar- 
ently occurs  more  often  in  the  male  sex.  A  history  of  chronic  con- 
stipation precedes  it,  but  the  acute  symptoms  start  abruptly.  Pain 
is  always  present,  at  first  intermittent,  but  finally  constant,  and 
there  is  usually  tenderness  over  the  sigmoid  flexure.     The  pain. 


II30  A   MANUAL  OF  SURGERY 

vomiting,  and  collapse  arc  not  so  severe  or  marked  as  in  other  forms 
of  strangulation,  but  abdominal  distension  from  excessive  flatus,  and 
resulting  dyspnoea  and  thoracic  embarrassment,  are  very  distressing. 
Tenesmus  is  occasionally  present.  A  locahzed  peritonitis  is  usually 
developed,  but  sometimes  it  becomes  diffuse.  Natural  cure  is  un- 
known, the  patient  dying  either  in  five  or  six  days  from  collapse 
and  interference  with  respiration,  or  at  a  somewhat  later  date  from 
peritonitis. 

3.  Impacted  Foreign  Bodies,  which  may  cause  intestinal  obstruc- 
tion, are  of  three  types:  gall-stones,  foreign  bodies  that  have  been 
swallowed,  or  intestinal  concretions  (enteroliths).  The  general  facts 
connected  with  their  presence  in  the  intestine  have  been  already 
noted  (p.  1019). 

Gall-stones  only  cause  obstruction  when  of  large  size,  and  then 
usually  gain  entrance  to  the  intestine  by  ulceration  from  the  gall- 
bladder into  the  duodenum.  The  usual  site  of  impaction  is  in  the 
lower  ileum.  Women  over  fifty  are  most  often  the  subjects  of  this 
condition,  and  there  may  be  merely  a  history  of  some  inflammatory 
lesion  in  the  region  of  the  gall-bladder,  and  none  of  bihary  cohc. 
Such  patients  frequently  suffer  from  intermittent  subacute  attacks 
of  incomplete  obstruction,  which,  though  severe  for  a  time,  are  re- 
lieved by  purgatives.  If  the  gall-stone  is  not  passed,  a  final  acute 
attack  supervenes,  M'hich  begins  suddenly  with  pain  and  slight  col- 
lapse, followed  b}^  vomiting,  which  is  constant  and  copious,  and  in 
twenty-four  to  thirty-six  hours  becomes  faecal.  The  obstruction  is 
often  incomplete,  flatus  and  even  faeces  being  occasionally  passed. 
The  abdomen  is  soft  and  flaccid,  and  the  affected  coil  and  the  gall- 
stone are  rarely  to  be  felt.  Necessarily  the  symptoms  vary  with  the 
site  of  impaction,  usually  becoming  more  urgent  as  the  duodenum  is 
approached.     Death  results  from  peritonitis  or  exhaustion. 

Similarly,  enteroliths  are  usually  impacted  near  the  caecum,  and  if 
causing  acute  obstruction  the  symptoms  are  similar  to  those  pro- 
duced by  a  large  gall-stone,  being  preceded  by  chronic  attacks  and 
severe  colicky  pain.  In  thin  persons  their  presence  may  be  detected 
by  palpation  of  the  abdomen. 

4.  Acute  obstruction  ensues  when  a  coil  of  intestine  lodges  across 
a  tightly-drawn  adhesion,  the  lumen  at  each  end  being  thereby 
entirely  occluded,  and  the  circulation  arrested.  The  usual  acute 
symptoms  follow,  which  may,  however,  be  relieved  spontaneously. 
Sudden  kinking  of  the  gut  may  lead  to  the  same  result,  being  due  to 
the  contraction  of  fibrous  adhesions  or  the  dragging  of  diverticula. 

5.  For  Acute  Intussusception,  see  p.  1138. 

6.  When  acute  symptoms  are  developed  at  the  termination  of  a 
case  of  chronic  obstruction,  the  pain  which  had  been  intermittent 
becomes  constant,  the  vomiting  more  violent  and  faecal  in  character, 
and  the  fatal  termination  is  due  to  acute  peritonitis,  or  to  exhaustion 
and  toxaemia.  Absolute  constipation  is  always  present,  and  the 
abdomen  much  distended. 

7.  True  obstruction  is  sometimes  associated  with  acute  localized 


INTESTINAL  OBSTRUCTION 


1131 


enteritis  or  peritonitis,  such  as  is  seen  in  appendicitis,  when  the 
intestinal  walls  are  paralyzed.  This  symptom  is  sometimes  very 
marked,  and  even  faecal  vomiting  may  occur,  but  by  careful  atten- 
tion to  the  history  and  general  condition  of  the  patient  a  correct 
diagnosis  should  be  reached.  We  append  a  table  illustrating  the 
chief  diagnostic  points  between  acute  strangulation  and  acute  ap- 
pendicitis associated  with  peritonitis,  one  of  the  commonest  causes 
of  d3'namic  ileus: 


Onset  - 
Rigor  - 
Temperature 

Pain    - 

Tenderness  - 

Vomiting 

Abdominal 
parietes 

Acute  Internal  Strangulation. 

Acute  Appendicitis  with 
Peritonitis. 

Abrupt. 

Absent. 

Subnormal  at  first,  rising  a1 
onset  of  peritonitis. 

Severe;  referred  to  the  um- 
bilicus. 

Absent  till  peritonitis  come.' 
on. 

Early,    marked,    and     soon 

faecal. 
Flaccid     till    peritonitis    is 

present. 

May  be  preceded  by  local  pain. 

Often  present. 

High  at  first,  falling  later  from 

exhaustion  or  toxaemia. 
Severe ;  usually  referred  to  the 

right  iliac  fossa. 
Present    over   caecum   even   in 

early  stages,   and  gradually 

spreading. 
Less  urgent,  and  seldom  faecal, 

except  as  a  late  symptom. 
Tense  and  rigid  from  the  first. 

In  most  forms  of  dynamic  ileus  the  obstructive  phenomena  are 
usually  secondary  to  some  peritonitic  trouble,  or  to  some  intra- 
abdominal lesion  which  produces  its  own  symptoms  first,  and  then 
obstructive  phenomena  only  as  a  secondary  result  of  inflammatory 
paralysis.  Thus  in  torsion  of  the  pedicle  of  an  ovarian  cyst,  the 
patient  first  complains  of  pain,  and  the  tumour  becomes  large  and 
tender.  Should  it  be  neglected,  aseptic  peritonitis  ensues;  after  a 
variable  period  intestinal  paralysis  follows,  and  obstructive  symp- 
toms of  a  distressing  type  are  produced,  which  will  probably  prove 
fatal,  even  if  the  cause  is  removed. 

8.  Enterospasm  is  the  name  applied  to  a  functional  disorder  occur- 
ring in  patients  of  a  neurotic  type,  in  which  one  or  more  sections  of 
the  intestinal  canal  undergo  purposeless  tetanic  contraction.  The 
colon  is  more  commonly  affected  than  the  small  bowel,  and  especi- 
ally the  csecal  and  sigmoid  sections.  In  the  acute  form  the  symp- 
toms of  urgent  obstruction  may  be  produced,  and  even  peritonitis 
simulated;  but  more  frequently  the  attacks  are  chronic,  and  per- 
sistent constipation  results.  Sometimes  the  appendix  is  tender, 
and  has  been  removed  for  this  affection  without  benefit.  Anti- 
spasmodics of  the  belladonna  tjrpe  are  required,  and  purgatives 
do  but  little  good. 

For  diagnosis  and  method  of  examination  of  cases  of  acute  obstruc- 
tion, see  p.  1140. 

The  Treatment  of  acute  obs^■ruction  is  practically  included  in  one 
word — Laparotomy.     The  condition  of  the  gut  is  in   most  cases 


II32  A   MANUAL  OF  SURGERY 

identical  with  that  found  in  a  strangulated  hernia,  and  although  a 
few  patients  may  recover  by  palliative  measures — e.g.,  enemata, 
opium,  ice,  etc. — yet  the  majority  would  be  gravely  injured  by  the 
delay  caused  by  their  employment.  The  danger  of  laparotomy 
increases  directly  with  delay;  hence,  the  sooner  it  is  undertaken, 
the  better  for  the  patient.  Whilst  preparations  for  the  operation  are 
being  made,  an  enema  may  be  administered  to  clear  the  lower  bowel, 
ice  being  given  to  suck,  and  a  small  dose  of  opium  to  relieve  urgent 
pain.  Two  main  objects  must  always  be  striven  after  in  the  opera- 
tive treatment  of  such  cases- — viz.,  (a)  to  empty  the  distended  bowel, 
and  {b)  to  remove  the  cause  of  the  obstruction.  The  second  of  these 
requisites  is  always  most  dasirable,  but  unless  at  the  same  time  the 
putrid  contents  of  the  upper  portion  of  the  intestine  are  removed, 
little  real  good  has  been  accomplished,  since  the  patient  is  being 
slowly  poisoned  by  toxic  absorption.  The  late  Mr.  Greig  Smith 
declared  most  emphatically  that  '  no  operation  for  intestinal  ob- 
struction is  complete  if  the  patient  leaves  the  operating-table  with 
a  greatly  distended  abdomen.'  Hence,  in  many  cases  it  is  desirable 
to  deal  with  the  engorged  bowel  first  by  establishing  an  artificial 
anus,  and  to  leave  the  search  for  the  obstructing  body  till  a  later 
date.  A  very  high  death-rate  must  always  be  expected  in  these 
cases,  but  statistics  prove  that,  in  cases  where  the  cause  of  the 
obstruction  is  not  at  once  obvious,  primary  enterostomy,  if  followed 
by  a  satisfactory  discharge  of  the  intestinal  contents,  gives  results 
in  many  instances  equal  to,  or  even  better  than,  treatment  directed 
towards  the  cause  of  the  trouble. 

In  the  most  urgent  cases,  where  the  patient's  abdomen  is  acutely 
distended,  and  faecal  vomiting  has  been  present  for  some  time,  it  is 
not  advisable  to  administer  a  general  anaesthetic:  if  such  is  at- 
tempted, the  patient's  life  is  often  lost  from  stoppage  of  the  respira- 
tion, precipitated  possibly  by  a  severe  attack  of  faecal  vomiting. 
Local  anaesthesia  by  Schleich's  method  of  infiltration  must  be  relied 
on,  or  spinal  analgesia,  and  a  small  incision  made  through  the  linea 
alba  below  the  umbilicus;  the  first  presenting  coil  of  intestine  is 
withdrawn,  and  after  protecting  the  peritoneal  cavity  with  gauze  or 
swabs,  is  tapped  with  a  large  trocar  and  cannula  so  as  to  allow  the 
first  gush  of  flatus  and  faeces  to  be  carried  away  from  the  wound. 
The  opening  is  then  enlarged  sufficiently  to  allow  a  rubber  or  Paul's 
tube  to  be  introduced  and  tied  in,  and  whilst  the  bowel  is  emptying 
itself,  it  is  fixed  by  stitches  to  the  abdominal  wall.  The  stomach 
should  always  be  thoroughly  washed  out  with  warm  water  before  or 
during  the  operation. 

In  less  severe  cases,  the  stomach  should  be  washed  out  as  a  pre- 
liminary measure  before  administering  the  anaesthetic.  The  head 
must  not  be  placed  on  a  lower  level  than  the  stomach,  for  fear  of  fluid 
regurgitating  along  the  (tsophagus  and  choking  the  patient ;  several 
deaths  from  this  cause  have  been  reported.  The  abdomen  is  then 
opened  in  the  middle  line  below  the  umbilicus,  and  a  definite  search 
made  for  the  cause  of  the  obstruction  if  it  is  not  at  once  obvious.  The 


INTESTINAL  OBSTRUCTION  1133 

hand  is  lirst  passed  to  the  hernial  regions,  and  then  to  the  right  ihac 
fossa,  so  that  the  caicum  may  be  examined.  If  this  is  distended,  the 
cause  necessarily  lies  below  it;  it  collapsed,  above  it.  In  the  former 
case,  the  condition  of  the  sigmoid  flexure  should  next  be  investi- 
gated, and  finally,  if  this  viscus  is  collapsed,  the  hand  should  be  run 
along  the  colon,  special  attention  being  directed  to  the  splenic 
flexure.  If  the  caecum  is  collapsed,  perhaps  the  best  method  to 
adopt  IS  gently  to  withdraw  from  the  abdomen  successive  portions 
of  gut,  about  a  foot  at  a  time.  These  are  carefully  examined,  and 
replaced  by  the  assistant  whilst  the  next  portion  is  being  with- 
drawn. The  remainder  of  the  intestines  during  this  process  are 
protected  and  kept  back  by  the  application  of  hot  sterilized 
abdommal  cloths.  The  cause  of  the  obstruction  is  in  this  way 
sooner  or  later  discovered,  and  may  be  dealt  with  according  to  cir- 
cumstances. If  the  intestines  are  too  distended  to  allow  of  such 
manipulation,  it  may  be  advisable  to  open  or  tap  one  or  more  of 
the  dilated  coils,  and  thus  reduce  the  distension  before  proceeding 
with  any  methodical  search  for  the  obstruction.  For  this  pur- 
pose a  small  trocar  and  cannula  is  inserted  through  the  anti- 
mesenteric  border;  the  flatus  and  faeces  are  allowed  to  escape;  and 
the  puncture  is  subsequently  buried  by  a  purse-string  suture. 
It  IS  sometimes  necessary  to  perform  this  in  two  or  three  different 
situations. 

Omental  bands  or  peritoneal  adhesions  should  be  divided  between 
ligatures.  The  vermiform  appendix  may  be  removed,  or  a  Meckel's 
diverticulum  excised.  A  volvulus  should  be  untwisted,  if  possible ; 
but  this  IS  usually  impracticable,  owing  to  peritoneal  adhesions] 
and  in  such  cases  it  is  advisable  to  withdraw  the  coil  from  the 
abdomen,  and  if  the  large  intestine  is  involved,  an  artificial  anus 
should  be  made.  Foreign  bodies  are,  if  possible,  displaced  forwards 
or  backwards  to  a  more  healthy  portion  of  the  bowel,  and  then 
removed  by  a  longitudinal  incision  along  the  anti-mesenteric  border, 
the  wound  being  subsequently  closed  by  a  row  of  Lembert's  sutures! 
Of  course  volvulus  of  the  small  intestine  or  gangrene  of  the  gut,  if 
present,  may  necessitate  an  enterectomy,  but  it  must  always  be 
kept  in  view  that  the  essential  feature  of  the  operation  is  drainage 
of  the  intestine,  and  therefore  the  establishment  of  an  artificial 
anus  as  a  temporary  measure  is  often  desirable;  re-union  can  be 
effected  when  the  gut  has  emptied  itself. 

Chronic  Intestinal  Obstruction. 
The  Causes  of  chronic  obstruction  are  very  numerous;,  and,  looked 
at  from  an  anatomical  standpoint,  may  be  divided  into  the  followini' 
groups: 

1.  Intra-intestinal  conditions— g.g-.,  impaction  of  faces,  foreign 
bodies,  etc. 

2.  Affections  of  the  intestinal  wall,  such  as  stricture,  new  growths, 
especially  those  of  a  cancerous  type,  adhesions  or  matting  together  of 


II34  A   MANUAL  OF  SURGERY 

coils  of  intestine,  contraction  or  kinking  of  the  gnt  from  mesenteric 
gland  disease,  etc. 

3.  Compression  of  the  bowel  by  tumours,  cicatricial  bands,  etc, 
developing  outside  the  intestine. 

FjEcaJ  impaction  and  the  development  of  a  cancerous  growth  are 
far  and  away  the  commonest  causes  of  chronic  obstruction. 

The  General  Symptoms  of  chronic  obstruction  are  more  or  less  as 
follows:  The  patient  suffers  from  gradually  increasing  constipation, 
alternating  occasionally  with  watery  diarrhoea,  spurious  in  nature, 
and  set  up  partly  by  a  catarrhal  enteritis  due  to  the  irritation  of 
retained  faces,  partly  by  decomposition  of  the  faecal  material.  At 
irregular  intervals  more  severe  symptoms  arise,  consisting  of  pain, 
colic,  vomiting,  and  absolute  constipation,  owing  to  some  temporary 
complete  obstruction,  as  by  the  impaction  of  a  mass  of  undigested 
food  or  faces,   assisted  perhaps  by  a  valve-like  fold  of  mucous 

membrane  across  the  passage.  The 
abdomen  becomes  distended,  and  coils 
of  gut  may  be  seen  in  a  condition  of 
active  peristalsis.  These  attacks  usually 
pass  oh  after  a  time,  a  copious- evacua- 
tion of  the  bowels  taking  place,  either 
naturally  or  after  the  administration 
of  a  purgative.  Finally,  one  of  these 
seizures  persists  and  destroys  the 
patient,  either  by  exhaustion  or  by  per- 
foration follow^ed  by  peritonitis,  unless 
suitable  treatment  is  promptly  adopted. 
The  vomiting  is  never  such  a  marked 
Fig.   522.— Diagram    to    in-    feature  as  in  acute  obstruction,  until 

DICATE  THE   USUAL  SiTES  OF      ^J^g    ^^-^^y    ^^  ^^J^gj^    ^^    bcCOmCS  fSCal. 

F^CAL     Impaction  —  viz.,     t-i  1  j  •        1  1 

THE  C^cuM,     Transverse    ^he  abdomen  IS  always  more   or  less 
Colon,  and  Sigmoid.  distended    and    tympanitic,    and    its 

contour  varies  with  the  site  of  the 
obstruction;  if  this  is  situated  above  the  ileo-csecal  valve,  the 
swelling  is  mainly  central,  whilst  if  in  the  rectum  or  lower  portion  of 
the  colon,  it  is  most  marked  in  the  flanks.  Distended  coils  of  in- 
testine can  be  plainly  seen  through  the  abdominal  walls  in  thin 
subjects,  as  also  evident  peristalsis.  When  arising  from  simple 
stricture,  no  tumour  is  to  be  felt ;  but  if  due  to  malignant  disease, 
and  if  the  abdomen  is  not  very  distended,  the  growth  may  possibly 
be  detected. 

Fsecal  Impaction  occurs  in  adult  females  who  have  previously 
suffered  from  chronic  constipation.  The  caecum  and  sigmoid  fle.xure 
are  the  most  common  seats  of  obstruction,  but  the  transverse  colon 
is  not  unfrequently  affected  (Fig.  522) .  A  doughy  tumour  may  often 
be  felt  at  one  of  these  spots,  which  can  in  some  cases  be  indented 
with  the  fingers,  whilst  in  others  it  may  be  of  stony  hardness.  The 
surface  of  the  mass  is  usually  more  or  less  nodulated,  and  the 
intestine  tender  from  the  accompanying  inflammation.     The  tern- 


INTESTINAL  OBSTRUCTION  1135 

peiMturc  is  often  raised,  from  toxic  absorption  through  the  intestinal 
wall,  and  there  may  even  be  a  rigor.  The  acute  symptoms  are 
alwa^'^s  preceded  b}^  a  prolonged  period  of  malaise  and  ill -health,  the 
appetite  being]  defective,  the  breath  offensive,  and  the  tongue 
foul.  On  rectal  examination  the  presence  of  scybala  may  often  be 
detected. 

The  special  s\'mptoms  arising  from  the  other  conditions  which 
give  rise  to  chronic  obstruction,  such  as  stenosis  of  the  bowel,  have 
been  already  referred  to. 

The  Diagnosis  of  chronic  obstruction  is  obvious,  but  it  is  often  by 
no  means  easy  to  ascertain  the  exact  cause  of  the  trouble.  A 
thorough  investigation  of  the  case,  according  to  the  plan  given  here- 
after, must  be  undertaken,  and  by  this  means  some  conclusion  may 
be  arrived  at  as  to  the  nature  and  seat  of  the  obstruction. 

The  Treatment  of  chronic  obstruction  is  always  a  matter  of  diffi- 
culty and  anxiety,  owing  to  the  uncertainty  often  felt  as  to  the  diag- 
nosis. It  ought  to  be  possible,  however,  to  decide  whether  the  block 
is  located  in  the  large  or  small  intestine,  since  the  character  of  the 
abdominal  distension  and  the  symptoms  are  tolerably  distinctive  in 
the  two  forms. 

If  the  case  is  not  of  the  most  urgent  type,  the  patient  is  put  to 
bed,  the  diet  restricted  to  fluids,  and  belladonna,  combined  with 
small  doses  of  calomel,  administered.  At  the  same  time  copious 
enemata  should  be  given  two  or  three  times  daily,  and  preferably  in 
the  genu-pectoral  position,  or  lying  on  the  right  side  with  the  pelvis 
well  raised.  Purgatives  are  studiously  avoided,  as  also  opium ;  prob- 
ably the  patient  has  taken  plenty  of  the  former  before  coming  under 
observation,  whilst  the  latter,  although  it  may  check  vomiting  and 
relieve  pain,  is  certain  to  mask  symptoms,  and  thus  prevent  the  true 
course  of  the  disease  from  being  watched.  Should  the  symptoms  be 
urgent  from  the  commencement,  or  the  treatment  suggested  fail,  the 
question  of  operation  has  to  be  faced.  If  the  obstruction  is  located 
in  the  small  intestine,  a  laparotomy  must  be  undertaken,  using  the 
same  precautions  as  in  acute  ca^^r  If'the 'catis.e.of  the  trouble  is 
easih'  found,  a  coil  situated  just  above  is  withdr^^n  from  the  abdo- 
men, opened,  and  a  Paul's  tube  tied  in  so  as  to  allow  retained  faecal 
material  to  escape.  It  is  wiser  not  to  deal  with  the  local  trouble 
(unless  strangulation  is  present)  until  the  urgent  symptoms  have 
disappeared.  If,  however,  the  patient's  condition  is  serious,  and  the 
site  of  obstruction  cannot  be  readily  found,  any  distended  coil  may 
be  \vithdrawn  and  opened.  The  practice  of  allowing  numerous  coils 
of  intestine  to  escape  in  order  to  facilitate  the  exploration  of  the 
abdomen  is  not  to  be  recommended. 

When  the  cause  of  the  obstruction  is  located  in  the  large  intestine, 
colostomy  is  usually  required.  The  lumbar  operation  may  possibly 
be  undertaken;  but  the  majority  of  surgeons  at  the  present  time 
prefer  the  iliac  proceeding.  If  the  rectmn  or  sigmoid  flexure  is 
clearly  the  seat  of  the  trouble,  the  usual  incision  on  the  left  side  can 
be  made;  but  if  there  is  no  indication  as  to  the  part  of  the  colon 


II36 


A   MANUAL  OF  SURGERY 


involved,  a  median  laparotomy  is  perhaps  preferable,  a  distended 
portion  of  the  gut  being  withdrawn  and  tapped,  and  a  Paul's  tube 
tied  in. 

In  chronic  peritonitis,  where  the  intestines  are  hopelessly  matted 
together,  but  Httle  can  be  done  beyond  the  administration  of 
enemata,  and  possibly  abdominal  massage.  The  history  of  the  case 
will  generally  suffice  to  suggest  its  nature,  and  operative  treatment 
should  then  be  avoided. 

Faecal  impaction  requires  the  regular  and  repeated  administration 
of  large  enemata,  given  through  a  long  tube,  whilst  belladonna  and 
calomel  may  also  be  administered.  Should  hard  scybala  be  lodged 
in  the  rectum,  it  may  be  necessary  to  break  them  up  in  situ,  and 
remove  them  piecemeal. 

Intussusception. 

By  Intussusception  is  meant  the  protrusion  or  invagination  of  one 
part  of  the  intestine  into  another,  giving  rise  to  the  condition  illus- 
trated in  Fig.  523.  The 
constituent  parts  are  seen 
more  diagrammatically  in 
Fig.  524.  The  upper  por- 
tion is  always  prolapsed 
into  the  lower,  except 
occasionally  during  the 
irregular  peristalsis  which 
takes  place  during  the 
death  -  throes.  The  in- 
vaginated  portion  {a)  is 
known  as  the  intussuscep- 
tum,  whilst  the  lower  por- 
tion (&)  into  which  it  is 
protruded  is  known  as  the 
intussuscipiens.  An  in- 
tussusception, then,  con- 
sists of  three  layers — the 
outer  or  ensheathing  layer 
(i.),  an  inner  or  entering 
layer  (iii.) ,  and  between  the 
two  the  returning  layer  (ii.). 
Not  only  does  the  intes- 
tine enter,  but  with  it  a 
certain  portion  of  the  mesentery ;  and  it  is  to  the  constriction  of  the 
vessels  contained  therein,  and  "later  on  possibly  to  their  complete 
obstruction,  that  the  more  serious  phenomena  are  due — e.g.,  gan- 
grene, perforation,  or  rupture  of  the  gut.  In  addition  to  this, 
actual  obstruction  to  the  passage  of  the  intestinal  contents  may  be 
brought  about  by  the  traction  of  the  mesentery,  which  renders  the 
orifice  of  the  intussusceptum  slit-Hke,  by  the  swelling  and  con- 
gestion of  the  intestinal  wall,  or  perhaps  by  the  impaction  of  a 


Fig.  523. — Intussusception.     (From  Speci 
MEN  IN  College  of  Surgeons'  Museum.) 


INTESTINAL  OBSTRUCTION 


1137 


/T^ 


U 


nr 


n 


portion  of  undigested  food  within  the  kimcn  of  the  gut.  Peritonitis 
usually  follows,  being  possibly  due  to  the  invasion  of  a  portion  of 
the  damaged  intestinal  wall  by  the  B.  coli  or  other  intestinal  organ- 
isms. If  limited  in  extent,  it  may  merely  lead  to  irreducibility  of 
the  intussusception,  owing  to  adhesions  forming  between  the  serous 
coats  of  the  entering  and  returning  layers.  In  other  cases,  and  es- 
pecially when  ulceration  or  gangrene  is  present,  a  diffuse  peritonitis 
may  be  lighted  up,  and  this  may  result  in  the  death  of  the  patient. 
The  bowel  above  the  site  of  invagination  becomes  dilated,  and 
possibly  stercoral  ulcers  may  be  formed,  particularly  in  the  more 
chronic  cases. 

The  Cause  of  intussusception  is  generally  stated  to  be  irregular 
and  violent  peristalsis,  however  induced,  whether  by  the  presence  of 
irritating  ingesta,  or  by  the  exist- 
ence of  polypoid  tumours,  malig- 
nant growths  (Fig.  485),  or  possibly 
worms;  the  presence  of  scybalous 
masses  of  faeces  may  also  lead  to  its 
occurrence.  In  a  few  cases  injury 
■ — e.g.,  blows  on  the  abdomen,  or 
severe  strains  during  jumping— 
have  been  held  responsible  for  its 
onset,  but  very  frequently  no  cause 
can  be  assigned. 

Intussusception  is  met  with  in 
four  chief  situations:  (i)  The  ileo- 
ccBcal  variety  is  much  the  common- 
est, constituting  44  per  cent,  of  all 
cases  (Treves).  In  it  the  ileum  is 
protruded  into  the  colon^  the  apex 
of  the  intussusceptum  being  formed 
by  the  ileo-csecal  valve.  Owing 
to  the  great  mobility  of  the  ileum, 
a  considerable  portion  of  gut  may 
be  thus  invaginated,  and  a  good 
many  cases  have  been  observed  in 
which  it  has  actually  projected  through  the  anus.  (2)  The  enteric 
variety  involving  the  small  intestine  comes  next  in  order  of  fre- 
quency, being  met  with  in  30  per  cent,  of  the  cases.  It  is  most  often 
seen  in  the  lower  jejunum,  and  is  rarely  of  great  size.  (3)  The  colic 
form  may  occur  at  any  part  of  the  colon  or  rectum,  and,  owing  to 
the  fixity  of  this  portion  of  the  gut,  is  limited  in  extent.  It  is  met 
with  in  about' 18  per  cent,  of  the  cases.  (4)  The  ileo-colic  only  occurs 
in  8  per  cent.;  in  it  the  ileum  is  prolapsed  through  the  ileo-caecal 
valve,  which  for  a  time  retains  its  normal  position;  but  after  the 
intussusception  has  attained  a  certain  size,  the  valve  and  caecum 
are  also  invaginated  into  the  ascending  colon.  In  each  of  these 
varieties,  except  the  last,  the  intussusception  grows  at  the  expense 
of  the  external  or  ensheathing  layer,  the  apex  of  the  protrusion 

72 


Fig.  524. — Diagram   of  Intussus- 
ception. 

a,  Intussusceptum;  b,  intussus- 
cipiens;  I.,  ensheathing  layer; 
II.,  returning  layer;  III.,  enter- 
ing layer. 


1138  A  MANUAL  OF  SURGERY 

being  alwa3-s  formed  by  the  same  portion  of  gut ;  but  in  the  ileo-colic 
variety,  as  just  stated,  it  increases  by  the  passage  of  more  and  more 
ot  the  ileum  through  the  valve;  after  a  time  this  stops,  and  is  re- 
placed by  the  ordinary  form  of  growth. 

Intussusception  is  occasionally  met  with  as  a  post-mortem  pheno- 
menon, resulting  from  the  irregular  intestinal  movements  which 
occur  during  the  death  crisis.  The  condition  is  recognised  as  being 
of  this  nature  by  the  absence  of  inflammatory  signs,  by  the  fact 
that  it  is  sometimes  due  to  a  reverse  peristalsis,  and  by  more  than 
one  intussusception  being  present. 

The  Clinical  History  varies  according  to  whether  the  condition 
is  acute  or  chronic. 

Acute  Intussusception  occurs  most  frequently  in  infants  under  two 
years,  being  the  most  common  cause  of  obstruction  at  this  age.* 
The  onset  is  sudden,  the  child  being  attacked  with  severe  pain, 
possibly  localized  and  more  or  less  paroxismal  at  lirst,  but  rapidly 
becoming  continuous  and  diffused  over  the  abdomen.  This  is  fol- 
lowed by  vomiting,  which,  however,  is  less  severe  than  in  acute 
strangulation,  and  not  so  often  fseculent.  The  patient  rarely  suffers 
from  absolute  constipation;  but  diarrhoea  and  the  discharge  of 
blood-stained  mucus,  perhaps  associated  with  tenesmus,  and  often 
without  faeces,  are  common.  Collapse  soon  supervenes,  and  in  the 
worst  cases  this  may  be  so  severe  as  to  kill  the  patient  within  twenty- 
four  hours;  otherwise  a  fatal  issue  from  exhaustion  or  peritonitis 
is  reached  within  a  week.  On  examining  the  abdomen,  but  little 
distension  or  tenderness  is  noted,  unless  acute  peritonitis  is  present ; 
in  more  than  half  the  cases  a  distinct  tiunour  can  be  felt,  cylindrical 
in  outline,  and  sometimes  described  as  '  sausage-shaped,'  following 
the  course  of  the  intussusception  and  generally  curved,  owing  to 
the  traction  of  the  mesentery.  In  the  ileo-caecal  variety  it  extends 
from  the  right  iliac  fossa  across  the  brim  of  the  pelvis  to  the  left, 
the  colon  being  dragged  downwards.  This  may  be  associated  with 
an  absence  of  resistance  in  the  right  fossa,  which  feels  empty,  consti- 
tuting what  is  known  as  the  '  signe  de  Dance.'  In  other  cases  the 
tumour  may  be  more  limited,  and  distinctly  moveable.  The  rectum 
should  always  be  carefully  examined,  and  preferably  under  an 
anaesthetic  so  as  to  permit  a  thorough  bimanual  examination  of 
the  rectum  and  abdomen  to  be  made. 

A  natural  cure  occasionally  follows,  resulting  either  from  spon- 
taneous reduction,  or  from  sloughing  of  the  intussusceptum,  whilst 
the  peritoneal  cavity  is  shut  off  by  a  circle  of  plastic  lymph  uniting 
the  ensheathing  and  entering  layers  of  the  gut.  When  the  latter 
takes  place,  the  subsequent  condition  is  not  ver}-  satisfactory, 
owing  to  the  formation  of  a  fibrous  stricture. 

The  association  of  intussusception  with  Henoch's  purpura  is  an 
interesting  phenomenon.  This  disease  is  characterized  by  a  pur- 
puric eruption,  joint  pains,  vomiting,  and  intestinal  colic,  the  latter 

*  Out  of  187  cases  of  intussusception,  H.  L.  Barnard  found  72  per  cent,  were 
under  one  year  of  age. 


INTESTINAL  OBSTRUCTION  1139 

probably  due  to  hcemorrhagc  into  or  from  the  intestinal  wall.  There 
is  no  regularity  in  the  evolution  of  the  symptoms,  and  when  the 
intestinal  phenomena  are  early,  the  diagnosis  from  intussusception 
may  be  dithcult.  In  not  a  few  cases  intussusception  develops,  its 
existence  being  suggested  by  the  severity  and  persistence  of  the  colic 
and  perhaps  by  tenesmus  and  loss  of  blood  per  anwn,  and  confirmed 
by  the  discovery  of  a  tumour. 

Chronic  Intussusception  occurs  more  frequently  in  adults  than  in 
children,  the  onset  being  gradual  and  the  course  varying  widely  in 
different  cases.  The  patient  complains  of  intermittent  attacks  of 
pain  of  a  colicky  nature,  which  recur  at  intervals,  and  become 
more  frequent  and  prolonged  as  the  case  progresses.  Vomiting 
is  often  but  little  marked  during  the  intermissions.  The  bowels  are 
irregular  in  their  action,  and  there  is  sometimes  a  blood-stained 
mucous  discharge.  The  general  condition  is  not  at  first  much 
affected,  but  as  the  case  progresses,  emaciation  and  general  asthenia 
may  supervene.  On  examination,  the  abdomen  is  found  to  be  flaccid 
and  free  from  tenderness,  although  visible  coils  of  intestine  may  be 
observed  in  some  cases,  and  perhaps  a  tumour  felt.  The  symptoms 
are  rather  those  of  subacute  enteritis  and  chronic  obstruction  than  of 
strangulation,  and  the  case  may  be  brought  to  a  fatal  termination 
either  by  an  acute  attack  of  obstruction  or  by  peritonitis.  It  may, 
however,  last  a  long  time  before  being  recognised. 

Treatment. — In  the  most  acute  forms  of  the  disease  but  little  can 
be  done,  owing  to  the  extreme  prostration  of  the  patient ;  but  in  the 
less  severe  and  in  the  chronic  cases  the  results  are  generally  satis- 
factory if  the  condition  is  recognised. 

In  acute  intussusception  the  patient  should  be  at  once  placed 
under  the  influence  of  opium,  in  order  to  still  peristalsis  and  prevent 
the  increase  of  the  tumour.  Inflation  of  the  bowel  with  air,  or  the 
injection  of  copious  enemata  of  warm  water  or  oil,  may  then  be  care- 
fully undertaken.  No  undue  force  should  be  employed  in  this  pro- 
ceeding, and  a  hand  placed  over  the  tumour  may  enable  the  surgeon 
to  detect  whether  or  not  it  has  been  successful.  It  is  performed  by 
raising  the  patient's  pelvis  and  inserting  into  the  rectum  a  catheter, 
with  which  is  connected  an  indiarubber  tube  and  funnel,  held  about 
i^  or  2  feet  above  the  abdomen.  Should  this  not  succeed,  lapar- 
otomy should  be  performed  without  delay,  and  the  condition  of 
the  intussusception  investigated.  An  attempt  is  then  made  to 
reduce  it  by  grasping  the  tumour  in  one  hand  and  gently  trying  to 
peel  off  the  ensheathing  layer  from  the  upper  portion  of  the  bowel, 
which  is  steadied  by  the  other  hand.  In  about  half  the  cases  re- 
duction is  impracticable,  owing  to  the  presence  of  adhesions,  and 
then,  if  the  general  condition  of  the  patient  is  fairly  good,  the  intus- 
susception should  be  removed  and  the  divided  ends  of  the  bowel 
united  by  suture.  If,  however,  the  patient  is  in  a  condition  of  pro- 
found shock,  all  that  can  be  done  is  to  fix  the  bowel  in  the  wound 
and  make  an  artificial  anus.  The  results  of  these  procedures  are 
anything  but  encouraging,  as  it  has  been  shown  that  few  children 


XI40  A  MANUAL  OF  SURGERY 

recover  if  anything  more  than  simple  reduction  is  required  during 
a  laparotomy. 

Chronic  intussusception  is  more  favourable  in  its  prognosis.  It  is 
frequently  unrecognised  until  an  exploration  of  the  abdomen  is 
made,  and  hence  reduction  by  inflation  is  not  commonly  attempted. 
In  some  cases  the  tumour  may  be  reduced  by  simple  manipulation, 
but  as  a  rule  too  many  adhesions  are  present.  Excision  of  the  mass 
should  then  be  undertaken,  and  the  results  gained  have  been  very 
encouraging. 

Diagnosis  and  Method  of  Examination  of  a  Case  of  Intestinal 
Obstruction. 

A  grave  responsibility  rests  upon  the  medical  attendant  in  every 
case  of  obstruction.  The  condition  is  incompatible  with  life  beyond 
a  few  days,  and  the  time  occupied  in  observing  the  patient  and 
making  up  one's  mind  as  to  the  nature  of  the  case  is  valuable  time 
lost,  which  may  ruin  the  patient's  chances  of  recovery.  There  are 
three  things  to  be  avoided  in  conducting  a  case  of  this  nature: 
(i.)  Purgatives.- — The  patient  has  probably  taken  plenty  before 
sending  for  assistance,  and  the  only  result  to  be  expected  is  an 
increase  of  pain  and  vomiting,  (ii.)  Opium  has  its  place  in  the 
treatment  of  obstruction- — viz.,  in  relieving  the  agony  associated 
with  its  onset ;  but  beyond  this  it  merely  masks  symptoms,  and  can 
do  no  good  but  comfortably  to  conduct  the  patient  to  the  grave. 
It  causes  intestinal  paralysis,  and  therefore  may  check  the  most 
distressing  symptom,  vomiting,  but  it  aggravates  the  condition 
which  needs  treatment,  (iii.)  Delay  in  sending  for  surgical  assist- 
ance is  responsible  for  more  deaths  than  is  the  condition  itself. 
When  once  the  gut  has  become  generally  paralyzed,  there  is  but 
little  hope  for  the  patient. 

In  the  investigation  of  a  case  various  problems  of  some  difficulty 
have  to  be  solved,  and  it  is  well  to  undertake  this  task  methodically. 

1.  The  medical  attendant  must  satisfy  himself  that  obstruction  is 
present,  and  not  merely  aggravated  constipation.  In  the  latter,  how- 
ever, flatus  passes  readily,  and  the  general  condition  is  not  much 
impaired.  In  obstruction  there  is  usually  a  complete  arrest  of  flatus, 
and  abdominal  pain  and  vomiting  often  point  to  the  existence  of 
some  serious  lesion. 

2.  It  is  essential  to  ascertain  whether  the  obstruction  is  dynamic  or 
mechanical.  The  differences  and  distinctions  between  these  have 
been  already  alluded  to  (p.  1126). 

3.  The  question  as  to  whether  the  lesion  is  acute  or  chronic  must 
next  be  settled.  Initial  severe  pain  and  collapse,  the  rapid  onset  of 
vomiting,  a  localized  spot  of  fixed  tenderness,  and  the  quick  depre- 
ciation of  the  patient,  all  point  to  some  acute  vascular  lesion  of  the 
intestinal  wall,  which  will  prove  fatal  in  a  few  days  unless  suitably 
treated.  On  the  other  hand,  chronic  cases  are  often  preceded  by 
constipation  and  other  troubles  of  defsecation;  they  come  on  gradu- 


INTESTINAL  OBSTRUCTION  1141 

ally,  and  arc  at  first  unaccompanied  by  constant  pain  and  vomiting, 
although  colic  of  a  severe  type  may  be  present.  The.  examination  of 
the  abdomen  is  also  of  the  greatest  assistance;  in  acute  cases  intes- 
tinal paralysis  dominates  the  picture;  in  chronic  cases,  vigorous 
peristalsis  can  be  felt  and  often  seen,  unless  the  patient  has  been 
left  too  long. 

4.  An  effort  must  be  made  to  determine  the  site  and  nature  of  the 
lesion.  As  to  the  question  of  site,  the  following  points  may  be 
noted: 

(a)  When  the  upper  part  of  the  small  intestine  is  involved,  the 
vomiting  is  early,  tumultuous,  and  persistent ;  the  vomit  is  bilious, 
but  not  faecal.  Abdominal  distension  involves  the  epigastrium,  and 
particularly  the  stomach.  The  lower  part  of  the  abdomen  may  be 
retracted.  Collapse  is  early  and  rapidly  increases.  The  thirst  is 
terrible,  the  urinary  secretion  slight  or  even  suppressed;  gas  and 
fasces  may  pass  from  the  lower  bowel. 

(b)  When  the  lower  part  of  the  small  intestine  or  ccBcum  is  involved, 
faeces  and  flatus  cannot  pass;  the  vomiting  becomes  offensive,  but 
scarcely  faecal;  meteorism  is  marked,  and  involves  the  central  part 
of  the  abdomen,  the  flanks  not  being  affected.  In  chronic  cases 
peristalsis  is  very  evident. 

(c)  When  the  colon  or  rectum  is  the  site  of  obstruction,  the  symp- 
toms are  more  chronic  as  a  rule,  and  even  in  acute  cases,  such  as 
volvulus,  the  initial  collapse  is  slight.  Vomiting  is  later  in  appear- 
ing, but  may,  of  course,  become  faecal.  Meteorism  may  be  very 
marked,  and  involves  the  flanks  as  well  as  the  centre;  sometimes  it 
IS  possible  to  recognise  that  the  lesion  is  not  lower  than  the  splenic 
flexure  by  distension  of  the  left  flank  being  absent. 

The  determination  of  the  nature  of  the  case  will  largely  turn  on  the 
patient's  previous  history,  and  not  uncommonly  one  has  to  admit 
that,  although  one  can  locate  the  site  of  mischief,  there  is  no  clue 
as  to  its  nature  beyond  the  generalizations  learnt  from  statistics. 

The  actual  examination  of  the  patient  is  carried  on  along  the 
following  lines: 

1.  The  Previous  History  of  the  case  should  be  carefully  gone  into, 
in  order  to  ascertain  whether  or  not  the  patient  has  suffered  from 
bihary  colic,  chronic  constipation,  acute  diffuse  or  localized  peri- 
tonitis, uterine  derangements,  syphilis  or  dysentery,  etc. 

2.  The  History  of  the  Present  Attack  should  then  be  ascertained, 
noting  especially  the  manner  of  onset,  whether  acute  or  gradual,  the 
duration  of  the  symptoms,  and  whether  or  not  preceding  subacute 
attacks  have  occurred  from  time  to  time. 

3.  The  more  prominent  Symptoms  must  then  be  considered. 

[a)  Collapse  is  due  partly  to  reflex  nervous  disturbance,  partly  to 
the  absorption  of  toxic  materials,  and  partly  to  withdrawal  of  fluid 
from  the  body  as  a  result  of  the  vomiting;  the  portal  area  is  also 
much  engorged,  and  this  adds  to  the  want  of  fluid  in  the  systemic 
circulation.  The  nervous  cause  is  most  active  in  the  early  stage  of 
acute  obstruction,  especially  in  infants,  whilst  the  toxic  is  largely 


II42  A  MANUAL  OF  SURGERY 

responsible  for  the  exhaustion  seen  at  the  end  of  an  acute  attack  or 
in  the  clu'onic  variety.  Hence  colhipse  is  early  in  acute  cases,  late 
in  chronic.  Moreover,  the  higher  the  lesion,  the  greater  the  shock, 
owing  to  the  fact  that  the  upper  portion  of  the  bowel  is  more 
intimately  associated  with  the  sympathetic  nervous  centres. 

{b)  Pain  is  a  very  marked  symptom,  being  usually  referred  at  first 
to  a  little  above  the  umbilicus,  and  is  more  severe  in  lesions  of  the 
small  intestine  than  in  the  colon.  It  varies  greatly  with  the  com- 
pleteness or  not  of  the  obstruction.  This  matter  has  been  especially 
emphasized  by  Treves,  who  has  pointed  out  that  when  the  obstruc- 
tion is  only  partial,  the  pain  is  inteimittent ;  but  when  the  block  is 
complete,  the  pain  becomes  continuous.  Hence  in  acute  strangula- 
tion pain  is  almost  invariably  constant,  whereas  in  stricture  it  is 
markedly  intermittent  and  of  a  colicky  nature.  The  amount 
of  pain,  moreover,  varies  with  the  nervous  excitability  of  the 
patient;  it  is  increased  by  anything  which  induces  peristalsis 
(e.g.,  food  or  purgatives),  and  it  is  diminished  on  the  supervention 
of  gangrene. 

(c)  Abdominal  tenderness  is  rarely  observed  in  the  early  stages, 
being  caused  by  the  onset  of  peritonitis. 

[d]  Vomiting  is  an  almost  invariable  accompaniment  of  obstruc- 
tion. Its  cause  has  been  already  discussed  (p.  1125).  When  the 
obstruction  is  situated  in  the  jejunum  or  upper  part  of  the  ileum, 
the  vomiting  is  never  absolutely  fsecal,  although,  if  it  has  been  tem- 
porarily checked  by  opium,  the  ejecta  may  be  exceedingly  offensive 
and  dark  in  colour,  owing  to  decomposition ;  fsecal  or  stercoraceous 
vomiting  can  only  come  from  an  obstruction  to  the  lower  ileum  or 
colon. 

{e)  Constipation,  although  usually  present,  is  not  necessarily 
absolute,  as  it  is  possible  for  the  lower  bowel  to  be  emptied  in  cases 
of  obstruction,  whilst  the  patient  sometimes  passes  a  motion  as 
gangrene  supervenes  or  death  is  approaching. 

4.  A  most  careful  Physical  Examination  must  now  be  instituted. 

(fl)  An  inspection  of  the  uncovered  abdomen  should  first  be  made. 
The  amount  and  character  of  the  distension  is  observed,  and  whether 
or  not  it  is  situated  in  the  centre,  as  when  small  intestine  is  involved, 
or  in  the  flanks  when  the  obstruction  is  in  the  rectum  or  sigmoid 
flexure.  The  existence  of  visible  peristalsis  or  enlarged  coils  of 
intestine  should  be  noted;  such  are  rarely  seen  in  the  acute  cases, 
but  may  be  very  evident  in  the  chronic  forms.  Sometimes  one  coil 
remains  persistently  distended  and  always  at  the  same  spot;  its 
appearance  always  suggests  that  the  site  of  obstruction  is  not  far 
away.  Ihe  rise  and  fall  of  the  abdomen  during  respiration  should 
be  watched  to  ascertain  whether  the  movements  are  equal  on  both 
sides,  or  if  any  prominence,  such  as  would  be  caused  by  a  tumour,  is 
noticeable.  Ihe  general  condition  of  the  patient,  whether  emaciated 
or  not,  as  also  the  appearance  of  the  face  and  the  position  in  which 
he  lies,  should  be  observed. 

(b)  All  the  nomial  and  abnormal  hernial  apertures  are  thoroughly 


INTESTINAL  OBSTRUCTION  1143 

investigated,  and  a  careful  examination  made  from  the  rectum  and 
vagina. 

(f)  The  abdomen  is  carefully  palpated,  so  as  to  ascertain  the 
existence  of  any  tumour  or  increased  resistance  of  the  abdominal 
walls. 

{d)  Percussion  may  also  throw  some  light  on  the  case. 

{e)  Finally,  some  information  may  be  gained  b}'  the  use  of  enemata. 
When  the  obstruction  is  low  down  and  not  far  from  the  anus,  it 
may  be  impossible  to  introduce  more  than  a  small  quantity  of  fluid, 
and  this  in  spite  of  modifying  the  position.  Too  much  reliance, 
however,  must  not  be  placed  on  this  sign.  It  is  also  desirable  to 
auscultate  the  colon  during  the  administration  of  a  large  enema; 
it  is  sometimes  possible  to  hear  gurgling  sounds  as  far  round  as  the 
cfficum,  indicating  that  the  large  intestine  is  free  from  obstruction. 
We  would  call  attention  here  to  the  fallacy  of  using  a  long  tube  in 
the  expectation  of  being  able  to  pass  it  into  the  sigmoid  flexure.  A 
careful  study  of  the  rectum  and  its  valves  will  show  the  difficulty 
of  this,  whilst  the  use  of  the  genu-pectoral  position  renders  it 
unnecessarv. 


CHAPTER  XXXVIII. 
AFFECTIONS  OF  THE  RECTUM  AND  ANUS. 

The  rectum  from  the  anatomical  standpoint  consists  of  the  lowest  4  inches  of 
the  intestinal  canal,  but  for  the  surgeon  it  represents  the  lower  6  or  8  inches 
which  can  be  reached  more  or  less  from  the  anus.  Examination  of  the  rectum 
is  carried  out  by  the  following  methods: 

I.  Digital    Examination   in  which  the  index  finger  is  inserted  through  the 
anus.     Soap  should  be  smeared  under  the  nail  and  into  the  semilunar  fold  at  its 


Fig.  525. — Examination  of  the  Rectum  by  Martin's  Proctoscope. 

The  patient  is  in  the  genu-pectoral  position,  so  that  when  the  proctoscope  is 
introduced  air  rushes  in  and  distends  the  rectum;  the  observer,  utilizing 
either  an  electric  head-lamp  or  a  laryngoscopic  mirror,  can  easily  see  the 
interior.  In  the  above  diagram  the  projection  of  Houston's  valves  is 
clearly  indicated. 

base,  so  as  to  prevent  faecal  matter  from  lodging,  and  vaseline  may  be  applied 
both  to  the  finger  and  to  the  anus  to  facilitate  introduction.  It  is,  of  course, 
advisable  to  have  the  bowel  unloaded  b}'  purgative  or  enema  before  an  exam- 
ination is  made.  The  patient  lies  on  the  left  side  in  the  gynaecological  position, 
and  the  introduction  of  the  finger  is  usually  less  painful  if  he  strains  down  at 

1144 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1145 

the  same  time.  A  bimanual  examination  can  be  conducted  with  the  finger 
in  the  rectum,  and  the  other  hand  pressed  deeply  ov^er  the  patient's  hypogas- 
trium.  Although  the  great  majority  of  rectal  lesions  occur  within  the  lowest 
inch  and  a  half  of  the  bowel,  the  surgeon  must  never  omit  to  explore  the  upper 
part  of  the  rectum,  as  an  unsuspected  polypus  or  tumour  may  often  be  dis- 
covered in  this  wa}-;  the  pelvic  parietes  should  also  be  included  in  the  scope 
of  the  investigation. 

2.  The  introduction  of  the  whole  hand  has  been  recommended  by  some,  but 
the  hand  must  be  unusually  small  which  can  be  thus  utilized. 

3.  Visual  Examination  is  a  most  valuable  proceeding.  Martin's  proctoscope 
(Fig.  525)  is  the  most  suitable  appliance  to  use  for  this  purpose,  but  an  ordinary 
Fergusson's  speculum  answers  well.  The  patient  is  placed  in  the  genu-pectoral 
or  in  an  elevated  lithotomy  position;  the  former  is  preferable,  in  that  it  allows 
intestines  and  uterus  to  drop  forwards  away  from  the  rectum.  Two  index 
fingers,  well  greased  and  held  back  to  back,  are  then  introduced  into  the  bowel, 
and  the  anus  stretched  in  several  axes,  so  that  its  muscular  tone  is  lost  for  a 
time.  The  proctoscope  can  then  be  introduced,  and  it  will  be  found  that  if  the 
patient  is  in  the  correct  position  the  rectum  becomes  ballooned  by  an  inrush  of 
air,  and  its  interior  can  be  clearly  seen ;  a  head-lamp  or  a  laryngoscopic  mirror  is 
sometimes  useful  in  order  to  illuminate  the  interior.  Houston's  valves  stand 
out  clearly,  and  often  obstruct  the  view  of  the  upper  part,  but  they  can  usually 
be  pulled  aside  by  a  hook,  or  pushed  aside  by  the  speculum,  or  even  if  necessary 
they  can  be  divided.  In  this  way  6  inches,  if  not  more,  of  the  bowel  can  be 
brought  under  the  eye  of  the  surgeon,  and  topical  applications  can  be  made. 

A  sigmoidoscope  may  be  employed  for  seeing  the  condition  of  the  upper  part 
of  the  rectum  and  of  the  lower  end  of  the  sigmoid  flexure.  It  consists  of  a 
hollow  straight  tube,  14  inches  long,  -with  its  length  marked  on  the  outside  so 
that  one  may  know  how  far  it  has  been  introduced.  Suitable  arrangements  are 
made  for  distending  the  bowel  with  air,  and  for  illuminating  and  seeing  its 
interior.  A  blunt-ended  obturator  is  used  to  facilitate  its  introduction  in  the 
first  instance,  but  this  is  withdrawn  when  it  is  well  into  the  bowel. 

Congenital  Malformations — Imperforate  Anus  or  Rectum, — ^The 
lowest  portion  of  the  intestinal  canal  arises  from  the  union  of  two 
separate  divisions.  The  upper,  developed  from  the  lowest  portion 
of  the  primitive  hind-gut,  is  originally  in  communication  with  the 
bladder,  and  forms  a  joint  cavity  or  cloaca,  the  two,  however,  being 
earh'  separated;  the  posterior  segment,  which  becomes  the  rectum, 
extends  down  into  the  pelvis,  to  be  joined  by  an  epiblastic  pit  or 
involution  growing  in  from  the  perineum  known  as  the  '  procto- 
deum.' Failures  in  t\^pical  development  maj^  be  due  either  (a)  to 
the  proctodeum  being  absent  or  stenosed;  {b)  to  the  rectum  being 
absent  (Fig.  526,  A)  or  retaining  in  measure  its  cloacal  condition 
and  opening  into  some  other  viscus — e.g.,  the  bladder,  urethra, 
vagina,  or  vulva  (Fig.  526,  B) ;  or  (c)  to  want  of  union  between  the 
upper  and  lower  segments  (Fig.  526,  C).  The  following  are  the  chief 
clinical  varieties  of  malformation  met  with: 

(i.)  Absence  of  the  anus,  with  or  without  development  of  the 
rectum,  which,  if  present,  may  open  in  some  abnormal  situation. 
In  these  cases,  the  important  question  to  be  settled  by  the  practi- 
tioner is  the  existence  or  not  of  a  rectum,  and  this,  unfortunately, 
cannot  alwa^-s  be  determined  without  an  open  exploration  through 
the  perineum;  if,  however,  during  crying  and  straining  there  is  a 
distinct  bulge  in  the  middle  line  at  the  spot  where  the  anus  should 
be,  there  is  every  likelihood  of  the  viscus  being  present.  If  so,  it  is 
always  distended  and  club-shaped,  usually  lined  with  peritoneum  in 


1 146 


A   MANUAL  or  SURGERY 


front,  and  often  below.  If  the  rectum  is  absent,  it  usually  ends  near 
the  pelvic  brim,  and  is  merely  represented  by  a  librous  cord  below 
that  IqvvI  (Fig.  526,  A),  whilst  the  bony  pelvis  is  often  atrophic  and 
its  outlet  much  reduced  in  size.  Thus  in  one  such  case  an  interval 
of  only  I  inch  was  present  between  a  sound  passed  into  the  urethra 
and  the  tip  of  the  coccyx. 

(ii.)  A  membranous  septum  may  persist  between  the  upper  and 
lower  segments,  placed  about  an  inch  from  the  anus,  and  allowing 
the  retained  meconium  to  push  it  downwards.  This  is  the  type  of 
malformation  most  commonly  observed  (Fig.  526,  C). 

(iii.)  An  anus  is  occasionally  present,  whilst  the  rectum  ends 
blindly  above  the  pelvic  brim,  or  opens  elsewhere. 

(iv.)  The  anus,  though  present,  may  be  contracted. 

'ihe  Treatment  of  these  ca.ses  must  be  instituted  at  as  earty  a  date 
after  birth  as  possible,  so  as  to  prevent  intestinal  obstruction. 


A  B  C 

Fig.  526. — Three  Varieties  of  Malformation  of  Rectum.     (Tillmanns.  ) 

In  A  the  bowel  ends  at  the  brim  of  the  pelvis  in  a  cul-de-sac,  and  there  is  no 
evidence  of  an  anus;  in  B  the  anus  is  also  absent,  but  the  bowel  opens  into 
the  bladder;  in  C  the  anus  and  bowel  are  only  separated  by  a  small  space. 

Anal  stenosis  is  readily  dealt  wath  by  regular  dilatation  with 
bougies. 

Where  a  membranous  septum  persists  between  the  proctodeum 
and  rectum,  a  large  trocar  and  cannula  may  be  passed  through  it, 
and  the  meconium  allowed  to  escape;  the  aperture  thus  made  is 
enlarged,  and  maintained  by  the  subsequent  passage  of  bougies. 

Where  the  anus  is  absent,  whether  there  is  any  indication  of  the 
presence  of  a  rectum  or  not,  a  perineal  incision  is  first  made  through 
the  site  of  the  anus,  and  carried  upwards  and  backwards  along  the 
concavity  of  the  sacrum  strictly  in  the  middle  line  for  not  more  than 
2  inches.  It  is  an  open  question  whether  it  is  justifiable  to  proceed 
further  by  removing  the  coccyx  and  part  of  the  sacrum  (Kraske's 
operation,  p.  1171),  since  the  membranes  of  the  spinal  cord  extend 
much  further  down  in  the  infant  than  in  the  adult.  If  found,  the 
dilated  and  bulbous  cul-de-sac  is  drawn  down  as  far  as  possible,  and 
opened  towards  its  posterior  aspect;  the  mucous  membrane  is  then, 
if  feasible,  stitched  all  round  to  the  skin  so  as  to  leave  no  surface 
to  granulate,  thereby  preventing  subsequent  stenosis.  In  cases 
where  no  rectum  is  present,  colostomy  must  be  performed,  and  by 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1147 

preference  the  iliac  operation,  since  the  space  between  the  crest  of 
the  ihum  and  the  last  rib  is  exceedingly  small  in  an  infant.  When 
once  a  passage  for  the  faeces  is  established,  abnormal  openings  into 
the  bladder,  etc.,  usually  close  without  difhculty. 

Various  malformations  in  connection  with  the  post-anal  gut  have 
been  already  described  (p.  703). 

Injuries  of  the  rectum  are  usually  due  to  falling  on  some  pointed 
body,  such  as  a  stick  or  railing,  or  upon  a  piece  of  broken  china. 
They  are  sometimes  due  to  the  forcible  introduction  of  foreign  bodies 
by  lunatics  or  criminals.  They  may  merely  involve  the  mucous 
membrane,  or  may  penetrate  the  perineal  tissues,  enter  the  bowel, 
and  penetrating  the  upper  wall,  lay  open  the  peritoneal  cavity. 
Haemorrhage,  pain,  and  shock  follow,  and  acute  peritonitis  if  the 
serous  membrane  has  been  encroached  on.  Inflammatory  troubles 
may  involve  the  peri-rectal  tissues,  and  sinuses  may  result  from 
suppuration.  A  thorough  examination  must  be  made  under  an 
anaesthetic,  and  the  wounds  either  sutured  or  left  open  to  granulate. 
In  women  the  recto-vaginal  septum  may  be  torn,  but  the  surgeon 
need  be  in  no  great  hurry  to  interfere,  since  the  opening  usually 
closes  as  cicatrization  progresses;  in  some  cases,  however,  where 
the  lesion  is  of  some  length,  and  the  margins  not  bruised  or  inflamed, 
immediate  suturing  may  be  desirable.  If  the  peritoneal  cavity  has 
been  laid  open,  a  laparotomy  is  usually  required  in  order  to  cleanse  it 
and  close  the  wound;  if,  however,  the  wound  is  small  and  the 
rectum  at  the  time  of  injury  empty,  it  may  be  justifiable  to  delay 
interference  till  some  sign  of  inflammatory  reaction  shows  itself;  a 
piece  of  sterilized  gauze  packing  in  the  rectal  wound  will  often 
suffice  to  limit  the  inflammatory  mischief.  Peri-rectal  complica- 
tions are  dealt  with  as  they  arise. 

Foreign  Bodies  are  derived  from  various  sources.  Generally  they 
have  been  swallowed,  and  have  traversed  the  intestinal  canal.  Fish- 
bones and  small  tooth-plates  are  most  commonly  seen,  and  they 
usually  lodge  just  above  the  anus  in  one  of  the  so-called  '  pouches 
of  Morgagni.'  They  give  rise  to  severe  pain,  especially  on  de- 
faecation,  and  possibly  to  some  form  of  peri-rectal  abscess.  Large 
gall-stones  are  sometimes  lodged  in  the  lower  end  of  the  rectum, 
just  above  the  sphincter.  Foreign  bodies  may  be  introduced  from 
without,  and  cause  various  forms  of  traumatic  inflammatory  lesions. 
Inflammation  of  the  Rectum  [Proctitis)  causes  pain  of  a  bearing- 
down  character,  a  sensation  of  fulness,  constantly  recurring 
tenesmus,  accompanied  by  a  discharge  of  mucus,  muco-pus,  or 
blood.  It  may  arise  from  any  local  source  of  irritation — e.g.,  the 
presence  of  foreign  bodies,  or  of  a  poh^pus,  parasites,  or  piles; 
gonorrhoea  is  an  occasional  cause — in  women  possibly  owing  to 
infection  from  the  vaginal  discharge,  in  men  probably  from  direct 
infection.  In  dysentery  the  rectum  is  often  involved  as  well  as 
the  colon,  and  extensive  ulceration  may  be  present.  If  the  inflam- 
mation becomes  chronic,  a  simple  fibrous  stricture  may  result. 
Treatment. — Injections  of  lead  and  opium  or  of  borax  may  be  used 


1148  A   MANUAL  OF  SURGERY 

locally,  whilst  the  patient  is  kept  in  a  recumbent  position  and  on  a 
low  diet,  the  bowels  being  reguhirly  opened  by  the  administration 
of  laxatives  or  enemata.  If  much  bleeding  is  present,  hazehne 
will  often  serve  as  a  useful  styptic. 

Thread-worms  [Oxyiiris  vermicidaris)  are  the  most  constant  source 
of  irritation  of  the  rectum  in  infants  and  children.  They  give  rise 
to  pruritus  ani,  a  discharge  of  muco-pus,  and  many  reflex  pheno- 
mena. In  treating  such  a  case,  a  sharp  purgative  may  be  given 
every  morning  [e.g.,  pulv.  scamm.  co.,  grs.  v.),  and  salt  and  water 
or  an  infusion  of  quassia  used  as  an  injection.  Occasionally  this  is 
ineffective,  and  then  it  is  possible  that  the  csecum  or  even  the  ap- 
pendix is  the  main  site  of  lodgement  of  the  worms;  santonin  may 
then  be  necessary  in  order  to  clear  the  intestinal  canal. 

The  Bilharzia  haematobia  is  occasionally  found  in  the  rectum  as 
well  as  in  the  urinary  passages  (p.  1182).  It  gives  rise  to  fibro- 
adenomatous  polypi,  in  which  the  ova  can  be  readily  demonstrated; 
they  are  rounded  or  oval  bodies,  differing  from  those  found  in  the 
urine  in  that  they  possess  a  lateral  spine-like  projection,  whilst  in  the 
latter  it  is  terminal.  Considerable  tenesmus,  diarrhcea,  and  discharge 
of  blood  are  present,  and  the  haemorrhage  may  become  so  abundant 
as  to  destroy  the  patient's  life,  especially  when  urinary  symptoms 
are  co-existent.  They  occur  in  children  who  have  been  in  South 
Africa,  and,  unfortunately,  no  satisfactory  treatment  is  known. 

Rectal  and  Peri-rectal  Suppuration. — Many  forms  of  abscess  are 
found  in  and  about  the  rectum,  and  they  are  very  liable  to  leave 
behind  troublesome  fistulous  tracks.  As  regards  causation,  they 
are,  of  course,  due  to  germs,  and  these  are  derived  most  commonly 
from  the  bowel  as  a  result  of  the  impaction  of  foreign  bodies,  the 
extension  of  ulcerative  processes,  or  the  suppuration  of  piles.  Oc- 
casionally the  trouble  starts  from  the  skin  around  the  anus,  and 
sometimes  the  pus  reaches  the  peri-rectal  tissues  from  other  viscera 
— e.g.,  the  neck  of  the  bladder,  prostate,  etc.— or  from  above,  in 
connection  with  spinal  or  pelvic  abscesses.  Not  unfrequently  the 
abscess  is  attributed  to  injury  or  to  cold,  as  from  sitting  on  a  damp 
stone  or  a  draughty  closet.  These  latter,  if  having  any  influence, 
are  merely  the  final  exciting  agents. 

1.  An  Anal  Abscess  forms  immediately  under  the  anal  integument, 
and  superficial  to  the  external  sphincter  (Fig.  527,  A. A.) ;  it  is 
usually  due  to  inflammation  of  one  of  the  numerous  sebaceous 
follicles  in  that  locality.  It  may  be  acute  or  chronic,  and  is  one  of 
the  most  frequent  causes  of  fistula-in-ano.  It  must  be  freely 
opened  throughout  its  whole  length,  and  packed. 

Occasionally  a  sebaceous  follicle  becomes  affected,  constituting  a 
boil,  and  may  infect  several  others.  If  these  can  be  dealt  with 
early,  the  trouble  may  be  limited,  but  if  neglected  a  somewhat  ex- 
tensive anal  abscess  may  result. 

2.  A  Submucous  Abscess  (Fig.  527,  S.M.A.)  usually  forms  as  the 
result  of  a  suppurating  internal  pile.  The  pus  spreads  up  and  down 
under  the  mucous  membrane,  and  gives  rise  to  a  blind  internal 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS 


1 149 


fistula  (Fig.  529,  5).  It  is  usually  confined  to  one  side  of  the  bowel, 
and  causes  great  pain  on  defalcation.  Digital  examination  is  ex- 
tremely painful.  Treatment  consists  in  draining  it  at  the  most 
dependent  spot,  close  to  the  anus,  but  it  may  be  necessary  to  slit 
up  the  undermined  mucous  membrane  in  order  to  ensure  healing. 
Considerable  haemorrhage  may  follow  this  proceeding,  and  it  is  not 
easy  to  stop  except  by  firm  pressure. 

3.  Acute  Ischio-rectal  Abscess  is  due  to  infection  of  the  loose  fatty 
tissue  filling  the  ischio-rectal  fossa  (Fig.  527,  I.R.A.)  with  some 
pyogenic  organism,  reaching  it  either  through  the  perineum  or  from 
the  bowel.  The  B.  colt  is  usually  present,  and  in  consequence  the 
pus  has  the  ordinary  characteristic  offensive  odour.  A  red,  painful 
swelling  is  noticed  on  one  side  of  the  anus,  which  is  at|first  hard  and 


Fig.  527. — Diagrammatic  Section  of  Abscesses  situated  near  the 
Lower  End  of  the  Rectum. 

L.A.,  Levator  ani;  E.S.,  external  sphincter;  I.S.,  internal  sphincter;  I.R.A., 
ischio-rectal  abscess  ;  A. A.,  anal  abscess  ;  S.M.A.,  submucous  abscess; 
P.R.A.,  pelvi-rectal  abscess. 

brawny,  but  soon  becomes  soft  and  fluctuating.  Defsecation  is  ex- 
ceedingly painful,  as  also  digital  exploration  of  the  bowel,  and  the 
patient  is  unable  to  sit  with  any  comfort.  If  left  to  itself,  it  may 
burst  internally  or  externally,  or  in  both  directions,  and  a  fistula-in- 
ano  is  very  liable  to  follow.  Treatment. — In  the  early  stages  the 
part  should  be  well  fomented,  but  when  there  is  no  doubt  that  pus  is 
present,  a  free  opening  should  be  made,  the  cavity  washed  out,  and 
packed  with  some  antiseptic  dressing.  If  taken  early  enough,  rapid 
recovery  may  ensue  without  the  bowel  becoming  involved,  but  when 
the  mucous  membrane  has  been  encroached  upon  or  perforated,  the 
wound  will  not  heal  without  division  of  the  sphincter.  A  T-shaped 
or  crucial  incision  is  perhaps  the  best  to  employ  in  the  early  stages, 
as  indicated  in  Fig.  528;  the  cross  limb  of  the  T  is  parallel  to  the 
fold  of  the  nates,  and  should  extend  through  the  whole  of  the  in- 
flamed and  infiltrated  tissues. 


II50 


A   MANUAL  OF  SURGERY 


4.  Chronic  Ischio-rectal  Abscess  is  usually  met  with  in  run-down 
or  tuberculous  indi\icluals  during  young  adult  life,  and  is  not 
unfrequently  a  complication  of  phthisis.  A  deposit  of  tuberculous 
material  replaces  the  fat  ordinarily  occupying  the  ischio-rectal  fossa, 
and  this  after  a  time  undergoes  caseation  or  forms  an  abscess,  which 
gradually  spreads  without  pain  or  other  inflammatory  disturbance, 
until  it  may  extend  very  widely  and  almost  entirely  surround  the 
bowel.  After  it  has  burst  the  orifices  of  sinuses  may  be  found  at  a 
considerable  distance  from  the  anus.  The  Signs  and  Symptoms  are 
those  of  a  chronic  tuberculous  abscess.  An  indurated  and  painless 
mass  may  be  first  felt  in  the  fossa,  and  this  slowly  spreads,  softens, 
and  is  transformed  into  a  more  or  less  extensive  abscess  sac.  Oper- 
ative Treatment  is  desirable  in  most  of  these  cases,  and  if  possible  in 
the  early  stages,  or  before  suppuration  has  occurred;  incision,  re- 
moval by  a  sharp  spoon  of  all  tuberculous  tissue,  the  apphcation  of 


Fig.  528. — Situation  of  T-shaped  Incision  required  for  Opening 
AN  Ischio-rectal  Abscess. 


pure  carbolic  acid,  and  dressing  the  wound  with  gauze  infiltrated 
with  iodoform  are  the  essential  elements.  Where  extensive  sinuses 
or  fistulae  exist,  treatment  as  for  fistula-in-ano  must  be  adopted.  At 
the  same  time,  suitable  hygienic  treatment  is  instituted,  and  the 
more  so  if  physical  examination  of  the  lungs  or  bacteriological 
examination  of  the  sputum  indicates  the  co-existence  of  pulmonary 
tuberculosis. 

5.  The  Pelvi- rectal  Abscess  (Fig.  527,  P.R.A.)  consists  in  a 
locahzed  collection  of  pus  in  the  loose  cellular  tissue  above  the 
levator  ani  between  it  and  the  rectum.  It  may  be  secondary  to 
rectal  lesions,  such  as  penetration  of  the  wall  above  the  internal 
sphincter  or  extension  of  ulceration  from  a  carcinoma;  but  not  un- 
commonly it  originates  from  pelvic  lesions,  and  may  be  caused  by 
pelvic  cellulitis,  or  suppuration  in  the  meso-rectum,  prostate,  etc. 
The  ordinary  phenomena  of  a  deep  abscess  are  produced,  and  the 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1151 

pus  ma}-  burrow  dowuwards  through  the  levator  ani  to  the  ischio- 
rectal fossa,  or  may  travel  up  and  involve  the  pelvic  peritoneum. 
Sometimes  it  extends  laterally  and  may  almost  surround  the  bowel, 
causing  one  type  of  horseshoe  ftstula.  Other  collections  of  pus  may 
find  their  wa\^  into  this  region  from  different  parts — -e.g.,  a.  psoas 
abscess  from  spinal  disease,  appendix  abscesses,  etc.  Rectal  exam- 
ination indicates  the  existence  of  a  painful  swelling  high  up  in 
the  bowel.  As  soon  as  a  diagnosis  is  made,  the  abscess  should  be 
freely  laid  open  and  drained,  and,  if  possible,  by  an  incision  behind 
tlie  anus.  Of  course  an  abscess  which  is  secondary'  to  a  tuberculous 
spine  is  an  exception  to  this  rule ;  in  this  every  effort  must  be  made 
to  prevent  the  necessity  for  an  opening  in  this  region,  as  infection  is 
certain  to  follow. 

6.  Occasionally  a  diffuse  form  of  cellulitis  involves  the  peri-rectal 
connective  tissue,  not  uncommonly  resulting  in  gangrene  {gangrenous 
periproctitis).  It  is  most  likely  to  be  seen  in  wealdy  individuals  and 
old  people,  and  the  symptoms  are  very  asthenic  in  type.  The  sup- 
puration may  extend  above  the  levator  ani,  and  lead  to  deep  fistu- 
lous tracks.  The  parts  must  be  freely  opened  up,  the  gangrenous 
tissue  scraped  away,  and  the  raw  surfaces  treated  with  peroxide  of 
hydrogen.  The  wounds  are  then  packed  with  iodoform  gauze,  and 
subsequently  well  irrigated  twice  a  da^^  Free  stimulation  is  always 
required  in  Ihese  cases,  but  the  prognosis  is  very  bad,  death  being 
probably  caused  by  acute  toxsemia  or  pyaemia. 

Fistula-in-Ano. — The  term  '  fistula-in-ano  '  is  somewhat  loosely 
applied  to  all  those  conditions  in  which  suppurating  tracks  are  found 
in  the  neighbourhood  of  the  anus  and  the  lower  end  of  the  rectum. 
Many  of  these  are  merely  sinuses  which  have  but  one  opening. 

The  Cause  of  fistula  is  usuallj^  some  suppurative  condition — e.g., 
an  ischio-rectal  or  anal  abscess,  or  the  breaking  down  of  a  tuber- 
culous deposit  in  the  neighbourhood  of  the  bowel;  but  it  is  some- 
times the  result  of  a  simple  or  malignant  stricture  of  the  gut,  the 
inner  opening  being  either  above,  in  the  substance  of,  or  below  the 
cicatricial  mass.  This  is  moie  likely  to  be  the  case  when  multiple 
fistulge  exist. 

Varieties. — i.  The  Complete  Fistula  is  one  in  which  there  are  open- 
ings both  externally  and  into  the  bowel.  When  following  an  anal 
abscess,  they  are  both  close  to  the  anus,  and  the  track  lies  imme- 
diately beneath  the  skin  and  mucous  membrane  (Fig.  529,  i) .  When 
following  an  acute  ischio-rectal  abscess,  the  external  opening  is  a 
variable  distance  from  the  anus,  and  the  inner  not  more  than  i  inch 
up  the  bowel,  being  situated  in  relation  with  the  so-called  internal 
sphincter  (Fig.  529,  2) ;  occasionalh'  blind  submucous  or  sub- 
cutaneous extensions  are  met  wdth  branching  off  from  this  (2'*),  but 
not  so  frequently  as  when  the  fistula  follows  a  chronic  tuberculous 
abscess.  In  the  latter  case  the  skin  ma}'  be  extensively  undermined, 
looking  blue  and  congested,  and  the  fistulous  tracks  may  burrow 
widely,  opening  even  on  the  thigh,  or  in  the  perineum  or  buttock. 
The  so-called  horseshoe  fistula  passes  round  the  bowel,  usually  behind 


II52 


A   MANUAL  OF  SURGERY 


the  anus,  either  superficial  to  the  external  sphincter  or  beneath  it, 
and  opens  also  on  the  other  side.  Moreover,  the  mucous  membrane 
of  the  bowel  is  often  undermined,  and  stripped  from  the  muscular 
coat  for  some  distance  above  the  internal  opening  by  sinuses  or  an 
abscess  cavity.  Occasionally  the  complete  fistula  which  follows  an 
ischio-rectal  or  pelvi-rectal  abscess  opens  some  way  up  the  bowel  as 
well  as  externally,  and  traverses  the  levator  ani  (Fig.  529,  3),  consti- 
tuting a  much  deeper  and  more  serious  lesion. 

In  any  of  these  conditions  secondary  tracks  may  form,  burrowing 
in  all  directions,  and  sometimes  the  opening  up  of  these  passages  is 
a  serious  matter.  Thus  they  may  run  forwards  to  the  scrotum,  or 
outwards  into  the  gluteal  region. 

i  2.  The  Blind  External  Fistula  (Fig.  529,  4)  is  the  term  applied  to  a 
sinus  resulting  from  the  opening  of  an  ischio-rectal  abscess  in  which 


Fig.  529.- 


-dlagrammatic  representation  of  various  forms  of 
Fistula-in-Ano. 


I,  Superficial  fistula  resulting  from  an  anal  abscess;  2,  a  complete  fistula,  not 
involving  the  internal  sphincter;  20,  secondary  track  burrowing  under 
mucous  membrane;  3,  complete  fistula  opening  above  the  internal  sphinc- 
ter and  traversing  the  levator  ani;  4,  blind  external  fistula;  5,  blind 
internal  fistula;  E.S.,  external  sphincter;  I.S.,  internal  sphincter;  L.A.. 
levator  ani. 

no  communication  with  the  bowel  can  be  discovered.  A  probe 
passed  into  the  wound  can  often  be  felt  by  a  finger  in  the  rectum 
with  only  the  thickness  of  the  mucous  membrane  between.  In 
deahng  with  these  external  fistulae  the  possibility  of  the  original 
cause  being  at  a  distance  must  not  be  overlooked. 

3.  The  Blind  Internal  Fistula  (Fig.  529,  5)  is  constituted  by  a  sinus 
opening  into  the  bowel  just  above  the  anus.  Attention  is  usually 
drawn  to  the  condition  by  the  passage  of  pus  with  the  motions  or 
independently,  and  perhaps  by  preceding  inflammatory  disturbance. 
The  orifice  can  sometimes  be  felt  by  digital  exploration;  on  the 
insertion  of  a  speculum  it  may  perhaps  be  seen,  and  can  be  ex- 
amined by  a  straight  probe  or  one  bent  in  the  form  of  a  hook;  it  is 


AFFECTIONS  OF  TIUL  RECTUM  AND  ANUS  ii53 

often  associated  with  considerable  undermining  of  the  mucous  mem- 
brane, and  if  chronic  with  stenosis  of  tire  bowel. 

In  all  these  conditions  it  is  difficult  to  obtain  healing,  owing  to  the 
introduction  of  septic  material  from  the  bowel,  and  to  the  state  of 
unrest  in  which  the  parts  are  kept  by  the  continuous  movements, 
voluntary  and  involuntary,  of  the  sphincteri. 

Operation.— The  bowels  must  have  been  completely  evacuated, 
both  by  means  of  castor  oil  or  some  suitable  purgative,  and  about  an 
hour  previous  to  operation  by  enema,  a  most  important  prehrnin- 
ary,  not  only  for  the  comfort  of  the  operator,  but  also  because  it  is 
very  desirable  that  no  further  action  should  be  required  for  some 
days.  The  patient  is  placed  in  the  lithotomy  position,  and  the 
perineal  and  anal  regions  shaved  and  purified.  A  probe  is  passed 
along  the  fistula  into  the  rectum,  and  guided  by  it  a  grooved 
director,  along  which  a  curved  pointed  bistoury  is  introduced,  and 
the  intervening  structures  divided.  In  a  superficial  fistula,  both 
sphincters  may  escape  division,  and  in  a  deep  one  both  may  be  in- 
volved ;  in  the  majority  of  cases,  some  fibres  of  the  external  sphincter 
are  divided.  A  careful  search  is  made  for  pockets  or  tributary 
branches  of  the  main  track,  and  these,  if  found,  are  opened  up  and 
scraped  out,  undermined  and  unhealthy  skin  being  snipped  away 
with  scissors;  it  is  important,  however,  to  remember  that  the 
sphincter  ought  never  to  be  divided  in  more  than  one  place. 
Bleeding-points  are,  if  necessary,  tied,  and  the  cavity  is  carefully 
dusted  with  iodoform,  and  Hghtly  packed  with  oiled  lint  or  gauze 
soaked  in  iodoform  and  glycerine.  Pressure  by  a  graduated 
compress  of  sterilized  wool  should  be  applied  by  means  of  a 
T-bandage. 

When  a  sinus  extends  for  some  distance  under  the  mucous  mem- 
brane from  the  upper  end  of  the  original  fistula,  it  may  not  be  always 
desirable  to  lay  it  open  to  its  whole  extent,  since  such  might  mvolve 
serious  haemorrhage  at  a  spot  where  it  cannot  well  be  checked.  It 
will  often  suffice  partly  to  divide  and  scrape  it,  and  then,  if  the  mam 
fistula  has  been  satisfactorily  dealt  with,  it  will  probably  heal  with- 
out difficulty,  especially  if  syringed  out  occasionally  with  stimulating 
lotions. 

In  the  case  of  a  horseshoe  fistula,  the  sphincter  need  only  be 
divided  at  one  spot,  and  that  usually  in  the  middle  of  the  horseshoe. 
The  M'hole  track  must,  however,  be  opened  up,  the  cavity  scraped, 
loose  tags  of  skin  removed  by  the  scissors,  and  an  ordinary  dressing 
applied. 

A  small  superficial  fistula,  not  extending  beyond  the  anal  margin, 
can  sometimes  be  enrirely  excised,  and  the  wound  closed  by  sutures, 
thereby  securing  heahng  by  primary  union. 

After-Treatment.— The  bowels  should,  if  possible,  be  prevented 
from  acting  for  four  days,  and  most  scrupulous  care  taken  to  keep 
the  parts  clean.  The  deep  dressing  need  not  be  changed  for  the  first 
twenty-four  or  forty-eight  hours,  provided  that  the  surrounding 
skin  is  well  flushed  with  a  warm  carbohc  solution.     When  the  plugs 

73 


"54  A   MANUAL  OF  SURGERY 

are  removed,  fresli  small  stri])s  of  gauze  soaked  in  iodoform  and 
glycerine  are  introduced  night  and  morning  after  tfie  wound  has 
been  syringed.  On  the  fourth  day  a  good  dose  of  castor  oil  should 
be  given,  and  subsequently  an  action  of  the  bowels  must  be  secured 
daily.  The  wound  is  allowed  to  granulate,  and  care  taken  that 
irregular  healing  does  not  lead  to  a  re-formation  of  the  fistula. 
With  this  object  in  view,  it  is  often  advisable  to  pass  a  moderate- 
sized  bougie  from  time  to  time  at  the  end  of  a  fortnight. 

When  the  incision  is  not  carried  very  deeply,  the  patient's  sphinc- 
teric  control  after  operation  is  unimpaired;  but  if  the  internal 
sphincter  has  to  be  chvided,  all  control  of  the  bowel  is  lost  for  some 
time.  As  cicatrization  progresses,  however,  it  is  gradually  restored, 
and  when  healing  is  complete,  control  is  usually  perfect  except  when 
the  patient  is  suffering  from  diarrhoea. 

The  presence  of  tuberculous  material  locally  and  in  the  lungs  must 
be  carefully  considered  and  taken  into  consideration  in  advising 
operation.  If  the  pulmonary  trouble  is  early,  there  is  no  necessity 
for  delaying  operation ;  the  patient  will  derive  much  more  benefit 
from  sanatorium  treatment  if  his  fistula  has  been  first  cured,  or  put 
well  on  the  way  to  recovery.  In  the  later  stages,  however,  it  may 
be  advisable  to  leave  the  fistula  alone,  or,  at  any  rate,  only  to  do 
such  an  operation  as  shall  relieve  any  urgent  symptoms. 

Fissure  of  the  Anus.— Thia  is  a  most  painful  and  troublesome  com- 
plaint, met  with  most  commonly  in  men,  though  not  unfrequently  in 
women  of  a  neurotic  temperament.  It  is  occasionally  due  to  injury 
or  to  the  irritation  of  a  polypus,  but  more  often  to  the  pa:>sage  of 
large  scybalous  masses  in  patients  suffering  from  chronic  constipa- 
tion. The  fissure  is  usually  single,  extending  through  the  posterior 
border  of  the  anus  tovv-ard  the  coccyx;  a  '  sentinel  '  external  pile  is 
often  situated  immediately  over  it,  and  the  crack  may  lead  to  a  defi- 
nite ulcer  just  within  the  external  sphincter.  According  to  Ball  of 
Dubhn,  it  is  due  to  one  of  the  valve-like  tags,  left  at  the  junction  of 
the  proctodeum  and  rectum,  being  caught  by  a  scybalous  mass,  and 
torn  from  its  upper  connections.  Each  time'a  motion  passes  the  sore 
place  is  reopened,  and  the  valve  pushed  further  on,  until  finally, 
having  become  swollen  and  cedematous,  it  appears  at  the  orifice  as 
the  '  sentinel '  pile,  with  an  ulcerated  surface  behind  or  beside  it. 
Sometimes  several  fissures  are  met  with  in  the  same  individual,  and 
then  a  syphilitic  cause  is  probable,  especially  if  they  are  placed  at 
the  side  or  front  of  the  anus. 

The  Symptoms  of  this  condition  are  very  distressing,  consisting  of 
burning  pain  during  and  after  defsecation,  which  often  lasts  for  hours. 
The  pain  is  usually  associated  with  tenesmus,  and  may  rachate  down 
the  thighs  or  up  the  back,  and  not  uncommonly  to  the  left  sacro-ihac 
joint;  it  may  be  so  severe  as  to  lead  the  patient  to  refrain  from 
defsecation  for  prolonged  periods.  The  fseces  may  be  streaked  with 
blood  or  pus,  and  there  is  a  certain  amount  of  discharge  from  the 
anus.  On  examining  the  part,  the  sphincter  is  found  to  be  con- 
tracted spasmodically,  and  the  entrance  of  a  finger  is  forcibly  resisted. 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1155 

Treatment  in  the  earlier  stages  is  undertaken  by  regulating  the 
aetion  of  the  bowels  by  suitable  laxatives,  by  the  u^e  of  cocaine  sup- 
positories prior  to  defecation,  and  by  improving  the  general  healtli. 
bome_timcs  the  apphcation  of  a  hamamelis  ointment,  combined  with 
the  Ung.  hydrargyri  nitratis  dil.,  is  most  effective  in  giving  relief.  In 
confirmed  cases  the  sphincter  has  been  forcibly  dilated,  and  the 
crack  or  ulcer  cauterized;  but  by  far  the  most  satisfactory  treatment 
consists  m  dividing  its  base  with  a  straight  blunt-ended  bistoury, 
the  incision  at  the  same  time  including  the  superficial  fibres  of  the 
external  sphincter.  The  ulcer  and  the  edges  of  the  wound  are 
snipped  away  with  scissors,  to  facilitate  the  dressing  and  healing  of 
the  wound.  The  lower  bowel  should  in  all  cases  be  carefully  ex- 
plored with  the  finger,  especially  with  a  view  to  the  possible  existence 
oi  a  polypus,  which,  if  undetected,  would  cause  a  recurrence  of  the 
mischief.  Rest  being  thus  obtained,  heahng  soon  follows.  It  is 
sometimes  possible  to  close  this  small  wound  with  sutures  and  obtain 
primary  union. 

Pruritus  Ani  is  a  condition  characterized  by  intense  and  incessant 
itchmg  of  the  anus  and  its  surrounding  skin.  At  first  noticed  mainly 
at  night,  and  interfering  with  sleep,  it  may  in  time  become  persistent 
throughout  both  day  and  night,  preventing  the  patient  from  fixing  his 
attention  on  his  work,  and  wearing  him  out  through  want  of  sleep. 
Scratching  becomes  a  necessity,  and  yet  aggravates  the  condition, 
tt  IS  generally  due  to  parasites,  such  as  thread-worms,  or  to  some 
ulcerative  condition  of  the  anal  canal,  just  at  the  muco-cutaneous 
junction,  or  it  may  arise  from  some  neurosis  of  the  sensory  nerves. 
Ihe  skm  looks  red  and  excoriated;  it  is  usually  swollen  and  thrown 
into  oedematous  folds,  which  radiate  from  the  anus  in  a  characteristic 
fashion. 

Treatment.— Any  parasites  present  must  be  destroyed,  and  ulcers 
of  the  anal  canal  must  be  carefully  looked  for  and  cauterized.  For 
cases  which  persist  in  spite  of  such  measures.  Sir  Charles  Ball  has 
devised  an  operation  which  has  proved  of  value,  and  consists  in 
dividing  the  terminations  of  all  the  sensory  nerves  to  the  part.  Two 
semi-elhptical  incisions  are  made  around  the  anus,  leaving  a  narrow 
pedicle  in  front  and  behind;  the  wounds  are  deepened  to  expose  the 
sphincter,  and  the  flaps  raised  from  the  muscle  inwards  around  the 
anal  margin  and  up  to  the  muco-cutaneous  junction.  The  pedicles 
m  front  and  behind  are  undercut,  and  the  outer  margins  of  the 
incisions  also  to  an  extent  corresponding  to  the  area  of  irritation :  the 
flaps  are  then  replaced  and  sutured.  The  immediate  result  of  such 
an  operation  is  complete  anesthesia  of  the  skin  of  the  flaps  •  normal 
sensation  returns  after  a  time,  but  without  pruritus. 

Haemorrhoids,  or  Piles,  consist  in  a  varicose  condition  of  the  veins 
surrounding  the  anus  and  lower  inch  or  two  of  the  rectum. 

The  character  of  the  blood-supply  of  this  portion  of  the  bowel,  and 
the  conditions  under  which  it  is  carried  on,  go  far  to  explain  the 
frequency  of  this  affection.     The  circulation  in  the  pelvic  colon 


iijC'  A   MANUAL  OF  SURGERY 

is  similar  to  that  in  the  intestine  generally,  the  vessels  being 
distributed  transversely  around  the  gut;  but  in  the  rectum  they 
run  in  longitudinal  seiies  along  the  bowel,  being  connected  by 
transverse  branches,  which  form  a  plexus  around  and  just  above  the 
anus.  Their  situation  in  the  loose  submucous  tissue,  where  there  is 
but  little  support,  necessarily  exposes  them  to  great  and  .-.udden 
variations  of  pressure  before  and  aftcx  defgecation.  Their  dependent 
position  at  the  lowest  part  of  the  portal  area,  together  with  the 
absence  of  valves,  and  the  fact  that  they  constitute  an  important 
communication  between  the  portal  and  general  systems,  and  thus 
afford  the  chief  means  of  escape  from  a  block  on  the  poital  trunk- 
all  these  reasons  may  be  looked  on  as  Predisposing  Causes  of  the  con- 
dition. In  addition  to  the^e  we  must  also  mention  a  sedentary 
occupation,  alcohohc  excess,  and  chronic  constipation,  which,  by 
leading  to  congestion  of  the  liver,  are  frequent  precursors  of  piles. 
They  are  exceedingly  common  in  young  people,  especially  in  men 
about  twenty  years  of  age  forced  to  lead  a  sedentary  life;  up  to 
middle  age  the  tendency  diminishes,  but  in  elderly  individuals  many 
conditions — e.g.,  enlarged  prostate,  cr  stone  in  the  bladder — arise 
which  favour  their  development.  Simple  stricture  of  the  rectum  or 
malignant  disease  may  so  interfere  with  the  return  of  blood  as  to 
determine  a  development  of  haemorrhoids.  Young  women  are  re- 
markabl}.  exempt  from  piles,  owing  probably  to  the  regularity  of  the 
menstrual  discharge;  but  uterine  conditions,  such  as  pregnancy, 
displacements,  or  tumours,  which  cause  obstruction  to  the  venous 
return,  are  liable  to  be  associated  with  them. 

A  varicose  condition  of  the  veins  in  the  neighbourhood  of  the  anus 
is  often  present  without  being  recognised  by  the  individual;  but 
many  different  circumstances  may  bring  the  symptoms  into  promi- 
nence by  causing  an  attack  of  thrombosis,  such  as  the  use  of  drastic 
purgatives,  especially  aloes,  local  exposure  to  damp  and  cold,  as  by 
sitting  on  a  cold  wet  stone  or  in  a  draughty  closet,  or  sudden  con- 
gestion of  the  liver,  as  by  alcoholic  excess,  or  a  chill. 

Two  chief  varieties  of  piles  are  described — \iz.,  the  external  and 
internal;  but  frequently  a  combination  of  the  two  conditions  is 
present. 

External  Piles  are  found  at  the  margin  of  the  anus,  and  are  covered 
with  skin.  They  consist  of  a  small  central  vein  in  a  varicose  state, 
surrounded  by  a  development  of  subcutaneous  fibro-cellular  tissue, 
which  latter  is  much  more  abundant  than  the  vascular  element ;  in 
fact,  they  practically  consist  of  longitudinal  folds  of  skin  of  a  dark 
brown  colour  radiating  from  the  anus,  and  superficial  to  the  sphincter. 
In  the  usual  relaxed  state  in  which  they  are  found  the}^  give  rise  to 
no  Symptoms  bej-ond  a  little  pruritus,  and  perhaps  a  sense  of  fulness 
and  irritation  immediately  before  and  after  defaecation.  They  are 
very  liable,  however,  to  become  inflamed  from  local  irritation  or  cold, 
and  then  appear  as  tense,  bluish,  rounded  swellings,  exceedingly 
painful  and  tender,  and  often  preventing  the  patient  from  walking  or 
sitting  in  comfort.     In  such  a  state  the  vein  contained  in  the  pile  is 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1157 

distended  with  blood-clot.  Under  suitable  treatment  the  swelhn? 
subsides  ni  a  few  days,  usually  leaving  the  fleshy  fold  more  bulky 
and  harder  than  previously,  owing  to  the  partial  or  complete  organi- 
zation ot  the  thrombus. 

Ihe  Treatment  of  external  piles,  when  uninflamed,  is  very  simple 
w!n^  ^^''k'^"  "'f  ^  ^"^  relieved;  the  parts  should  be  kept  clean  and 
well  vv-ashed;  a  hamameli^  ointment  or  extract  may  be  occasionally 
applied,  and  great  care  taken  not  to  irritate  the  anus  after  defecation 
by  the  use  of  hard  papei-^.g'.,  newspaper.  Very  soft  curl-paper 
well  crumpled,  should  be  employed,  or  preferably  absorbent  wool! 
It  is  but  rarely  that  operative  measures  are  required  in  a  simple  ca.e  of 
external  piles;  where,  however,  external  and  internal  piles  co-exist 
It  IS  advisable  to  complete  any  operation  undertaken  for  the  latter 
condition  by  the  removal  of  the  more  prominent  fleshy  folds  sur- 
rounding the  anus.  This  is  accomplished  by  grasping  them  with 
lorceps  and  snipping  them  away  by  scissors  in  a  direction  radiating 

inr\   n   "'""i''  °^  ^t  '^'^y''  ^^^  resulting  wounds  being  sutured 

i^or    inflamed    and   thrombosed   external 

piles  the  patient  should  be  kept  in  bed, 

the    bowels   opened    by  a   copious  warm 

enema,  and  fomentations  apphed.     If  the 

pain    and    tension    are    very    great,    the 

tumour  should  be  incised   and  the'  clot 

turned  out;  the  margins  of  the  fold  may 

then  be  cut  away,  and  the  wound  dressed. 
Internal  Piles  consist  of  dilated  veins 
held_  together  by  a  certain  amount  of  con- 
nective tissue,  and  covered  by  mucous 
membrane.  At  fir:,t  they  are  quite  soft  and 
compressible,  and  easily  emptied  on  pres- 
sure; but  when  they  have  existed  for 
some  time  the  connective  tissue  may  be  increased  in  amount  and 
arterial  twigs  are  often  found  running  into  the  mass 

ihe  condition  is  limited  to  the  lower  2  inches  of  the  bowel 
and  may  present  very  varied  appearances  in  different  cases.  Thus' 
l^f  r  T7k  /  ^"V^^'  dilatation  of  the  veins  in  the  submucous  tissue 
^ithout  the  formation  of  any  distinct  tumours.     The  mucous  mem- 

fr  r.f  ^""V  -^  ^T?  ^^""''r*  ^°^°^^'  somewhat  thickened,  and  liable 
to  protrude  during  defsecation.  There  is  a  certain  amount  of  glairy 
mucous  discharge,  and  the  faeces  may  be  streaked  with  blood ;  but 

foirnw.H  K.  ^/^•7^^^'  ^'  ^°*  ^'%^^-  S^^h  ^  condition  is  usually 
followed  by  a  definite  formation  of  haemorrhoidal  tumours,  and  not 
unfrequently  runs  on  to  prolapse. 

When  distinct  hfeniorrhoidal  masses  form,  they  may  be  of  two 
types :  [a]  The  lon^ttudtnal  ox  fleshy  pile  (Fig.  530) ,  consisting  of  broad 
sessile  masses,  dusky  m  colour,  soft  and  compressible  in  consis- 
tency and  covered  by  mucous  membrane,  which,  although  thin  and 
stretched^  still  remains  smooth  and  shiny,  like  the  skin  of  a  black 
grape.     Between  the  piles  depressions  are  found,  in  which  small 


FiG-  530- — Internal 
Piles. 


1 158  A   MANUAL  OF  SURGERY 

portions  of  feces  may  lodge  and  produce  irritation.  This  form 
generally  bleeds  but  little.  (&)  The  globular  or  bleeding  pile  is  single 
or  multiple,  and  as  a  rule  somewhat  pedunculated;  the  surface  of 
the  tumour  is  roughened  and  granular,  like  a  strawberry,  due  to  the 
existence  of  dilated  capillaries.  When,  however,  a  portion  of  it  has 
been  repeatedly  protruded,  the  exposed  mucous  membrane  becomes 
hard,  and  practically  converted  into  skin,  and  the  columnar  epithe- 
lium may  be  replaced  by  the  squamous  type.  The  haemorrhage  may 
be  abundant,  and  comes  either  from  the  dilated  superficial  capillaries, 
or  occasionally  from  a  central  arterial  twig. 

The  Symptoms  arising  from  internal  piles  are  often  not  very- 
marked  until  haemorrhage  occurs;  but  there  is  usually  a  sense  of 
weight  or  fulness  about  the  anus,  with  sometimes  pain,  which  is 
increased  before  and  after  deftecation.  The  patient  feels  as  if  a 
foreign  body  were  present  in  the  bowel,  and  the  mass  not  unfre- 
quently  protrudes,  giving  rise  to  much  pain  and  inconvenience  until 
replaced  by  the  patient,  owing  to  the  grip  of  the  sphincter 
(Plate  XT).  Sooner  or  later  haemorrhage  is  almost  certain  to  be 
noticed,  coming  on  at  first  after  defaecation,  and  only  a  few  drops 
being  lost.  After  a  time,  however,  the  flow  increases,  and  may  con- 
tinue to  such  an  extent  as  to  cause  marked  anaemia.  If  the  case 
remains  untreated,  the  pain  and  inconvenience  increase;  a  blood- 
stained mucous  discharge  from  the  rectum  is  noticed,  soiling  the 
linen;  reflex  irritation  of  neighbouring  organs  is  produced,  and  a 
condition  of  nerve  prostration  from  pain  and  haemorrhage  may 
result.  In  cases  where  the  piles  are  due  to  portal  obstruction,  as  in 
cirrhosis  of  the  liver,  the  bleeding  may  be  beneficial,  and  must  nut 
always  be  checked. 

Complications  of  Piles. — Inflammation  of  the  venous  ampullae  con- 
tained in  piles  leads  to  what  is  popularly  termed  an  '  attack  of  piles,' 
although  this  is  much  less  common  with  the  internal  than  the  ex- 
ternal variety,  and  the  fleshy  form  is  that  usually  affected.  Evidences 
of  a  localized  phlebitis  manifest  themselves  in  the  shape  cf  a  painful 
distension  and  swelling  of  the  parts,  which  become  blue  in  colour 
and  exquisitely  sensitive.  They  subside  with  or  without  suppura- 
tion; in  the  latter  case  a  spontaneous  cure  may  result,  whiLt  in  the 
former  the  abscess  may  burst  into  the  bowel  or  may  burrow  exten- 
sively, and  even  give  rise  to  general  blood  contamination  and  pyaemia  . 
Strangulation  of  the  piles  by  the  sphincter  ani  may  follow  protrusion 
where  reposition  is  not  effected,  the  mass  becoming  painful,  tense, 
swollen,  and  livid  in  colour;  inflammation  running  on  to  ulceration 
and  sloughing  follows,  the  patient  suffering  from  sickness,  pain, 
and  toxaemia.  Pyaemia  may  ensue,  or  a  spontaneous  cure  be 
effected. 

The  Diagnosis  of  piles  from  other  swellings  which  occur  in  the 
neighbourhood  is  not  difficult.  From  prolapse  they  are  recognised 
by  their  irregularity,  the  swelling  not  being  of  a  rounded  smooth 
annular  variety,  as  in  the  former  case;  the  two  conditions  are,  how- 
ever, often  associated.     From  polypus  piles  are  distinguished  by 


PLATE  XI. 


/&rl- 


Prolapse  of  mucous  membrane  of  Rectum  and  Plaemorrhoiclal  tumours  in  an  old 
standing  case  of  Piles.  This  case  was  treated  most  effectively  by  Whitehead's 
operation. 


\;ro  face  page  1 1 58. 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1159 

being  multiple  rather  than  single,  by  being  softer  and  more  com- 
pressible, by  their  situation  close  to  the  anus,  by  the  absence  of  a 
pedicle,  and  by  the  haemorrhage  being  usually  more  marked. 
Mucous  tubercles  and  condylomata  are  often  mistaken  for  external 
piles,  but  are  easily  recognised  by  being  symmetrically  placed,  owing 
to  infection  of  one  lip  of  the  gluteal  fold  from  the  other,  by  their 
moist  surface,  and  their  situation  at  a  little  distance  from  the  anus. 
The  consistency,  appearance,  and  history  of  an  epithelioma  should 
effectually  prevent  any  error  in  diagnosis. 

It  is  important  also  to  remember  that  blood  may  be  passed  per 
ami  III  from  many  other  conditions  besides  piles.  In  the  latter  case 
the  blood  is  of  a  bright  red,  florid  colour,  and  often  coats  the  faeces, 
whereas  if  it  originates  higher  in  the  intestinal  canal  it  is  dark  or 
tarry  in  colour  {mclcBua),  and  is  more  intimately  mixed  with  the 
excreta.  A  visual  and  digital  examination  of  the  rectum  should 
always  be  made  in  order  to  ascertain  the  exact  cause  of  the  bleeding. 

The  Treatment  of  internal  piles  is  both  general  and  local. 

General  Treatment  consists  in  removing  all  possible  sources  of 
venous  congestion,  in  regulating  the  bowels,  and  assisting  the 
functions  of  the  liver.  The  latter  may  be  effected  by  the  judicious 
administration  of  natural  mineral  waters,  such  as  Hunyadi  Janos 
and  Friedrichshall,  or  by  the  use  of  some  such  mild  aperients  as  the 
confections  of  senna  and  sulphur,  or  castor  oil;  aloes  should  generally 
be  avoided.  At  the  same  time  the  food  is  regulated,  alcohol  for- 
bidden, and  suitable  exercise  enjoined.  When  dependent  on  the 
pressure  of  a  gravid  uterus,  little  can  be  done  beyond  attending  to  the 
regular  action  of  the  bowels  until  the  child  is  born. 

Local  Treatment  in  the  earlier  stages  consists  merely  in  palliative 
measures.  Thus  the  parts  must  be  protected  from  injury  and  cold; 
only  soft  paper  or  cotton- wool  used  after  defaecation;  and  when 
protruding,  the  piles  should  be  sponged  with  cold  water  and  gently 
returned.  An  ointment  containing  an  extract  of  witch-hazel 
(hamamelis),  or  the  injection  of  a  hazeline  lotion  (i  in  8),  is  also 
advisable,  and  bleeding  from  piles  can  often  be  arrested  by  this 
means.  The  Ung.  gallae  c.  opio  of  the  Pharmacopceia  is  often 
emploved,  but  is  not  so  efficacious. 

When  there  is  much  pain  or  bleeding,  and  the  piles  have  attained 
some  size.  Radical  Treatment  by  operation  is  necessary.  Care  must 
be  taken  before  advising  it  to  ascertain  that  no  other  serious  disease 
of  the  rectum. — -such  as  cancer — is  present,  and  that  the  piles  are  not 
dependent  on  hepatic  or  cardiac  disease,  when  an  operation  might  be 
injudicious  and  harmful.  In  all  cases  the  bowels  are  thoroughly 
emptied  by  a  dose  of  castor  oil  given  the  night  before  and  an  enema 
on  the  morning  of  the  operation,  whilst  the  patient  sits  over  hot 
water  for  half  an  hour  beforehand.  The  lithotomy  position  is 
adopted,  the  perineum  is  shaved  and  cleansed,  and  the  surgeon 
thoroughly  stretches  the  sphincter  by  introducing  the  two  index 
fingers  and  then  separating  them  forcibly,  by  this  means  bringing 
into  view  the  whole  of  the  diseased  area  of  mucous  membrane, 


ii6o  A   MANUAL  OF  SURGERY 

which  never  extends  beyond  2  inches  from  the  anus.     The  following 
plans  of  treatment  are  those  chiefly  used: 

1.  Removal  by  clamp  and  cautery,  as  introduced  by  the  late  Mr. 
Henry  vSmith.  The  mucous  membrane  having  been  everted,  as  just 
described,  each  of  the  hfemorrhoidal  tumours  is  grasped  by  a  pair 
of  ring-ended  catch  forceps,  and  thus  temporarily  secured;  by  this 
means  the  scope  of  the  operation  required  can  be  readily  gauged. 
The  clamp  is  then  applied  to  each  mass  successively  in  a  direction 
corresponding  to  the  long  axis  of  tlie  gut,  great  care  being  taken  not 
to  include  the  external  skin.  The  clamp  is  tightened  by  the  screw 
attached  to  its  handle,  and  the  projecting  mass  of  the  pile  removed 
by  scissors.  The  cut  surface  is  then  thoroughly  seared  by  a  cautery 
at  a  dull  red  heat,  and  the  pressure  of  the  clamp  slowly  relaxed,  so 
as  to  ascertain  that  all  bleeding  has  ceased.  External  piles  may  be 
snipped  away  as  indicated  above  (p.  1157),  the  mucous  membrane 
re-inverted,  the  parts  dusted  with  iodoform,  and  a  carefully  graduated 
compress  of  antiseptic  wool  applied  with  a  T-bandage.  The  parts 
are  bathed  each  day  with  some  mild  antiseptic  lotion,  and  should  be 
healed  in  ten  to  fourteen  days.  The  use  of  the  catheter  may  be 
necessary  for  the  first  forty-eight  hours  after  a  severe  case,  owing  to 
retention  of  urine.  The  bowels  are  not  opened  until  the  fourth  or 
fifth  da}',  and  then  a  good  dose  of  castor  oil — e.g.,  1  ounce  in  adults  - 
should  be  administered.  It  is  better  to  allow  the  patient  to  sit  on  a 
commode  for  the  evacuation  of  the  bowels.  This  operation,  if  effici- 
ently carried  out,  is  absolutely  safe  and  free  from  danger,  and  suited 
to  cases  where  definite  hsemorrhoidal  tumours  are  present ;  any  com- 
plications from  infection,  haemorrhage,  etc.,  are  due  to  the  careless- 
ness of  the  surgeon,  and  not  to  the  character  of  the  operation. 

2.  Ligature  is  an  operation  much  in  vogue  for  the  treatment  of 
piles,  and  if  carried  out  with  due  antiseptic  precautions,  is  followed 
by  a  large  amount  of  success.  The  hsemorrhoidal  tumours  are 
grasped  by  forceps,  the  mucous  membrane  divided  around  them,  and 
the  base  ligatured  with  silk;  the  mass  is  then  snipped  off,  and  the 
hgature  cut  short,  the  knot  being  allowed  to  separate  by  subsequent 
ulceration.  Sometimes  it  is  possible  to  suture  up  this  wound,  and 
then  healing  is  more  expeditiously  effected. 

3.  Excision  of  the  individual  piles  is  a  very  successful  procedure, 
and  consists  in  dividing  the  mucous  membrane  longitudinally 
around  the  pile,  whicli  is  then  removed,  bleeding  vessels  being 
secured,  and  the  wound  sutured.  Perhaps  the  best  way  of  affecting 
this  is  to  grasp  the  pile  longitudinally  with  a  pair  of  Kocher's 
artery  forceps,  and  then,  after  cutting  away  the  redundant  portion, 
to  introduce  a  continuous  catgut  suture,  including  the  forceps  and 
the  mucous  membrane  on  either  side.  The  forceps  is  removed  and 
the  suture  tightened,  thereby  preventing  bleeding ;  the  wound  is  effec- 
tively sealed,  and  the  bowels  may  be  allowed  to  act  at  an  early  date. 

4.  Where  the  hsemorrhoidal  condition  is  general,  and  both  internal 
and  external  piles  are  present,  there  is  no  question  tliat  Whitehead's 
operation  is  much  the  best  that  can  be  employed.     It  consists  in  the 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS 


1161 


total  removal  of  this  pile-bearing  area  in  the  same  way  as  for  excision 
of  the  rectum.  An  incision  is  made  round  the  margin  of  the  anus  at 
the  junction  of  the  skin  and  mucous  membrane,  exposing  thereby 
the  distended  veins,  which  together  with  the  mucous  membrane  are 
separated  from  the  underl\-ing  sphincter  by  successi\'e  snips  of  the 
scissors,  and  cut  away,  all  bleeding-points  being  secured.  The  lower 
end  of  the  divided  mucous  membrane  is  united  bv  suture  to  the  skin, 
the  stitches  passing  deeply  under  the  surface  of  the  wound,  and  not 
merely  through  the  margins.  Excellent  results  follow  such  treat- 
ment in  suitable  cases. 


Rectal  Prolapse. — A  certain  tendency  to  eversion  of  the  mucous 
membrane  of  the  bowel  is  a  constant  and  normal  accompaniment 
of  the  act  of  defaecation;  if,  however,  this  becomes  abnormally 
increased,  the  condition  may  be  maintained  after  the  evacuation  of 
the  bowels  is  concluded,  constituting  a 
condition  of  prolapse.  At  first  onl}' 
the  mucous  membrane  is  protruded, 
and  this  is  known  as  an  incomplete  pro- 
lapse; if,  however,  the  condition  per- 
sists, the  whole  thickness  of  the  bowel, 
mucous  membrane,  submucosa,  and 
even  the  muscular  and  serous  coats, 
may  become  involved,  gi\dng  rise  to 
the  complete  variety  (Fig.  531).  The 
former  condition  (sometimes  badly 
termed  a  prolapsus  ani)  is  more  com- 
monly met  with  in  adults,  and  the 
latter  (the  so-called  prolapsus  recti)  in 
children ;  but  it  must  be  understood 
that  the  latter  is  always  preceded  bv  Fi^.  531. —Longitudinal  Sec- 
,   ^         .  1  •     •  J     1     ,       ,  1  -  TioN   OF   Complete   Prolap- 

an  mcomplete   stage,   Imiited  to  the       sus  Recti.     (Tillmanxns.) 
mucous  membrane,  and  that  in  adults 
complete     prolapse    is     occasionally 
observed. 

Causes. — i.  It  may  be  produced  by 
a  simple  relaxation  of  the  tissues,  as  met  with  in  wealdy  individuals, 
and  those  who  have  been  much  exposed  to  the  debilitating  effects  of 
residence  in  tropical  climates,  especially  when  chronic  constipation 
or  diarrhoea  has  caused  the  evacuation  of  the  bowels  to  be  accom- 
panied b}^  straining  efforts.  In  children  the  malnutrition  following 
measles  and  whooping  cough  may  predispose,  whilst  the  loss  of  fat 
from  the  peri-rectal  cellular  tissue  ma}'  assist.  2.  Conditions  which 
have  led  to  chronic  tenesmus  or  violent  expulsive  efforts — e.g.,  piles, 
chronic  constipation,  diarrhoea,  rectal  irritation,  as  from  worms 
in  children — or  diseases  of  neighbouring  organs,  such  as  vesical 
calculus,  stricture,  or  enlarged  prostate,  may  also  determine  prolapse. 

Symptoms  and  Diagnosis. — The  anal  orifice  is  occupied  by  a  smooth 
rounded  swelling,  red  or  purplish  in  colour,  covered  by  mucous 


X  Indicates  the  serous  sac  in  the 
anterior  wall  due  to  protrusion 
of  the  peritoneum. 


ii62  A   MANUAL  or  SURGERY 

iiiembiaiie;  this  piutiusion  in  the  early  stages  can  be  easily  re[)lacefl 
by  a  little  pressure,  but  returns  if  the  patient  strains  or  coughs. 
When  the  swelling  is  of  large  size,  reduction  is  increasingly  difficult 
and  painful  from  infiltration  and  fibrous  overgrowth  of  the  sub- 
mucosa,  and  it  is  very  liable  to  become  inflamed  and  ulcerated  from 
friction.  Incontinence  of  faeces  is  also  a  common  result.  When 
the  whole  thickness  of  the  gut  is  protruded,  the  serous  lining  may 
accompauv  the  tumour,  but  this  is  usually  limited  to  the  anterior 
surface,  and  into  the  sac  thus  formed  small  intestine  or  omentum 
may  pass,  and  even  become  strangulated  (Fig.  531,  X).  The  pro- 
lapse itself  may  also  be  constricted  if  allowed  to  remain  for  long 
unreduced;  the  mass  is  then  livid,  swollen,  and  intensely  painful, 
and  if  left  to  itself  may  slough  away,  and  thus  lead  to  a  spontaneous 
cure,  although  severe  septic  symptoms  may  supervene,  and  even 
perforative  peritonitis. 

There  should  be  but  little  difficulty  in  recognising  a  prolapse;  the 
only  condition  for  which  it  can  be  mistaken  is  an  intussusception 
protruding  from  the  anus;  in  this,  however,  the  finger  or  a  probe 
can  be  inserted  into  the  rectum  by  the  side  of  the  protruding  gut, 
which  is  impossible  with  a  prolapse. 

Treatment. — Tn  the  earlier  stages,  all  that  is  needed  is  the  removal, 
if  possible,  of  the  cause  of  the  tenesmus — e.g.,  dilatation  of  a  urethral 
stricture,  removal  of  a  vesical  calculus — or  the  regulation  of  the 
bowels  so  as  to  check  either  chronic  diarrhoea  or  constipation.  When 
piles  are  present,  they  should  be  treated  as  described  above,  and  the 
prolapse  will,  as  a  rule,  subsequently  disappear.  Thread-worms 
must  be  dealt  with  by  suitable  means  {q.v.).  Beyond  this,  cold  or 
astringent  injections  may  be  employed,  e.g.,  sulphate  of  iron  (i  to 
3  grains  to  i  ounce),  and  it  is  advisable  for  the  individual  to  acquire 
the  habit  of  having  the  daily  motion  at  bedtime,  whilst  children  are 
made  to  defsecate  lying  on  the  side,  one  buttock  being  pulled  up  for 
the  purpose.  The  prolapse  is  carefully  washed,  reduced  by  pres- 
sure with  the  fingers,  and  retained  by  strapping  the  nates  together, 
particularly  in  children,  or  by  apptying  some  suitable  pad  and 
a  T- bandage.  Electric  treatment  to  tone  up  the  sphincter  and 
levatores  ani  may  be  of  assistance,  and  in  children  palliative  treat- 
ment of  this  type  is  usually  successful. 

In  adults,  however.  Operative  Treatment  has  frequently  to  be 
undertaken. 

In  the  slighter  cases  of  incomplete  prolapse,  it  will  suffice  to 
diminish  the  size  of  the  anal  orifice  by  snipping  away  radiating  folds 
of  skin  and  mucous  membrane,  including  any  piles  that  may  be 
present.  In  worse  cases  it  may  be  advisable  to  remove  a  wedge  of 
the  posterior  wall  of  the  prolapse,  including  a  portion  of  the  sphincter, 
the  edges  being  brought  together  by  deep  stitches.  Where  this  has 
failed,  or  is  thought  insufficient,  the  prolapse  may  be  completely 
removed  by  the  following  procedure:  The  patient's  buttocks  are  well 
raised,  so  as  to  prevent  any  protrusion  of  intestine  if  the  peritoneal 
cavity  is  opened.     An  incision  is  made  at  the  junction  of  the  skin 


AFFECTIOXS  OF  THE  RECTUM  AND  ANUS  1163 

and  inuooLis  moinbraiie  at  the  anal  niargiu,  and  is  gfadually  deepened. 
The  base  of  the  prolapse  is  divided  anteriorly  on  a  level  with  the 
anus,  the  opening  in  the  peritoneum  temporarily  packed  with  steri- 
lized gauze,  and  the  remainder  of  the  mass  removed  by  scissors, 
bleeding-points  being  secured  as  di\'ided.  The  serous  cavity  is  then 
carefully  closed  by  sutures,  and  the  divided  end  of  the  bowel  united 
to  the  skin  at  the  anus.  No  motion  is  allowed  to  pass  for  a  week, 
but  tlie  anal  orifice  and  lower  gut  should  be  thoroughh'  washed  out 
twice  or  thrice  daily  to  prevent  accumulation  of  septic  material. 
Control  over  the  bowel  is  usually  regained,  though  often  somewhat 
slo^^•ly,  and  the  after-treatment  is  likely  to  be  prolonged. 

The  ultimate  results  are  often  ^'ery  disappointing,  as  the  prolapse 
often  recurs  after  operation,  and  it  is  probable  that  operations  of  this 
type  should  be  entirely  discarded.  The  most  reasonable  proceedings 
are  those  directed  towards  fixation  of  the  rectum  {rectopexy)  either 
backwards  to  the  posterior  pelvic  w^all,  or  fiom  above.  Various 
operations  of  this  type  have  been  described  and  practised,  with  some 
measure  of  success.  Thus  the  posterior  wall  of  the  rectum  may  be 
exposed  by  an  incision,  extending  from  the  tip  of  the  coccyx  to  the 
anal  margin;  if  need  be,  the  posterior  wall  can  be  infolded  in  the 
long  axis,  and  the  lumen  of  the  bowel  diminished  thereby.  Stitches 
are  then  introduced  transversely  through  the  rectal  wall  (avoiding 
the  mucous  membrane),  and  the  ends  are  passed  through  the  sacro- 
sciatic  ligaments  on  either  side  and  tied  firmly  over  a  pad  of  gauze, 
being  retained  in  situ  for  three  weeks.  The  rectum  is  thereby  fixed 
posteriorly,  and,  with  careful  after-treatment  as  to  the  action  of 
the  bowels,  good  results  may  follow.  As  a  modification  of  this 
procedure,  the  post-rectal  space  may  be  opened  up  and  packed 
with  gauze,  thereby  determining  cicatricial  fixation  of  the 
bowel. 

Abdominal  operations  in  the  form  of  colopcxy  have  also  been  under- 
taken, the  pehdc  colon  being  fixed  to  the  lateral  wall  of  the  pelvis  by 
stitches,  after  stripping  awa}-  a  portion  of  the  parietal  peritoneum. 
The  former  method  of  fixation  is  the  more  desirable. 

Tuberculous  Disease  of  the  Rectum  occurs  in  the  form  of  ulcers, 
which  are  usually  multiple,  and  may  be  very  extensive.  Infection 
may  be  due  to  the  swallowing  of  infected  sputum,  but  is  probably 
the  result  of  dissemination  by  the  blood;  the  affection  is  often 
secondarv  to  pulmonarv  disease.  It  starts  in  the  submucosa,  and 
the  ulcers  w-hich  follow  ha^•e  the  usual  features,  with  undermined 
edges  and  prominent  granulations.  There  is  usually  a  marked 
tendency  to  the  production  of  fistulse  by  extension  of  the  process 
outwards.  The  symptoms  are  those  of  rectal  irritability,  pain  on 
defecation,  and  discharge  of  muco-pus  and  perhaps  blood.  Treat- 
ment is  generally  palliative,  the  rectum  being  emptied  by  enemata  or 
medicine  according  to  the  patient's  comfort,  and  possibly  healing 
ointments  introduced.  In  the  worst  cases,  colostomy  ma}^  be 
required  in  order  to  put  the  bowel  at  rest.  Sanatorium  and  vaccine 
treatment  will  probably  be  required  in  addition. 


II 64  A    MANUAL  OF  SURGHRY 

Syphilitic  Disease  of  the  Rectum  and  Anus. — The  rectum  and  anus 
are  attacked  by  syphilitic  disease  in  a  variety  of  ways,  the  most 
prominent  being  as  follows: 

{o)  The  initial  lesion  or  primary  chancre  is  occasionally  met  with 
in  the  neighbourhood  of  the  anus. 

(b)  In  the  secondary  stage  mucous  tubercles  or  condylomata  are 
frequently  seen,  being  placed  either  at  the  anal  margin  or  sym- 
metrically on  either  side,  cf  the  gluteal  fold,  the  sores  on  one  side 
having  evident^  infected  the  other.  They  are  of  the  usual  type 
(p.  159),  and  are  treated  by  dusting  with  powdered  calomel,  and 
keeping  a  piece  of  dressing  between  the  lips  of  the  fold. 

(c)  In  the  tertiary  period  diffuse  syphilitic  disease  of  the  rectum  is 
not  uncommon,  occurring  most  often,  but  not  solely,  in  \^oung 
married  women  of  the  poorer  classes.  It  is  a  somewhat  early  tertiary 
manifestation,  and  usuall}'  commences  within  easy  reach  of  the 
finger,  about  3  inches  from  the  anus.  It  starts  as  a  diffuse  gum- 
matous infiltration  of  the  rectal  mucous  membrane  and  submucous 
tissue,  which  become  thickened  and  indurated,  ulceration  soon 
following.  These  phenomena  are  not  limited  to  the  rectum,  but 
frequenth'  spread  up  the  intestine  towards  the  sigmoid  flexure  and 
down  to  the  anus,  and  likewise  involve  the  recto-vaginal  septum  and 
vagina,  passing  down  the  latter  canal  to  invade  the  perineum  and 
neighbouring  structures,  so  that  in  a  neglected  case  the  whole 
external  genitals  and  anus  may  be  involved  in  an  irregular  hyper- 
trophic mass,  somewhat  resembling  elephantiasis.  In  addition,  the 
ulcerative  process  may  extend  more  deeply,  leading  to  the  forma- 
tion of  fistulse,  not  only  between  the  rectum  and  neighbouring 
viscera  [e.g.,  vagina  or  bladder),  but  also  communicating  with  the 
exterior.  From  the  cicatrization  occurring  in  the  submucous 
tissue,  contraction  of  the  gut  results,  causing  syphilitic  stricture, 
which  may  extend  for  some  distance  up  the  bowel.  The  symptoms 
consist  in  pain,  increased  on  defsecation,  irritability  of  the  bowel, 
and  discharge  of  blood  and  pus  by  the  anus,  whilst  obstructive 
phenomena,  or  alternating  attacks  of  constipation  and  diarrhoea, 
may  also  be  present.  On  examination,  the  diffuse  ulceration  and 
infiltration  of  the  part  are  suggestive  of  malignant  disease,  but  the 
patient's  age  and  history,  and  the  painlessness  and  course  of  the 
case,  are  usually  sufficient  to  determine  the  diagnosis.  The  general 
health  remains  good  in  the  earlier  stages  of  the  affection,  but  later 
on  may  be  undermined  by  the  pain  and  constant  purulent  discharge. 

Treatment  consists  in  administering  salvarsan,  or  mercurj^  and 
iodide  of  potassium,  the  former  perhaps  in  the  shape  of  suppositories, 
whilst  locally  contraction  is  prevented  as  far  as  possible  by  the  regular 
use  of  bougies.  Possibly  thiosinamin  or  iodolysin  will  be  found 
useful  in  the  later  stages  to  assist  in  the  complete  removal  of  the 
newly-formed  cicatricial  tissue.  In  advanced  cases  colostomy  is 
essentia]  in  order  to  secure  rest  to  the  parts,  and  give  theni  a  chance 
of  healing.  Possibly  in  a  few  instances  only  a  temporary  opening 
of  the  bowel  may  be  required,  but  where  much  contraction  exists 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1165 

and  a  considerable  tendency  to  obstruction,  the  artificial  opening 
must  remain  permanently.  Sometimes  the  ulceration  persists  in 
spite  of  colostomy,  and  care  must  then  be  taken  to  prevent  the 
retention  of  discharges  by  the  occasional  passage  of  bougies. 

Fibrous  Stricture  of  the  Rectum  is  usually  met  with  in  women  over 
forty  years  of  age,  and  is  most  often  situated  2  or  3  inches  from  the 
anus,  or  as  high  as  its  junction  with  the  sigmoid  flexure.  In  this 
position,  it  is  generally  due  to  the  cicatrization  and  contraction  of 
ulcers  following  prolonged  diarrhoea  and  dysentery,  although  occa- 
sionally it  follows  tuberculous  or  syphilitic  disease.  Any  form  of 
chronic  proctitis — e.g.,  gonorrhoea — may  also  lead  to  it.  It  occurs 
sometimes  as  a  sequela  of  pelvic  celluHtis  and  suppuration,  from  the 
contraction  of  fibrous  bands  which  may  bind  the  rectum  backwards 
to  the  sacral  wall,  or  may  merely  constrict  it ;  the  stricture  is  in  these 
cases  usually  at  a  lower  jpoint  than  in  the  former.  Repeated  attacks 
of  inflamed  piles  may  also  lead  to  steno5i:>  at  or  just  above  the  anus. 
A  stricture  sometimes  results  from  traumatism,  or  follows  operations 
invohdng  the  whole  or  at  any  rate  the  greater  portion  of  the  circum- 
ference of  the  bowel.  As  already  mentioned,  it  may  be  associated 
with  a  fistula,  especially  if  the  latter  has  existed  for  long,  and  is  then 
due  to  a  chronic  inflammatory  fibrosis  lighted  up  by  the  persistent 
irritation  of  the  stricture;  the  inner  opening  is  then  found  in  the 
substance  of  the  stricture. 

The  earliest  Symptoms  of  stricture  are  often  alternating  attacks  of 
diarrhoea  and  constipation,  in  which,  of  course,  the  constipation  is 
primary,  and  the  diarrhoea  due  to  a  catarrhal  enteritis  arising  from 
the  irritation  of  the  retained  faces.  Gradually  the  difficulty  in  pass- 
ing motions  becomes  more  and  more  marked  until  no  relief  is  obtained 
apart  from  medicine;  the  fseces  themselves  become  narrow^ed,  flat- 
tened, and  elongated,  something  like  pipe-stems,  or  small  masses 
like  shrimps  may  alone  succeed  in  passing.  This  is  associated  with 
pain  and  uneasiness  referred  to  the  lower  bowel ;  a  certain  amount 
of  blood  and  mucus  may  be  mixed  with  the  excreta,  and  sooner  or 
later  marked  d3^spepsia  and  abdominal  distension  supervene.  If  the 
case  is  allowed  to  run  on  without  treatment,  absolute  obstruction  of 
a  chronic  type  may  result  and  lead  to  a  fatal  issue;  or  the  mucous 
membrane  of  the  bowel  above  the  stricture  becomes  ulcerated,  an 
abscess  forms,  and  subsequently  a  fistula,  through  which  a  certain 
small  amount  of  faecal  material  passes.  If  several  of  these  fiatulse 
are  estabhshed,  the  patient  may  finally  succumb  to  chronic  septic 
poisoning  and  exhaustion. 

An  examination  of  the  bowel  with  the  finger  may  reveal  a  smooth, 
regular  constriction  of  the  gut  as  if  a  band  had  been  tied  round  it, 
the  fibrous  mass  and  the  aperture  in  it  feeling  something  Hke  an  os 
uteri.  In  other  cases,  the  bowel  is  stenosed  for  some  distance,  and 
its  surface  more  or  less  idcerated;  whilst  if  due  to  pelvic  celluhtis,  it 
mav  be  drawn  up  and  fixed  to  the  posterior  pelvic  wall.  When  the 
stricture  is  too  high  for  the  finger  to  reach,  the  gut  may  appear 
normal,    though   somewhat   dilated    (ballooning).     Sometimes   the 


1166  A   MANUAL  OF  SURGERY 

stricture  is  smooth,  £ind  free  from  nodular  irregularities  and  excres- 
cences; often,  however,  it  is  ulcerated  and  irregular,  the  examina- 
tion causing  great  pain.  The  gut  above  the  contraction  is  hyper- 
trophied  and  distended,  whilst  if  filled  with  retained  faeces,  the 
mucous  membrane  may  show  signs  of  inflannnation,  or  even  stercoral 
ulcers.  The  gut  below  the  stricture  is  usually  dilated  (ballooned), 
partly  from  paralysis  of  its  walls,  and  partly  by  invagination  of  the 
mass  fiom  above. 

The  Treatment  in  the  early  stages  consists  in  keeping  the  bowels 
regular  and  the  motions  soft  by  means  of  paraffin  and  laxatives, 
such  as  castor  oil  oi  salines,  whilst  the  passage  of  the  excreta  is 
assisted  by  enemata.  The  diet  is  regulated,  so  that  there  is  no  un- 
necessary dcbiis.  Locally,  the  stricture,  if  within  reach,  should  be 
dilated  by  means  of  bougies  passed  in  increasing  size.-?  eveiy  two 
or  three  days,  care  being  taken  that  the  point  of  the  instrument 
engages  the  stricture,  and  is  not  caught  against  folds  of  mucous 
membrane  or  turned  backward-.  The  utmost  gentleness  must  be 
used,  in  order  to  stretch  the  mucous  membrane,  and  not  tear  it. 
Laminaria  or  compressed  sponge-tents  are  of  use  in  some  cases,  fol- 
lowed subsequently  by  bougies.  When  situated  low  down,  the 
stricture  may  be  notched  posteriorly,  or  sHghtly  nicked  in  several 
places  with  a  blunt-ended  bistoury,  and  bougie.,  then  passed.  As 
there  is  always  a  great  tendency  in  these  strictures  to  contract 
again,  treatment  is  usually  prolonged.  If  the  stricture  is  out  of 
reach,  or  signs  of  obstruction  manifest  themselves  in  spite  of  treat- 
ment, colostomy  is  the  final  resource. 

Tumours  of  the  Rectum.^ — Polypus  Recti  occurs  most  frequently  in 
children,  and  consists  usually  of  an  adenoma  of  Lieberkiihn's  folli- 
cles, but  occasionally  of  simple  fibrous  tissue  covered  with  mucous 
membrane.  They  are  commonly  found  within  easy  reach  of  the 
anus,  and  present  an  appearance  something  like  a  small  cherry  with  a 
long  pedicle,  pendulous  and  freely  mobile.  The  Symptoms  caused 
are  irritabihty  of  the  bowel  and  the  passage  of  blood  by  the  anus, 
which  latter  when  occurring  in  a  child  without  symptoms  of  obstruc- 
tion is  almost  pathognomonic  of  polypus.  The  tenesmus  excited 
may  lead,  as  mentioned  elsewhere,  to  prolapse  or  to  the  occurrence 
of  an  intussusception.  It  is  occasionally  associated  with  a  fissure 
of  the  anus,  which  probably  arises  as  a  secondary  result  of  the 
irritation  cau?ed  by  the  partial  extrusion  of  the  polypus  during 
defcecation.  A  natural  cure  can  be  effected  by  rupture  of  the  atten- 
uated pedicle,  which  is  at  fiist  attended  by  a  certain  amount  of 
hemorrhage.  Treatment.^ — The  polypus  is  cut  away  after  tying  or 
twisting  its  pedicle,  or  the  clamp  and  cautery  may  be  employed. 

Papilloma  of  the  rectum  is  a  rare  disease,  and  gives  rise  to  haemor- 
rhage from  and  irritability  of  the  bowel,  or,  if  large,  even  to  obstruc- 
tion. This  condition  is  not  always  limited  to  the  rectum,  but  may 
extend  through  the  greater  portion  of  the  intestine,  and  then  proves 
fatal  from  haemorrhage.  Treatment  consists  in  removal  by  ligature 
or  wire  snare,  where  practicable. 

Sarcoma  is  another  uncommon  disease  in  the  rectum.     It  occurs 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1167 

in  the  shape  of  a  large  fleshy  tumour  growing  from  the  submucous 
tissue,  and  piojecting  into  the  lumen  of  the  gut  so  as  to  cause 
obstruction.  It  is  less  painful  than  cancer,  and  usually  occurs  at  an 
earlier  age.  The  symptoms  are  much  as  in  the  latter  disease,  and 
the  treatment,  when  feasible,  is  the  same,  viz.,  extirpation  of  the 
growth,  but  it  will  very  probably  recur. 

Epithelioma  of  the  Anus — i.e.,  of  the  skin  covering  the  anal  margin 
— occurs  as  a  primary  development  similar  to  that  on  the  lip,  and  is 
then  of  the  squamous  type.  It  presents  the  usual  features — viz.,  an 
indurated  nodular  mass,  which  readily  ulcerates,  and  runs  the 
typical  course  of  such  a  disease,  infecting  the  inguinal  glands.  It 
is  readily  dealt  with  in  the  earlier  stages  by  an  operation  somewhat 
similar  to  that  for  excision  of  the  rectum. 

Cancer  of  the  Rectum  appears  in  the  form  of  columnar  carcinoma, 
consisting,  as  described  elsewhere  (p.  224),  of  an  overgrowth  of 
Lieberkuhn's  follicles,  not  only  into  the  lumen  of  the  gut  (centri- 
fugal or  papillomatous  type  of  growth),  but  also  invading  the  deeper 
portions  of  the  bowel  wall,  infiltrating  the  submucous  and  muscular 
layers  (centripetal  growth).  A  vascular  fibro -cellular  stroma  is 
found  between  the  glandular  acini,  and  the  physical  characters  of  the 
tumour  are  largely  dependent  on  the  relative  amount  of  these  two 
elements.  Thus,  (a)  if  the  stroma  is  abundant  and  fibro-cicatricial, 
the  growth  is  comparatively  slow;  the  tumour  is  hard  and  nodular; 
it  usually  starts  on  one  side  of  the  bowel  as  a  mahgnant  wart -like 
mass,  but  gradually  encircles  the  gut,  and  is  always  Hkely  to  produce 
obstructive  phenomena  from  its  contraction;  ulceration  occurs  after 
a  while,  {b)  In  the  softer,  more  rapidly  growing  type,  the  stroma  is 
less  abundant,  and  merely  fibro-cellular  in  character.  The  tumour 
projects  into  the  bowel,  and  early  involves  the  whole  circumference; 
ulceration  and  bleeding  are  constant  features,  and  the  pain  is  usually 
considerable.  There  is  always  greater  destruction  of  tissue,  so  that 
obstruction  to  the  onward  passage  of  faeces  is  much  less  likely  to 
occur  in  it  than  in  the  former  type,  where  cicatricial  contraction  is  a 
marked  feature.  The  ulcer  which  develops  in  the  bowel  is  of  the 
usual  malignant  type,  with  an  excavated  surface  and  raised,  in- 
durated, and  everted  edges  (Fig.  532,  and  Plate  XII.) ;  it  bleeds 
readily,  and  its  investigation  is  very  painful.  Colloid  degeneration 
is  occasionally  seen  in  cancer  of  the  rectum. 

As  the  disease  progresses,  it  invades  surrounding  parts,  and  thus 
the  tumour  may  become  adherent  either  to  the  pelvic  walls  or  to  the 
bladder,  vagina,  or  prostate;  sometimes  the  ihac  vessels  or  sciatic 
nerves  are  compressed,  causing  oedema  or  neuralgia  respectively. 
Of  course  it  must  be  understood  that  this  invasion  is  in  part  inflam- 
matory, and  due  to  absorption  of  bacteria,  etc.,  from  the  ulcerated 
surface,  and  this  is  always  a  grave  addition  to  the  case.  Peri-rectal 
abscesses  and  fistulse  sometimes  form,  opening  externally  in  the 
ischio-rectal  fossae,  or  perhaps  internally  into  the  bladder  or  vagina, 
and  then  the  tumour  begins  to  develop"^  along  the  line  of  the  fistula, 
and  may  actuallv  form  a  mass  of  some  size  in  the  bladder. 

The  glands  in  the  meso -rectum  and  the  lumbar  glands  become 


ii68 


A   MANUAL  OF  SURGERY 


enlarged,  but  for  a  time  this  may  be  merely  inflammatory  in  type, 
though  later  on  they  become  cancerous.  Anal  cancer,  of  course, 
leads  to  involvement  of  the  inguinal  glands.  Secondary  deposits 
may  also  be  found  in  the  liver,  but  this  is  more  common  when  the 
cancer  is  higher  up  the  bowel;  the  disease  may  even  be  disseminated 
throughout  the  body,  though  this  is  decidedly  rare. 

The  Symptoms  of  the  disease  are  often  so  slight,  and  the  onset  so 
insidious  as  to  raise  no  suspicions  of  the  existence  of  any  growth 
until  it  has  attained  considerable  size.  The  patient  is  usually  an 
adult,  and  more  often  male  than  female.     At  first  there  may  be 


-*,=»5^*^« 


FiG.  532. — Carcinoma  of  the  Rectum.  (King's  College  Hospital  Museum.) 
I,  Anus,  split  open  posteriorly;  2,  2,  margins  of  the  ulcerated  growth. 

merely  some  slight  constipation,  requiring  an  increased  amount  of 
opening  medicine.  Then  may  come  more  definite  attacks  of  con- 
stipation, alternating  with  diarrhoea,  and  the  discharge  of  large 
quantities  of  mucub,  often  blood-stained.  A  sense  of  weight  or 
dragging  pain  is  noticed  in  the  rectum,  and  the  patient  after  defaeca- 
tion  feels  as  if  there  is  still  something  to  be  passed.  This  sensation 
increases  until  true  tenesmus  and  straining  at  stool  are  present, 
together  with  constant  pain,  which  may  radiate  up  the  back  and 
down  the  legs,  causing  sitting  on  any  hard  substance  to  be  painful. 
At  first  a  blood-stained  discharge  may  be  seen  on  the  faeces,  which 
become  flattened  and  pipe-like,  if  stenosis  is  present,  but  later  it 


PLATE   XII. 


Malignant    disease    of     Rectum, 

The  growth  was  an  ulcerated  columnar  carcinoma  on  the  posterior  wall, 
situated  about  3  inches  from  the  anus,  and  had  extended  nearly  round  the 
whole  circumference  ;  it  caused  much  irritability  and  diarrhoea,  and  was 
removed  by  Kraske's  method,  without  interfering  with  the  anal  canal. 


[  To  face  page  1 1 68. 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1169 

passes  indep.'ndently  of  the  motions.  On  examination,  an  ulcer- 
ating, crateriform  mass  is  met  with,  wliich  may  be  limited  to  one 
segment  of  the  gut  wall,  and  is  then  usually  firm,  and  perhaps 
associated  with  stenosis ;  or  it  may  surround  the  bowel,  and  feel  soft 
and  spongy,  readily  breaking  down  under  the  finger,  and  bleeding 
freely.  The  bowel  below  the  growth  is  usually  '  ballooned.'  This 
examination  is  generally  painful,  as  also  the  process  of  defaecation, 
and  sometimes  the  patient  abstains  from  the  latter  for  lengthened 
periods  on  account  of  the  exquisite  agony  caused  thereby.  When 
the  anterior  wall  is  involved,  the  bladder  is  often  fixed  to  the  mass, 
and  micturition  becomes  painful ;  moreover,  every  time  the  bladder 
is  emptied  a  discharge  may  occur  from  the  bowel,  and  this  may 
continue  even  after  colostomy-  has  been  performed.  Marked 
cachexia  supervenes,  the  digestion  becomes  impaired,  any  meal 
causing  pain  and  flatulent  distension;  natural  sleep  is  impossible, 
and  if  a  recto-vesical  fistula  forms,  the  patient's  troubles  are  further 
aggravated  by  the  passage  of  fsaces  and  flatus  by  the  urethra. 

The  case  runs  a  more  or  less  rapid  course  to  the  fatal  issue,  which 
on  an  average  ensues  about  seventeen  months  after  the  onset  of 
symptoms,  if  no  operation  has  been  undertaken  (Jessop*),  and  may 
be  due  to  a  variety  of  causes.  Faecal  obstruction  occurs  in  about 
30  per  cent,  of  the  cases,  being  more  marked  in  the  chronic  forms, 
and  in  those  where  the  disease  starts  high  up  the  bowel,  on  account 
of  the  peristalsis  causing  invagination  of  the  mass  and  occlusion  of 
the  tube;  whilst  if  ulceration  is  excessive,  or  the  disease  situated 
low  down,  obstruction  is  less  common,  invagination  being  here 
impossible,  and  peristalsis  being  expended  on  the  onward  passage  of 
the  faeces.  Exhaustion  from  haemorrhage,  pain,  sleeplessness,  or 
toxic  absorption,  accounts  for  most  of  the  fatal  results,  whilst  septic 
peritonitis  following  the  perforation  of  stercoral  ulcers  above  the 
growth  occurs  in  a  few  instances. 

The  Treatment  of  cancer  of  the  rectum  consists  in  the  radical  measure 
of  excision  of  the  mass,  or  in  the  palliative  operation  of  colostomy. 
Excision  of  the  Rectum,  or  proctectomy,  is  only  applicable  to  cases 
in  which  there  is  a  reasonable  prospect  of  the  whole  disease  being 
removed.  This  depends  not  so  much  on  the  upward  extent  of  the 
growth  as  on  the  question  of  fixation  to  surrounding  parts.  When 
the  mass  is  not  fixed  anteriorly  so  as  to  endanger  other  viscera^^.g., 
the  prostate  or  bladder),  the  case  is  a  favourable  one  for  excision. 
Fixation  of  the  mass  laterally  or  behind  is  not  so  important,  although 
it  will  prevent  removal,  if  extensive.  Enlargement  of  glands  in 
the  meso-rectum  does  not  necessarily  contra-indicate  operation,  as 
they  may  be  included  in  the  scope  of  the  high  operation.  When  the 
lumbar  glands  are  involved,  or  the  liver,  excision  is  obviously  useless 
and  should  not  be  undertaken.  Formerly  it  was  considered  of  vital 
importance  to  avoid  opening  the  peritoneum ;  but  at  the  present  day 
this  is  frequently  done,  and  with  no  untoward  result,  if  due  pre- 
cautions are  taken;  so  that,  although  the  growth  may  be  situated 
high  up,   if  it  is  freely  moveable,   and  there  is  no  evidence  of 

*  British  Medical  Joumcil,  1889,  ii.,  p.  407. 

74 


II70  A   MANUAL  OF  SURGERY 

secondary  deposits,  an  attempt  should  be  made  to  take  it  away.  It 
must  be  remembered  that  in  the  male  the  peritoneum  is  reached  on 
the  anterior  aspect  of  the  gut  about  2  J  inches  from  the  anus  with  an 
undistended  bladder,  whilst  it  may  be  pushed  up  another  inch  when 
that  viscus  is  full ;  in  the  female  the  peritoneum  is  situated  about 
4  inches  from  the  anus,  being  reflected  to  the  posterior  aspect  of  the 
cervix  uteri.  Posteriorly,  the  lower  4  or  5  inches  of  the  bowel  are 
uncovered  by  serous  membrane  in  both  sexes. 

Excision  of  the  rectum  must  include  in  its  scope  not  only  the 
removal  of  the  growth,  but  also  of  a  considerable  margin  of  ap- 
parently healthy  intestinal  wall,  both  above  and  below,  together  with 
the  lymphatic  vessels  and  glands  draining  this  area  and  lying  in  the 
hollow  of  the  sacrum.  This  removal  can  be  effected  in  several 
ways,  and  the  choice  of  operation  depends  chiefly  on  the  character, 
position,  and  extent  of  the  growth,  but  also  to  some  degree  upon 
the  condition  of  the  patient.  The  actual  operations  are  known  as 
(i)  the  perineal  or  Langenbeck's  operation;  (2)  the  trans-sacral  or 
Kraske's  method;  (3)  the  abdominal;  and  (4)  the  combined 
abdomino-perineal  procedure,  where  the  growth  is  attacked  both 
from  above  and  below. 

I.  Perineal  Proctectomy,  or  Langenbeck's  Operation,  is  a  satisfac- 
tory procedure  in  cases  of  early  cancer  of  the  lower  part  of  the  rectum 
when  the  glands  in  the  hollow  of  the  sacrum  are  not  obviously 
involved.  In  most  cases  preliminar\'  colostomy  is  a  desirable  pro- 
cedure, especially  if  the  whole  circumference  of  the  bowel  for  a 
distance  of  3  inches  or  more  has  to  be  removed,  and  the  more  so  if 
the  anus  has  to  be  sacrificed.  The  passage  of  fseces  over  and  through 
the  raw  surface  of  the  wound  is  not  only  a  source  of  septic  con- 
tamination, but  also  causes  extreme  pain,  whilst  the  ultimate  issue 
of  the  operation  is  an  opening  which  is  almost  certain  to  become 
unduly  patulous  or  too  much  contracted,  and  there  is  always 
a  total  loss  of  control.  An  effective  anus  in  the  left  iliac  region 
obviates  all  these  difficulties,  whilst  the  preliminarv  opening  of  the 
abdomen  gives  the  surgeon  an  opportunity  of  investigating  the  con- 
dition of  the  lumbar  and  sacral  glands,  and  of  ascertaining  the  extent 
of  the  growth  up  the  bowel,  and  whether  or  not  secondary  deposits 
are  present  in  the  liver. 

The  Operation  itself  is  conducted  as  follows  :  The  rectiun 
having  been  thoroughly  washed  out  and  emptied,  and  the  patient 
placed  in  the  lithotomy  position,  the  perineum  is  shaved  and 
purified,  and  the  posterior  wall  of  the  rectum  and  anus  slit 
open  in  the  middle  line  as  far  as  the  tip  of  the  coccyx.  An 
incision  is  now  made  all  round  the  anus  at  the  junction  of  the 
skin  and  mucous  membrane,  if  the  anus  is  healthy;  when  diseased, 
the  incision  is  extended  beyond  the  margin  so  as  to  include  the 
growth.  The  rectum,  together  with  the  tumour,  is  then  separated 
from  surrounding  structures  by  scissors  and  fingers,  commencing 
posteriorly,  where  this  is  readily  effected,  di\nding  the  levator  ani 
on  each  side,  and  working  gradually  upwards  and  to  the  front,  where 
great  care   must   be  taken   to   protect   the  vagina,  prostate,  or 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1171 

membrani)us  urethra.  In  the  male,  a  bougie  or  catheter  may  be 
passed  into  the  urethra  with  advantage.  Bleeding-points  can  be 
secured  during  this  process  by  pressure-forceps.  The  upper  attach- 
ments of  the  gut  are  divided  either  by  scissors,  ecraseur,  or  clamp 
and  cautery.  Haemorrhage,  which  is  generally  very  free,  is  arrested 
by  ligature  or  cautery,  and  the  gaping  wound  powdered  with  iodo- 
form, and  packed  for  twenty-four  hours  with  gauze,  the  posterior 
incision  not  being  closed  by  suture,  and  no  attempt  made  to  drag 
down  the  mucous  membrane.  Subsequently  the  wound  may  be  left 
without  any  internal  dressing,  an  external  pad  of  salicylic  wool 
sufficing ;  it  is  thoroughly  washed  out  two  or  three  times  a  day  with 
some  dilute  antiseptic,  such  as  sanitas  (i  in  10),  Condy's  solution,  or 
carbolic  acid  lotion  (i  in  60),  which  may  be  used  alternately ;  granula- 
tions gradually  cover  the  surface,  and,  as  cicatrization  progresses,  the 
mucous  membrane  is  b}^  degrees  approximated  to  the  skin  margin, . 
and  the  patulous  cavity  diminished  in  size  until  healing  is  complete. 

2.  The  Trans-sacral  or  Kraske's  Operation  consists  in  the  removal 
of  the  growth  after  a  portion  of  the  coccyx  or  sacrum  has  been  cut 
away.  It  may  be  undertaken  in  cases  where  the  growth  extends 
upwards  from  the  lower  into  the  upper  parts  of  the  rectum,  but  is 
more  especially  suitable  to  cases  in  which  the  anal  canal  is  not 
involved,  and  the  lower  edge  of  the  growth  is  situated  3  or  4  inches 
up  the  bowel. 

The  question  of  a  preliminary  colostomy  has  again  to  be  con- 
sidered. In  this  operation  it  is  desirable  that  the  surgeon  should  aim 
at  a  restoration  of  the  canal,  so  that  the  patient  shall  afterwards  pass 
faeces  normally.  Whilst  admitting  that  this  is  not  the  usual  ter- 
mination of  the  case,  yet  it  is  sometimes  obtained,  and  therefore  a 
colostomv  is  prima  facie  undesirable.  It  can  always  be  established 
at  a  later  date  if  a  sacral  anus  or  fsecal  fistula  in  the  sacral  region 
persists  and  is  troublesome.  If,  however,  the  patient  is  previously 
suftering  from  obstructive  phenomena,  and  probably  has  a  collection 
of  hard  faecal  matter  above  the  growth,  a  colostomj^  is  essential  in 
order  to  clear  the  bowel ;  it  is  advisable,  however,  to  make  it  in  such 
a  way  that  it  may  be  subsequently  closed. 

Operation.- — The  patient  reclining  on  his  right  side,  an  incision  is 
made  in  the  median  line  from  just  behind  the  anus  to  the  middle  of 
the  sacrum,  but  without  opening  the  bowel.  The  coccyx  is  excised, 
and  the  great  sacro -sciatic  ligament  and  gluteus  maximus  are  de- 
tached from  the  left  side  of  the  sacrum.  Part  of  the  left  wing  of  the 
latter  bone  is  now  removed  by  chisel  and  hammer,  the  incision  being 
curved,  and  extending  from  the  median  line  below,  through  or  above 
the  fourth  posterior  sacral  foramen  to  the  under  border  of  the  third, 
and  then  to  the  left  border  of  the  bone  at  that  level  (Fig.  533,  a  b). 
The  loose  cellular  tissue  behind  the  rectum  is  thus  exposed,  and  the 
gut,  together  with  the  tumour  and  the  enlarged  glands  in  the  hollow 
of  the  sacrum,  is  freed  from  its  connections,  and  amputated  from  the 
sound  gut  abo^•e,  the  peritoneum  being  usualty  encroached  on  in  this 
stage  of  the  proceedings.  A  strip  of  sterile  gauze  is  packed  in  to 
protect  the  ca\-ity  from  infection,  and  the  opening  is  subsequently 


1 1 72  A   MANUAL  OF  SURGERY 

sutured.  If  the  growth  extends  to  the  anus,  the  whole  length  of 
the  rectum  below  is  excised,  and  then  the  upper  segment  is  drawn 
down  after  being  mobinzed  by  division  of  the  peritoneum  on  either 
side  of  the  meso-rectum,  and  sutured  to  the  skin.  If  the  sphincter 
and  lower  inch  or  two  are  free  from  disease,  they  are  left  in  situ,  and 
carefully  sutured  to  the  lower  end  of  the  upper  segment,  although  it 
is  very  probable  that  complete  union  \\  ill  not  occur.  The  wound  is 
carefully  washed  out,  and  stuffed  with  gauze  sprinkled  with  iodo- 
form ;  even  if  the  peritoneal  sac  has  been  opened,  no  harm  will  usually 
come  of  it.  The  results  which  have  followed  this  severe  operation 
are,  on  the  whole,  encouraging.  Should  partial  union  of  the  upper 
and  lower  segments  occur,  and  merely  a  fistula  be  left,  it  may  be 
possible  to  clo^e  this  by  a  secondary  operation. 

Various  modifications  of  Kraske's  proceeding  have  been  suggested, 
one  of  the  best  being  that  performed  by  Bardenheuer.     The  sacrum 


Fig.  533.— Pelvis  seen  from  Behind  to  indicate  the  Lines  of  Section 
OF  THE  Sacrum  and  Coccyx  in  Kraske's  Operation. 

a  b,  Kraske's  original  operation;  a  c,  Bardenheuer's  modification. 

is  exposed,  sawn  across  just  below  the  thiid  foramina  (Fig.  533,  a  c), 
and  the  portion  thus  detached  is  totally  removed.  By  this  means 
a  much  more  extensive  view  is  obtained  of  the  pelvic  contents,  and 
the  scope  of  the  operation  increased.  In  all  such  procedures  the 
importance  of  preserving  the  third  sacial  neives  which  supply  the 
bladder  must  be  kept  in  mind. 

3.  The  Abdominal  Operation  is  only  possible  when  the  lower  3  or 
4  inches  of  the  bowel  are  free  from  disease.  Its  object  is  to  remove 
the  upper  segment  of  the  rectum,  part  of  the  pelvic  colon,  and  of  the 
attached  mesentery  with  its  lymphatic  glands  and  cellular  tissue,  and 
to  restore  the  continuity  of  the  bowel  by  suturing  the  ends  together 
from  above.  The  operation  is  conducted  in  the  Trendelenburg 
position,  and  the  rectum  must  be  previously  thoroughly  irrigated 
with  lysol  or  some  other  antiseptic.  The  abdomen  is  opened  in  the 
middle  line,  and  the  intestines  drawn  down  out  of  the  way  and  pro- 
tected     A  full  examination  of  the  parts  is  then  feasible,  and  a  final 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  ii73 

determination  reached  as  to  the  character  of  the  operation  required. 
The  rectum  immediately  below  the  disease  is  carefully  clamped  and 
cut  across;  the  lower  segment  is  temporarily  guarded.  The  peri- 
toneum on  either  side  of  the  upper  segment  is  now  divided,  and  the 
tissue.-,  of  the  meso-rectum  freed  therefrom.  A  portion  of  the  sigmoid 
suitable  for  approximation  to  the  lower  end  is  selected,  and  by 
dividing  the  peritoneum  of  the  nieso  sigmoid  on  its  outer  side  the 
loop  is  freely  mobihzed.  The  guc  is  clamped  above,  and  the 
diseased  segment  removed,  the  vessels  supplying  it  being  secured  by 
hgatures,  and  this  may  even  include  the  main  branches  of  the  inferior 
mesenteric  artery.  The  upper  and  lower  segments  are  then  united 
by  sutures,  either  within  the  pelvis  or  by  invaginating  the  two 
through  the  anus  and  performing  the  anastomosis  outside,  with 
subsequent  reposition.  An  effort  is  made  to  restore  the  continuity  of 
the  peritoneum  by  suturing,  and  it  may  be  wise  to  insert  a  large 
drainage-tube  through  the  anus  so  as  to  reach  above  the  line  of 
suture  and  allow  flatus  to  pass.  In  weakly  patients  it  is  sometimes 
undesirable  to  prolong  the  operation  by  attempting  the  restoration  of 
the  canal,  and  in  stout  patients  it  may  be  impossible  to  effect  this 
owing  to  the  amount  of  fat  present.  Under  such  circumstances  it  is 
wise  to  complete  the  operation  by  the  formation  of  a  terminal 
artificial  anus  in  the  left  iliac  fossa,  and  by  closing  completely  the 
anal  segment  of  the  bowel. 

4.  The  combined  Abdomino-perineal  Operation  is  chiefly  used  as 
an  alternative  to  the  perineal  or  to  Kraske's  method,  and  has  the 
great  advantage  of  permitting  a  wider  removal  of  lymphatic  vessels 
and  glands.  The  abdomen  is  opened  usually  through  the  left  rectus, 
with  the  patient  in  the  Trendelenburg  position.  After  due  examma- 
tion,  the  bowel  above  the  growth  is  divided  in  a  suitable  position; 
the  lower  end  is  completely  closed,  whilst  the  upper  has  a  Paul's 
tube  tied  into  it,  and  i.^  fixed  in  the  wound  so  as  to  form  a  permanent 
colostomy.  The  peritoneum  of  the  mesentery  of  the  distal  segment 
is  then  divided  on  each  side  close  to  its  parietal  attachment,  and  the 
bowel  with  all  the  tissues  behind  it  lying  in  the  hollow  of  the  sacrum 
is  peeled  downwards  to  the  pelvic  floor,  care  being  taken  to  guard 
the  ureters  and  main  iliac  vessels.  The  peritoneum  of  Douglas's 
pouch  is  then  incised  transversely,  and  the  separated  bowel  and  the 
tissues  connected  with  it  are  pushed  down  below  it,  and  covered  over 
by  suturing  together  the  divided  segments  of  peritoneum.  The 
abdomen  may  then  be  closed,  and  the  rest  of  the  operation  is  con- 
ducted in  the  left  lateral  position  as  in  the  perineal  procedure.  After 
the  bowel  has  been  removed,  the  perineal  wound  may  be  entirely 
closed,  special  care  being  directed  to  securing  together  the  divided 
segments  of  the  levator  ani.  Whenever  possible,  it  is  desirable  that 
this  operation  should  be  conducted  by  two  surgeons  working 
together,  one  from  the  abdomen,  and  one  from  the  perineum; 
much  time  is  thereby  saved,  and  shock  is  minimized. 

Occasionally  it  is  possible  to  avoid  the  formation  of  a  colostomy  by 
carrying  the  lower  end  of  the  divided  sigmoid  flexure  downwards, 
and  fixing  the  lower  end  in  the  perineum. 


£174  A   MANUAL  OF  SURGF.RY 

The  mortality  after  all  these  operations  is  high,  reaching  at  least 
to  26  per  cent. ;  this  is  largely  due  to  the  grave  risks  of  infection, 
and  in  a  less  degree  to  the  severity  of  the  i)rocediire.  Perhaps  the 
abdominal  methods  which  include  the  formation  of  an  artihcial  anus 
have  some  advantage  by  reducing  the  chances  of  f cecal  contamina- 
tion. The  tendency  to  recurrence  is  also  considerable,  but  even 
should  this  occur  the  recurrence  is  often  less  painful  than  the  primary 
disease  owing  to  the  previous  removal  of  the  nerve  terminals. 

Excision  of  the  rectum  is  only  practicable  in  a  small  percentage  ot 
the  cases  of  cancer  which  come  under  observation;  usually  the 
disease  has  progressed  too  far  by  the  time  that  the  patient  is  first 
seen  by  the  surgeon.  Practitioners  and  students  ahke  must  be 
warned  emphatically  of  the  importance  of  making  a  thorough 
examination  of  the  rectum  in  all  cases  where  haemorrhage  or  dis- 
charge occurs,  or  persistent  discomfort  is  complained  of. 

As  already  stated,  if  the  radical  operation  is  not  feasible,  Colostomy 
is  sometimes  justifiable  as  a  means  of  relief  to  the  patient's  symp- 
toms. Cases  where  excision  cannot  be  attempted  may  be  divided 
into  two  groups  according  to  the  character  of  the  s\miptom3 — i.e., 
whether  obstructive  or  irritative  phenomena  predominate. 

1.  When  the  main  trouble  arises  from  difficulty  to  the  onward 
passage  of  the  bowel  contents,  much  benefit  will  be  derived  from  an 
early  colostomy,  {a)  It  allows  the  patient  to  indulge  in  solid  food, 
and  thus  assists  in  maintaining  the  general  health;  (b)  it  frees  him 
from  the  pain  arising  from  the  passage  of  faeces  over  the  ulcerated 
surface,  but  not  from  that  due  to  the  growth  and  traction  of  the 
tumour  upon  surroimding  nerves;  [c)  it  may  possibly  retard  the 
growth  of  the  disease  b\^  eliminating  the  irritating  action  of  the 
faeces;  {d)  it  removes  all  chance  of  intestinal  obstruction  from  the 
growth  itself;  and  (e)  it  diminishes  the  absolute  risk  of  the  opeiation 
by  undertaking  it  when  the  patient  is  comparatively  well  and  hearty, 
and  when  there  is  no  urgency.  Formerly,  when  performed  for  ob- 
struction alone,  the  death-rate  was  about  30  or  40  per  cent.;  in  an 
early  iliac  operation  it  is  now  practically  nil,  or  at  most  3  or  4  per 
cent. 

2.  In  the  ulceyalive  type,  where  there  is  but  little  tendency  to 
stenosis,  colostomy  will  do  but  little  good,  as,  although  it  may  pre- 
vent faeces  from  irritating  the  surface  of  the  growth,  yet  the  dis- 
charge of  muco-pus  and  blood  will  continue  unchecked,  causing 
tenesmus  and  constant  calls  to  empty  the  bowel  below  the  artificial 
opening.  The  additional  attention  required  by  the  colostomy 
wound  may  make  the  patient's  Hfe  a  burden  to  him. 

For  details  as  to  colostomy,  see  p.  1034. 

Should  the  patient  refuse  colostomy,  or  should  it  be  contra- 
indicated,  treatment  consists  in  limiting  the  diet  to  such  materials  as 
strong  broths,  arrowroot,  etc.,  with  some  stimulant,  so  as  to  give  as 
little  faecal  remains  as  possible,  and  to  enable  him  to  do  without  an 
action  of  the  bowels  for  about  a  week  at  a  time.  The  strength  is 
husbanded  by  keeping  him  in  bed,  and  pain  is  checked  by  the 
administration  of  moiphia. 


CHAPTER  XXXIX. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS. 


The  kidneys  are  placed  on  either  side  of  the  middle  line,  and 
extend  from  the  eleventh  rib  above  to  midway  between  the  last  rib 
and  the  iliac  chest  below,  the  right  kidney  being  somewhat  lower 
than  the  left,  owing  to  the  presence  of  the  liver.  The  hilum  is 
situated  opposite  the  spinous  process  of  the  first  lumbar  vertebra, 
and  the  upper  ends  of  the  organs 
are  nearer  to  the  spine  than  the 
lower. 

The  kidnej^s  may  be  exposed 
by  two  chief  routes,  viz.,  the 
lumbar  and  the  abdominal. 

The  Lumbar  incision  (Fig.  534, 
B)  commences  at  a  point  corre- 
sponding to  the  outer  border  of 
the  erector  spinae,  and  ^  inch 
below  the  last  rib,  extending 
downwards  and  outwards  in  the 
direction  of  the  fibres  of  the 
external  oblique  towards  the 
anterior  superior  iliac  spine. 
The  posterior  portions  of  the 
abdominal  muscles  and  the  fascia 
lumborum  are  divided  seriatim, 
and  the  fatty  tissue  surrounding 
the  kidney  is  thus  easily  reached 
and  opened.  Variations  of  the  incision  must  be  made  to  suit  the 
particular  requirements  of  the  case. 

In  the  Abdominal  operation  the  kidney  is  exposed  from  the  front, 
either  through  the  linea  semilunaris  or  some  other  suitable  incision ; 
the  peritoneal  cavity  is  opened  or  not,  as  may  be  thought  necessary. 
If  the  peritoneum  is  opened,  the  colon  is  displaced  inwards  and 
held  aside,  as  also  the  other  intestines,  by  cloths  soaked  in  warm 
salt  solution ;  the  peritoneum  covering  the  posterior  abdominal  wall 
is  incised  to  the  outer  side  of  the  colon,  and  the  organ  thus  exposed. 
When,  however,  the  kidney  is  enlarged,  it  is  often  unnecessary  to 


Fig. 


534. — Diagram    to 
Lumbar  Incisions 


ILLUSTRATE 


A,  For  lumbar  colotomy;  B,  for  expos- 
ing the  kidney. 


1 1 76  A   MANUAL  OF  SURGERY 

open  tlie  peritoneal  cavity,  the  colon  and  other  peritoneal  contents 
being  displaced  inwards. 

Examinationof  the  Kidney  and  its  Function. —  i.  Manual  examina- 
tion of  tile  kidney  is  mack'  with  the  jiatient  (ni  the  back,  with  the 
legs  raised,  the  head  supported  by  a  pillow,  and  the  mouth  open. 
The  surgeon,  kneeling  or  standing  at  the  side  of  the  couch,  places  one 
hand  under  the  loin  and  presses  it  upwards,  whilst  the  other  is  gently 
but  firmly  pressed  backwards  in  the  lumbar  region,  especially  during 
expiratory  movements.  Unnatural  mobihty,  enlargement,  or  dis- 
placement downwards  of  the  organ,  will  be  thereby  detected,  as  also 
irregularities  in  outline  or  modification  of  tension. 

An  enlarged  kidney  is  recognised  by  the  following  general  char- 
acters: A  swelling  is  noticed  in  the  loin,  which  is  shaped  more  or 
less  like  the  kidney,  a  notch  being  occasionally,  though  rarely,  felt 
on  the  inner  border,  and  the  outer  margin  being  rounded.  The 
flank  is  always  dull  on  percussion,  the  note  remaining  unaltered 
whatever  the  patient's  position,  and  intestine  never  finding  its  way 
behind  the  tumour.  The  passage  of  the  colon  in  front  of  the  kidney 
not  unfrequently  gives  rise  to  a  band  of  resonance  over  its  anterior 
surface;  the  bowel,  however,  soon  gets  pushed  aside  inwards  by  the 
growth  of  the  tumour.  On  the  right  side  it  is  not  unusual  for  the 
renal  dulness  to  be  continuous  with  that  due  to  the  liver;  there  is 
always  distinct  resonance  below  and  to  the  inner  side  of  the  mass 
towards  the  pelvis,  thereby  distinguishing  it  from  a  pelvic  swelling. 
The  mass  moves  slightly  on  respiration,  though  less  distinctly  than 
the  liver  or  spleen. 

On  the  left  side  it  has  to  be  distinguished  from  an  enlarged 
spleen ;  the  latter  viscus  hugs  the  anterior  abdominal  wall,  and  has 
no  gut  in  front  of  it,  whilst  the  loin  is  usually  resonant. 

2.  The  Existence  and  Functional  Utility  of  a  second  kidney  must  be 
carefully  investigated  in  any  case  where  the  removal  of  a  diseased 
kidney  is  being  considered,  {a)  The  only  safe  test  lies  in  securing 
a  satisfactory  specimen  of  the  urine  from  the  second  kidney.  This 
can  best  be  effected  by  catheterization  of  the  ureters,  which  has 
practically  displaced  all  other  methods.  The  bladder  is  carefully 
washed  out  and  disinfected,  and  after  putting  lo  ounces  of  clear 
water  in  it,  a  suitable  cystoscope  is  introduced,  with  a  catheter 
ready  for  insertion.  Considerable  practice  is  necessary  in  order 
to  effect  this  quickly  and  satisfactorily,  but  it  is  a  most  valuable 
proceeding.  (5)  Separators  of  various  types  were  employed  before 
ureteral  catheterism  became  common,  and  of  these  Luys'  instru- 
ment (Fig.  535)  was  the  most  satisfactory.  The  bladder  is  first 
thoroughly  irrigated,  and  the  instrument  introduced.  The  india- 
rubber  septum  is  then  drawn  into  place,  and  the  urine  collected 
from  the  two  sides  as  it  enters  the  bladder.  To  act  effectively  the 
curved  end  must  be  pressed  well  backwards  against  the  posterior 
vesical  wall,  and  the  patient  must  be  in  the  sitting  position,  (c)  A 
small  injection  of  methylene  blue  {vide  infra)  is  given,  and  the  passage 
of  the  discoloured  urine  from  the  ureter  into  the  bladder  watched 


SURGICAL  AFFECTIOXS  OF  THE  KIDXEYS 


1177 


by  means  of  the  cystoscope.  {d)  It  is  sometimes  necessary  to  remove 
a  kidney  during  an  operation  when  a  previous  thorough  examina- 
tion has  not  been  practicable.  In  such  a  case  the  only  safe  pro- 
ceeding is  to  open  the  peritoneal  cavity  and  pass  the  hand  across 
and  palpate  the  opposite  organ,  not  only  noticing  its  size  and  shape, 
but  also  the  condition  of  the  pelvis  and  the  renal  vessels.  Although 
the  organ  may  be  defectiv^e  in  function,  the  surgeon  by  observing 
such  a  precaution  will  be  preserved  from  the  tragedy  of  removing 
the  onl}-  available  kidney. 

3.  The  Activity  of  the  Renal  Function  for  both  kidneys  or  for  each 
separatel}-  can  be  estimated  by  a  number  of  methods,  of  which, 
however,  one  can  only  give  the  briefest   notice  here.*     (i.)    Ihe 


Fig.  535. 


-LuYs'   Segregator  in  Position  for  Collecting  Separately 
THE  Urine  escaping  from  the  Two  Ureters. 


The  indiarubber  septum  can  be  seen  stretching  across  the  bladder  cavity,  and 
the  curved  beak  fits  down  firmly  into  the  '  bas  fond  '  of  the  bladder,  so 
that  the  urine  will  at  once  pass  into  the  openings  on  either  side  of  the 
septum,  and  so  up  to  the  collecting  glasses.  The  screw-head  of  the  instru- 
ment controls  the  septum,  which  is,  of  course,  only  stretched  into  position 
after  the  introduction  of  the  instrument. 

Methylene-hliie  test  is  based  on  the  fact  that  when  a  solution  of  this 
substance  is  injected  into  a  muscle,  it  is  absorbed  into  the  blood 
as  a  colourless  product,  but  is  eliminated  both  in  the  bile  and  urine. 
In  the  latter,  part  of  it  appears  as  a  blue  or  bluish-green  colouring 
matter,  part  as  a  colourless  product  (chromogen),  which  can  be 
made  apparent  by  boiling  with  acetic  acid.  If  5  minims  of  a  10  per 
cent,  solution  is  injected  into  a  healthy  person,  chromogen  appears 
in  fifteen  minutes,  and  the  blue  colour  in  the  excretion  is  at  its 
maximum  in  four  or  five  hours,  remains  stationary  for  a  few  hours, 
and  then  gradually  decreases;  about  half  of  the  methylene  blue  is 
ehminated  in  twenty-four  hours,  but  it  is  often  five  or  seven  days 
before  it  disappears  entirely.     In  disease  of  the  kidney's  involving 

*  For  fuller  details,  see  Thomson  Walker's  Hunterian  Lectures  on  '  The 
Renal  Function  in  Health  and  Disease,'  Lancet,  March  16  and  23,  1907. 


117^  A   MANUAL  OP  SURGlUiV 

defective  function  the  elimination  of  this  substance  is  kite  in  appear- 
ing and  prolonged  beyond  the  normal  period.  This,  of  course,  can 
be  estimated  for  each  kidney  separately  by  catheterism  of  the 
ureters,  (ii.)  The  Phloridzin  test.  If  lo'  minims  of  a  solution  of 
phlorid/in  (i  in  200)  are  injected  beneath  the  skin,  sugar  appears 
in  the  urine  of  a  healthy  person  in  fifteen  to  twenty  minutes,  and 
the  glycosuria  lasts  for  two  to  three  hours,  the  total  output  of  sugar 
being  between  i  and  2 '50  grammes.  Where  the  function  of  the 
kidney's  is  defective,  the  amount  eliminated  is  much  diminished, 
or  it  may  be  entirely  absent. 

Diminution  in  or  loss  of  the  functional  activity  of  the  kidneys 
results  in  an  accumulation  of  toxic  products  of  varying  characters 
in  the  blood,  which  leads  sooner  or  later  to  the  development  of  a 
condition  of  Uraemia,  which  ma}'  have  a  gradual  or  sudden  onset, 
and  be  represented  by  a  multiplicity  of  varying  symptoms.  Head- 
ache, vomiting  and  convulsions,  are  probably  the  most  characteristic 
features,  but  there  are  many  other  suggestive  manifestations,  such 
as  delirium,  vai'lous  paralyses,  asthmatic  attacks,  etc.  In  con- 
sidering the  advisability  of  operating  on  man}?  renal  conditions,  the 
possibility  of  the  development  of  an  acutely  fatal  attack  of  uraemia 
as  the  result  of  the  anaesthetic  must  be  kept  in  mind,  and  a  careful 
examination  of  the  urine  made.  In  every  renal  case  the  daily  output 
of  urine  and  its  specific  gravity  should  always  he  noted  ;  a  persistent 
low  specific  gravity  (loio)  and  a  defective  urea-content  are  always 
danger-signals.  The  amount  of  urine  passed  apart  from  a  know- 
ledge of  its  specific  gravity  is  no  guarantee  of  the  efficiency  of  the 
renal  secretion. 

4.  A  thorough  Examination  of  the  Urine,  chemical,  microscopical, 
and  bacteriological,  is  essential  in  all  conditions  aftecting  the 
urinary  organs,  and  particularly  in  affections  of  the  kidney.  In 
the  majority  of  cases  the  chemical  test  limits  itself  to  ascertaining 
whether  or  not  albumen  or  sugar  is  present. 

Albuminuria,  or  the  escape  of  some  of  the  albuminous  contents  of 
the  blood  with  the  urine,  is  a  condition  of  such  frequent  occurrence, 
and  so  important  in  its  results,  that  the  precaution  should  always 
be  adopted  of  testing  the  urine  of  every  patient  before  undertaking 
any  operative  proceedings ;  and  this  is  the  more  essential  because  it 
is  well  known  that  this  condition  often  exists  t]uite  vmexpectedly 
and  entirely  apart  from  symptoms. 

Tests. — Many  different  methods  have  been  adopted  for  detecting 
the  presence  of  albuminuria.  The  following  are,  however,  the 
chief:  (i)  On  simply  boiling  the  urine  a  milky  white  deposit  forms 
similar  to  that  which  is  caused  by  an  excess  of  phosphates ;  the  latter, 
however,  disappears  entirely  on  the  addition  of  a  single  drop  of  dilute 
acetic  acid,  whilst  the  former  persists  or  increases.  (2)  Nitric  acid 
gives  a  white  cloud  or  light  brown  flocculent  precipitate.  The  urine 
should  first  be  boiled  and  the  acid  added,  but  not  in  excess,  as  the 
deposit  may  be  re-dissolved.  A  more  delicate  test  consists  in  pour- 
ing the  cold  urine  into  a  test-tube,  and  cprefully  adding  the  acid  so 


SURGICAL  .lI'/'/'CTfOMS  OF   I'lli:  KIDMF.YS  ii;9 

as  to  form  a  stratum  below  t\\v  urine;  at  the  line  of  junction  of  the 
two.  a  white  film  is  formed,  if  albumen  is  present.  (3)  With  picric 
acid  a  yoUowish-white  precipitate  is  thrown  down,  increased  by 
boihn^t^.  If  the  urine  is  neutral  or  alkaline,  it  must  first  be  rendered 
shglitly  acid  by  the  addition  of  a  few  drops  of  acetic  acid. 

\\'hen()nce  the  existence  of  albumen  in  the  urine  has  been  ascer- 
tamed,  its  source  and  its  significance  must  be  investigated.  A 
careuil  microscopical  examination  of  the  sediment  is  made,  so  as  to 
determine  whether  casts  or  pus  cells  are  present  The  condition  of 
the  peripheral  bloodvessels  in  the  limbs  and  the  character  of  the 
pulse  should  be  noted,  as  also  the  previous  history  of  the  patient. 

Albuminuria  arises  from  a  variety  of  sources,  and  its  significance 
necessarily  turns  on  the  origin  of  the  affection,     (i)  When  it  is 
associated  with  long-stanchng  suppuration,  as  in  diseases  of  bones 
or  joints,  it  is  probably  due  to  lardaceous  change  in  the  kidneys. 
If  the  urine  is  of  low  specific  gravity,  and  light  in  colour,  and  with 
but  few  casts,  only  an  early  stage  of  the  condition  is  present,  and 
conservative  measures  directed  to  the  treatment  of  the  primary  lesion 
will  probably  suffice;  if,  however,  the  urine  is  scanty  and  of  high 
specific  gravity  with  much  albumen  and  many  casts,  the  affection 
has  probably  progressed,  some  way,  and  radical  treatment,  such  as 
amputation,  should  be  undertaken  to  save  the  patient's  life.     The 
surgeon  must  be  careful  to  prevent  any  undue  absorption  of  carbolic 
acid  in  the  operation,  as  thereby  acute  nephritis  may  be  lighted  up, 
and  even  a  fatal  issue  determined.     (2)  Albuminuria  may  be  inter- 
mittent (cyclical) ,  and  is  then  due  to  some  temporary  "functional 
disturbance ;  this  can  only  be  ascertained  by  testing  the  urine  from 
time  to  time.     In  such  cases  operation  is  not  contra-indicated,  the 
albumen  usually  disappearing  with  rest  and  careful  diet.     (3)  When 
caused  by  chronic  Bright 's  disease,  the  concurrent  phenomena  of 
that  affection  will  also  be  present  in  the  shape  of  thickened  arteries 
and  high  pulse  tension,  whilst  possibly  a  certain  amount  of  anasarca 
may  be  noted,  or  the  history  of  such  at  an  earlier  date.     If  there  is 
but  little  albumen,  and  a  fair  amount  of  urea  is  being  passed,  it  is 
possible  by  rest  and  suitable  diet  so  to  diminish  it  as  to  warrant  the 
performance  of  slight  operations ;  but  where  the  condition  is  at  all 
advanced,    all   opemtions   de  complaisance   are  absolutely  contra- 
indicated,  and  only  the  chief  surgical  emergencies  should 'be  know- 
ingly  dealt   with,    viz.,    haemorrhage,    asphyxia,    grave   intraperi- 
toneal lesions,  and  retention  of  urine.     In  severe  injuries,  amputa- 
tion is  generally  indicated  under  circumstances  where  in  a  healthy 
individual  conservative  measures  would  be  adopted.     Operation 
for  malignant  disease  may  be  undertaken  at  the  request  of  the 
patient  if  the  increased  risks  have  been  explained  to  him.     The  risk 
depends  on  the  facts  that  such  patients  tolerate  an  anesthetic  badlv, 
that  the  tissues  are  in  a  condition  of  lowered  vitality,  and  hence  the 
process  of  repair  is  hindered ;  infective  inflammations  and  erysipelas 
are  very  prone  to  develop,  whilst  secondary  hsemorrhage  is  predis- 
posed to  by  the  high  pulse  tension.     Again,  boils  and  carbuncle^ 


ii8o  A   MANUAL  OF  SURGERY 

are  very  common  in  these  patients,  and  where  such  conditions  are 
met  with,  and  especially  if  they  recur,  the  urine  should  always  be 
examined.  (4)  Albuminuria  may  arise  by  extension  of  inflamma- 
tion to  the  kidneys  from  surgical  affections  of  the  lower  urinary 
organs,  and  a  fatal  result  from  shock  or  suppression  of  urine  may 
follow  an  operation  under  these  conditions.  (5)  It  is  sometimes 
the  result  of  cardiac  disease,  owing  to  valvular  incompetence  and 
regurgitation  into  the  systemic  veins,  and  it  is  then  advisable  to  delay 
all  operative  measures  until  suitable  treatment  has  relieved  the 
urgent  s^-mptoms. 

Glycosuria  and  Diabetes  are  alike  characterized  by  the  presence 
in  the  urine  of  sugar  (glucose),  but  whilst  the  former  may  be  tem- 
porary and  of  comparatively  little  significance,  the  latter  is  generally 
permanent  and  due  to  disease  of  the  pancreas.     The  mere  existence 
of  sugar  in  the  urine  is  not  nowadays  looked  on  as  an  absolute  contra- 
indication to  operative  treatment,  as  was  the  case  formerly,  and  yet 
the   urine  of  all  patients   requiring  operation  should  always  be 
examined  as  a  routine  preliminary  in  order  to  ascertain  whether 
or  not  it  is  present.     The  chief  tests  employed  are  as  follows: 
(i)  Equal  parts  of  liquor  potassae  and  solution  of  copper  sulphate 
are  boiled  together,  and  then  a  few  drops  of  the  suspected  urine 
added;  if  sugar  is  present,  a  yellowish-red  precipitate  forms  by  the 
reduction  of  the  cupric  salt  to  cuprous  oxide.     (2)  The  same  result 
follows  the  use  of  Fehling's  solution.     It  is  better  to  keep  the  copper 
solution  separate  from  the  potash;  equal  parts  of  them  are  boiled 
together,  and  a  few  drops  of  the  urine  added;  if  sugar  is  present,  a 
red  deposit  occurs.     (3)  Picric  acid  and  liquor  potassae  are  mixed 
and  boiled,  and  the  urine  added;  the  presence  of  sugar  is  indicated 
by  the  solution  turning  to  a  dark,  blackish-red  colour.     The  admix- 
ture of  2  grains  of  sugar  to  the  ounce  is  sufficient  to  determine  this 
discoloration  to  such  an  extent  as  to  render  the  fluid  quite  opaque. 
Simple  Glycosuria  arises  from  many  different  conditions,  included 
amongst  which  may  be  mentioned  an  excess  of  carbohvdrates  and 
of  fatty  or  sweet  things  in  the  dietary,  the  liver  being  unable  to  store 
them  away,  hepatic  disturbances  of  various  types,  and  injuries  or 
diseases  of  the  medulla  or  upper  part  of  the  cord.     An  interesting 
form  of  glycosuria  occurs  in  some  infective  conditions  of  the  t37pe 
of  cellulitis  (boils,  carbuncles,  etc.),  where  the  presence  of  glucose  in 
the  urine  appears  to  be  secondary,  and  disappearance  quicklv  follows 
effective  operative  treatment.     The  explanation  of  this  condition  is 
not  at  all  obvious. 

True  diabetes  is  now  generally  considered  to  be  due  to  lesions  of 
the  pancreas .  Experimentally,  total  removal  of  the  gland  in  animals 
is  followed  by  diabetes,  and  in  man  clinical  research  has  demon- 
strated that  certain  types  of  chronic  pancreatitis,  in  which  degenera- 
tion or  destruction  occurs  of  the  curious  cellular  bodies  known  as  the 
Islands  of  Langerhans,  are  associated  with  diabetic  phenomena. 
These  islands  are  supposed  to  form  the  internal  secretion  of  the 
gland,  a  ferment  upon  the  activity  of  which  the  glycogenic  function 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1181 

of  the  liver  depends.  In  the  vast  majority  of  the  accredited  cases 
of  diabetes  lesions  of  the  pancreas  are  demonstrable,  and  the  con- 
dition is  often  improved  by  hydrotherapy  and  measures  directed  to 
relieving  hepatic  engorgement.  It  is  quite  reasonable  to  consider 
seriously,  in  all  cases  of  diabetes,  the  question  of  exploring  the 
bihary  and  pancreatic  passages  with  a  view  to  remove  calculi,  or 
relieve  congestion  by  temporary  drainage.  Although  the  condition 
may  not  be  absolutely  cured,  yet  great  benetit  has  frequently  resulted. 

In  simple  glycosuria  limitation  of  diet  for  a  few  days  and  rest  in 
bed,  with  some  attention  to  the  activity  of  the  Hver  and  of  the  bowels, 
will  frequently  cause  a  diminution  in  the  excretion  of  sugar,  and 
under  such  circumstances  a  surgeon  need  not  hesitate  to  perform 
ordinary  operations.  But  if  the  sugar  persists  in  spite  of  such 
treatment,  and  there  is  reason  to  suspect  that  the  case  is  one  of  true 
pancreatic  diabetes,  operations  must  be  undertaken  very  cautiously. 
The  tissues  are  always  in  a  condition  of  lowered  vitality,  so  that 
infection  readily  occurs,  as  indicated  by  the  frequency  of  such  con- 
ditions as  boils,  carbuncles,  and  infective  gangrene  of  the  extremities. 
In  old-standing  cases,  peripheral  neuritis  and  sclerosis  of  the  smaller 
vessels  are  induced,  and  gangrene  is  not  an  uncommon  sequela 
(p.  117).  It  is  therefore  obvious  that  operative  proceedings  should 
not  be  resorted  to  unless  they  are  absolutely  necessary ;  but,  unless 
the  case  has  progressed  very'' far,  there  is  no  reason  why  necessary 
operations  should  not  be  performed,  granted  that  the  most  rigid  care 
is  taken  as  to  the  maintenance  of  asepsis.  Thus  several  cases  have 
been  reported  in  which  such  serious  proceedings  as  total  removal  of 
the  breast  and  axillary  contents  for  scirrhus,  or  appendicectomy, 
have  been  safely  undertaken  in  confirmed  diabetics. 

One  of  the  chief  dangers  of  neglected  or  serious  diabetes  is  the 
supervention  of  Diabetic  Coma,  which  may  develop  without  apparent 
reason,  or  be  lighted  up  by  some  septic  compHcation,  or  the  operative 
treatment  required  for  the  same,  especially  if  a  general  anaesthetic  is 
given.  The  patient  becomes  apathetic,  and  finally  dies  in  a  condi- 
tion of  coma ;  his  breath  smells  of  acetone,  and  the  blood  is  defective 
in  its  alkalinity.  The  explanation  of  this  is  as  follows :  in  diabetes 
there  is  always  an  excessive  production  of  acid  in  the  body^mainly 
i8-oxybutyric  acid — which  in  health  is  either  not  formed,  or  is 
oxidized  to  CO2  and  HgO.  In  this  disease  it  is  excreted  in  com- 
bination with  alkalies,  mainly  with  the  ammonium  which  is  normally 
formed  into  and  removed  from  the  body  as  urea.  The  sodium  and 
potassium  of  the  blood  are  also  called  on  to  neutralize  it,  and  even 
calcium  or  magnesium  mav  be  dissolved  from  the  bones.  The  blood 
therefore  suffers  in  its  alkahnity;  the  carbonic  acid  is  no  longer 
carried  to  the  lungs,  and  consequently  dyspnoea,  with  or  without 
cyanosis,  mav  result.  Diacetic  acid  is  also  formed,  especially  just 
before  coma  "occurs.  It  arises  by  oxidation  of  the  /3-oxybutyric 
acid,  and  breaks  up  in  its  turn  into  acetone  and  carbolic  acid.  Its 
presence  can  be  demonstrated  in  the  urine  by  the  addition  of  ferric 
chloride,  when  a  claret  colour  appears ;  if  the  urine  is  subsequently 


1 1 82  A   MANUAL  OF  SURGERY 

boiled,  this  discoloration  disappears  (p.  1346).  Naturally  the 
presence  of  this  acid  in  the  urine  of  a  diabetic  patient  is  a  danger 
signal,  warning  the  surgeon  that  coma  is  not  far  distant,  and  that 
general  anaesthetics  must  be  avoided.  Large  doses  of  sodium  bi- 
carbonate given  by  mouth  or  rectum,  or  even  by  intravenous 
infusion,  may  be  of  use  in  checking  the  progress  of  this  condition. 
For  the  influence  of  diabetes  and  albuminuria  in  the  choice  of  an 
anaesthetic,  see  pp.  1345  and  1354. 

Hsematuria,  or  the  admixture  of  blood  with  the  urine,  is  a  frequent 
symptom  in  diseases  of  any  part  of  the  urinary  track,  and  it  is  some- 
times a  little  difficult  to  ascertain  the  exact  source  from  which  the 
blood  is  derived. 

((?)  Renal  hxma.tnna  results  from  acute  inflammation,  congestion, 
calculus,  tumours,  or  injuries  of  the  kidney.  The  urine  is  sometimes 
deeply  coloured  with  the  blood,  and  may  be  as  dark  as  porter. 
Blood-casts  of  the  renal  tubules  are  often  observed,  and  even  long 
sinuous  clots,  corresponding  to  the  shape  of  the  ureter. 

{b)  Vesical  hsematuria  is  due  to  injury,  calculus,  tumours,  ulcera- 
tion, simple  congestion  of  the  bladder  with  varicosity  of  the  vesical 
veins,  or  the  presence  of  the  Bilharzia  hcematohia.^  The  blood  is 
intimately  mixed  with  the  urine,  but  is  more  abundant  at  the  end  of 
micturition,  and  clots  are  often  present. 

The  Bilharzia  is  a  parasite  which  inhabits  some  of  the  rivers  and 
pools  of  South  Africa.  It  is  taken  into  the  system  by  the  mouth, 
and  may  develop  either  in  the  urinary  track,  or  sometimes  in  the 
k)wer  bowel  (p.  1148).  The  adult  worms  are  found  in  the  body 
inhabiting  the  radicals  of  the  portal  and  vesical  veins,  and  discharge 
their  ova  through  the  mucous  membrane  of  the  bowel  or  bladder, 
giving  rise  to  haemorrhage.  By  an  extension  to  the  kidney,  pyone- 
phrosis may  be  induced.  No  specific  treatment  has  at  present  been 
discovered,  but  in  most  cases  the  disease  after  a  time  disappears 
spontaneously.  Microscopic  examination  reveals  the  presence  in 
the  urine  of  the  characteristic  ova — ovoid  bodies  with  a  terminal 
spike. 

(c)  Prostatic  hematuria  may  be  caused  bv  congestion,  calculus, 
ulceration,  or  malignant  disease,  or  especially  by  the  passage  of  a 
catheter  or  bougie  used  in  the  diagnosis  or  treatment  of  any  of  these 
conditions.  The  blood  may  pass  back  into  the  bladder,  and  hence 
the  phenomena  simulate  the  vesical  condition,  but  frequently  it 
escapes  from  the  urethra,  particularly  if  due  to  traumatism.  Ex- 
amination of  the  prostate  from  tfle  rectimi  may,  however,  give  a 
clue  to  the  source  of  the  mischief:     ' 

{d)  Urethral  haematuria  arises. from  acute  gonorrhoea,  laceration, 
or  instrumentation.  The  blood  often  flows  from  the  urethra  inde- 
pendently of  micturition,  whilst  the  first  few  drops  of  the  stream 
are  also  coloured. 

[e)  Haematuria  is  occasionally  oi  constitutional  origin,  arising  from 
purpura,  scurvy,  or  haemophilia;  other  manifestations  of  these 
diseases  will  be  observed,  and  render  the  diagnosis  evident. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1183 

lAIicroscopical  examination  of  the  urine  should  always  be  made  to 
ascertain  whether  or  not  blood-corpuscles  are  present,  since  the 
condition  may  be  simulated  by  that  known  as  '  paroxysmal  hamo- 
globnuiria,'  in  which  corpuscles  are  absent.  The  latter  condition 
is  supposed  to  be  due  to  vaso-motor  spasm  of  the  renal  arterioles, 
and  is  not  uncommonly  associated  with  Raynaud's  disease. 

The  only  certain  test  for  the  presence  of  blood  is  by  spectrum 
analysis ;  but  that  most  usually  relied  on  consists  in  mixing  together 
equal  parts  of  tincture  of  guaiacum  and  ozonic  ether.  The  sus- 
pected urine  is  subsequently  added,  and  sinks  to  the  bottom  of  the 
test-glass;  a  copious  precipitate  forms  at  the  hue  of  junction  of  the 
two  fluids,  which  on  standing  becomes  a  bright  blue  colour  if  blood 
is  present. 

The  investigation  of  a  case  of  hsematuria  in  order  to  ascertain  its 
origin  should  be  conducted  in  the  following  way:  [a]  The  history  of 
the  patient  and  of  his  urinary  trouble  should  be  taken,  {b)  The 
character  of  the  urine  should  be  investigated,  noting  its  colour,  and 
whether  or  not  the  blood  is  intimately  mixed  with  it.  (c)  The  relation 
of  the  passage  of  the  blood  to  the  act  of  micturition  should  be  noted 
by  making  the  patient  pass  the  first  and  last  portions  of  the  urine 
into  separate  vessels  from  that  in  which  he  passes  the  bulk;  if  the 
urine  in  all  three  vessels  is  equally  discoloured,  the  haemorrhage 
usually  comes  from  the  kidneys ;  if  most  of  the  blood  is  in  the  first 
vessel,  it  comes  from  the  urethra  or  prostate,  whilst  if  the  bulk  of  it 
is  contained  in  the  last  vessel,  it  is  probably  derived  from  the  bladder. 
(d)  Microscopical  examination  of  the  urine  may  lead  to  the  discovery 
of  shreds  of  tumour,  epitheHal  cells,  or  blood-casts,  which  could  be 
alone  derived  from  some  special  part  of  the  urinarv  track.  By  these 
means  the  source  of  the  haemorrhage,  whether  from  kidney,  bladder, 
prostate,  or  urethra,  may  be  detected,  and  an  opinion  formed  as  to 
the  nature  of  the  disease. 

Pyuria  is  the  term  appHed  to  the  admixture  of  pus  or  muco-pus 
with  the  urine.  It  always  results  from  inflammatory  affections  of 
the  mucous  membrane  lining  the  urinary  passages,  and  may  be  renal, 
vesical,  prostatic,  or  urethral  in  origin;  the  methods  of  investigation, 
in  order  to  ascertain  its  exact  source,  are  the  same  as  for  hagmaturia. 

Pus  in  urine  is  mainly  recognised  by  the  microscope,  whilst-  on  the 
addition  of  liquor  potassse  it  becomes  ropy. 

Chyluria  arises  from  distension  or  rupture  of  the  lymphatic 
vessels  in  the  \-esical  mucous  membrane,  and  is  usually  due  to  the 
presence  of  the  Filaria  sanguinis  hominis  (p.  361).  The  urine  is 
milky  in  colour,  and  on  microscopical  examination  this  is  found  to 
be  due  to  the  presence  of  an  emulsion  of  fat. 

Urinary  Deposits  of  various  kinds  are  of  frequent  occurrence,  and 
require  for  their  investigation  both  chemical  and  microscopic 
examination.  Uric  or  lithic  acid  is  eliminated  in  the  form  of 
'  cayenne-pepper  '  granules,  usually  known  as  gravel.  On  micro- 
scopic examination,  the  granules  are  found  to  consist  of  flat  rhom- 
boidal,    lozenge-shaped    plates,    or    masses    of    acicular    crystals 


1 1 84 


A   MANUAL  OF  SURGERY 


(Fig.  536).  They  are  of  a  dusky  brownish-red  colour,  due  to  the 
absorption  of  urobilin,  the  normal  pigment  of  the  urine.  The  secre- 
tion in  these  cases  is  always  acid,  and  usually  of  high  specific 
gravity.  The  deposit  is  not  soluble  in  boiling  water,  but  readily  so 
in  alkaline  fluids;  and  on  re-acidulating  such  a  solution,  the  uric 
acid  is  precipitated  in  the  shape  of  white  needle-shaped  crystals. 

Urates  or  lithates  of  potassium,  sodium,  or  ammonium  are  of  fre- 
quent occurrence  in  the  urine,  appearing  as  a  deposit  of  amorphous 
granules  of  variable  colour,  according  to  the  amount  of  urinary  pig- 
ment present,  and  this  is  often  known  as  a  '  lateritious,'  or  brick-dust 
sediment.  The  ammonium  salt  is  sometimes  found  in  the  shape  of 
spiculated  globular  bodies  (Fig.  537).  Urates  always  occur  in  acid 
urine  of  high  specific  gravity,  and  are  freely  soluble  in  boiling  water; 
on  the  addition  of  dilute  hydrochloric  acid  the  uric  acid  is  precipi- 
tated. The  murexide  test  may  be  applied  for  either  uric  acid  or  its 
salts;  it  consists  in  mixing  the  substance  to  be  tested  with  a  little 


Fig.  536. — Uric  Acid  Crystals. 


Fig.  537. — Urate  of  Ammonium 
IN  Amorphous  Granules  and 
Hedgehog-shaped  Bodies. 


nitric  acid,  and  evaporating  to  dryness,  when  an  orange-red  dis- 
colouration is  produced,  which  on  the  addition  of  liquor  ammoniae 
changes  to  a  deep  purple-red. 

A  deposit  of  uric  acid  or  urates  is  either  a  temporary  condition 
dependent  on  some  trivial  derangement  of  the  system,  or  a  pheno- 
menon constantly  recurring  and  due  to  too  great  an  indulgence  in 
nitrogenous  food,  too  little  fresh  air  and  exercise,  or  imperfect  diges- 
tion, the  result  of  some  hepatic  disturbance.  It  is  also  noted  in  con- 
ditions where  great  tissue  change  is  occurring,  as  after  violent  exer- 
cise or  in  fevers.  Under  these  circumstances  the  materials  which 
should  be  changed  into  urea  are  transformed  into  uric  acid  or  its 
salts.  When  such  a  tendency  is  continually  present,  the  patient  is 
said  to  be  suffering  from  Lithiasis  or  Lithsemia.  Should  the  material 
thus  formed  not  be  eliminated,  an  attack  of  gout  is  hkely  to  super- 
vene, whilst  it  must  always  be  borne  in  mind  that  the  formation  of  a 
uric  acid  calculus  is  merely  a  manifestation  of  the  same  diathesis, 
which  needs  careful  treatment  after  the  removal  of  the  stone,  if  a 
recurrence  is  to  be  prevented. 

The  Treatment  of  lithaemia  or  lithiasis  consists  mainly  in  attention 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


1185 


to  the  personal  hygiene.  The  patient's  diet  is  regulated,  all  sweets, 
pastry,  and  alcoholic  stimulants  (with  the  exception,  perhaps,  of  a 
little  whisky  well  diluted  with  lithia  or  potash  water)  being  avoided. 
Fish  and  poultry  are  permitted,  but  butcher's  meat  is  forbidden. 
Regular  habits  are  enforced,  and  plenty  of  outdoor  exercise  recom- 
mended. The  hepatic  secretion  is  stimulated,  and  the  bowels  regu- 
lated by  the  administration  of  saline  purgatives,  especially  natural 
mineral  waters  [e.g.,  Friedrichshall,  Carlsbad,  or  Hunyadi  Janos), 
whilst  an  occasional  dose  of  blue  pill  or  podophyllin  is  advisable. 
Lithia  salts  and  piperazine  have  also  been  employed  with  advantage. 
A  course  of  treatment  at  a  recognised  spa  is  most  useful  in  these 
cases. 

Oxalate  of  lime  usually  occurs  in  the  urine  of  dyspeptic  and  hypo- 
chondriacal patients,  who  are  pale,  nervous,  and  irritable.  It  is  "sup- 
posed to  arise  from  the  incomplete  oxidation  of  carbohydrate  foods. 
The  urine  is  of  low  specific  gravity,  pale  and  abundant  in  quantity, 
and  slightly  acid  in  reaction;  an  excess  of  mucus  is  usually  present, 
causing  the  crystals  to  adhere  to  any  irregularities  in  a  test-glass. 


Fig.  537A. — Oxalate  OF  Lime  IN 
Octahedral  Crystals  and 
Dumb-bell-shaped  Masses. 


Fig.  53S. — Crystals   of  Triple  Phos- 
phate IN  Urine. 


On  microscopic  examination  they  are  found  to  be  regular  octahedra, 
or  in|the  shape  of  dumb-bells  (Fig.  537 a).  The  treatment  of  oxaluria 
consists  in  regulation  of  the  diet,  which  must  be  light  and  nourishing, 
all  heavy  food  being  avoided,  as  also  rhubarb,  which  contains  large 
quantities  of  oxalates,  and  the  patient  is  directed  to  drink  only  boiled 
or  distilled  water.  Tonics,  such  as  mineral  acids,  iron,  and  quinine, 
ma}'  be  ordered,  but  the  best  treatment  consists  in  change  of  air  and 
removal,  if  possible,  from  causes  of  anxiety-  and  worr\'. 

Phospkatic  deposits  in  the  urine  occur  in  three  forms :  (i.)  The  triple, 
or  ammonio-magnesic,  phosphate  is  found  in  alkaline  or  decom- 
posing urine,  and  is  alwaj's  vesical  in  origin.  It  exists  in  the  form 
of  hexagonal  prisms,  three  of  the  sides,  however,  being  very  narrow; 
the  ends  also  are  bevelled  off,  so  that  the  appearance  of  a  '  knife-rest  ' 
is  produced  (Fig.  538).  (ii.)  The  amorphous  phosphate  of  lime  is 
exceedingly  common,  forming  the  main  mass  of  any  phosphatic 
sediment.  It  is  always  present  in  chronic  cystitis,  and  is  not  unfre- 
quently  met  with  a  few  hours  after  a  meal,  constituting  what  is 
known  as  the  '  alkaline  tide. '  This  condition  is  often  observed  about 
twelve  o'clock  in  the  morning,  especially  if  ari  alkaline  saline  purga- 

75 


1 1 86  A   MANUAL.  OF  SURGERY 

tive  lias  been  taken  before  breakfast,  llie  plios])hatic  material 
is  voided  at  the  end  of  the  act  of  micturition,  and  may  give  rise  to 
considerable  anxiety  on  the  part  of  the  patient,  who  mistakes  it  for 
seminal  fluid,  (iii.)  The  most  usual  condition  in  which  phosphates 
are  met  with  in  urine  is  a  mixture  of  the  two  varieties  described 
above.  \\'hichever  form  is  present,  the  deposit  becomes  more 
evident  on  boiling,  disappearing,  however,  on  the  addition  of  a  few 
drops  of  acetic  acid.  The  treatment  of  phosphaturia  is  always 
directed  to  the  vesical  condition,  except  in  those  unusual  cases 
where  it  is  due  to  some  constitutional  error. 

A  bacteriological  examination  of  the  urine  has  often  to  be 
made  in  order  to  make  sure  of  the  diagnosis  of  a  case.  Bacteria 
may  find  their  way  into  the  urinary  passages  through  the  kidneys, 
or  gain  an  entrance  to  the  bladder  per  urethram,  and  thence  spread 
up  the  ureters,  or  may  obtain  a  foothold  in  some  part  of  the  walls 
of  the  urinary  track  and  thence  become  disseminated.  Sometimes 
they  are  present  in  great  abundance,  and  render  the  urine  opalescent 
to  the  naked  eye  (bacilluria),  but  have  little  or  no  effect  upon  the 
lining  walls.  Care  in  diagnosis  must  be  taken  to  ensure  that  the 
sample  examined  has  not  been  contaminated  by  passage  through 
the  external  organs ;  this  is  especially  needful  in  women,  and,  indeed, 
no  bacteriological  examination  of  the  urine  of  a  woman  is  of  any 
value  which  has  not  been  secured  by  aseptic  catheterism.  Bacilluria 
is  a  condition  of  frequent  occurrence  in  women,  and  the  Bacillus  coli 
is  the  organism  most  often  present.  In  some  conditions  the  number 
of  bacteria  present  is  so  small  that  they  can  only  be  found  on  a  careful 
search  after  straining  the  centrifugahzed  deposit  from  the  urine — e.g., 
the  B.  tuberculosis  in  various  tuberculous  affections  of  the  kidney  or 
bladder;  it  is  sometimes  impossible  to  find  them  microscopically, 
and  then  inoculation  experiments  with  the  deposit  must  be  under- 
taken. 

5.  Finally,  a  radiographic  examination  of  the  kidnej^s  and 
ureters  is  often  necessary  in  order  to  ascertain  whether  anything 
in  the  form  of  a  calculus  is  present.  The  use  of  a  soft  tube  will  often 
enable  the  lower  pole  of  a  normal  kidney  to  be  detected ;  still  more 
obvious  does  the  same  part  of  an  abnormally  enlarged  organ  appear, 
especially  if  the  seat  of  chronic  inflammatory  trouble  or  of  a 
malignant  tumour. 

There  is  now  not  much  difficulty  in  making  certain  of  the  presence 
or  absence  of  a  stone  in  the  kidney  or  ureter,  although  the  per- 
meability to  the  rays  of  a  pure  uric  acid  calculus  still  renders  mistakes 
possible.  A  large  stone  of  this  character  held  in  the  hand  in  front 
of  the  screen  cast  no  shadow  deeper  than  the  muscles  of  the  thenar 
eminence.  Oxalate  calculi,  or  those  formed  of  phosphates,  cystine, 
or  of  a  mixed  composition,  ought  in  all  cases  to  be  demonstrable, 
and  their  number,  site,  and  position  ascertainable. 

The  differential  diagnosis  of  the  shadows  of  calculi  from  those 
produced  by  other  conditions  which  may  appear  on  the  plates  has 
been  rendered  easier  by  the  more  perfect  detail  which  can  now  be 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1187 

obtained  in  the  radiogram.  In  most  cases  it  is  possible  to  show  the 
outhne  of  the  kidney,  as  well  as  the  stones  contained  in  it  (Fig.  542), 
and  one  can  thus  eliminate  the  shadows  produced  by  calcified 
mesenteric  glands,  bowel  contents,  or  appendicular  concretions 
(Fig.  495).  Gall-stones  as  a  rule  cast  no  shadow,  but  occasionally 
some  abnormal  change  in  the  gall-stone  makes  it  visible,  and  this 
may  lead  to  a  mistake  in  diagnosis. 

The  positi\'e  diagnosis  of  ureteral  calculi  (Fig.  543)  is  sometimes 
more  difficult,  as  they  have  to  be  distinguished  from  phleboliths, 
calcified  pelvic  glands,  appendicular  concretions,  bowel  contents, 
calcified  appendices  epiploicse,  and  calcified  uterine  fibroids,  whether 
pedunculated  or  sessile.  It  may  be  necessary  to  pass  an  opaque 
bougie  up  the  ureter  and  repeat  the  examination  before  a  diagnosis 
can  be  made.  Pel\-ic  glands  are  nearly  always  circular  and  frequently 
multiple,  although  it  is  not  uncommon  to  find  a  single  calcified  gland 
opposite  and  internal  to  the  ilio-pectineal  eminence  on  one  or  both 
sides.  Calcified  inguinal  glands  are  easily  recognised  by  their 
superficial  position  on  stereoscopic  examination.  Bowel  contents 
are  excluded  by  repeating  the  examination  after  effective  purgation, 
and,  indeed,  this  is  a  course  which  should  always  be  followed  except 
in  cases  which  are  absolutely  characteristic.  Calcified  fibroids  simu- 
lating ureteral  or  vesical  calculi  can  generally  be  detected  on  clinical 
examination. 

The  details  of  radiographic  methods  for  ensuring  good  results 
cannot  be  entered  into  here,  as  they  are  too  specifically  technical; 
but  one  may  note  that  the  first  essential  to  success  is  the  effective 
preparation  of  the  patient,  and  the  second  complete  immobilization 
of  the  area  of  examination.  A  general  ^^ew,  including  both  loins 
and  the  upper  ureteral  regions,  should  first  be  taken,  and  sub- 
sequently the  affected  side  should  be  more  carefully  examined 
through  some  form  of  diaphragm  to  limit  the  diffusion  of  the  rays. 

The  preparation  of  the  patient  for  the  examination  is  of  great 
importance,  especially  in  one  of  heav}'  build.  The  intestine  must 
be  empty  in  order  to  get  good  results,  and  the  patient  should,  if 
possible,  be  kept  on  light  diet  for  some  days  previously.  A  course 
of  purgation  for  two  or  three  days,  followed  by  a  long-tube  enema 
on  the  morning  of  the  examination  before  the  patient  has  had  any 
food,  is  the  ideal  preparation. 

In  addition  to  calculi,  the  X-rays  are  capable  of  demonstrating  the 
existence  of  calcified  caseous  deposits  in  old-standing  tuberculous 
kidneys,  and  by  injecting  some  10  per  cent,  collargol  up  the  ureter 
through  an  ureteral  catheter,  and  subsequently  X-raying  the  side, 
it  is  possible  to  demonstrate  the  size  and  shape  of  the  pelvis  of  the 
kidney. 

Congenital  Affections  of  the  Kidney.- — Many  different  malforma- 
tions and  displacements  are  met  with  affecting  this  organ. 

The  chief  Malformations  are  as  follows:  (i)  Complete  absence  of 
one  organ,  a  very  rare  condition.  (2)  Congenital  atrophy  of  one 
kidney;  it  being  represented  by  a  mass  of  fatty  tissue.     In  both 


[1 88  A   MANUAL  OF  SURGERY 

cases  the  other  kidney  is  correspondingly  enlarged  and  hypertro- 
phied.  (3)  The  kidneys  may  be  fused  together,  either  forming 
one  large  organ  in  the  median  line  and  more  or  Kss  normal  in  shape, 
or  sometimes  constituting  the  so-called  horseshoe  kidney,  the  con- 
vexity being  directed  downwards.  The  latter  condition  is  not  very 
uncommon,  being  present  once  in  about  1,100  bodies  examined;  it 
is  usually  associated  with  an  increased  number  of  ureters  or  renal 
vessels.  (4)  Deep  lobulation  of  the  kidney,  as  in  some  animals,  is 
occasionally  seen,  especially  if  the  organ  is  displaced;  this  may  be 
carried  to  such  an  extent  as  to  divide  it  into  two  or  more  portions. 
(5)  The  ureter  and  pelvis  may  be  double,  this  malformation  affecting 
the  pelvis  alone,  or  extending  as  far  as  the  bladder.  (6)  The  renal 
artery  may  arise  from  the  aorta  in  two  or  more  main  branches. 

The  majority  of  these  malformations  are  of  very  little  clinical 
importance,  except  in  the  operation  of  nephrectomy,  when  they  may 
necessitate  some  modification  of  the  usual  proceedings. 

Congenital  Displacement  of  the  Kidney  occurs  about  once  in  every 
thousand  individuals,  the  organ  being  either  depressed,  so  as  to  lie 
over  the  sacro-iliac  synchondrosis  or  sacral  promontory,  or  raised 
above  its  normal  position.  The  left  kidney  is  more  frequently 
affected  in  this  way  than  the  right,  and,  when  lying  in  the  iliac  fossa, 
the  descending  colon  is  usually  displaced  inwards,  so  that  the  rectum 
starts  to  the  light  of  the  middle  hue.  The  adrenal  bodies  retain 
their  normal  position,  and  do  not  move  with  the  kidney. 

Cystic  disease,  sarcoma,  and  hydronephrosis  may  also  occur 
congenitally,  and  will  in  turn  be  described  below. 

Floating  and  Moveable  Kidney. — The  normal  kidney  is  not  a  fixed 
organ,  but  moves  up  and  down  on  respiration,  although  usually  this 
movement  cannot  be  detected  on  palpation.  It  is  therefore  neces- 
sary to  define  as  precisely  as  possible  what  is  meant  clinically  by  the 
terms  '  moveable  '  and  '  floating  '  kidney.  Three  stages  of  abnormal 
mobility  may  be  described:  (i.)  A  palpable  kidney  is  one  the  lower 
half  or  more  of  which  can  be  definitely  felt  on  deep  inspiration, 
(ii.)  A  moveable  kidney  is  one  in  which  the  examining  hand  can  define 
the  upper  end  of  the  organ,  and  can  restrain  it  from  returning  to  its 
old  position  during  expiration,  (iii.)  A  floating  kidney  is  one  which 
can  be  moved  freely  about  the  abdomen  in  all  directions,  and  even 
across  the  middle  line  in  some  cases.  Formerly  this  last  term  was 
applied  to  a  supposed  congenital  lesion,  in  which  the  kidney  was 
attached  to  the  posterior  abdominal  wall  by  means  of  a  mesentery; 
it  is  more  than  doubtful  whether  such  a  condition  exists. 

In  the  earlier  stages  the  movements  occur  within  the  fatty  capsule 
which  surrounds  the  organ,  but  later  on  mild  attacks  of  inflammation 
attach  the  fatty  to  the  fibrous  capsule,  and  the  kidney  with  its 
associated  fatty  envelope  moves  behind  the  peritoneum.  Two  forms 
of  movement  are  possible:  (i.)  An  up-and-dowai  or  in-and-out  move- 
ment in  one  plane  {cinder-sifting  movement),  the  kidney  merely 
swinging  on  its  pedicle;  or  (ii.)  a  movement  of  torsion  may  accom- 
pany this,  either  round  a  transverse  axis  when  the  lower  end  of 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1189 

the  kidney  becomes  prominent,  or  round  a  vertical  axis  when  the 
outer  convex  border  swings  forwards.  In  the  latter  case  kinking 
of  the  ureter  or  renal  vessels  is  very  likely  to  ensue. 

Mo\-eable  kidney  occurs  more  frequently  in  women  than  in  men 
(10  to  i),  and  more  often  on  the  right  than  on  the  left  side  (12  or  13 
to  i),  partly  because  the  renal  vessels  are  longer  on  this  side  than  on 
the  other,  and  parth"  because  the  descending  colon  is  more  fixed  than 
the  ascending. 

Causes. — -The  kidney  is  placed  between  the  layers  of  the  peri- 
nephric fascia,  which  in  turn  are  derived  from  a  splitting  of  the 
fascia  transversalis.  In  children  this  perinephric  capsule  is  attached 
closely  to  the  kidney  front  and  back  without  any  intervening  fat; 
but  as  development  proceeds,  fat  is  packed  in  around  the  kidney 
in  increasing  amount,  and  hence  in  stout  subjects  the  perinephric 
capsule  is  considerably  distended,  and  the  kidney  is  firmly  supported. 
In  addition  to  this,  however,  the  tension  of  the  peritoneimi,  the  main- 
tenance of  the  intra-abdominal  pressure,  and  the  support  of  the 
muscular  abdominal  parietes,  have  much  to  do  in  keeping  it  in 
place.  Anj-thing  that  seriously  modifies  these  three  factors  may  lead 
to  displacement  and  mobihty"  of  the  organ.  Parturition  accounts 
for  some  cases;  firstty,  because  of  the  sudden  diminution  of  the 
intra-abdominal  pressure,  and,  secondly,  owing  to  the  resulting 
pendulous  and  relaxed  state  of  the  abdominal  muscles,  especially 
if  the  patient  too  early  resumes  the  erect  posture,  or  undertakes 
physical  work  without  efficient  external  support;  hence  it  is  more 
frequent  among  the  poor  than  amongst  the  rich.  It  may  also  follow 
the  removal  of  large  abdominal  tumours  which  stretch  the  abdominal 
w^alls,  or  rapid  emaciation,  whereby  the  perinephric  fat  is  absorbed, 
whilst  tight-lacing  or  traumatic  influences  may  be  responsible  for 
some  cases.  It  is  frequently  associated  with  that  form  of  displace- 
ment downwards  of  the  abdominal  viscera  w^hich  is  known  as 
Glenard's  disease,  or  enteroptosis  (p.  1028).  Constipation  is  an  im- 
portant element  in  the  production  of  moveable  kidney,  and  probably 
acts  by  the  loaded  csecum  dragging  upon  the  anterior  layers  of  the 
perinephric  fascia,  and  thus  displacing  it  forwards. 

Symptoms. — A  moveable  kidney  is  often  discovered  by  accident, 
and  may  be  entirely  free  from  s\aTiptoms.  In  some  cases  the  patient 
comes  under  observation  because  she  has  observed  a  moveable  lump 
in  the  abdomen,  which  on  handling  is  painful,  the  pain  being  often 
associated  with  nausea  and  vomiting.  In  other  cases,  pain  and 
vomiting  bring  the  patient  under  observation,  the  doctor  discovering 
the  moveable  kidney.  The  pain  is  referred  to  the  back,  or  perhaps 
shoots  along  the  ureter  to  the  groin,  testis,  or  labium,  majus. 
Vomiting  is  a  significant  sign,  and  the  surgeon  should  never  omit  to 
examine  the  loins  in  cases  of  obstinate  vomiting  with  no  apparent 
cause.  Periodical  exacerbations  of  these  symptoms,  with  a  tem- 
porary diminution  in  the  amount  of  urine,  result  from  kinking  of  the 
ureter  {Dietl's  crises) ;  sudden  relief,  followed  by  an  increased  flow  of 
urine,  possibly  containing  some  muco-pus,  indicates  that  the  organ 


1 1  go  A   MANUAL  OF  SURGERY 

has  returned  to  its  normal  situation.  Repeated  attacks  of  this  type 
may  result  in  pyelitis  and  hydronephrosis.  On  examining  the 
abdomen,  a  moveable  tumour  can  often  be  observed  with  ease  if  the 
abdominal  parietes  are  not  loaded  with  fat,  and  on  manipulation 
pain  and  vomiting  may  be  induced.  The  adoption  of  the  genu- 
pectoral  position  will  sometimes  enable  a  moveable  kidney  tr  be 
more  certainly  felt,  whilst  a  distinct  loss  of  resistance  is  noticed 
external  to  the  erector  spiucC  on  the  affected  side. 

The  patient  is  usually  of  a  neurotic  t^^pe,  but  possibly  this  may 
result  in  part  from  the  mobility  of  the  organ  which  necessarily 
involves  a  certain  amount  of  traction  upon  the  sympathetic  centres 
in  the  abdomen.  Evidence  of  the  displacement  of  other  abdominal 
viscera  is  often  found,  so  that  the  detection  of  a  moveable  kidney 
does  not  necessarily  explain  the  whole  case,  or  indicate  operation. 
After  many  an  operation  for  moveable  kidney,  the  symptoms  (pain, 
vomiting,  etc.)  have  persisted,  even  though  the  organ  remained 
anchored  to  the  abdominal  wall. 

Treatment. — In  the  great  majority  of  cases  of  moveable  kidney 
operation  is  not  required,  and,  indeed,  it  is  usually  unwise  to  tell  the 
patient  that  such  a  condition  is  present.  If  it  is  associated  with 
marked  debility,  bodily  or  nervous,  and  perhaps  with  general 
enteroptosis,  a  rest-cure  in  bed  for  six  weeks,  with  abdominal  and 
general  massage  and  an  abundance  of  milk  and  fatty  foods,  will  do 
much  to  steady  the  kidney  and  improve  the  general  condition. 
The  application  of  a  carefully-fitted  kidney  support  will  then  suffice 
to  keep  her  comfortable.  This  may  consist  of  an  abdominal  truss, 
with  an  end  shaped  like  a  cup  to  fit  over  the  kidney,  or  of  an  air- 
cushion  fitted  into  an  abdominal  belt.  The  cushion  should  be 
triangular  in  shape,  its  sides  corresponding  to  the  costal  border, 
Poupart's  ligament,  and  the  linea  semilunaris;  it  is  put  on  in  the 
recumbent  posture,  and  for  choice  with  the  pelvis  raised. 

The  indications  for  operation  are — (i)  Extreme  mobility,  so  that 
the  organ  cannot  be  fixed  by  a  support;  (2)  extreme  tenderness,  so 
that  a  support  cannot  be  tolerated ;  (3)  the  recurrence  of  acute  attacks 
of  pain  and  vomiting  (Dietl's  crises) ;  (4)  persistent  discomfort  in  the 
loin,  combined  with  dyspeptic  symptoms,  vomiting,  and  a  great 
variety  of  neurasthenic  manifestations :  as  a  rule  a  kidney  sufficiently 
mobile  to  produce  such  symptoms  is  tender  to  the  touch,  and 
examination  causes  pain  and  nausea;  and  (5)  the  supervention  of 
hydronephrosis  or  pyelitis. 

Nephrorrhaphy  01  Nephropexy  is  the  name  applied  to  the  operation 
for  fixing  the  kidney.  It  is  obvious  that  a  rounded  body  like  the 
kidney  with  a  smooth  fibrous  capsule  is  not  easily  fixed,  and  the 
more  so  since  the  renal  parenchyma  has  great  absorbent  power,  so 
that  sutures,  even  of  silk,  passed  through  its  substance  are  readily 
disintegrated  and  absorbed;  hence,  although  the  kidney  may  seem 
to  be  efficiently  immobilized  at  the  completion  of  the  operation,  it 
readily  becomes  loose  again.  There  are  only  two  certain  methods  of 
fixing  the  organ,     (i.)  The  wound  down  to  the  kidney  is  left  open 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1191 

and  jxickeid  with  gauze,  so  that  heahng  occurs  by  granulation;  the 
cure  is  certain,  but  tedious,  and  a  lumbar  hernia  may  follow,  (ii.)  The 
plan  now  usually  adopted  is  to  expose  the  organ  through  the  loin. 
The  fatty  covering  is  opened,  and  as  much  of  it  as  possible  removed. 
A  portion  of  the  true  fibrous  capsule  is  now  dissected  up  and  fixed 
to  the  abdominal  parietes  so  as  to  expose  the  raw  and  slightly 
bleeding  cortex.  Many  methods  of  dealing  with  the  capsule  have 
been  suggested,  but  it  matters  little  which  is  employed.  The  follow- 
ing plan  suggested  by  Mr.  W.  Billington,  of  Birmingham,*  has  been 
extensively  tested,  and  gives  excellent  results.  A  lateral  incision  is 
employed,  extending  from  just  above  the  last  rib  almost  vertically 
down  to  the  crista  ilii;  the  muscles  are  divided;  the  last  dorsal  nerve 
is  retracted  and  protected;  and  the  kidney  in  its  fatty  capsule  ex- 
posed and  cleared.  The  upper  half  of  the  fibrous  capsule  is  then 
dissected  up  from  the  posterior  surface  and  carried  round  the  last 
rib  to  serve  as  a  sling  to  the  kidney;  the  apex  of  this  flap  is  secured 
to  its  own  base.  Two  silkworm-gut  stitches  are  passed  under  the 
capsule  of  the  lower  half  of  the  organ  in  a  semicircular  fashion,  and 
carried  through  the  muscles  and  skin  at  the  upper  angle  of  the 
incision,  being  finally  tied  over  a  pad  of  gauze  and  retained  in  situ 
for  three  weeks.  The  wound  is  then  closed  in  the  usual  way,  and 
dressed,  special  care  being  taken  to  exercise  pressure  over  the  right 
iliac  fossa  below  the  kidney  by  a  suitable  pad  of  sterilized  wool. 
The  organ  is  thus  firmly  fixed,  but  it  is  wise  to  keep  the  patient 
in  bed  for  four  or  five  weeks  subsequently,  to  allow  of  consolidation, 
and  afterwards  a  binder  or  belt  should  be  worn  for  a  time. 

Injuries  of  the  Kidney  are  usually  due  to  crushes  of  the  body,  as 
between  the  buffers  of  railway  cars,  or  when  a  cart  passes  over  the 
abdomen,  or  from  blows  or  falls.  Considerable  haemorrhage  follows, 
both  into  the  substance  of  the  kidney  or  its  pelvis,  and  into  the  peri- 
nephric fatty  tissue,  and  this  even  when  the  capsule  has  not  been 
torn.  The  integrity  of  this  structure  is  a  point  of  great  impoi"tance, 
since  it  limits  to  some  extent  the  bleeding  and  prevents  urinary 
extravasation;  the  kidney  may  be  crushed  to  a  pulp  without  any 
external  hsemorrhage,  and  under  these  circumstances  clots  are  likely 
to  pass  down  the  ureter,  and  may  obstruct  it  and  lead  to  its  subse- 
quent occlusion.  When  the  anterior  portion  of  the  capsule  is  torn, 
the  peritoneum  may  also  be  involved,  especially  in  children,  and  then 
evidences  of  intraperitoneal  bleeding  may  manifest  themselves,  and, 
indeed,  if  the  kidney  is  extensively  lacerated,  fatal  haemorrhage  may 
result,  though  this  is  unusual.  Rupture  of  the  posterior  surface  of 
the  kidney  opens  up  the  perinephric  cellular  tissue,  which  becomes 
infiltrated  with  blood  and  urine,  and  suppuration  is  almost  certain  to 
follow,  resulting  in  pyaemia,  or  at  a  later  date  in  exhaustion  from 
chronic  septic  poisoning.  Not  unfrequently  other  severe  injuries  are 
present,  such  as  fracture  of  the  pelvis,  spine,  or  skull,  bruising  or 
tearing  of  intestine  or  liver,  and  from  these  associated  lesions  serious 
phenomena  may  arise. 

*  British  Medical  Journal,  November  30,  1907. 


1 192  A   MANUAL  OF  SURGERY 

The  Symptoms  consist  in  severe  shock,  followed  by  nausea,  vomit- 
ing, pain  in  the  loin,  shooting  down  into  the  testis  or  thigh,  localized 
tenderness  and  perhaps  swelling  over  the  injured  organ,  and  haema- 
turia.  The  amount  of  blood  lost  in  this  way  varies  considerably ;  in 
the  slighter  cases  the  haematuria  is  of  short  duration,  but  in  more 
extensive  lesions  it  may  be  severe  and  so  persistent  as  to  threaten  life. 
The  passage  of  clots  down  the  ureter  gives  rise  to  renal  colic,  and 
obstruction  of  that  duct  may  lead  to  total  suppression  of  the  secre- 
tion on  the  affected  side.  The  bladder  may  in  some  cases  become 
greatly  distended  with  clots,  the  blood  coagulating  after  it  has  entered 
the  viscus.  Haemorrhage  into  the  perinephric  tissues  is  indicated  by 
the  formation  of  a  swelling  in  the  loin,  and  laceration  of  the  peri- 
toneum is  followed  by  distension  of  the  abdomen,  increasing  anaemia 
from  persisting  haemorrhage,  and  the  onset  of  peritonitis.  The 
development  of  a  perinephritic  abscess  is  recognised  by  fever,  rigors, 
increased  pain  in  the  loin,  and  the  usual  phenomena  of  deep  sup- 
puration (p.  1200). 

The  Treatment  usually  required  is  to  keep  the  patient  quiet  in  bed, 
with  an  icebag  or  Leiter's  tubes  applied  to  the  loin;  pain  may  be 
relieved  by  strapping  the  side  or  by  applying  a  firm  bandage.  Per- 
sistent haemorrhage  necessitates  the  administration  of  ergot,  tannic 
acid,  or  turpentine;  but  if  it  is  threatening  the  patient's  life,  an 
exploratory  incision  is  required,  and,  if  need  be,  removal  of  the 
organ,  although  it  is  sometimes  possible  to  stitch  up  a  limited  rent, 
the  sutures  being  passed  deeply  through  the  glandular  tissue.  Some- 
times the  blood  does  not  escape  externally,  and  then  the  rapid  de- 
velopment of  a  swelling  in  the  loin,  with  increasing  anaemia  and 
rapidity  of  pulse-rate,  would  indicate  that  operation  is  desirable. 
Distension  of  the  bladder  must  be  relieved,  the  clots  being  washed 
out  through  a  large-eyed  catheter.  The  occurrence  of  peritonitis 
or  of  a  perinephritic  abscess  will  call  for  suitable  surgical 
measures,  the  injured  viscus  being  dealt  with  according  to  its 
condition. 

Rupture  of  the  Ureter  is  a  rare  accident,  usually  due  to  direct 
violence,  but  occasional^  happening  during  pelvic  operations,  such 
as  removal  of  the  uterus.  When  the  result  of  a  subcutaneous  injury, 
it  cannot  be  recognised  at  once,  but  extravasation  of  urine  takes 
place,  leading  to  the  formation  of  a  perinephritic  abscess.  This  is 
incised  sooner  or  later,  and  on  exploring  the  cavity  it  may  be  possible 
to  detect  the  rent  in  the  ureter,  but  more  frequently  its  situation 
cannot  be  found,  and  then  a  doubt  will  necessarily  exist  as  to  whether 
the  lesion  involves  the  ureter  or  the  pelvis  of  the  kidney.  In  either 
case  a  urinary  fistula  in  the  loin  results,  which  may  possibly  close 
after  a  time ;  if  the  fistula  persists,  nephrectomy  will  be  required,  and 
then  the  sooner  such  an  operation  is  undertaken  the  better.  In  a 
few  favourable  cases  it  has  been  possible  to  suture  the  rent  in  the 
ureter  by  the  following  plan:  The  lower  end  of  the  divided  ureter  is 
closed,  the  exposed  mucous  membrane  being  tucked  in  by  sutures 
passing  through  the  muscular  coat ;  the  upper  end  is  then  implanted 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  ii93 

into  a  longitudinal  opening  made  in  the  side  of  the  lower  segment, 
and  accurately  stitched  in  position. 

Two  cases  probably  of  this  natui'e  came  under  treatment  at  hospital.  Both 
occurred  in  young  boys,  and  both  were  due  to  cab  accidents.  In  the  first,  alter 
the  preliminary  shock  had  passed  off,  nothing  special  was  noted  for  about  ten 
days,  when  on  sitting  up  sharp  pain  was  experienced  in  the  side,  and  this  was 
followed  by  a  retroperitoneal  collection  of  fluid,  together  with  some  amount  of 
fever.  On  incision  a  large  quantity  of  limpid  urine  escaped,  with  but  very 
little  pus — an  interesting  illustration  of  the  fact  that  healthy  urine  does  com- 
paratively little  damage  to  tissues  into  which  it  is  extravasated .  The  finger 
introduced  into  the  wound  passed  beyond  the  middle  line,  and  the  ureter  could 
be  felt  traversing  the  cavity;  but  the  rent  could  not  be  found.  Drainage  was 
provided,  and  for  a  time  a  urinary  fistula  persisted;  finally,  the  wound  healed 
completely.  In  the  second  case  the  inflammatory  phenomena  were  more 
marked,  but  an  incision  was  not  made  until  the  twelfth  day;  here  also  the  lesion 
could  not  be  found,  and  drainage  was  resorted  to,  but  without  avail,  nephrec- 
tomy being  subsequently  required.     Both  children  recovered. 

Hydronephrosis  is  a  condition  characterized  by  distension  of  the 
pelvis  and  calyces  with  urine,  as  a  result  of  some  obstruction  to  its 
exit. 

Causes. — (i.)  It  may  be  congenital  in  origin.  It  must  be  borne  in 
mind  that  the  body  of  the  kidney  is  developed  from  the  metanephros, 
and  that  the  ureter  unites  subsequently  with  it  to  form  its  excretory 
duct;  such  union  is  occasionally  defective  at  the  upper  end,  well- 
marked  obstruction  occurring  at  the  junction  of  the  ureter  with  the 
infundibulum  of  the  pelvis.  Similar  trouble  sometimes  arises  from 
the  ureter  becoming  kinked  over  an  abnormally-placed  renal  artery. 
It  is,  however,  more  frequently  due  to  an  impervious  condition  of  the 
urethra,  or  to  the  existence  of  a  membranous  septum  therein ;  both 
kidneys  are  then  necessarily  affected.  The  amount  of  distension  in 
some  of  these  cases  is  such  as  to  interfere  seriously  with  parturition 
until  the  abdomen  has  been  tapped.  The  infants  are  often  born  dead, 
or  succumb  shortly  after  birth,  (ii.)  Acquired  forms  of  obstruction 
are  by  no  means  uncommon,  and  may  be  arranged  under  the  follow- 
ing heading:  (a)  Blocks  within  the  urinary  passages  from  the 
presence  of  stones,  parasites,  foreign  bodies,  or  even  blood-clot; 
(6)  changes  of  structure  affecting  the  walls  of  the  urinary  passages — 
e.g.,  inflammatory  swelling  of  the  mucosa,  cicatrices,  stenosis,  or 
tumours;  (c)  kinking  of  the  ureter  in  cases  of  floating  kidney;  and 
{d)  the  pressure  of  extrinsic  tumours  or  cicatrices,  as  after  pelvic 
cellulitis,  or  from  uterine  or  rectal  cancer.  Hydronephrosis  may  be 
unilateral  or  bilateral;  in  the  former  case  the  obstruction  arises 
within  the  ureter,  or  from  some  vesical  condition  involving  its 
entrance  into  the  bladder;  in  the  latter  case  the  cause  is  generally 
to  be  looked  for  below  this  spot. 

It  must  be  clearly  understood  that  a  sudden  and  absolute  block 
never  leads  to  hydronephrosis.  Should  it  occur  as  the  result  of  im- 
paction of  a  calculus  in  one  of  the  ureters  or  of  ligature  of  the  ureter, 
as  has  occurred  in  hysterectomy,  the  secretion  on  that  side  is  totally 
suppressed  as  soon  as  the  tension  within  the  pelvis  and  calyces  is 
sufficiently  high.      Atrophy  of  the  renal  epithelium  follows  after  a 


1194 


A   MANUAL  OP  SURGERV 


time,  but  if  the  obstruction  is  relieved  within  six  weeks  of  its  inci- 
dence, the  secretion  of  urine  will  probably  be  re-established.  Should, 
however,  the  obstruction  be  intermittent  or  incomplete,  so  that  some 
of  the  urine  escapes,  thereby  relieving  the  pressure,  hydronephrosis 
develops.  Sudden  and  complete  occlusion  of  the  urethra  Hkewise 
results  in  dilatation  of  the  bladder  and  rupture  either  of  that  viscus 
or  of  the  urethra,  whilst  a  gradually  increasing  obstruction  is  always 
likely  to  lead  to  hydronephrosis. 

Pathological  History.— The  earliest  result  of  obstruction  to  the 
flow  of  urine  consists  in  dilatation  of  the  ureter  and  pelvis,  which  is 
soon  followed  by  expansion  of  the  calyces.  Ihe  pyramids  are 
flattened,  and  the  cortex  expanded  and  thinned,  so  that  the  whole 
kidney  looks  larger  than  usual  (Fig.  539).  A  certain  amount  of  inter- 
stitial infiltration  of  the  cortex  is 
always  present ;  the  urine  secreted 
in  the  early  stages  is  usually 
abundant  and  of  low  specific 
gravity. 

If  the  obstruction  continues, 
the  renal  tissue  becomes  more  and 
more  atrophied,  until  finally  it  dis- 
appears entirely,  the  kidney  being 
represented  by  a  thin  -  walled 
multilocular  cyst.  At  any  stage 
septic  phenomena  may  supervene, 
giving  rise  to  pyonephrosis  {vide 
infra) . 

The  Clinical  History  varies  con- 
siderably with  the  method  of  onset 
and  the  cause  of  the  trouble.    Fre- 
quently all  that  happens  is  a  pain- 
FiG.  539.-HYDRONEPHROSIS.  (From  ^^ss  enlargement  of  the  affected 
Specimen   in    Bristol    Hospital  organ;    if    both   kidneys    are   in- 
MusEUM.)  volved,  there  may  be  at  first  some 

increase  in  the  amount  of  urine 
secreted,  which  is  pale,  limpid,  and  of  a  low  specific  gravity ;  after  a 
time  the  quantity  diminishes,  and  finally  anuria  and  uramia  follow, 
especially  if  septic  changes  supervene,  as  is  so  commonly  the  case. 
When  only  one  kidney  is  affected,  the  excretion  may  remain  normal  in 
quantity  and  quality,  owing  to  compensatory  hypertrophy  of  its 
fellow.  An  elastic  swelhng,  fluctuant  if  of  considerable  size,  is 
produced  by  hydronephrosis ;  it  presents  all  the  physical  signs  of  a 
renal  tumour  (p.  1176),  and  its  formation  maybe  associated  with 
pain,  vomiting,  and  increased  frequency  of  micturition.  Finally, 
a  perinephritic  abscess  may  develop,  owing  to  ulceration  of  the 
pelvis  or  ureter,  and  if  this  bursts  externally,  the  cyst  may  eventually 
discharge  through  the  loin.  Occasionally  the  size  of  the  tumour  varies 
considerably  from  time  to  time,  as  a  result  of  the  obstruction  being 
temporarily  overcome  by  the  pressure  of  retained  urine  behind  it. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1195 

When  due  to  a  congenital  stricture  of  the  upper  cud  of  the  ureter 
or  to  a  kink  over  a  branch  of  the  renal  artery,  there  is  usually  a 
history  of  occasional  attacks  of  painful  swelling  on  the  affected  side, 
which  has  disappeared  when  the  patient  rested.  Urinary  symptoms 
may  accompany  this,  but  it  is  often  supposed  to  be  a  bilious  attack, 
or  a  mild  appendicitis.  Some  pyelitis  may  follow,  but  sooner  or  later 
an  acute  attack  supervenes,  which  does  not  improve,  and,  if  left,  sup- 
puration and  perforation  will  follow.  Such  cases  are  by  no  means 
uncommon. 

The  Treatment  of  hydronephrosis  should  in  the  first  place  be 
directed  to  removal  of  the  cause,  if  practicable,  and  where  the 
obstruction  exists  in  the  prostate  or  urethra,  no  other  treatment  is 
feasible.  In  some  cases  of  congenital  hydronephrosis  due  to  mal- 
formation of  the  upper  end  of  the  ureter,  it  is  possible  to  transplant 
it  and  thereby  relieve  the  obstruction ;  or  the  pinhole  orifice  of  the 
ureter  may  be  exposed  within  the  pelvis,  and  divided  longitudinally, 
with  subsequent  stitching  open  of  the  margins.  This  type  of  uretero- 
plasty  is  sometimes  very  successful.  In  the  later  stages,  where  sup- 
puration is  threatening  or  present,  nephrectomy  will  probably  be 
required.  Acquired  unilateral  hydronephrosis  may  be  dealt  with  by 
aspiration  as  a  temporary  measure ;  but  this  is  rarely  satisfactory,  and 
usually  needs  to  be  followed  by  an  exploratory  incision  (nephrotomy), 
by  means  of  which  it  may  be  possible  in  a  few  cases  to  reach  and  deal 
with  the  obstruction.  Inthe  majority,  however,  the  block  is  situated 
so  low  down  that  it  cannot  be  reached,  and  the  condition  is  often 
so  aggravated  that  nephrectomy  is  the  only  reasonable  treatment. 
Nephritis,  or  inflammation  of  the  kidney,  is  an  affection  which 
occurs  in  many  dift'erent  conditions,  and  is  suitably  discussed  in 
medical  text-books.  The  presence  of  albuminuria  is  of  considerable 
significance  to  surgeons,  and  in  all  cases  demanding  surgical  inter- 
ference the  urine  should  be  carefully  tested.  It  has  been  already 
discussed  at  p.  1179. 

In  addition,  we  must  note  that  surgical  interference  has  been 
utilized  in  cases  of  chronic  Bright's  disease.  Edebohl*  of  New  York 
and  others  have  completely  removed  the  capsule  of  both  kidneys  in 
some  of  these  patients.  The  technique  is  simple,  and  needs  no 
special  description,  but  the  operation  is  often  difficult  in  fat  oedema- 
tous  subjects.  It  is  claimed  that  this  operation,  or,  perhaps  better, 
nephrostomy  (p.  1199),  is  most  suitable  to  young  people  with  post- 
scarlatinal chronic  nephritis,  and  may  save  life  when  suppression 
of  urine  follows  catheterism  or  exposure  to  cold.  The  further 
history  of  these  procedures  will  be  watched  with  much  interest. 

Pyogenic  Infections  of  the  Kidney  and  Ureter  may  develop  from 
manv  distinct  sources,  and  give  rise  to  several  allied,  though  distin- 
guishable, chnical  conditions.  Thus,  (i.)  the  infective  material  may 
reach  the  kidney  from  the  blood  in  the  shape  of  emboli,  as  in  pyaemia, 
causing  a  diffuse  inflammation  of  the  renal  substance  with  a  develop 
ment  of  many  scattered  abscesses  [acute  suppumtive  interstitial 
*  Medical  Record.  March  28,  1903. 


II96  A   MANUAL  OF  SURGERY 

nephritis),  or  of  one  larger  abscess.  Sometimes  a  focus  of  disease  pre- 
exists in  the  kidney  {e.g.,  stone,  tubercle,  or  cancer),  and  the  super- 
added infection  adds  much  to  the  gravity  of  the  symptoms,  (ii.)  When 
once  the  kidney  substance  is  involved,  the  trouble  is  only  too  likely 
to  spread  to  the  pelvis,  causing  a  suppurative  pyelitis  (or,  inasmuch 
as  the  renal  parenchyma  is  already  invaded,  a  suppurative  pyelo- 
nephritis) ;  and  thence  the  mischief  spreads  down  the  ureter,  and  may 
perhaps  infect  the  lower  urinary  passages,  constituting  a  condition 
of  descending  pyelonephritis.  (iii.)  A  common  method  of  origin 
consists  in  pyogenic  organisms  spreading  upwards  from  the  bladder 
to  the  ureter  and  kidney.  This  may  arise  from  a  primary  cystitis, 
but  is  seen  most  frequently  in  the  affection  which  used  to  be  termed 
'  surgical  kidney,'  and  follows  in  the  train  of  many  diseases  accom- 
panied by  cystitis — e.g.,  stricture  of  the  urethra,  enlarged  prostate, 
stone  in  the  bladder,  etc.  It  will  be  remembered  that  the  ureter 
passes  through  the  bladder  in  an  oblique  direction,  and  is  guarded 
by  strong  sphincteric  muscular  fibres,  and  thereby  the  spread  of 
infection  upwards  is  rendered  more  difficult.  It  is  probable,  how- 
ever, that  the  mucous  membrane  lining  the  orifice  becomes  itself 
inflamed,  and  a  small  plug  of  mucus  develops  wathin  it,  through 
which  the  germs  are  able  to  pass  upwards.  In  other  cases  they 
certainly  find  their  way  via  the  lymphatics  of  the  mucous  membrane, 
which  are  continuous  in  the  ureter  and  bladder.  When  the  phe- 
nomena caused  by  this  infection  from  below  are  hmited  to  a  sup- 
purative condition,  it  is  known  as  an  ascending  pyelonephritis ;  but  if 
to  them  is  added  an  element  of  distension,  due  to  the  cause  being  of 
an  obstructive  type,  then  the  distended  suppurating  kidney  is 
known  as  a  pyonephrosis,  (iv.)  Sometimes  the  infection  reaches 
the  urinary  passages  from  neighbouring  organs,  as  in  disease  of  the 
rectum  or  even  of  the  appendix ;  in  the  former  the  bacteria  are  dis- 
seminated by  the  lymphatics ;  in  appendicitis  an  abscess  may  open 
into  the  kidney  or  ureter,  or  the  latter  structure  may  be  involved 
in  the  inflammatory  deposit.  In  the  female  infection  may  easily 
spread  along  the  short  urethra  from  the  vulva. 

The  organisms  usually  present  are  staphylococci,  streptococci,  or 
the  B.  coli,  which,  as  will  be  seen  later,  is  constantly  associated  with 
inflammation  of  the  bladder. 

I.  Pyelitis  is  the  term  applied  to  an  inflammation  involving  the 
pelvis  of  the  kidney,  the  calyces,  and  perhaps  the  ureter.  The  chief 
causes  from  which  it  arises  are:  [a]  The  presence  of  a  calculus,  or 
the  passage  of  uric  acid  crystals  in  gouty  individuals;  {b)  tuberculous 
disease,  either  starting  primarily  in  the  kidney,  or  extending  upwards 
from  the  bladder;  (c)  extension  of  septic  inflammation  from  the 
bladder  and  urethra;  [d]  malignant  disease  of  the  kidney;  [e)  occa- 
sionally in  floating  or  moveable  kidney ;  (/)  the  ingestion  of  irritating 
drugs — e.g.,  cantharides,  turpentine,  and  even  cubebs  or  copaiba; 
(g)  the  presence  of  foreign  bodies,  such  as  needles,  bullets,  and  para- 
sites— e.g.,  the  Bilharzia  hcematobia  or  the  Strongylns  gigas  ;  {h)  a 
pyaemic  embolus ;  and  (i)  possibly  cold.     In  the  milder  cases  and  in 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1197 

the  early  stages  it  may  be  a  simple  catarrhal  inflammation,  but  it  is 
almost  certain  to  become  purulent  if  it  lasts  long. 

\Miate\-er  the  cause,  the  pathological  phenomena  are  the  same, 
consisting  in  the  lining  membrane  becoming  congested  and  thick- 
ened, and  secreting  a  muco-purulent,  or  even  purulent,  discharge. 
Owing  to  the  swelling  of  the  mucous  membrane,  the  entrance  to  the 
ureter  is  encroached  on,  and  a  certain  amount  of  distension  of  the 
pelvis  and  calyces  (hydronephrosis)  follows.  Where  micro-organ- 
isms are  present,  as  in  cases  due  to  distension  from  the  bladder,  the 
kidnev  is  likely  to  be  involved  in  the  process  (pyelonephritis) ,  or  the 
condition  may  be  followed  by  a  urinary  abscess  in  the  loin  or  sup- 
purative perinephritis. 

The  Symptoms  of  pyelitis  consist  of  pain  and  tenderness  over  the 
affected  kidney,  increased  frequency  of  micturition,  and  the  inter- 
mittent discharge  of  pus  in  acid  urine.  The  intermissions  are  due  to 
the  inflammatory  swelling  of  the  mucous  membrane,  which  tem- 
porarity  blocks  the  upper  entrance  to  the  ureter,  and  necessitates  a 
certain  degree  of  pressure  of  the  urine  and  pus  accumulated  in  the 
pelvis  of  the  kidney  in  order  to  overcome  the  obstruction.  Neces- 
sarily, where  pyelitis  follows  chronic  cystitis,  the  acid  reaction  is 
neutralized  if  the  urine  in  the  bladder  has  become  alkaline ;  in  such 
cases  a  nocturnal  elevation  of  temperature  is  usually  noted. 

The  Treatment  of  pyelitis  is  mainly  directed  to  the  cause.  Where 
this  is  removeable  [e.g.,  calculus  or  foreign  bodies),  an  operation  is 
advisable.  In  the  ascending  type,  which  originates  in  the  bladder, 
treatment  should  be  first  directed  towards  the  latter  viscus.  In  the 
simple  catarrhal  variety  the  patient  is  kept  warm,  and  his  diet 
restricted  to  bland  fluids ;  urotropine,  alkalies,  and  sedatives  are  pre- 
scribed. If  these  measures  fail  and  the  condition  becomes  painful  and 
purulent,  the  affected  kidney  should  be  explored,  as  a  stone  may  pos- 
sibly be  present,  and  the  pelvis  drained  temporarily  (nephrostomy). 

2'.  Pyelonephritis,  or  inflammation  of  the  pelvis  of  the  kidney 
together  with  the  renal  parenchyma,  is  almost  invariably  suppura- 
tive in  type,  and  either  due  to  extension  upwards  from  the  lower 
urinarv  organs,  or  to  a  local  lesion  of  pelvis  or  kidney,  such  as  calcu- 
lous or  tuberculous  disease. 

In  almost  all  cases  of  pyelitis  a  certain  degree  of  renal  congestion 
is  present;  but  when  the  condition  becomes  confirmed,  and  especi- 
ally when  infective  matter  is  present  in  the  calyces,  it  is  certain  to 
hght  up  a  subacute  interstitial  nephritis.  In  the  latter  stages 
bacteria  invade  the  pyramids  and  travel  upwards  along  the  lym- 
phatics or  renal  tubules,  gi\dng  rise  to  abscesses,  either  scattered 
through  the  connective  tissue  of  the  organ  or  within  its  tubules, 
in  either  case  seriously  damaging  its  excretory  function.  In  both 
instances  it  is  possible  for  many  of  these  minute  foci  of  pus  to  run 
together  and  form  a  large  collection,  which  in  time  becomes  recognis- 
able from  outside ;  but  more  usually  the  patient  dies  of  toxaemia  or 
uraemia  before  that  stage  is  reached.  When  the  affection  ascends  from 
the  bladder,  it  may  commence  suddenly  and  with  acute  symptoms. 


1 1 98  A   MANUAL  OF  SURGERY 

and  then  probul:)h'  r  suits  from  some  surgical  operation  or  sim])ly  from 
catheterism  in  a  patient  whose  bladder  is  in  a  highly  septic  condition. 
The  organisms  find  their  way  upwards  along  the  lymphatics  in  the 
mucous  lining  of  the  ureters,  and  soon  infect  the  pelvis ;  the  walls 
of  the  ureters  may  in  such  cases  be  studded  with  miliary  abscesses. 

Clinical  History. — In  acute  cases  the  symptoms  probably  com- 
mence with  a  severe  rigor,  associated  with  pain  in  the  loins  or  back, 
headache,  vomiting,  great  thirst,  and  probably  some  amount  of 
drowsiness,  perhaps  passing  into  a  condition  of  coma.  The  rigor 
may  be  repeated,  or  the  fever  may  remain  high  without  exacerba- 
tions, but  if  uraemia  is  present  or  threatening,  the  temperature  may 
be  subnormal.  The  kichieys  are  felt  to  be  enlarged  and  tender,  and 
the  urine  is  usually  diminished  in  amount,  and,  indeed,  may  be  sup- 
prtssed  entirely;  if  any  passes,  it  is  high-coloured  and  contains 
albumen  and  perhaps  blood,  with  some  amount  of  pus,  which  is 
probably  derived  largely  from  the  lower  portion  of  the  urinary  track. 
The  prognosis  of  the  worst  cases,  which  supervene  on  old  bladder 
trouble,  is  nearly  hopeless,  the  patient  being  almost  certain  to  die  of 
uraemia,  especially  as  both  kidneys  are  generally  affected.  In  less 
acute  cases,  occurring  perhaps  in  young  people,  secondary  to  a 
bacillary  cystitis,  the  symptoms  often  improve  in  a  few  days  and 
quiet  down;  but  the  urine  is  swarming  with  bacilH,  and  recurrence 
of  the  trouble  is  not  uncommon.  Abscess  may  sometimes  supervene. 

In  the  more  chronic  cases,  the  symptoms  are  those  of  pyrexia,  at 
first  only  slight,  but  gradually  increasing  and  taking  on  the  hectic 
type.  The  kidney  is  slightly  enlarged  and  tender ;  the  urine  contains 
epithelial  cells  from  the  pelvis  or  renal  casts,  and  may  be  acid  in  the 
early  stages,  but  is  usually  alkaline  in  the  late.  As  the  condition 
progresses,  the  temperature  rises ;  the  patient  wastes ;  appetite  and 
digestive  functions  flag;  slight  delirium  supervenes  at  night;  and 
unless  the  cause  can  be  removed  or  dealt  with  effectively,  death 
from  uraemia  is  hkely  to  follow.  If,  however,  effective  treatment 
of  the  cause  is  possible,  recovery  may  follow,  but  the  kidney  is,  of 
course,  permanently  damaged,  and  some  degree  of  sclerosis  is  certain 
to  ensue. 

Treatment. — In  the  chronic  variety,  the  cause  must  first  be  dealt 
with,  but  the  surgeon  must  not  forget  that  an  acute  attack  may 
be  easily  lighted  up  by  injudicious  instrumentation  or  operations. 
Hence  it  is  often  desirable  to  drain  and  wash  out  the  bladder  first,  as 
by  a  perineal  cystotomy,  rather  than  to  dilate  or  divide  a  stricture  of 
the  urethra.  An  enlarged  prostate  or  calculus  must  be  removed, 
but  it  may  be  desirable  to  wash  out  or  drain  the  bladder  for  a  few 
days  before  undertaking  such  operations,  so  as  to  diminish  the  risks 
of  infection.  At  the  same  time  the  patient  is  kept  in  bed,  and 
encouraged  to  drink  plenty  of  bland  fluids.  If  the  urine  is  swarming 
with  the  B.  coli,  an  autogenous  vaccine  of  that  organism  is  desirable, 
and  must  be  continued  for  some  time  in  gradually  increasing  doses. 
In  the  acute  form  the  patient  is  kept  warm  in  bed,  and  plenty  of  fluid, 
such  as  milk  or  barley-water,  is  given ;  stimulants  are  avoided,  as  also 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1199 

opium.  Hot-air  baths,  wet  packs,  and  the  hypodermic  injection  of 
pilocarpine,  will  suffice  to  get  the  skin  to  act  well,  and  watery  pur- 
gatives, such  as  jalap  and  scammony,  are  needed  for  the  bowels. 
The  loins  are  fomented  or  cupped,  but  if  the  urinary  secretion 
is  not  re-established,  or  if  it  is  suppressed,  or  if  the  phenomena  of 
suppuration  supervene,  incision  of  the  kidney  and  drainage  of  the 
pelvis  (nephrostomy)  are  essential.  It  is  sometimes  remarkable  to 
observe  how  rapidly  the  symptoms  improve  after  such  a  procedure, 
and  how  quickly  the  urinary  secretion  is  re-established. 

3.  Pyonephrosis  is  the  term  applied  to  indicate  the  association  of  a 
chronic  pyelonephritis  with  distension  of  the  pelvis  and  ureter,  as  a 
result  of  obstruction  to  the  passage  of  urine.  When  unilateral,  it 
is  commonly  due  to  the  presence  of  a  calculus,  or  of  tuberculous 
disease,  the  obstruction  being  caused  by  the  swelling  of  the  ureteral 
mucous  membrane;  if  the  affection  is  secondary  to  obstruction  in  the 
lower  urinary  passages,  it  is  usually  bilateral.  The  lining  membrane 
of  the  pelvis  is  inflamed,  thickened,  and  perhaps  ulcerated;  decom- 
posing urine  and  pus  collect  in  the  dilated  pelvis  and  calyces,  and  a 
soft,  friable,  phosphatic  calculus  may  develop,  even  in  cases  where 
the  originating  cause  is  not  of  a  calculous  nature.  Obstruction  to 
the  outlet  may  lead  to  such  an  accumulation  of  pus  as  to  constitute 
an  abscess  of  the  kidney,  whilst  a  certain  amount  of  perinephritis 
is  always  present. 

The  Clinical  Signs  are  very  similar  to  those  of  pyelonephritis,  but 
to  them  are  added  those  of  an  enlarged,  tender,  and  painful  kidney, 
and  a  more  or  less  abundant  pyuria,  usually  intermittent.  The 
temperature  is  somewhat  raised,  especially  at  night,  from  the  ab- 
sorption of  toxic  products;  the  patient  steadily  loses  ground,  and 
becomes  emaciated ;  the  tongue  is  dry,  the  appetite  diminished,  and 
nausea  and  vomiting  are  sometimes  present.  The  urine  is  generally 
scanty  in  amoimt,  and  if  both  kidneys  are  involved,  the  excretion 
gradually  diminishes,  leading  to  a  fatal  issue  from  uraemia,  unless  the 
patient  dies  previously  from  toxsemia  or  pyemia. 

Treatment. — -Where  both  kidneys  are  involved  as  a  result  of  some 
urethral  or  prostatic  affection,  no  special  treatment  directed  to  the 
kidneys  is  feasible;  but  if  the  condition  is  unilateral,  and  not 
secondarv  to  disease  of  the  lower  urinary  organs,  nephrotomy  should 
be  undertaken,  and  any  removeable  cause  dealt  with.  Failing  this, 
the  cavity  may  be  drained,  or  even  nephrectomy  performed. 

4.  Abscess  of  the  Kidney  may  follow  any  of  the  conditions  already 
alluded  to,  in  which  bacteria  gain  access  to  the  organ  from  below,  the 
pus  then  collecting  in  the  pelvis  and  dilated  calyces.  It  also  occurs 
in  connection  with  pysemia,  and  sometimes  develops  after  the  general 
infective  fevers.  In  acute  interstitial  nephritis  the  abscesses  are 
multiple  and  at  first  small,  being  located  between  the  tubules  or 
sometimes  \\athin  them;  the  pyramids  then  have  a  streaky -white 
appearance  due  to  their  infiltration  with  pus,  and  the  abscesses  form 
in  the  cortical  substance  at  their  base.  Larger  collections  are  caused 
by  the  amalgamation  of  several  of  the  smaller.     In  pyaemia  the 


1200  A   MANUAL  OF  SURGERY 

abscesses  are  preceded  by  infarcts,  which  appear  immediately 
beneath  the  capsule  as  wedge-shaped  areas  of  a  chocolate  colour, 
which  turns  a  yellowish- white  as  suppuration  occurs.  The  kidney 
becomes  enlarged  and  tender,  and  can  usually  be  felt  from  outside, 
but  fluctuation  is  rarely  to  be  detected.  The  abscess  may  buist  into 
the  pelvis  and  discharge  through  the  ureter,  but  when  due  to  an 
ascending  pyelonephritis  from  obstruction  this  is  not  likely  to  be  the 
case.  The  inflammation  is  more  liable  to  spread  outwards  through 
the  kidney  substance,  and  give  rise  to  a  suppurative  perinephritis. 
The  general  symptoms  produced  are  similar  to  those  present  in  acute 
pyelonephritis.  Treatment  of  an  abscess  of  the  kidney  consists  in 
nephrostomy  for  drainage  purposes,  or  perhaps  nephrectomy. 

The  more  chronic  varieties  are  probably  tuberculous  in  origin,  and 
may  then  attain  considerable  dimensions,  all  that  is  noted  being  the 
lumbar  swelling,  whilst  pyuria  is  not  necessarily  present,  owing  to 
the  ureter  becoming  blocked. 

5.  Perinephritis  cannot  be  recognised  unless  suppurative  in  nature ; 
it  results  either  from  infected  wounds  or  from  ulceration  involving 
the  walls  of  the  pelvis  and  calyces,  or  from  the  transmission  of 
micro-organisms  from  the  interior  of  a  suppurating  kidney  or  pelvis 
without  any  breach  of  surface.  A  perinephritic  abscess  may  also 
arise  from  inflammation  spreading  from  the  intestine,  appendix, 
pleural  cavity,  spine,  ribs,  or  elsewhere. 

The  Symptoms  may  be  acute  or  chronic  in  nature.  In  acute  peri- 
nephritis, signs  of  deep  suppuration  in  the  loin  are  produced — viz.,  an 
indurated  painful  swelling,  associated  with  fever,  and  perhaps  pre- 
ceded by  rigors.  The  body  is  held  stiff  and  rigid,  wath  an  inclination 
towards  the  affected  side.  Fluctuation  may  sometimes  be  detected 
when  pus  has  formed,  but  the  abscess  is  often  so  deeply  placed  that 
it  is  difficult  to  recognise  at  first ;  it  is  likely  to  point  at  the  side  of 
the  erector  spinae,  or  may  burrow  forwards  between  the  abdominal 
muscles,  and  find  an  exit  on  the  anterior  abdominal  wall.  Occasion- 
ally it  bursts  into  the  peritoneal  or  pleural  cavities,  or  into  the  intes- 
tine. If  it  comes  to  the  surface,  it  is  preceded  by  congestion  and 
oedema  of  the  skin.  Chronic  perinephritis  gives  rise  to  no  character- 
istic symptoms  until  an  abscess  forms  which  is  large  enough  to  be 
felt.  Sometimes  it  is  of  a  simple  type,  and  does  not  suppurate;  but 
the  kidney  becomes  adherent  to  surrounding  parts,  and  to  such  an 
extent  as  to  render  nephrectomy  difficult  and  dangerous. 

Treatment  in  the  suppurating  variety  consists  in  giving  exit  to  the 
pus  through  an  incision  at  the  outer  border  of  the  erector  spinas ;  the 
cavity  is  then  carefully  examined,  and  the  cause  of  the  suppuration, 
if  possible,  determined,  and  treated  according  to  the  requisites  of  the 
case. 

Tuberculous  Disease  of  the  Kidney  occurs  in  one  of  three  forms. 
[a]  It  may  arise  in  the  course  of  acute  general  tuberculosis,  when 
miliary  tubercles  are  found  studding  the  organs,  but  giving  rise  to  no 
special  S3'mptoms.  The  patient  is  usually  a  child.  Treatment,  of 
course,  is  impracticable. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


{b)  It  may  extend  upwards  from  a  similar  affection  of  the  bladder, 
and  then  almost  invariably  involves  both  kidneys.  The  mucous 
membrane  of  the  ureter  becomes  thickened  and  transformed  mto 
cedematous  granulation  tissue  containing  tubercles,  and  that  of  the 
pelvis  and  calyces  is  similarly  affected;  finally,  the  renal  parenchyma 
itself  becomes  infiltrated  with  tuberculous  tissue  spreadmg  from  the 
pyramids.  The  patients  are  usually  young  adult  males,  and 
this  fact  is  explained  by  their  Habihty  to  genital  tuberculosis. 
Clinically,  enlargement  of 
both  kidneys  is  noticed,  aris- 
ing partly  from  the  deposit 
of  tubercle  within  the  organ 
and  partly  from  obstruction 
within  the  ureter.  The 
symptoms  caused  by  the 
renal  mischief  cannot  at  first 
be  distinguished  from  those 
due  to  the  vesical  trouble. 
Perinephritic  abscess  occa- 
sionally follows,  and  the 
patient  dies  from  exhaus- 
tion, toxic  absorption,  or 
uraemia.  Treatment  in  these 
cases  is  of  no  avail. 

(c)  Primary  Tuberculosis 
of  the  kidney  is  generally 
unilateral,  and  commences 
as  a  deposit  of  tubercle  in 
the  cortex  or  at  the  base  of 
one  of  the  pyramids.  It 
may  early  involve  the  pelvis, 
and  give  rise  to  an  ulcerative 
pyelitis,  or  may  invade  the 
renal  parenchyma  more  par- 
ticularly, replacing  it  by 
caseous  masses,  which  in 
chronic  cases  may  become  calcified,  and  even  cast  a  shadow  on  the 
radiographic  screen.  In  the  former  case  a  tuberculous  pyonephrosis 
follows,  and  the  process  spreads  for  some  distance  down  the  ureter, 
and  even  infects  the  bladder  (Fig.  540) .  A  tuberculous  ureter  is  always 
thickened  and  hard,  due  to  the  infiltration  of  the  mucous  membrane; 
obstruction  to  the  flow  of  urine  and  to  the  escape  of  discharge 
ensues,  and  in  old-standing  cases  the  ureter  contracts  and  drags 
upon  its  outlet  in  the  bladder,  which  can  be  seen  to  be  retracted. 
Suppuration  of  a  chronic  type  sometimes  occurs  in  the  kidney,  and 
large  quantities  of  pus  may  be  dammed  back  behind  the  thickened 
ureter.  Suppurative  perinephritis  may  also  supervene,  and  give 
rise  to  an  abscess  which  bursts  externally. 

The  Symptoms  are  at  first  indefinite.     The  patient  is  usually  a 

76 


Fig.  540. — Tuberculous  Kidney,  show- 
ing Thickening  of  Mucous  Membrane 
OF  Pelvis  and  Ureter.  (From  Speci- 
men IN  College  of  Surgeons'  Museum.) 


I202  A   MANUAL  OF  SURGERY 

young  adult,  and  rather  more  frequently  a  male  than  a  female.  He 
complains  of  increased  frequency  of  micturition,  and  unilateral  pain 
in  the  loin,  neither  of  which  conditions  is  improved  by  rest,  remaining 
the  same  at  night  as  in  the  day,  and,  indeed,  sometimes  being  worse. 
The  pain  is  generally  of  an  aching  character,  and  more  or  less 
constant,  although  exacerbations  may  occur,  taking  on  the  type 
of  mild  renal  colic,  in  consequence  of  the  passage  of  fragments  of 
disintegrated  mucous  membrane,  or  of  caseous  material.  The  urine 
is  acid,  and  usually  contains  a  certain  proportion  of  pus,  in  which  on 
examination  the  B.  tuberculosis  can  sometimes  be  detected.  More 
frequently  they  are  not  detected,  unless  the  urine  is  centrifugalized, 
and  cultivation  or  inoculation  of  the  deposit  may  then  demonstrate 
the  presence  of  the  bacilli.  Hematuria  is  not  marked,  even  if 
present  at  all.  In  the  earliest  stages  albuminuria  is  sometimes 
present  without  any  evidence  of  pus.  On  examination  the  kidney 
may  be  found  to  be  slightly  enlarged,  but  is  not  tender,  except  in  the 
later  stages,  when  it  constitutes  a  tumour  of  considerable  size,  which 
may  contain  a  large  quantity  of  pus  and  even  a  phosphatic  con- 
cretion. Loss  of  flesh,  night  sweats,  and  a  nocturnal  rise  of  tempera- 
ture, are  present  in  the  later  stages. 

The  Diagnosis  of  primary  renal  tuberculosis  is  usually  a  matter  of 
doubt,  if  the  presence  of  bacilli  in  the  urine  cannot  be  demonstrated, 
since  the  symptoms  are  very  similar  to  those  of  renal  calculus.  The 
age  of  the  patient  and  his  personal  and  family  history  may  be  of 
importance,  and  he  should  be  carefully  examined  for  evidences 
of  tuberculous  disease  elsewhere,  especially  in  the  genital  organs. 
A  bacteriological  examination  of  the  urine  will  often  decide  the  case. 
The  chief  points  of  distinction  clinically  are  that  the  symptoms  are 
less  influenced  by  exercise  or  rest,  and  there  is  less  hsematuria  or 
renal  colic  than  when  a  calculus  is  present,  whilst  the  kidney  is 
usually  not  so  tender  on  manipulation;  of  course  the  condition  is 
much  less  common  than  that  of  stone.  Radiography  will  determine 
the  presence  or  absence  of  a  stone,  but  also  of  calcified  caseous 
deposits.  Cystoscopy  may  reveal  the  existence  of  tuberculous 
ulcers  in  the  bladder  close  to  the  ureteral  orifice  in  the  earlier  stages, 
or  of  a  retracted  ureter,  when  the  latter  has  become  transformed  into 
a  sohd  cord.  In  cases  of  doubt  the  final  distinction  is  made  by 
exploring  the  organ  through  an  incision  in  the  loin.  In  calculus  the 
surface  is  uniformly  even  and  dark  red,  and  if  any  areas  of  softening 
are  present,  they  are  of  a  bluish-red  colour;  the  pelvis  and  upper 
end  of  the  ureter  are  usually  lax  and  distended.  The  tuberculous 
kidney  is  generally  mottled  in  colour  and  pallid-looking,  whilst 
hard,  scattered,  caseous  nodules  may  be  felt,  which  become  fluid 
on  pressure,  or  on  incision  give  exit  to  caseous  pus.  The  condition 
of  the  ureter  is  also  diagnostic ;  in  calculus,  if  altered  at  all,  it  is  thin 
and  dilated;  in  tubercle  it  is  thickened  and  indurated,  and  this  con- 
dition may  sometimes  be  detected  on  rectal  or  vaginal  examination. 

Treatment. — In  the  earliest  stages  the  routine  anti-tuberculous 
treatment  (p.  184)  maybe  employed,  creosote  (lT\.xv.  or  n\  xx.,  t.d.s.) 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


being  perhaps  useful  as  a  drug,  and  tuberculin  in  small  doses  being 
valuable.  Operation  must  not  be  delayed  too  long,  however,  owing 
to  the  grave  results  that  may  follow  from  extension  of  the  mischief. 
If  on  exploration  of  the  kidney  the  disease  is  found  to  be  strictly 
limited  and  the  pelvis  unaffected,  it  may  be  possible  to  cut  or  scrape 
away  the  diseased  tissues,  carefully  purifving  the  cavity  by  liquefied 
carbolic  acid,  and  packing  the  wound  thus  formed  with  gauze.  In 
other  cases  it  may  be  possible  to  excise  wedge-shaped  areas  of  the 
renal  cortex,  securing  the  wounds  by  sutures.  In  the  majority  of 
instances,  however,  the  disease  will  have  spread  much  too  extensively 
through  the  ureter,  pelvis,  and  calyces  for  such  conservative  treat- 
ment, or  the  kidney  may  consist  of  a  series  of  cysts  filled  with 
offensive  pus.  If  the  surgeon  is  tolerably  certain  that  the  other 
kidney    is    healthy,   ne- 

should     be  .ie<^'^ ""-w^P*^:,^.^    X 


phrectomv 

performed,  care  being 
taken  to  divide  the  ureter 
below  the  farthest  limit 
of  the  disease,  the  in- 
cision being  suitably  pro- 
longed (p.  1209).  The 
occurrence  of  a  peri- 
nephritic  abscess  neces- 
sitates an  incision  in  the 
loin,  and  through  this 
opening  the  kidney  can 
be  explored  and,  if  neces- 
sary, removed. 

Renal  Calculus. — 
Renal  Calculi  are  usually 
met  with  in  individuals 
suffering  from  lithiasis, 
as  indicated  by  the  pass- 
age of  sand  or  gravel 
in  the  urine.  The  general  causes  of  this  condition  have  been 
detailed  elsewhere  (p.  11S4).  All  renal  concretions  are  primarily 
excreted  in  a  crystalline  form  from  the  renal  tubules,  but  under 
ordmary  circumstances  are  sufficientlv  small  to  find  their  way  into 
the  peMs  of  the  kidney,  and  thence  along  the  ureter  to  the  bladder. 
If,  however,  they  are  obstructed  in  their  onward  course,  either  on 
account  of  their  size  or  shape,  or  some  narrowing  of  the  tubules, 
they  may  become  lodged  in  the  kidney  substance  or  in  one  of  the 
caljxes,  and  by  the  gradual  deposit  of  the  same  material  increase 
m  s]ze  until  large  enough  to  give  rise  to  sjonptoms.  Renal  calculi 
are  usually  not  of  great  bulk;  occasionally,  however,  the  whole 
of  the  pelvis,  and  some  of  the  calyces,  may  be  occupied  by  a  concre- 
tion, which  takes  the  shape  of  the  cavity  in  which  it  lies  (Plate 
XIII.,  Fig.  I).  When  many  calcuh  are  present  in  the  pelvis  of  a 
kidney,  they  are  usually  faceted  (Fig.  3).     Chemically  thev  consist 


Fig.  541. — Calculous  Kidney. 

OF  Surgeons'  Museum.) 


(College 


I204 


A   MANUAL  OF  SURGERY 


either  of  uric  acid  or  urate  of  ammonium;  sometimes,  however, 
they  are  com])()secl  of  oxalate  or  acid  phosphate  of  hme. 

The  Pathological  Phenomena  connected  witli  renal  calculi  vary 
with  their_  size,  shape,  number,  and  position.  If  situated  in  the 
substance  of  the  renal  parenchyma,  they  may  give  rise  to  but  little 
trouble,  being  more  or  less  encapsuled  in  a  cavity  lined  by  granula- 
tion tissue  and  surrounded  by  a  dense  fibrous  capsule.  Sometimes, 
however,  ulceration  of  the  wall  and  suppurative  perinephritis  may 
follow;  the  calculus  may  even  find  its  way  into  the  abscess  cavity, 
and  be  discharged  spontaneously  or  removed  through  the  loin,  a 
urinary  fistula  perhaps  resulting.  If  the  calculus  is  held  in  place  in  one 
of  the  calyces  by  its  branched  shape,  thereby  limiting  its  mobility. 


Fig.  542. — Radiogram  of  Multiple  Renal  Calculi.     (Dr.  Knox.) 


a  suppurative  pyelonephritis  follows  (Fig.  541),  by  which  the  kidney 
substance  is  seriously  damaged,  the  pelvis  may  become  dilated,  and 
possibly  perinephritis  ensues,  with  or  without  suppuration,  and  the 
formation  of  a  urinary  fistula.  When  occupying  the  pelvis  of  the 
kidney,  calculi  set  up  a  suppurative  pyelitis,  and  from  the  obstruction 
to  the  flow  of  urine,  caused  partly  by  the  thickening  of  the  mucous 
membrane,  and  partly  by  the  calculus  engaging  the  orilice  of  the 
ureter,  produce  dilatation  of  the  pelvis  of  the  kidney,  and  the  phe- 
nomena of  hydro-  or  pyo-nephrosis.  If  the  calculus  passes  down  the 
ureter,  it  gives  rise  to  the  s^miptoms  of  renal  colic.  When  small  and 
smooth,  it  usually  reaches  the  bladder  without  much  difficulty,  and 
is  then  voided  with  the  urine,  or  remains  as  a  vesical  calculus. 


FLA'l'E   Xlll. 


Renal  Stones. 

Fig.  I. — Large  branched  calculus,  firmly  held  in  the  calyces  of  the 
pelvis.  Fig.  2. — Oxalate  of  lime  stone.  Fig.  3. — Two  facetted  stones  of 
uric  acid.  The  patient  passed  two  of  this  collection  per  urethram  ;  six 
were  removed   by  nephro-lithotomy. 


[To  face  page  1204. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1205 

Occasionally,  owing  to  its  size  or  irregular  shape,  it  becomes 
impacted  in  the  ureter,  usually  at  its  upper  end,  giving  rise  to  acute 
obstruction  and  the  cessation  of  the  urinary  secretion  on  that  side, 
followed  in  time  by  disorganization.  If  the  kidney  thus  affected  is 
the  only  one  available  for  excretory  purposes,  or  if  both  ureters  are 
similarly  obstructed,  the  patient,  if  unrelieved,  dies  in  a  few  days 
from  suppression  of  urine  [calculous  anuria).  In  other  cases  the 
stone  ulcerates  through  the  wall  of  the  ureter,  giving  rise  to  a  retnj- 
peritoneal  urinary  abscess,  or  possibly  to  suppurative  peritonitis. 
If  the  ureter  is  only  partially  obstructed  by  the  calculus,  the  changes 
which  take  place  in  the  kidney  are  more  gradual,  and  result  in  hydro- 
or  pyo-nephrosis. 

The  tvpical  Symptoms  arising  from  renal  calculus  are  as  follows : 
The  patient  complains  of  pain  in  the  loin,  more  or  less  persistent, 
and  often  paroxysmal  in  nature,  which  is,  however,  always  increased 
on  exercise  or  jolting;  it  is  frequently  referred  to  distant  regions,  but 
most  commonlv  follows  the  course  of  the  genito-crural  nerve,  giving 
rise  to  pain  in  front  of  the  thigh,  accompanied  by  retraction  of  the 
testicle;  in  the  female  it  is  also  experienced  in  the  labium  majus; 
sometimes  it  extends  down  the  back  of  the  thigh.  It  is  almost 
invariably  associated  with  haematuria,  and  often  with  p5'uria,  the 
amoimt  of  blood  or  pus  being  increased  on  exertion.  Frequency  of 
micturition  is  a  prominent  symptom,  whilst  if  the  pelvis  is  enlarged 
the  kidney  may  be  tender  and  distinctly  palpable.  If  the  calculus 
is  lodged  in  the  renal  parenchyma,  the  urinary  secretion  may  be  but 
little  influenced,  although  the  characteristic  pain  is  well  marked;  the 
patient  also  finds  that  at  night  he  can  onty  gain  relief  by  lying  on  the 
affected  side,  and  on  manual  examination  the  kidney,  though  some- 
what tender,  is  not  much  enlarged.  When  the  calculus  lies  in  the 
pelvis  or  one  of  the  calyces,  the  typical  phenomena  described  above 
are  produced;  but  it  is  then  noticed  that  at  night  the  patient  lies  on 
the  sound  side,  since  the  organ  is  both  enlarged  and  tender.  On  the 
other  hand,  it  is  an  undoubted  fact  that  stones  even  of  large  size  may 
exist  for  years  in  the  kidney  without  giving  rise  to  any  symptoms 
whatever. 

The  pa,ssage  of  a  calculus  down  the  ureter  is  accompanied  by  the 
symptoms  known  as  Renal  Colic.  They  consist  of  excruciating  pain 
of  a  paroxysmal  nature,  which  comes  on  suddenty,  and  is  referred 
both  to  the  loin  and  along  the  course  of  the  genito-crural  nerve. 
It  is  always  associated  vnth  vomiting  and  severe  shock,  the  patient 
often  lying  on  the  floor  writhing  in  agony,  vnt\\  cold  perspiration 
standing  in  beads  on  his  forehead.  The  temperature  is  subnormal, 
and  the  pulse  weak  and  rapid.  Strangury  is  usually  present,  the 
patient  suffering  from  frequent  paroxysmal  efforts  to  pass  water, 
but  only  succeeding  in  passing  a  small  amount,  and  that  generally 
blood-stained.  After  lasting  for  a  variable  period,  the  pain 
suddenly  ceases,  as  a  residt  of  the  passage  of  the  calculus 
into  the  bladder,  or  of  its  slipping  back  into  the  pel\4s  of  the 
kidney. 


I206 


A   MANUAL  OF  SURGERY 


Impaction  in  the  Ureter  may  occur  eitlicr  2  inches  below  the  pelvis 
of  the  kidney,  or  near  the  brim  of  the  pelvis,  or  near  the  vesical 
orifice,  sometimes  even  protruding  through  it.  There  is  usually  only 
one  stone,  but  occasionally  more ;  the  size  is  rarely  greater  than  a 
coffee-bean,  and  the  shape  is  usually  somewhat  elongated,  like  a 
date-stone.*  In  thin  persons  it  has  been  detected  on  palpation 
through  the  abdominal  wall,  and  when  low  down  has  been  felt  on 

rectal  or  vaginal  examina- 
tion. Persistent  pain  and 
hasmaturia  extending  over 
days  or  weeks  should  cer- 
tainly suggest  the  presence 
of  a  ureteral  calculus,  and 
the  more  so  if  with  each  suc- 
ceeding attack  the  pain  and 
tenderness  are  located  lower 
down.  The  result  may  be 
that  the  stone  will  ulcerate 
through  into  the  retroperi- 
toneal tissue,  and  be  dis- 
charged in  an  abscess;  or 
more  frequently  the  kidney 
is  disorganized,  and  perhaps 
the  patient's  life  destroyed 
through  the  resulting  renal 
incompetence. 

Occasionally  the  function 
of  both  kidneys  is  brought 
to  an  end — on  the  one  side 
by  the  back  pressure  of  urine 
due  to  the  impaction  of  a 
small  calculus ;  on  the  sound 
side,  by  reflex  suppression 
of  urine.  In  a  case  of  this 
character  recently  operated 
on  all  the  symptoms  were 
on  the  left  sound  side,  and 
in  the  unavoidable  absence  of  a  radiograph  the  kidney  and  ureter 
on  this  side  were  first  explored  and  found  normal ;  the  peritoneum 
was  then  opened,  and  an  impacted  stone  detected  in  the  right 
ureter,  and  through  a  second  incision  this  was  removed.  The 
urinary  secretion  was  at  once  recommenced. 

Should  the  ureter  of  a  solitary  kidney  be  blocked  by  a  stone,  grave 

*  Sometimes  a  calculus  will  remain  in  the  ureter  for  a  considerable  period, 
acting  as  a  ball-valve,  and  permitting  a  certain  amount  of  urine  to  pass.  It 
may  increase  in  size,  and  reach  considerable  dimensions.  The  author  recorded 
a  case  {Proceedings,  Royal  Society  of  Medicine,  vol.  iii.,  No.  3,  Clinical  Section, 
p.  63)  in  which  he  had  removed  a  stone  from  the  lower  end  of  the  ureter 
weighing  803  grains.  The  ureter  above  it  was  dilated  like  a  coil  of  intestine, 
and  filled  with  pus. 


1 

10 

^m^mt 

^^^^^H 

Fig.  543. — Radiogram  of  Stone  in  the 
Pelvic  Portion  of  the  Ureter. 

The  actual  stone  is  seen  in  the  inset  against 
a  centimetre  scale ;  it  was  removed  by  a 
retro-peritoneal  operation. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1207 

symptoms  of  calculous  anuria,  or  suppression,  will  arise.  The 
condition  is  ushered  in  by  pain  in  the  loin  of  the  usual  character, 
which  often  passes  away  in  two  or  three  da3's.  The  anuria  is  rarely 
complete  at  first,  a  few  ounces  of  pale  limpid  urine  being  passed  at 
intervals,  whilst  occasionally  distinct  polyuria  is  present.  Sooner 
or  later  definite  uremic  phenomena  supervene ;  the  most  usual  period 
IS  seven  or  eight  days  after  the  onset,  but  incomplete  obstruction  or 
a  pre-existing  condition  of  hydronephrosis  may  delay  matters. 
The  onset  of  uraemia  is  indicated  by  persistent  vomiting,' a  slow,  full 
pulse  becoming  irregular,  contraction  of  the  pupils,  and  muscular 
tremors.  Coma  and  convulsions  are  rarely  seen,  and  there  is  no 
dyspnrea;  the  temperature  is  subnormal. 

The  Diagnosis  of  renal  calculus  is  often  a  matter  of  uncertainty  in 
the  absence  of  a  history  of  the  passage  of  gravel  or  of  the  occurrence 
of  renal  cohc.  It  is  most  likely  to  be  mistaken  for  tuberculous 
disease;  the  differential  diagnosis  between  the  two  conditions  has 
already  been  considered  (p.  1302).  The  final  determination  of  the 
presence  or  not  of  a  renal  or  ureteral  calculus  is  now  usually  made 
by  radiography,  which  has  made  such  advances  that  it  may  be  relied 
on  with  almost  absolute  certainty,  except  perhaps  in  the  case  of  small 
pure  uric  acid  calculi. 

Reference  has  already  been  made  (p.  1187)  to  some  of  the  con- 
.ditions  which  must  be  observed  if  a  reliable  result  is  to  be  obtained. 
It  is  a  good  rule  to  follow  that  a  second  confirmatory  examination 
should  be  made  after  an  interval  of  two  or  three  days  in  all  cases 
where  the  diagnosis  has  not  been  established  beyond  all  shadow  of 
doubt.  If  a  small  stone  has  been  located  in  the  kidney,  and  opera- 
tion has  for  some  reason  or  other  been  deferred,  it  is  always  advisable 
that  a  confirmatory  radiogram  be  taken  immediately  before  the 
operation.  Cases  have  been  known  where  a  stone  had,  during  an 
interval,  shifted  its  position  from  the  kidney  to  within  an  inch  or 
two  of  the  lower  end  of  the  ureter  without  any  symptom  which 
could  suggest  the  change  of  position. 

Treatment.— In  the  early  stages  treatment  is  directed  to  the  cure 
of  hthiasis  (p.  1185).  The  patient's  diet  and  general  habits  of  hfe 
must  be  suitably  regulated,  and  he  is  instructed  to  make  use  of 
alkaline  waters,  such  as  those  derived  from  Contrexeville  or  Vichy, 
or  citrate  of  Hthia  and  sulphate  of  soda  may  be  administered  in  a 
mixture.  Plenty  of  bland  fluid  should  be  ordered,  such  as  boiled  or 
distilled  water,  in  the  hope  of  softening  the  stone  or  assisting  its 
onward  passage  to  the  bladder.  Sometimes  it  may  become  encysted 
if  the  patient  is  kept  absolutely  at  rest;  the  sj/mptoms  will" then 
gradually  improve,  and  finally  disappear. 

Attacks  of  renal  colic  are  treated  by  the  use  of  hot  hip-baths, 
warm  drinks,  and  hypodermic  injections  of  morphia  and  atropine; 
in  the  more  severe  cases  chloroform  must  be  administered. 

In  former  days,  when  the  presence  of  a  calculus  could  only  be 
suspected  from  the  history  or  symptoms,  the  question  of  operation 
and  when  to  undertake  it  was  a  subject  of  much  discussion.     Even 


i2o8  A   MANUAL  OF  SURGERY 

at  that  time  Sir  Henry  Morris  wrote  that  an  '  unsuspected  renal 
calculus  is  a  source  of  very  real  danger;  and  when  its  presence  is 
disclosed,  whether  by  accident  or  by  the  systematic  examination  of 
the  urine,  we  should  recommend  its  immediate  removal,  regardless 
of  the  fact  that  it  is  not  causing  pain,  unless  the  general  condition  of 
the  patient  contra-indicates  an  operation.'  At  the  present  day, 
when  radiography  has  placed  in  our  hands  a  means  of  almost  certain 
diagnosis,  the  same  advice  holds  good^whenever  a  stone  is  found, 
remove  it,  unless  special  contra-indications  exist.  Especially  is  this 
the  case  when  a  considerable  amount  of  blood  or  pus  is  being  passed 
in  the  urine,  and  the  patient's  temperature  is  raised.  Pain  in  both 
kidneys  is  no  contra-indication  to  operation,  since  there  is  no 
objection  to  exposing  and  even  removing  calculi  from  both  organs. 
The  constant  passage  of  gravel,  moreover,  need  not  deter  one  from 
operating,  for  when  once  the  kidney  has  been  relieved  by  removal 
of  the  larger  masses,  the  tendency  to  recurrence  may  be  checked  by 
suitable  diet  or  drugs. 

Nephro-lithotomy  is  alwaj^s  undertaken  through  the  loin.  When 
exposed,  the  kidney  is  carefully  freed  from  its  connections,  and 
drawn  up  into  the  wound;  in  the  majority  of  patients  it  can  be 
brought  out  on  the  loin,  and  this  is  certainl}'  a  desirable  manoeuvre. 
The  whole  gland  is  then  carefully  palpated,  as  also  the  pelvis  and 
upper  part  of  the  ureter,  so  as  to  locate,  if  possible,  the  stone. 
Should  it  be  distinctly  felt  within  the  kidney  substance,  an  incision 
is  made  over  it  through  the  renal  parenchyma;  free  haemorrhage 
follows,  but  this  is  readily  controlled  by  inserting  the  finger  into  the 
wound,  or  b}^  grasping  the  vessels  in  the  hilum.  Should  the  stone 
not  be  palpable,  an  incision  is  made  through  the  convex  border  of 
the  kidne}^  substance,  a  little  posterior  to  the  mesial  plane  of  the 
organ  and  at  the  junction  of  its  inferior  and  middle  thirds.  One  of 
the  lower  catyces  is  opened  by  this  means,  and  the  interior  of  the 
pelvis  is  carefully  and  fully  explored  by  finger  and  probe.  Some- 
times the  incision  in  the  kidney  has  to  be  considerably  enlarged, 
and  the  discovery  of  a  small  calculus  may  be  a  task  of  some  difficulty. 
When  the  pelvis  is  much  distended  and  the  patient  has  previously 
passed  a  good  deal  of  pus,  careful  precautions  must  be  taken  to  pro- 
tect the  surrounding  tissues  from  infection.  Sterile  gauze  is  packed 
into  the  angles  and  hollows  of  the  wound,  and  the  assistant  must 
press  up  the  abdominal  wall.  The  incision  is  usually  made  through 
the  cortex  in  preference  to  opening  directly  into  the  pelvis ;  but  the 
objection  often  stated  that  a  pelvic  incision  heals  with  difficulty, 
and  is  liable  to  leave  a  fistula,  is  not  true,  and  most  surgeons  now 
deliberately  open  the  pelvis  in  order  to  extract  stones  if  it  is  more 
convenient  to  get  at  them  in  this  way.  Accurate  suturing  with  catgut 
is  generally  successful  in  securing  immediate  healing,  but  the  sutures 
must  not  encroach  on  the  mucous  membrane.  Stones  are  removed 
by  dressing-forceps,  or  scoop,  and  care  must  be  exercised  to  prevent 
any  from  falling  backwards  into  the  ureter.  Large  branched 
calculi  are  often  held  very  tightly,  and  require  an  extensive  incision 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1209 

and  careful  peeling  off  of  the  kidne}'  substance.  The  pelvic  cavity 
need  not  be  irrigated  under  ordinary  circumstances,  but  when  dilated 
and  suppurating  it  is  well  to  do  so  with  a  hot  solution  of  sublimate 
or  of  Condy's  fluid.  Before  closing  the  wound  in  the  kidney  the 
ureter  should  be  thoroughly  examined;  it  is  sometimes  possible  to 
introduce  a  ureteral  sound  through  the  open  wound,  but  this  is  by 
no  means  easy,  and  it  is  often  wiser  to  make  a  tiny  opening  through 
the  pelvic  infundibulum,  through  which  the  sound  is  passed,  and 
which  is  subsequently  closed  by  a  Lembert's  suture.  Bleeding  is 
usually  controlled  without  difficulty  by  stitches  passed  through  the 
kidney  substance,  to  which  in  bad  cases  may  be  superadded  pressure 
b}^  sponge  or  a  gauze  plug  in  the  wound.  It  is  useless  to  attempt 
to  place  a  ligature  on  a  vessel  divided  in  the  renal  parenchyma. 
Should  bleeding  persist,  sutures  of  the  mattress  type  should  be  intro- 
duced and  tied  firmly.  It  is  often  wise  to  insert  a  drainage-tube 
down  to  the  sutured  wound  in  the  kidney,  after  it  has  been  replaced. 
The  abdominal  parietes  may  then  be  closed  in  the  usual  way. 

To  explore  and  expose  the  ureter  the  incision  should  be  prolonged 
downwards  and  forwards  in  a  direction  parallel  with  Poupart's  liga- 
ment towards  the  inguinal  canal  (the  lumbo-ilio-inguinal  incision  of 
Sir  Henry  Morris).  The  peritoneum  and  its  contents  are  pushed 
bodily  inwards,  and  the  ureter  attached  to  the  posterior  peritoneal 
wall  can  be  followed  down  to  within  a  few  inches  of  the  bladder. 
For  a  stone  impacted  near  the  lower  end  of  the  ureter,  uretero- 
lithotomy is  performed  with  the  patient  in  the  Trendelenburg 
position.     The  operation  may  be  trans-  or  retro-peritoneal. 

1.  The  trans-peritoneal  operation  is  conducted  through  an  incision 
in  the  middle  line.  The  stone  is  located,  and,  if  possible,  coaxed  by 
the  finger  out  of  the  depths  of  the  pelvis  to  a  more  accessible  position. 
It  is  then  cut  down  on  through  the  peritoneum,  and  the  stone 
removed.     The  incision  is  closed  by  a  Lembert  suture  or  two. 

2.  The  retro-peritoneal  operation  requires  an  incision  similar  to 
that  for  tying  the  common  iliac  artery.  The  peritoneum  and  its 
contents  are  displaced  inwards,  and  the  ureter  is  easily  found 
running  down  on  its  posterior  aspect.  The  stone  is,  if  possible,  dis- 
placed up  from  the  pelvis,  and  removed.  Cases  seem  to  do  equally 
well  whether  the  ureter  is  sutured  or  not,  granting  that  the  stone  is 
small.  For  large  calculi,  where  much  pus  is  present,  it  may  be  wise 
to  drain  the  ureter  for  a  day  or  two.  The  uncertainty  of  the  local 
condition,  which  may  be  disclosed  on  operation,  leads  the  author 
to  favour  the  retroperitoneal  operation  as  the  safer  of  the  two  pro- 
cedures. A  calculus  impacted  close  to  the  bladder  has  been 
removed  through  the  rectum  or  vagina,  or  by  a  trans  -  sacral 
operation. 

When  the  kidney  is  totally  disorganized,  nephrectomy  may  be 
required,  but  such  treatment  is  not  always  advisable,  especially 
when  sinuses  have  resulted  from  a  suppurative  perinephritis.  In 
such  cases  the  renal  tissue  has  often  entirely  disappeared,  and  dis- 
integrating calculous  material  may  occupy  the  pelvis,  which  is  sur- 


A   MANUAL  OF  SURGERY 


rounded  by  a  mass  of  dense  libro-cicatricial  tissue,  the  ri'nioval  of 
which  is  impracticable  and  even  dangerous.  All  that  should  be 
attempted  locally  is  the  extraction  of  the  stone  and  the  purihcation 
of  the  cavity.  If  the  inconvenience  arising  from  the  clischarge  of 
pus  and  perhaps  urine  in  the  loin  is  too  great,  it  may  be  possible  to 
check  it  in  large  measure  by  the  plan  suggested  and  practised  by 
Colonel  Holt,  D.S.O. — viz.,  ligature  of  the  renal  artery.* 

Tumours  of  the  Kidney.^ — -The  different  forms  of  tumour  which 
originate  in  the  kidney  may  be  classified  as  the  simple  and  the 
malignant.  Several  cystic  conditions  also  occur.  The  general 
features  of  an  enlarged  kidney  have  been  already  described  (p.  1176). 

The  simple  tumours  of  the  kidney  are: 

1.  Diffuse  Cystic  Disease  (or,  as  it  has  been  termed,  adenoma  of 
the  kidney),  which  may  be  congenital  or  acquired.     It  is  not  un- 

frequently  bilateral,  especially 
when  congenital.  The  kidney  is 
enlarged  and  occupied  by  cysts, 
varying  in  size,  but  rarely  ex- 
ceeding that  of  a  cherry;  they 
are  lined  with  epithelium,  which 
is  generally  flattened,  and  filled 
with  a  limpid  fluid  containing 
urea  and  perhaps  cholesterine. 
The  cysts  are  often  very  numer- 
ous, and  may  project  from  the 
surface  of  the  kidney  as  nodular 
elastic  outgrowths. 

The  pelvis  remains  unaffected 
until  the  later  stages  of  the 
disease  (Fig.  544) .  Generally  the 
whole  kidney  is  involved,  and 
may  attain  enormous  dimensions, 
constituting  large  swellings 
which  can  be  easily  felt,  and  with 
a  distinctly  nodulated  surface; 
occasionally  the  growth  is  limited  to  one  portion  of  the  organ.  The 
origin  of  this  condition  is  uncertain,  but  it  is  supposed  to  be  due  to 
the  persistence  of  the  mesonephros  (or  Wolffian  body)  in  the  sub- 
stance of  the  true  kidney  (or  metanephros),  and  its  development 
into  cysts.  In  the  early  stages  no  symptoms  are  produced,  except, 
perhaps,  a  sense  of  dragging  weight  in  the  loins  from  the  size  of  the 
tumours ;  but  later  on  the  secretion  of  urine  is  interfered  with  to  such 
an  extent  as  to  produce  renal  incompetency  and  finally  uraemia. 
The  tendency  of  this  affection  to  affect  both  kidneys  prevents  any 
hope  of  benefit  from  operation. 

2.  Papilloma  of  the  renal  pelvis  is  a  rare  condition,  characterized 
by  the  development  within  its  cavity  of  a  villous  mass,  identical  in 
structure  with  that  met  with  in  the  bladder.     It  has  usually  been 

*  Trans.  Royal  Med.  Chir.  Soc,  1907. 


Fig.  544. — Cystic  Disease  of  Kidney. 
(King's  College  Hospital  Museum.) 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  izii 

observed  in  elderly  people,  and  the  chief,  if  not  the  only,  symptom 
is  excessive  haematuria.  It  cannot  be  diagnosed  with  certainty,  but 
if  discovered  in  an  exploratory  operation,  it  can  be  removed  with 
success. 

Malignant  tumours  of  the  kidney  may  be  divided  into : 

1.  The  Sarcomata  of  Infants,  which  are  often  congenital,  but  may 
be  acquired  within  the  tirst  few  years  of  life.  They  are  encapsuled, 
the  kidney  substance  being  spread  over  them,  and  consist  of  round 
or  spindle  cells,  the  latter  often  showing  a  cross-striation,  resembhng 
that  of  muscular  fibres  (myo-sarcomata).  They  grow  to  a  great  size, 
and  may  affect  both  organs,  but  pain  and  haematuria  are  absent. 
Death  results  from  general  dissemination  or  from  exhaustion,  or  may 
follow  mechanical  obstruction  to  the  circulation,  as  by  the  detach- 
ment of  a  sarcomatous  embolus,  which  travels  upwards  and  blocks 
the  pulmonary  vessels.  Treatment  by  nephrectomy  has  given  most 
unsatisfactory  results,  the  operative  mortahty  having  been  high  and 
recurrence  almost  invariable  within  a  short  period.  The  operation 
itself  is  not  particularly  di^cult,  but  a  large  incision  is  required,  and 
care  must  be  taken  to  avoid  displaced  structures,  such  as  the 
mferior  vena  cava.  When  both  kidneys  are  affected  nothing  can 
be  done. 

2.  The  Sarcomata  of  Adults  occur  between  the  thirtieth  and 
fiftieth  years  of  hfe,  and  are  of  the  spindle-celled  variety,  often 
originating  from  the  capsule.  Only  one  kidney  is  generally  involved, 
giving  rise  to  a  rapidly-growing  swelHng,  associated  with  haematuria 
and  perhaps  pain.  CalcuH  are  often  found  in  the  pelvis  of  such 
organs,  and  may  be  causative  or  consecutive.  Secondary  deposits 
form  in  the  viscera ;  extension  through  and  beyond  the  capsule  is  not 
uncommon,  and  death  is  usually  due  to  exhaustion.  The  results  of 
nephrectomy  have  not  been  very  encouraging. 

3.  Primary  Carcinoma  is  an  uncommon  form  of  tumour  in  the 
kidney.  It  presents  the  same  cHnical  features  as  a  sarcoma,  except 
that  there  is  rather  more  pain,  and  can  only  be  recognised  on  micro- 
scopic examination.  One  symptom,  however,  requires  special 
mention,  since  it  is  extremely  suggestive  of  the  presence  of  cancer — 
viz.,  the  development  of  a  varicocele.  It  is  due  to  the  pressure  of 
enlarged  and  cancerous  lymphatic  glands  upon  the  root  of  the 
spermatic  vein,  and  hence,  whenever  an  elderly  person  develops  a 
varicocele,  a  careful  examination  of  the  kidney  on  the  affected  side 
should  always  be  instituted. 

4.  The  commonest  tumours  of  the  kidney,  however,  are  the  so- 
called  Hypernephromata  (75  to  80  per  cent,  of  all  renal  tumours). 
They  are  looked  on  as  growing  from  accessory  and  misplaced  adrenals 
{adrenal  rests),  and  develop  primarily  in  the  cortex  as  localized 
growths,  gradually  increasing  in  size  and  encroaching  on  the  pelvis. 
They  are  of  firm  consistence,  but  show  areas  of  necrosis  and  soften- 
ing, and  some  deep  red  patches  due  to  haemorrhage  (Fig.  545) ;  the 
section  is  more  or  less  mottled,  and  some  bright  yellow  areas  are  very 
evident.     On   microscopic   examination   their   appearance   closely 


A   MANUAL  OF  SURGERY 


resembles  the  zona  fasciculata  of  the  adrenal  bodies,  but  this  theory 
as  to  their  origin  is  not  universally  accepted.  They  are  malignant  in 
type,  being  disseminated  by  the  bloodvessels,  and  secondary 
growths  are  found  in  the  lungs,  liver,  or  bones. 

H\7)ernephromata  usually  occur  in  adults  between  fifty  and 
seventy  years  of  age,  and  are  of  comparatively  slow  growth.  They 
give  rise  to  haematuria,  but  it  is  late  in  appearance,  and  less  persistent 
than  in  other  malignant  growths  of  the  kidney.     Pain  is  often  well 

marked  and  referred  to 
the  loin ;  it  has  two  main 
t}''pes — a  persistent  ach- 
ing pain,  which  may  be 
very  severe  and  wear- 
ing, and  a  colicky  pain, 
due  to  the  passage  of 
clots  down  the  ureter. 
The  renal  enlargement 
is  usually  characteristic, 
but  outgrowths  from 
diffusion  beyond  the 
capsule  may  render  the 
swelling  of  irregular 
shape.  Treatment  con- 
sists in  removal,  if  there 
is  no  evidence  of  second- 
ary deposits  in  the  lungs 
or  elsewhere.  The  opera- 
tion is  by  no  means 
simple  in  cases  that 
are  at  all  advanced,  as 
serious  adhesions  in 
various  directions  may 
be  present,  and  the 
bleeding  may  be  severe. 
Various  Cystic  Condi- 
tions of  the  kidney  must 
be  noted  in  addition  to 
the  general  cystic  dis- 
ease, alreadv  described. 
{a)  Hydatid  Disease 
affects  the  kidney,  as  it 
may  involve  any  other 
organ  in  the  body.  It  starts  either  beneath  the  capsule  or  in  the 
glandular  substance.  In  the  former  case  it  is  likely  to  form  a  rounded 
projection,  which  maybe  detected  on  palpation  of  the  loin;  in  the 
latter  it  expands,  or  even  destroys,  the  whole  of  the  glandular  tissue, 
and  may  burst  into  the  renal  pelvis,  the  cysts  being  passed  along  the 
ureter,  accompanied  by  more  or  less  colic.  Suppuration  may  com- 
plicate matters,  but,  unless  the  cyst  has  ruptured  into  the  renal 


Fig.  545. — HYPEKxtpHKoMA.    (King's  College 
Hospital  Museum.) 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1213 

pelvis,  diagnosis  is  scarcely  feasible  apart  from  an  exploratory  in- 
cision.    Treatment  consists  in  cutting  down  on  the  kidney,   and 
enucleating  the  mass,  if  possible.     Failing  this,  drainage  may  be 
undertaken,  but  in  bad  cases  nephrectomy  is  necessary. 
{b)  Dermoid  Cysts  have  also  been  found. 

(c)  Serous  Cysts  are  occasionally  met  with,  arising  possibly  as  a 
result  of  obstruction  to  some  of  the  ducts,  or  due  to  lymphatic 
obstruction.  Rounded  swellings,  simple  or  multiple,  are  produced, 
growing  outwards  from  the  cortex,  and  containing  a  thin  fluid,  with 
a  small  amount  of  albumen  and  saline  substances  in  solution.  They 
give  rise  to  no  symptoms  except  from  their  size,  and  rarely  require 
treatment  other  than  simple  aspiration  or  drainage.  If  discovered 
at  an  operation,  and  of  considerable  size,  they  should  be  incised,  and 
either  dissected  out,  or  the  outer  wall  cut  away,  and  the  inner  left 
continuous  with  the  renal  capsule. 

[d)  Not  unfrequently  a  number  of  small  cysts  develop  in  con- 
nection with  chronic  granular  nephritis,  but  they  are  of  no  clinical 
importance. 

Nephrectomy,  or  total  removal  of  the  kidney,  is  performed  for  the 
following  conditions :  (a)  For  tuberculous  disease,  when  conservative 
measures  have  failed  or  are  impracticable,  or  when  the  pelvis  and 
ureter  are  extensively  involved;  (6)  for  calculous  pyonephrosis,  when 
the  renal  parenchyma  is  disintegrated;  (c)  for  hydronephrosis,  when 
palliative  measures  or  drainage  have  failed  to  give  relief;  {d)  for 
malignant  disease;  {e)  for  traumatic  lesions,  such  as  disintegration 
or  rupture,  especially  if  complicated  by  laceration  of  the  peritoneum; 
and  (/)  for  some  cases  of  ruptured  ureter. 

Before  undertaking  the  excision  of  any  kidney,  however  diseased, 
it  is  essential  that  the  surgeon  should  satisfy  himself  as  to  the  exist- 
ence of  another,  and  also,  if  possible,  ascertain  that  it  is  capable  of 
undertaking  the  increased  duties  which  will  subsequently  fall  upon 
it.  Many  different  plans  of  doing  this  have  been  already  alluded  to 
(p.  1176). 

Nephrectomy  may  be  undertaken  through  the  abdomen  or  through 
the  loin;  but  sundry  combinations  or  modifications  of  these  opera- 
tions have  been  recommended  by  various  authorities. 

The  A  hdominal  Operation  is  chiefly  utilized  when  the  organ  is  much 
enlarged,  on  account  of  the  readier  access  obtained,  especially  to  the 
pedicle.  The  peritoneum  is  likely  to  be  opened,  and  may  be  exposed 
to  septic  contamination,  when  the  pelvis  and  the  upper  part  of  the 
ureter  are  distended  with  decomposing  pus,  as  is  frequently  the  case ; 
but  this  is  easily  prevented.  Drainage  is  obtained  for  the  cavity  left 
after  the  removal  of  the  organ  by  a  counter-opening  made  through  the 
loin.  One  great  advantage,  as  before  stated,  is  that  the  other  kidney 
can  be  first  examined,  if  required,  and  its  condition  ascertained. 
As  to  the  technique :  there  is  frequently  no  necessity  to  open  the  peri- 
toneal cavity,  since  the  kidney  is  almost  always  enlarged,  but  an 
opening  is  often  made,  intentionally  or  accidentally.     The  colon  and 


I2I4  A   MANUAL  OF  SURGERY 

peritoneum  are  peeled  off  the  organ  and  displaced  inwards;  it  is  then 
freed  from  its  adhesion  to  surrounding  tissues,  the  surgeon  endeavour- 
ing to  keep  outside  its  true  capsule,  but  inside  the  layer  of  condensed 
perinephric  tissue.  Special  precautions  must  be  adopted  in  dealing 
with  the  deep  aspect  of  the  tumour,  particularly  on  the  right  side, 
where  it  is  occasionally  adherent  to  the  inferior  vena  cava.  The 
mass  is  now  lifted  from  its  bed,  and  its  pedicle,  consisting  of  the 
ureter  and  renal  vessels,  isolated.  These  latter  are  secured  separately 
by  ligature  and  divided,  a  clamp  being  applied  to  the  distal  ends. 
'1  he  ureter  is  dealt  with  in  the  same  way,  small  pieces  of  gauze  being 
packed  round  so  as  to  receive  any  secretion  which  may  escape ;  the 
exposed  mucous  membrane  in  the  portion  which  is  left  is  carefully 
touched  over  with  pure  carbolic  acid.  The  kidney  thus  freed  is 
removed,  and  the  wound  in  the  abdominal  parietes  closed  in  the 
usual  way,  provision  for  drainage  having  been  previously  made  either 
through  the  loin  or  from  the  front.  Considerable  shock  is  often  ex- 
perienced from  this  operation,  and  the  death-rate  is  somewhat  high. 

Occasionally  the  perinephric  adhesions  are  so  firm  and  extensive 
that  the  only  practicable  plan  of  removing  the  organ  is  to  enucleate 
it  from  within  the  capsule  as  far  as  the  hilum;  the  capsule  is  then 
torn  or  cut  through  so  as  to  expose  the  pelvis  and  renal  vessels, 
which  are  secured. 

The  Lumbar  Method  can  be  employed  when  the  kidney  is  not  too 
greatly  enlarged.  The  organ  is  exposed  by  the  incision  already 
described,  enucleated  from  its  surroundings,  and  the  pedicle  dealt 
with  as  in  the  abdominal  operation.  If  the  condition  of  the  opposite 
organ  has  not  previously  been  ascertained,  the  peritoneiun  should  be 
incised  at  the  outer  margin  of  the  wound,  so  as  to  enable  the  hand  to 
be  inserted  across  the  middle  line,  and  thus  allow  an  exploration  of 
the  opposite  loin. 

Should  it  be  desirable  to  include  the  ureter  in  the  scope  of  the 
operation,  the  incision  may  be  prolonged  into  the  groin  in  the 
direction  of  the  fibres  of  the  external  oblique,  and  the  peritoneum 
and  its  contents  pushed  forwards ;  by  this  means  it  can  be  traced 
down  almost  to  the  bladder. 


CHAPTER  XL. 
BLADDER  AND  PROSTATE. 

Methods  of  Examining  the  Bladder. — When  a  patient  presents  himself  com- 
plaining of  increased  frequency  of  micturition  and  other  evidences  suggestive 
of  chronic  disease  of  the  bladder,  a  systematic  examination  of  the  individual 
and  his  urinary  passages  must  always  be  instituted.  The  history  of  the  case, 
the  character  of  the  symptoms,  and  the  condition  of  the  urine,  are  carefully 
gone  into.  An  examination  of  the  bladder  should  then  be  made,  (i)  The 
patient  is  laid  on  a  couch,  and  the  lower  part  of  the  abdomen  uncovered. 
The  hypogastrium  is  then  examined  by  inspection,  palpation,  and  percussion, 
so  as  to  ascertain  whether  or  not  the  bladder  is  distended,  or  if  any  abnormal 
resistance  can  be  felt,  either  from  thickening  of  the  wall  or  the  presence  of  a 
tumour.  (2)  A  sound  is  then  passed  according  to  the  method  described  at 
p.  1233,  and  the  interior  of  the  viscus  explored;  by  this  means  a  calculus  may 
be  detected,  and  even  sometimes  a  tumour,  as  also  a  rough  and  irregular 
condition  of  the  mucous  membrane.  (3)  The  finger  is  inserted  into  the 
rectum,  or,  in  the  female,  into  the  vagina,  before  the  sound  is  withdrawn,  so  as 
to  enable  the  condition  of  the  posterior  vesical  wall  to  be  investigated  between 
the  point  of  the  finger  and  the  sound.  Enlargement  of  the  prostate  or  of  the 
vesiculae  seminales  can  also  be  detected  in  this  way.  (4)  The  patient  may 
then  be  asked  to  void  urine,  after  which  a  rubber  catheter  may  be  introduced, 
and  the  amount,  if  any,  of  residual  urine  estimated.  (5)  As  mentioned  else- 
where, Bigelow's  evacuator  is  useful,  not  only  to  wash  out  the  bladder,  but 
also  to  detect  the  presence  of  very  small  calculi  which  the  sound  may  have 
missed.  (6)  Of  recent  years  a  new  means  of  examining  the  interior  of  the 
bladder  has  been  introduced  in  the  shape  of  the  cystoscope.  This  consists 
of  a  straight  tube  with  a  short  end  bent  at  an  angle,  in  which  an  electric 
lamp  is  placed,  the  wires  leading  to  it  being  carried  within  the  tube.  A 
small  window  covered  with  glass  is  situated  close  to  the  angle,  and  a  prism  is 
here  inserted  in  such  a  manner  that,  when  the  surgeon  looks  through  an  eye- 
piece placed  at  the  end  of  the  instrument,  he  is  able  to  see  the  portion  of  the 
vesical  wall  illuminated  by  the  electric  lamp.  To  use  it  the  bladder  must  be 
previously  washed  out,  if  necessary,  and  the  patient  anaesthetized,  if  thought 
desirable.  About  ten  or  twelve  ounces  of  boric  acid  lotion  or  clear  water 
should  be  present  in  the  bladder,  so  as  to  prevent  the  vesical  wall  from  being 
injured  by  the  instrument,  which  always  becomes  hot  after  the  lamp  has  been 
used  for  some  time.  Considerable  practice  is  needed  for  any  useful  informa- 
tion to  be  gained  by  the  aid  of  this  instrument,  but  in  skilled  hands  much 
may  be  learnt  as  to  the  condition  of  the  mucous  membrane.  (See  Plate  XIV.) 
Slight  modifications  of  the  instrument  permit  of  the  passage  of  a  solid  bougie  or 
small  catheter,  which  can  be  passed  into  the  ureteral  orifice  and  up  the  ureter 
(Plate  XIV.,  Fig.  i).  (7)  Finally,  in  cases  where  great  irritability  of  the 
bladder  exists  in  spite  of  treatment,  and  its  presence  cannot  be  explained, 
an  exploratory  cystotomy,  either  suprapubic  or  perineal,  is  justifiable. 

A  distended  bladder  constitutes  a  rounded  swelling,  which  projects  above 
the  symphysis  pubis,  and  naay  even  reach  to  the  umbilicus  in  some  cases. 

1215 


I2l6 


A   MANUAL  OF  SURGERY 


The  swelling  may  be  visible  to  the  naked  eye,  and  is  dull  on  percussion,  the 
dulness  rising  directly  above  the  symphysis;  it  is  quite  immoveable,  and 
therein  differs  from  many  ovarian  and  uterine  tumours.  Bimanual  examina- 
tion per  vaginam  or  per  rectum  should  at  once  indicate  its  nature ;  and  when  at 
all  doubtful,  a  catheter  should  be  introduced. 

Congenital  Affections  oJ  the  Bladder. — i.  Ectopia  Vesicae,  or 
Extroversion  of  the  Bladder,  is  the  term  employed  to  denote  total 
absence  of  the  anterior  wall  of  the  bladder  and  of  the  lower  portion 
of  the  abdominal  parietes,  as  a  result  of  which  the  mucous  membrane 

of  the  posterior  vesical 
wall  is  exposed  and 
rendered  somewhat  pro- 
minent by  the  pressure 
from  behind  of  the 
abdominal  contents 
(Fig.  546,  I).  This  sur- 
face is  usually  not  much 
more  than  an  inch  in 
diameter  in  an  infant, 
and  is  often  irregular, 
and  covered  with  papil- 
liform  processes ;  the 
orifices  of  the  ureters  are 
easily  recognised  below, 
urine  being  occasionally 
emitted  from  them  in 
forcible  j  ets.  The  condi- 
tion is  necessarily  one 
of  the  greatest  discom- 
fort, not  only  from  the 
constant  dribbling  of 
urine  causing  excoria- 
tion and  eczema  of  the 
thighs  and  surrounding 
parts,  but  also  from  the 
pain  and  irritation  due  to  friction  of  the  clothes  against  the  exposed 
mucous  membrane.  The  s^onphysis  pubis  is  always  absent,  and  the 
horizontal  ramus  of  the  pubic  arch  terminates  on  either  side  in  the 
inguinal  region  (4).  The  innominate  bones  are  usually  rotated  out- 
wards, and  the  sacrum  is  convex  anteriorly  from  side  to  side  instead 
of  being  concave.  In  consequence  of  this  pelvic  malformation,  the 
patient's  gait  and  powers  of  progression  are  considerably  impaired. 
The  penis  (2)  is  cleft,  and  in  a  condition  of  complete  epispadias ;  it  is 
drawn  upwards  and  backwards  over  the  trigone,  so  that  it  requires 
pulling  down  to  expose  the  ureteral  orifices.  The  testes  are  often 
found  in  the  inguinal  canal,  or,  if  in  the  scrotum,  are  accompanied  by 
congenital  hernise.  No  umbilicus  is  present.  The  condition  is  due 
to  impaired  development  of  the  anterior  wall  of  the  allantois  and 
the  lower  segment  of  the  abdominal  parietes.     At  birth  the  lower 


Fig.  546. — Ectopia  Vesicae. 

I,  Exposed  mucous  membrane  of  posterior  wall 
of  bladder;  2,  glans  penis  drawn  up  to  cover 
lower  part  of  vesical  mucosa  and  orifices  of 
the  ureters;  3,  scrotum;  4,  projection  of 
pubic  ramus. 


PLA'l'E  XTV. 


Cystoscopic  appearance  of  the  Bladder  in  various  conditions. 

Fig^  I.— Passage  of  ureteral  catheter  through  a  somewlmt  congested  right  ureteral 

"''VJ^'  2.— Tuberculous  bladder  and  kidney.  The  left  ureteral  orifice  is  thickened 
and  pouting  ;  a  small  tubercle  is  seen  on  the  outer  side  of  it  ;  a  spurt  ot  pus  is  being 
ejected  from  it.  Towards  the  middle  line  is  seen  a  more  diftuse  tuberculous  inhltra- 
tion  of  the  vesical  nniscosa. 

Fig.  3. — Stone    in    Bladder. 

Pig^  4. — Papilloma  of  Bladder. 


[To  face  page  12 16. 


BLADDER  AND  PROSTATE  121 7 

portion  of  the  umbilical  cord  is  expanded  over  the  raw  surface,  con- 
stituting the  anterior  vesical  wall.  When  the  cord  separates,  the 
posterior  vesical  wall  is  necessarily  exposed. 

The  Treatment  of  this  distressing  malformation  is  most  unsatis- 
factory, and  hence  in  the  majority  of  the  cases  the  appHcation  of  a 
urinal  has  been  recommended,  although  the  instriunents  hitherto 
devised  are  not  particularly  efficient.  Various  operative  measures 
have  also  been  practised,  {a)  Trendelenburg's  operation  consists  in 
division  of  the  sacro-iliac  ligaments  from  behind  so  as  to  enable  the 
lateral  halves  of  the  pelvis  to  be  compressed  together.  By  this 
means  the  posterior  vesical  wall  is  thrown  backwards  and-  its 
tendency  to  protrude  lessened.  The  wounds  are  allowed  to  granu- 
late, and,  if  successful,  the  bladder  wall  finally  hes  at  the  bottom  of 
the  srdcus,  which  can  usually  be  covered  over  by  a  plastic  operation 
without  much  difficulty.  The  main  objections  to  this  method  are 
that  it  involves  a  very  severe  operation,  and  also  leads  to  a  further 
weakening  of  the  pelvic  arch,  the  integrity  of  which  is  already  much 
impaired  by  the  absence  of  the  pubic  symphysis,  {h)  Plastic  opera- 
tions without  interfering  with  the  pelvis  were  introduced  and  prac- 
tised by  the  late  Professor  John  Wood,  Thiersch,  and  others.  For 
full  details,  we  must  refer  to  larger  text-books.  Suffice  it  here  to 
state  that  a  skin  flap  is  turned  down  from  the  anterior  abdominal 
wall  above  the  breach  of  surface,  and  sutured  on  either  side  to  the 
margins  of  the  defect.  The  cutaneous  surface  of  this  flap  constitutes 
the  anterior  wall  of  the  newly-formed  bladder,  if  such  it  can  be 
called,  whilst  its  raw  outer  surface  is  covered  in  eithsr  by  flaps 
derived  from  either  side,  or  by  undercutting  the  neighbouring  skin 
and  shding  it  inwards  to  the  middle  fine,  where  it  is  united  by 
sutures,  as  suggested  and  successfully  carried  out  by  Mr.  Boyce 
Barrow.  The  after-treatment  is  always  prolonged  and  tedious,  and 
the  patients  are  likely  to  experience  much  subsequent  inconvenience 
owing  to  the  growth  from  the  under  surface  of  the  abdominal  flap 
of  hairs,  which  become  encrusted  with  phosphates,  (c)  More 
recently  various  methods  of  implanting  the  ureters  into  the  rectum 
have  been  practised,  and  it  is  claimed  that  the  urine  is  easily  re- 
tained for  some  hours,  and  voided  independently  of  the  fseces.  This 
is  much  the  best  procedure,  although  the  patient  runs  the  risk  of  an 
ascending  infection  of  his  urinary  track. 

2.  An  Umbilical  Urinary  Fistula  is  sometimes  met  with  as  a  result 
of  imperfect  closure  of  the  urachus. 

3.  Occasionally  in  cases  of  malformation  of  the  rectum  the 
Primitive  Cloaeal  Condition  may  in  part  persist  (see  p.  ii45)- 

Traumatic  Affections  of  the  Bladder.— -Rupture  may  be  produced 
in  several  ways:  (i)  It  may  be  due  to  direct  violence  appHed  to  the 
lower  part  of  the  abdomen,  especially  when  the  viscus  is  distended. 
(2)  It  may  comphcate  a  fracture  of  the  pelvis,  either  as  a  direct 
result  of  the  violence,  or  from  penetration  of  a  spicule  of  bone  from 
the  OS  pubis.  (3)  The  bladder  may  be  opened  by  a  penetrating 
wound.     (4)  Apart  from  traumatic  lesions,  rupture  may  occur  from 

77 


1 21 8  A   MANUAL  OF  SURGERY 

simple  over-distension,  especialh^  if  destructive  ulceration  of  its  walls 
is  present;  or  it  may  follow  ulceration  of  a  saccule  if  it  contains  a 
])h()sphatic  concretion. 

Rupture  of  the  bladder  is  divided  into  two  main  classes,  according 
to  whether  or  not  the  peritoneal  cavity  is  opened.  The  peritoneum 
covers  the  upper  and  back  part  of  the  viscus,  being  reflected 
anteriorly  along  the  urachus,  laterally  along  the  obliterated  hypo- 
gastric arteries,  and  posteriorly  on  to  the  rectum. 

Intraperitoneal  Rupture  involves  the  posterior  or  superior  portions 
of  the  viscus,  and  is  the  variety  most  frequently  met  mth.  The 
symptoms  produced  are  severe  shock,  associated  with  hypogastric 
pain  of  a  burning  nature.  The  patient  experiences  a  constant 
desire  to  micturate,  but,  as  a  rule,  nothing  is  passed,  except  perhaps 
a  little  blood.  Peritonitis  soon  follows,  running  a  rapidly  fatal 
course,  especially  if  efficient  treatment  is  not  adopted.  On  passing 
a  catheter  the  bladder  is  usually  found  empty,  or  possibly  a  little 
blood-stained  urine  may  be  withdrawn ;  if,  however,  the  instrument 
happens  to  be  insinuated  through  the  rupture  into  the  peritoneal 
cavity,  a  considerable  quantity  of  blood-stained  urine  can  be  drawn 
off,  and  the  point  of  the  catheter  may  be  felt  under  the  anterior 
abdominal  wall.  A  useful  diagnostic  sign  consists  in  injecting  a 
measured  amount  of  boric  acid  lotion  into  the  bladder,  and  noting 
how  much  of  it  returns;  when  a  rupture  exists,  some  considerable 
discrepancy  will  probably  be  noted  between  the  two  quantities ;  this 
test  cannot,  however,  always  be  relied  on. 

The  Treatment  of  these  cases  consists  in  immediate  laparotomy; 
the  fluid  within  the  peritoneal  sac  is  removed  by  swabs,  and  the 
wound  in  the  bladder  clearly  demonstrated,  preferably  with  the 
patient  in  the  Trendelenburg  position  (p.  960),  which  must  not, 
however,  be  adopted  until  the  urine  and  inflammatory'  effusion  have 
been  removed.  The  rent  is  carefully  closed  by  means  of  a  row  of 
Lembert  sutures,  not  involving  the  mucous  membrane,  which  should 
always  extend  a  little  beyond  each  extremit}^  of  the  wound.  Possibly 
a  drainage-wick  or  a  Keith's  tube  may  need  to  be  inserted  for  a  few 
hours,  so  as  to  remove  any  exudation.  The  abdominal  wall  is  then 
closed  in  the  usual  way,  and  the  patient  put  back  to  bed.  The 
urine  is  either  drawn  off  at  regular  intervals,  or  a  catheter  may  be 
tied  in  the  bladder,  the  urine  being  syphoned  by  an  attached  rubber 
tube  into  a  vessel  placed  beneath  the  bed. 

Extraperitoneal  Rupture  of  the  bladder  involves  its  anterior  wall 
or  base.  The  urine  finds  its  way  into  the  pelvic  cellidar  tissue,  and 
if  unhealthy  at  once  gives  rise  to  a  most  virulent  fonn  of  suppurative 
pelvic  cellulitis,  which  is  usually  fatal  from  toxaemia  or  pyaemia. 
Abscesses  generalh*  point  either  above  the  pelvic  brim  or  in  the 
perineum.  The  treatment  consists  in  free  incisions  through  the 
perineum,  or  above  the  brim  of  the  pelvis.  In  the  latter  case  it  may 
be  possible  to  reach  the  rent  in  the  bladder  and  suture  it ;  otherwise 
it  may  be  possible  to  introduce  into  the  bladder  a  large  tube,  through 
\\'hich  the  urine  can  escape  freel}-  for  a  time.     As  soon  as  the  tissues 


BLADDER  AND  PROSTATE  1219- 

are  sealed  off  by  the  development  of  granulations,  the  tube  may  be 
withdrawn.  The  prognosis  largely  depends  on  the  condition  of  the 
urine,  whrthcr  healthy  or  contaminated  wath  bacteria,  and  on  the 
length  of  time  it  was  allowed  to  remain  in  contact  with  the  tissues. 

Foreign  Bodies  introduced  into  the  bladder  from  without  are  of 
various  natures,  such  as  portions  of  catheters  or  bougies,  pins,  etc. 
They  give  rise  to  symptoms  of  chronic  C3'stitis,  and  usually  become 
encased  with  phosphatic  deposit.  They  should  be  removed  as  early 
as  possible  with  a  lithotrite,  but  if  of  large  size  or  thickly  covered 
with  phosphates,  must  be  treated  by  perineal  or  suprapubic  cyst- 
otom5^  In  the  female,  digital  dilatation  of  the  urethra  is  the  best 
means  of  gaining  access  to  the  interior  of  the  viscus. 

Cystitis  ma}-  be  due  to  a  great  variety  of  causes,  but  is  always  in 
essence  of  bacterial  origin.  Many  different  forms  of  bacteria  may 
be  found,  but  those  most  usually  present  are  the  ordinary  pyogenic 
cocci,  especially  the  Staphylococcus  aureus,  which,  together  with  the 
Diplococcus  uvecB  liquefaciens,  has  the  power  of  decomposing  urea  and 
setting  free  ammonia,  whilst  the  B.  coli  is  also  commonly  found 
in  these  cases.  This  latter  organism  has  no  power  of  rendering  the 
urine  alkaline,  and,  indeed,  develops  badly  in  alkaline  media,  and 
hence  if  present  in  a  pure  infection  the  urine  remains  acid,  though 
stale  and  offensive  to  the  smell.  The  methods  of  invasion  of  the 
bladder  are  diverse:  (i)  Bacteria  may  reach  the  viscus  from  above, 
either  owing  to  a  suppurative  lesion  of  the  kidney  or  its  pelvis,  or 
escaping  into  the  urine  from  the  blood.  (2)  They  may  travel  up 
the  urethra.  This  is  a  matter  of  no  difficulty  in  the  short  and 
comparatively  large  urethra  of  a  woman,  and  hence  cystitis  is 
frequentty  associated  with  vulvitis  or  is  seen  after  labour.  In  girls 
a  pure  bacillary  c^'stitis  with  acid  urine  is  not  uncommon,  and  is 
probably  secondarv  to  a  vulvo -vaginitis,  which  arises  from  con- 
tamination of  the  vulva  with  the  faeces  where  cleanliness  is  neglected. 
In  the  male  sex,  infection  from  the  urethra  is  unusual  unless  urethri- 
tis has  previousl}'  existed  or  some  irritation,  due  to  the  passage  of 
instruments.  Even  if  they  are  carefully  sterilized,  mucus  is  liable 
to  form  and  cling  about  the  urethral  wall,  and  along  this  bacteria 
can  find  their  way.  Naturally  the  introduction  of  an  unsterilized 
dirty  instrument  may  suffice  to  cause  cystitis.  (3)  Bacteria  can 
invade  the  bladder  from  surrounding  organs,  being  transmitted  by 
lymphatic  dissemination.  Thus  an  injury  of  the  rectum  may  easily 
lead  to  cystitis.  ' 

The  mere  presence  of  bacteria  in  the  bladder  is,  however,  not 
sufficient  as  a  rule  to  determine  an  attack  of  c^^stitis.  Large  quanti- 
ties of  pus  are  frequently  discharged  from  the  kidney  through  the 
bladder,  and  that  over  lengthy  periods,  and  yet  no  inflammatory 
reaction  follows.  Some  local  predisposing  factor  must  be  added  in 
order  to  excite  their  acti\dty,  and  amongst  the  most  favourable  are 
the  following:  (i.)  Congestion  of  the  mucous  membrane,  determined 
bj'  exposure  to  cold;  this  is  peculiarh^  liable  to  occur  in  gouty 
indi\iduals,  and,  indeed,  there  are  people  who  '  take  cold  '  in.  their 


I2  20  A   MANUAL  OF  SURGERY 

bladders  instead  of  developing  a  nasal  or  bronchial  catarrh,  (ii.)  In- 
jury, as  by  the  presence  of  a  foreign  body,  a  calculus,  or  rough 
handling  during  an  operation,  may  serve  to  render  bacteria  active 
and  virulent,  (iii.)  One  of  the  most  important  causes  is  retention 
of  urine,  from  whatever  cause  it  is  due — e.g.,  enlarged  prostate, 
stricture,  etc.  The  bacteria  develop  and  decompose  the  urine, 
rendering  it  offensive  and  ammoniacal,  and  the  toxins  and  irritating 
bodies  thereby  produced  affect  the  vesical  mucosa,  (iv.)  The 
j)resence  of  irritants  in  the  urine  may  determine  cystitis,  as  also 
pyelitis — e.g.,  after  the  absorption  of  cantharides.  Other  drugs  may 
light  up  bacterial  activity  m  some  predisposed  individuals — e.g., 
copaiba  or  cubebs.  (v.)  Loss  of  nervous  control  is  a  most  important 
predisposing  factor,  and  comes  prominently  into  play  in  spinal 
injuries.  The  greatest  difficulty  is  experienced  in  protecting  such 
patients,  and  even  effective  purification  of  penis,  hands,  and  catheter 
and  the  application  of  a  sterilized  dressing  to  the  organ  after  the 
catheter  has  been  used,  may  not  suffice  to  prevent  an  outbreak  of 
cystitis,  which  is  due  to  infection  from  the  kidney  or  rectum.  In 
these  patients  the  disease  always  runs  a  virulent  course,  and  is  likely 
to  kill  the  patient  by  extension  up  the  ureter. 

Pathological  Anatomy. — In  acute  cases  the  mucous  membrane  of 
the  bladder  becomes  congested  and  thickened;  the  epithelium  is 
shed;  mucus  is  excreted,  and  is  soon  transformed  into  muco-pus, 
which  may  be  extremely  viscid,  and  develops  in  large  quantities. 
Ulceration  of  the  bladder  wall  may  occur,  or  even  sloughing ;  in  the 
worst  cases  the  whole  of  the  mucous  lining  may  necrose,  and  be 
cast  off  as  a  slough.  Sometimes  a  membranous  form  of  inflamma- 
tion occurs,  the  patient  frequently  passing  flakes  of  some  size,  which 
on  examination  are  found  to  be  chiefly  composed  of  fibrin. 

In  chronic  cases  the  mucous  membrane  is  thickened  and  con- 
gested, the  superficial  veins  dilated  and  even  varicose,  whilst 
ulceration  is  not  uncommon.  The  continued  repetition  of  the  act 
of  micturition  leads  to  hypertrophy  of  the  bladder  wall,  which 
becomes  thickened  and  fasciculated;  this  effect  is  of  course  most 
marked  when  the  cystitis  is  associated  with  obstruction  to  the  out- 
flow of  urine.  The  mucous  membrane  may  protrude  outwards 
between  the  muscular  fasciculi,  giving  rise  to  pouch-like  saccules,  in 
which  phosphatic  concretions  are  sometimes  formed,  and  the  re- 
tained urine  undergoes  decomposition.  Perforative  ulceration  occa- 
sionally follows,  originating  a  fatal  peritonitis  or  pelvic  celluHtis 
from  extravasation  of  urine.  The  contracted  state  of  the  bladder 
and  the  overgrowth  of  its  muscular  substance  lead  to  compression  of 
the  openings  of  the  ureters,  hydronephrosis  being  thus  induced. 
A  plug  of  viscid  mucus  often  finds  its  way  into  the  ureteral  orifice, 
and  by  becoming  infected  with  bacteria  causes  an  extension  of  the 
infective  mischief  to  the  kidney. 

The  Symptoms  of  Acute  Cystitis  consist  in  pain  referred  to  the 
perineum  and  hypogastrium,  together  with  tenderness  on  pressure 
over  the  symphysis  pubis.     This  is  accompanied  by  extreme  irrita- 


li LADDER  AND  PROSTATE  1221 

bility  of  the  bladder,  frequent  efforts  of  a  painful  and  spasmodic 
nature  being  made  to  pass  water  (strangury) ;  but  little  urine  is 
voided  at  a  time,  for  as  soon  as  any  amount  has  collected  it  is 
ejected  forcibly.  It  generally  contains  blood  and  pus,  soon  becoming 
alkaline,  and  teeming  with  bacteria.  Some  amount  of  fever  is 
generally  noted,  as  also  vomiting,  whilst  tenesmus  may  be  induced 
as  a  result  of  the  proximity  of  the  rectum  to  the  inflamed  bladder. 
The  usual  termination  of  the  case  is  in  resolution,  but  sometimes 
chronic  irritability  may  persist.  In  rare  instances  the  inflammation 
is  of  such  a  virulent  nature  as  to  cause  death.  The  urine  in  these 
cases  is  often  exceedingly  foul,  and  the  fatal  issue  is  due  to  ex- 
haustion, peritonitis,  suppurative  pyonephrosis,  or  even  acute 
toxaemia.  In  some  patients,  however,  when  the  inflammation  is 
concentrated  at  the  neck  of  the  bladder,  retention,  distension,  and 
atony  may  ensue. 

Treatment. — The  patient  should  be  kept  in  a  warm  atmosphere, 
and  preferably  in  bed,  and  fomentations  applied  to  the  lower  part  of 
the  abdomen ;  hot  hip-baths  twice  daily,  maintained  for  some  time, 
are  very  advantageous.  The  diet  should  be  restricted  to  fluid,  and 
the  patient  encouraged  to  partake  freely  of  barley-water  and  other 
bland  liquids.  Alkalies  and  henbane  may  be  administered,  and 
morphia  and  belladonna  suppositories  are  useful  to  allay  the  pain  and 
irritability.  x\s  a  rule,  no  instrument  should  be  passed  during  the 
acute  stage,  unless  retention  is  present;  but  if  the  urine  becomes 
very  foul,  the  bladder  may  be  gently  washed  out,  or  even  drainage  of 
the  bladder  through  the  perineum  may  be  necessary  (see  Perineal 
Cystotomy,  p.  1223).  Urinarj^  antiseptics,  such  as  urotropine  (5  to 
10  grains  three  or  four  times  a  day),  salol  (10  to  20  grains,)  and  boric 
acid  (15  to  20  grains),  together  with  acid  phosphate  of  soda,  adminis- 
tered by  the  mouth,  may  do  good. 

Chronic  Cystitis  is  much  more  common  than  the  acute  variety,  and 
is  usualh^  associated  with  some  irritation  of  the  walls  of  the  viscus, 
as  from  calculi,  tumours,  foreign  bodies,  tuberculous  ulceration,  or 
retention  and  decomposition  of  urine,  especially  if  associated  with 
obstruction  to  the  outflow,  as  by  a  stricture  or  enlarged  prostate.  It 
may  also  follow  acute  cystitis. 

The  Symptoms  are  those  of  irritability  of  the  bladder,  the  patient 
constantly  desiring  to  pass  water,  and  having  to  rise  at  night, 
perhaps  several  times,  for  this  purpose.  The  urine  becomes  turbid, 
and,  on  standing,  deposits  a  variable  amount  of  mucus  or  muco-pus, 
mixed  with  epithelial  cells,  crystals  of  triple  phosphate,  and  a 
granular  sediment  of  phosphate  of  lime.  It  is  usually  alkaline  (unless 
due  to  a  pure  infection  with  the  B.  coli),  perhaps  foul-smelling  and 
ammoniacal,  containing  an  abundance  of  micro-organisms.  There 
is  often  but  little  pain,  though  when  a  calculus  exists,  or  the  neck 
of  the  bladder  is  ulcerated,  this  may  become  a  prominent  s}Tnptom. 
The  patient's  general  health  is  not  at  first  affected;  but  if  the 
symptoms  persist  it  soon  becomes  impaired — partly  from  the 
absorption  of  septic  products  from  the  bladder,  and  partty  from  the 


1222  A   MANUAL  OF  SURGERY 

want  of  rest  and  sleep  arising  from  nocturnal  disturbance — and  this 
may  be  so  marked  as  to  lead  to  fatal  exhaustion.  In  other  cases  the 
inflammation  may  spread  from  the  bladder  along  the  ureters  to 
the  kidneys,  and  the  phenomena  of  septic  pyelonephritis  manifest 
themselves  (p.  1197). 

The  Diagnosis  of  chronic  cystitis  is  readily  made  from  the  charac- 
teristic symptoms  of  irritation  of  the  bladder  and  the  condition  of  the 
urine;  but  considerable  difficulty  may  be  experienced  in  determining 
its  cause.  In  investigating  a  case,  not  only  must  the  character  of 
its  onset  be  considered,  but  also  the  general  history  of  the  patient; 
whilst  a  thorough  examination  of  the  lower  urinary  passages  must 
be  instituted,  and  the  urine  examined  microscopically  and  bacterio- 
logically.  The  passage  of  a  catheter  or  sound  will  generally  detect 
any  obstruction  located  in  the  urethra,  whilst  the  bladder  is  also 
examined  by  the  cystoscope  and  other  methods  described  at  p.  1215. 
The  Treatment  of  chronic  cystitis  is  naturally  directed  towards  its 
cause,  if  such  can  be  discovered ;  thus,  calculi  or  foreign  bodies  should 
be  removed,  and  a  stricture  dilated.  In  most  cases,  even  where  the 
cause  is  not  apparent,  great  benefit  will  be  derived  from  washing  out 
the  bladder. 

The  bladder  is  best  irrigated  by  passing  a  soft  rubber  instrument 
to  the  end  of  which  is  attached  a  portion  of  drainage-tube,  about 
3  feet  long,  and  beyond  this  a  glass  funnel,  into  which  the  material 
employed  is  poured.  By  raising  the  funnel  the  fluid  runs  into  the 
bladder,  whilst  on  depressing  it  below  the  bed  or  couch  the  fluid 
returns  on  the  syphon  principle.  The  patient's  sensations  must  guide 
the  surgeon  as  to  how  much  fluid  can  be  borne  in  any  particular 
case.  Various  solutions  are  employed  for  this  purpose,  but  perhaps 
the  most  useful  are  weak  Condy's  fluid,  sanitas  (i  in  10),  boric  acid 
(20  grains  to  i  ounce),  perchloride  of  mercury  (i  in  5,000),  a  neutral 
solution  of  quinine  (2  grains  to  i  ounce),  or  nitrate  of  silver  (J  grain 
to  I  ounce),  and  they  may  be  used  alternately  with  advantage. 
The  frequency  with  which  the  injections  are  made  must  vary  with 
the  severity  of  the  symptoms ;  it  is  not  often  necessary  to  perform 
the  operation  more  than  once  or  twice  a  day.  Of  course  the  most 
stringent  precautions  must  be  taken  as  to  sterilization  of  the  patient's 
penis,  of  the  surgeon's  hands,  and  of  the  instruments  employed. 

At  the  same  time  that  this  local  treatment  is  being  adopted,  the 
patient's  general  habits  of  life  must  be  regulated.  The  diet  should 
be  bland  and  unstimulating ;  alcohol  is  better  avoided,  but  if  essential 
for  other  reasons,  well-diluted  gin  or  whisky  may  be  given.  Tea  and 
coffee  should  be  prohibited,  whilst  milk  should  be  given  freely, 
together  with  barley-water  and  some  mild  alkaline  water — -such  as 
that  derived  from  Contrexeville.  As  to  medicines,  there  are  none 
which  can  alter  the  reaction  of  the  urine  from  alkaline  to  acid,  but 
perhaps  salol,  boric  acid,  or  benzoic  acid  maybe  of  some  assistance. 
Urotropine  is  useful,  acting  by  setting  free  formahn  in  the  bladder. 
Hot  infusions  of  buchu,  uva  ursi,  and  triticum  repens  act  as  mild 
diuretics,  and  as  alteratives  to  the  vesical  mucous  membrane;  full 


BLADDER  AND  PROSTATE 


1223 


doses,  however,  such  as  a  pint  or  a  pint  and  a  half  in  the  course  of 
the  day,  are  needed.  Where  much  muco-pus  is  excreted,  copaiba, 
cubebs,  turpentine,  or  sandal-wood  oil  may  be  given,  wliilst  injec- 
tions of  dilute  astringents  have  been  advised,  but  must  be  used  with 
caution. 

Vaccine  treatment  should  be  employed  if  the  B.  coli  is  the  active 
organism;  but  in  such  cases  the  results  are  often  very  disappointing, 
possibly  because  the  vaccine  is  in  the  blood  and  the  bacteria  in  the 
urine.  The  patient  may  remain  apparently  well,  and  yet  the  urine 
teems  with  bacteria,  and  occasional  bouts  of  cystitis  occur,  which  must 
be  treated  by  alkaline  drugs  and  by  washing  out  the  bladder  either 
with  Condy's  fluid  or  with  a  very  dilute  solution  of  nitrate  of  silver. 

In  cases  which  do  not  improve,  and  if  the  patient  is  becoming 
exhausted  from  the  constant  interference  with  his  rest,  etc.,  the  only 


Fig.  547. — Perineal  Cystotomy      (Fergusson.) 

means  of  treatment  left  is  that  of  opening  the  bladder  through  a 
perineal  incision.  Perineal  Cystotomy  is  undertaken  not  only  for 
draining  a  chronically  inflamed  bladder,  but  also  to  explore  the 
mucous  lining  of  the  viscus  to  remove  growths  and  foreign  bodies, 
as  also  sometimes  to  deal  with  prostatic  enlargements  and  calculi. 
The  bladder  is  first  thoroughly  washed  out,  a  few  ounces  of  antiseptic 
solution  being  left  within  it.  After  anaesthesia  has  been  induced,  a 
staff  with  a  median  groove  is  passed  into  the  bladder,  and  then  the 
patient  is  placed  in  the  lithotomy  position,  and  the  perineum  shaved. 
An  incision  is  made  in  the  middle  line  of  the  perineum,  from  a  point 
2|  inches  in  front  of  the  anus  to  about  i  inch  from  that  opening. 
The  knife  divides  the  deeper  structures  of  the  perineum,  and,  guided 
by  the  left  index  finger  in  the  wound  (Fig.  547),  is  made  to  enter  the 
groove  in  the  staff  at  a  point  corresponding  to  the  membranous 
portion  of  the  urethra.  It  is  then  carried  upwards  and  backwards 
along  the  groove,  incising  the  prostate  and  entering  the  bladder. 


12  2^  A   MANUAL  OF  SURGERY 

The  knitc  is  carefully  withdrawn,  the  linger  gently  inserted  into  the 
cavity,  and  the  staff  removed.  After  digital  exploration  of  the 
bladder,  a  full-sized  gum-elastic  catheter  (No.  i6  or  i8)  is  passed  in 
through  the  wound  and  fixed,  a  long  piece  of  rubber  tubing  being 
attached  to  allow  of  the  constant  escape  of  the  urine,  as  well  as  to 
permit  of  occasional  ii ligation.  The  catheter  is  removed  and 
changed  at  the  end  of  forty-eight  hours,  and  in  favourable  cases  may 
be  discontinued  altogether  at  the  end  of  a  w^eek ;  in  severer  cases  a 
permanent  opening  nia\'  haxe  to  be  maintained. 

Complications  and  Dangers  of  Perineal  Cystotomy.— (i)  llcemorrhage  may 
arise  from  the  superlicial  arteries  of  the  perineum,  tlie  deep  branches  of  the 
pudic  (especially  that  which  passes  to  the  bulb),  ami  the  veins  of  the  prostatic 
plexus.  The  first  of  these  are  divided  in  the  superlicial  incision,  and  may  be 
readily  secured  by  forceps.  If  the  artery  to  the  bulb  or  its  branches  in  the  bulb 
are  cut.  free  haemorrhage  follows,  which  is  usually  stopped  without  difficulty 
b\-  opening  up  the  wound  and  seizing  the  bleeding  pomts  with  forceps,  or  by 
packing  around  a  catheter.  \'enous  haemorrhage  from  the  prostate  is  more 
serious,  and  is  especially  prone  to  occur  in  elderh-  persons.  Venous  blood  wells 
up  from  the  depths  of  the  wound,  or  passes  back  into  the  bladder,  which 
becomes  distended  with  clot,  considerable  pain  being  thereby  induced.  It  is 
treated  by  syringing  out  the  wound  with  iced  lotion,  and  the  insertion  of  an 
air  tampon  or  a  petticoated  tube.  The  former  contrivance  consists  of  a  gum- 
elastic  catheter,  the  deep  portion  of  which  is  surrounded  by  an  indiarubber  bag, 
which  can  be  inflated  with  air  through  a  small  tube  fitted  with  a  stop-cock,  to 
which  a  force-pump  can  be  attached.  The  petticoated  tube  is  used  when  the 
former  is  not  obtainable  or  fails  to  act ;  it  is  made  by  tying  a  petticoat  of  lint  or 
gauze  around  the  distal  end  of  a  vaginal  tube;  this  is  then  passed  into  the 
bladder,  and  the  space  between  the  petticoat  and  the  tube  packed  with  gauze. 
If  the  bladder  becomes  filled  with  blood-clot,  this  must  be  broken  up  and 
removed  by  syringing  with  hot  water  through  a  large-eyed  catheter,  and  the 
wound  subsequently  plugged  around  a  catheter.  (2)  A  Wound  of  the  Rectum 
may  be  caused  by  carrying  the  incision  too  far  backwards,  or  by  not  maintain- 
ing the  point  of  the  knife  strictly  in  the  groove;  it  is  more  liable  to  happen, 
however,  whilst  withdrawing  the  knife,  the  point  being  swept  backwards,  thus 
opening  the  bowel.  It  is  often  not  recognised  until  flatus  and  faeces  are  passed 
through  the  wound  at  a  later  date.  If  of  small  size  and  situated  low  down,  it 
will  probably  close  b^-  cicatrization  without  special  treatment;  but  when  high 
up  and  more  extensive,  a  rccto-vesical  fistula  is  likely  to  follow.  The  treatment 
usually  recommended  in  such  a  case  is  to  divide  the  .sphincter,  and  thus  lay 
the  lower  end  of  the  rectum  and  the  cystotomy  wound  into  one  cavity,  the 
communication  being  sometimes  closed  by  the  contraction  of  the  granulation 
tissue  which  fills  up  the  wound.  In  suitable  cases  it  may  be  possible  to  stitch 
up  the  opening  from  the  rectum  after  paring  its  edges.  (3)  Pelvic  Cellulitis  is 
caused  by  cutting  beyond  the  limits  of  the  prostate,  and  thus  opening  up  the 
recto-vesical  fascia,  or  by  bruising  and  over-distension  of  the  neck  of  the 
bladder  by  dragging  through  it  too  large  a  stone.  In  either  case  urinary 
extravasation  and  diffuse  septic  inflammation  are  likely  to  follow,  resulting  in 
grave  constitutional  disturbance  of  a  septic  nature,  and  possibly  in  the  death 
of  the  patient.  The  treatment  suggested  is  to  support  the  general  health  by 
suitable  diet  and  stimulants,  whilst  local  tension  is  relieved  by  extending  the 
wound  backwards  even  into  the  rectum.  (4)  An  acute  ascending  pyelo- 
nephritis is  occasionally  lighted  up,  in  .spite  of  all  precautions,  and  cannot  be 
prevented.     For  symptoms,  etc.,  see  p.  119S. 

Tuberculous  Disease  of  the  Bladder  may  be  primary  or  secondary, 
the  latter  being  the  more  usual,  and  extending  from  the  kidney, 
prostate,  or  testicle.  It  is  much  more  common  in  men  than  in 
women,  and  is  most  frequently  seen  in  young  adults.     It  commences 


BLADDER  AND  PROSTATE  1225 

in  the  submucous  tissue  as  a  deposit  of  miliary  tubercle  (Plate  XI\'., 
Fig.  2),  which  caseates  and  suppurates,  breaking  down,  and  giving 
rise  to  ulcers  with  undermined  edges ;  these  are  rarely  of  large  size  at 
hrst.  are  usually  multiple,  and  situated  in  or  near  the  trigone.  The 
Symptoms  are  those  of  chronic  cystitis  and  hematuria,  the  irrita- 
bility of  the  viscus  being  very  marked.  The  diagnosis  is  made  by 
demonstrating  the  bacillus  of  tubercle  in  the  urine,  and  by  the  cysto- 
scope.  The  course  of  the  case  is  unfavourable,  the  ulcers  increasing 
in  size,  and  death  resulting  from  exhaustion,  general  infection, 
phthisis,  or  extension  to  the  kidne3'-s. 

Treatment. — The  case  is  usually"^  treated  for  some  time  as  one  of 
chronic  cystitis  before  its  nature  as  a  tuberculous  affection  is  ascer- 
tained. In  the  milder  cases  it  will  suffice  to  attend  to  the  general 
health  and  hygiene  of  the  individual,  and  to  wash  out  the  bladder 
\v\t\\  some  antiseptic  two  or  three  times  a  week,  leaving  a  drachm  or 
two  of  a  10  per  cent,  solution  of  iodoform  in  olive  oil  or  glycerine 
within  the  viscus.  Injections  of  tuberculin  (p.  184)  have  been 
found  decidedly  valuable  in  this  condition.  In  more  advanced  cases 
cystotomy'  has  been  undertaken  bv  the  suprapubic  method,  and  the 
ulcerated  surfaces  scraped  and  disinfected  by  applying  the  galvano- 
cautery  or  pure  carbolic  acid.  To  effect  this  the  patient  should  be 
placed  in  the  Trendelenburg  position,  and  a  suitable  speculum  used 
as  a  caisson  through  which  to  work.  It  is  doubtful,  however, 
whether  such  practice  is  of  much  ultimate  value.  When  the  primary 
lesion  in  kidney  or  testis  is  efficiently  treated,  a  secondary  bladder 
trouble  often  improves. 

_  \^ery  similar  Symptoms  may  be  induced  by  the  presence  of  a 
Simple  Ulcer  of  the  Bladder,  which,  according  to  Fenwick,  occurs  not 
unfrequently.  It  is  usually  single,  and  situated  near  the  neck  or 
tngone,  gi^dng  rise  to  great  irritabihty  of  the  viscus  and  hematuria, 
■  although  the  urine  remains  clear,  the  diagnosis  is  best  made  by 
the  cystoscope.  Phosphatic  deposits  sometimes  form  over  the 
ulcerated  surface,  and  may  suggest  the  existence  of  a  stone.  Treat- 
ment consists  in  washing  out  the  bladder  with  lactic  acid  (i  to  3  per 
cent.),  or  in  scraping  and  cauterizing  the  base  of  the  sore  through  a 
suprapubic  incision. 

Tumours  of  the  Bladder. — New  growths  from  the  vesical  wall  are 
not  very  uncommon ;  they  may  be  simple  or  malignant. 

Simple  Tumours  occur  in  'the  form  of  fibroma,  myoma,  and 
myxoma ;  but  that  most  often  seen  is  the  Papillomatous  or  Villous 
Tumour,  which  appears  as  a  soft  fiocculent  mass,  usually  situated 
near  the  trigone,  and  close  to  the  opening  of  one  of  the  ureters 
(Fig.  548  and  Plate  XIV.,  Fig.  4).  The  floating  tufts  or  villous 
processes  consist  of  an  extremely  dehcate  connective  tissue,  covered 
with  a  layer  or  two  of  epithelium  similar  to  that  lining  the  bladder, 
and  traversed  by  bloodvessels.  Occasionally  the  grov/ths  have  a 
narrow  base,  and  are  pedunculated,  but  more  frequently  are  sessile. 
They  may  be  single,  or  may  multiply  rapidly,  and  spread  all  over 
the  bladder  by  infection  from  the  primary  growth. 


1226  A   MANUAL  OF  SURGERY 

The  Symptoms  are  those  of  recurrent  h;einorrhagc,  the  ])loi)d  being 
of  a  bright  red  colour,  followed  later  on  by  irritaliility  of  the  bladder. 
At  first  the  haemorrhage  is  intermittent,  considerable  intervals  oc- 
curring between  the  attacks;  but  subsequently  it  becomes  more 
continuous.  The  irritability  of  the  bladder  is  generally  induced  by 
chronic  cystitis,  and  when  the  urine  has  undergone  alkaline  changes, 
there  is  a  copious  exudation  of  ropy  mucus,  which,  mixing  with  the 
urine,  causes  considerable  difficulty  in  micturition,  leading  in  some 
cases  to  strangury.     The  urine  may  also  contain  portions  of  the 


i^ 


f*^^ 


h 


v^^' 


Fig.   548. — Villous   Tumour   of   the   Bladder.     (From   King's  College 
Hospital  Museum.) 

tmnour  which  have  been  set  free,  and  occasionally,  if  situated  near 
the  neck  of  the  bladder,  some  of  the  fimbriated  ends  may  be  swept 
into  the  urethral  orifice,  and  interfere  with  micturition.  In  the 
same  way  the  opening  of  one  or  both  ureters  may  be  encroached 
upon,  leading  to  hydro-nephrosis.  On  examination  of  the  bladder 
with  a  sound,  nothing  definite  can  be  detected,  unless  the  surface  of 
the  growth  becomes  encrusted  with  phosphates,  and  no  abnormality 
is  noticed  on  rectal  examination.  Occasionally  a  small  portion  of 
the  growth  may  be  caught  in  the  eye  of  a  catheter. 

The  Prognosis  of  the  case  is  unsatisfactory  in  the  absence  of  effec- 


BLADDER  AND  PROSTATE 


11-2.'] 


tive  operative  treatment,  sinee,  although  the  tumour  is  not  malig- 
nant, it  may  give  rise  to  multiple  growths  by  tissue  implantation, 
and  then  their  removal  is  almost  an  impossibility,  and  the  patients 
are  likely  to  bleed  to  death.  True  malignant  disease  is  said  some- 
times to  supervene,  but  this  is  very  doubtful.  The  after-result  of 
operations  for  a  single  mass  is  usually  satisfactorj'. 

Sarcoma  of  the  bladder  is  an  uncommon  disease,  more  often  seen  - 
in  children  than  in  adults.     In  the  former  it  gives  rise  to  multiple 
polvpoid  growths;  in  the  latter  it  is  often  single  and  sessile.     The 
tumour  grows  rapidly,   and  may  attain  considerable  dimensions, 


Fig.  549. — Cancer  of  the  Bladder.     (From    Royal    College    of 
Surgeons'  Museum.) 


spreading  outside  the  bladder,  and  even  invading  the  pelvic  bones. 
Lymphatic  glands  may  be  implicated  at  an  early  date. 

Cancer  of  the  bladder  may  originate  in  that  viscus,  or  may  spread 
to  it  from  the  rectum  or  neighbouring  organs.  In  the  former  case, 
the  growth  is  generally  a  squamous  epithelioma;  in  the  latter,  its 
nature  is,  of  course,  similar  to  that  of  the  primary  disease;  thus, 
when  secondary  to  rectal  cancer,  the  tumour  is  of  a  columnar  type. 
Most  frequently  the  affection  commences  in  the  posterior  wall 
above  the  trigone,  extending  forwards  to  the  neck  of  the  bladder. 
The  growth  is  sometimes  superficial,  projecting  into  the  vesical 
cavity  as  a  soft  spongy  mass,  which  does  not  ulcerate  early,  or  invade 
the  muscular  walls  till  late;  but  more  frequentty  the  neoplasm  ex- 
tends into  and  infiltrates  the  walls,  whilst  marked  ulceration  is  also 


1228  A   MANUAL  OF  SURGERY 

present  (Fig.  549),  the  raw  surface  often  becoming  coated  in  places 
with  a  phosphatic  deposit.  A  cancerous  growth  in  the  bladder  is 
always  more  or  less  likely  to  become  papillated.  The  disease  is 
much  more  common  in  men  than  in  women. 

The  Symptoms  vary  somewhat  in  these  two  forms,  although  the 
conspicuous  features  of  each  are  haematuria  and  irritability  of  the 
bladder.  In  the  slowly-growing  superficial  variety,  the  tumour 
often  attains  a  considerable  size  before  causing  any  trouble,  beyond 
possibly  some  slight  irritability  of  the  bladder.  A  severe  attack  of 
haematuria,  unaccompanied  by  pain,  is  usually  the  first  symptom  of 
importance,  and  may  be  induced  by  some  injury  which  causes  a 
crack  or  fissure  in  the  growth.  This  painless  haematuria  closely 
simulates  the  early  symptoms  of  a  simple  villous  tumour,  but  is 
more  persistent,  and  yields  less  readily  to  treatment.  After  one  or 
more  of  such  prolonged  attacks,  cystitis  follows,  and  the  subsequent 
history  resembles  that  of  the  harder  and  more  rapidly  growdng 
infiltrating  tumours.  In  such,  the  symptoms  of  vesical  irritability 
precede  those  of  haematuria.  Dysuria  and  severe  pain  referred  to 
the  bladder  and  perineum  are  complained  of,  and  the  urine  early 
becomes  alkaline  and  putrescent;  shreds  of  the  growth  may  also 
be  found  in  the  urine  on  microscopic  examination.  If  the  tmnour 
involves  the  internal  meatus,  micturition  may  be  considerably  im- 
paired; whilst  if  the  orifices  of  the  ureters  are  obstructed,  hydro- 
nephrosis results.  On  passing  a  sound,  the  tumour  can  be  detected 
as  an  irregular  mass  projecting  into  the  bladder,  whilst  the  posterior 
vesical  wall  may  be  felt  pey  rectum  to  be  hard  and  resistant ;  its 
ulcerated  surface  may  also  be  seen  with  the  cystoscopy 

The  course  of  the  case  is  similar  to  that  of  a  somewhat  rapidly 
growing  carcinoma,  leading  to  early  and  marked  cachexia,  increased 
by  the  sleeplessness  resulting  from  the  vesical  irritation;  secondary 
deposits  are  found  in  the  \ascera  and  lumbar  glands,  whilst  perfora- 
tion of  the  wall  may  occasionally  follow,  causing  urinarv  extravasa- 
tion, septic  celluHtis,  and  death.  Another  most  distressing  com- 
pHcation  is  the  estabhshment  of  a  recto-vesical  fistula,  through 
which  the  urine  makes  its  way  into  the  rectum,  thus  intensif^-ing 
the  sufferings  of  the  patient. 

The  Diagnosis  of  a  vesical  tmnour  can  only  be  made  with  certainty 
by  the  cystoscopy  or  by  discovering  fragments  of  its  substance  in 
the  urine,  though  in  the  female  it  is  easy  to  dilate  the  urethra,  and 
explore  the  bladder  with  the  finger.  Whenever  haemorrhage  is 
associated  with  marked  vesical  irritabihty,  and  cannot  otherwise  be 
explained,  a  tumour  of  the  bladder  may  be  suspected,  and  cysto- 
scopy must  be  undertaken.  In  this  viscus,  as  in  others,'  the 
only  hope  of  curing  malignant  disease  lies  in  early  operation,  and 
if  the  practitioner  waits  until  the  diagnosis  is  assured  by  the  symp- 
toms, the  patient's  case  is  probabl}^  hopeless.  Early  cystoscopy  is 
all-important. 

In  simple  papilloma  and  the  superficial  type  of  epithelioma, 
haemorrhage  precedes  the  irritability;  but  whilst  it  is  usually  im- 


BLADDER  AND  PROSTATE  1229 

possible  to  detect  the  villous  growth  either  by  examination  with  the 
sound,  or  from  the  rectum,  a  f  ungating  malignant  growth  may  some- 
times be  recognised  by  the  sound.  In  the  infiltrating  type  of  malig- 
nant disease,  on  the  other  hand,  pain  and  dysuria  always  precede 
the  bleeding  for  a  considerable  interval ;  whilst  definite  evidence  of 
the  existence  of  the  growth  can  usually  be  made  out,  both  by  the 
sound  and  on  rectal  examination.  A  worn  and  exhausted  appear- 
ance must  not  be  looked  on  as  necessarily  the  outcome  of  advanced 
cancerous  cachexia,  since  the  loss  of  rest  and  sleep  due  to  chronic 
vesical  irritability  can  of  itself  lead  to  a  somewhat  similar  condition. 

Treatment  of  Tumours  o£  the  Bladder. — ^In  the  early  stages,  when 
the  diagnosis  of  a  tumour  has  not  been  confirmed,  the  hEematuria 
may  be  treated  with  ordinary  haemostatic  remedies,  such  as  a  mix- 
ture containing  dilute  sulphuric  acid  and  ergot,  or  turpentine  ad- 
ministered in  capsules  (10  minims  three  times  a  day). 

When  once  a  diagnosis  has  been  established,  removal  by  opera- 
tion is  the  only  plan  which  holds  out  any  hope  to  the  patient,  and 
this  can  only  be  undertaken  with  any  prospect  of  success  in  benign 
growths,  or  in  the  very  earliest  stages  of  malignant  disease.  The 
suprapubic  operation  is  alwaj^s  employed.  The  bladder  is  first 
washed  out,  and  the  patient  placed  in  the  Trendelenburg  position. 
After  opening  the  bladder  and  exploring  it  with  the  finger,  a  specu- 
lum is  introduced  and  its  interior  illuminated  by  an  electric  lamp 
fitted  to  the  surgeon's  head.  If  more  room  is  required,  one  of  the 
rectus  muscles  may  be  cut  across  about  ih  inches  above  its  inser- 
tion, and  the  viscus  can  then  be  freely  opened. 

Papillomata  and  other  simple  tumours  are  removed,  together  with 
the  mucous  membrane  from  which  they  grow,  by  cutting  round 
them  with  the  knife  or  scissors.  The  base  is  ligatured  and  the 
growth  removed,  or  a  cautery  knife  may  be  used  for  this  purpose. 
The  fingers  of  an  assistant  in  the  rectum  will  suffice  to  press  up  the 
posterior  wall  and  to  give  support.  If  possible,  the  incision  in  the 
mucous  membrane  should  be  closed  by  catgut  stitches.  Where  the 
papillomata  are  large  or  multiple,  this  may  involve  an  extensive 
operation,  but  with  careful  after-treatment  there  is  a  good  prospect 
of  recovery. 

For  malignant  disease  of  the  bladder,  partial  or  complete  cystec- 
tomy may  be  possible.  Partial  Cystectomy  consists  in  removal  of 
the  whole  thickness  of  the  vesical  wall  involved  by  the  growth,  and 
according  to  its  location  this  may  involve  opening  the  peritoneal 
cavity  or  not.  The  bladder  is  exposed  as  described  above,  and  the 
peritoneum  is  detached  up  to  and  beyond  the  growth,  which  is  cut 
away,  the  solution  of  continuity  in  the  wall  being  made  good  by 
careful  suturing  with  catgut.  Complete  Cystectomy  has  been  under- 
taken for  extensive  malignant  disease,  and  may  include  removal  of 
the  prostate  and  seminal  vesicles,  the  scope  of  the  operation  ex- 
tending nearly  to  th;  membranous  urethra.  Necessarily,  pre- 
liminary arrangements  have  to  be  made  as  to  the  ureters.  Three 
plans  are  feasible;  (i)  They  are  implanted  into  the  rectum,  and  the 


I230  A   MANUAL  OF  SURGERY 

patient  must  run  the  chance  of  an  ascending  pyelonephritis ;  (2)  the 
ureters  are  brought  out  of  incisions  in  the  loin  and  drained;  or  (3)  a 
double  nephrostomy  is  performed,  and  the  pelvis  drained  on  either 
side,  the  patient  then  experiencing  the  discomfort  of  a  double 
urinary  fistula.  The  subsequent  operation  of  removing  the  bladder  is 
not  one  of  extreme  difficultv,  but  requires  care  to  protect  the  patient 
from  haemorrhage  and  from  infection  of  the  peritoneal  cavity. 

When  removal  is  impracticable,  it  only  remains  to  ease  the 
patient's  sufferings  by  means  of  morphia,  the  bladder  also  being 
occasionally  washed  out;  but  if  the  irritabihty  is  very  great,  a 
permanent  suprapubic  or  perineal  opening  may  be  established. 

Stone  in  the  Bladder. 

Varieties. — A  vesical  calculus  may  be  formed  of  almost  any  of  the 
urinary  deposits  commonlv  met  with,  and  each  has  its  own  special 
characteristics. 

[a]  The  uric  acid  calculus  (Plate  XV.,  i  and  2)  is  usually  an 
oval,  flattened  body  of  considerable  density,  with  a  smooth  or 
slightly  nodular  surface,  and  of  a  nut-brown  colour.  On  section 
it  is  distinctly  laminated,  and  it  may  be  surrounded  by  a  crust  of 
phosphatic  material. 

[h]  The  urate  of  ammonium  calculus  is  of  very  similar  structure, 
but  of  a  lighter  colour,  and  the  lamination  is  less  distinct. 

(c)  The  oxalate  of  lime  or  mulberr\-  calculus  (Plate  XVI.)  is  a 
rough,  irregular  body,  sometimes  evenly  nodular,  but  not  imfre- 
quently  tuberculated,  or  even  spiculated.  It  is  extremely  hard  and 
dense,  laminated,  and  of  a  dark  red-brown  colour,  or  sometimes 
black,  owdng  to  admixture  uath  blood.  It  is  rarely  of  great  size,  oh 
account  of  the  irritation  caused  b}'  its  presence,  and  its  slowness  of 
growth. 

[d]  A  pure  phosphatic  calculus  (Plate  XV.,  4  and  5)  is  ver}-  im- 
common,  but  any  stone  or  foreign  bodv  is  certain  to  become  coated 
with  a  phosphatic  deposit  when  chronic  cystitis  has  resulted  in 
alkaline  decomposition  of  the  urine.  Occasionallv  concretions  of  a 
similar  nature  form  spontaneouslv  in  saccules  of  the  bladder ;  such 
bodies  are  white  and  chalk\-  in  appearance,  friable  in  consistency, 
with  no  evidence,  or  but  little,  of  lamination,  and  on  removal  are 
exceedingly  offensive.  These  concretions  consist  of  a  mixture  of 
the  triple  phosphate  and  phosphate  of  lime.  Less  commonly  an 
excess  of  the  triple  phosphate  is  present ;  if  in  the  proportion  of  two 
parts  of  the  latter  to  one  of  phosphate  of  lime,  a  laminated  and 
somewhat  denser  calculus  is  produced,  which  is  sometimes  termed 
di  fusible  calculus,  owing  to  the  fact  that  it  fuses  to  a  bead  imder 
the  blowpipe  flame.  Occasionally  a  phosphate  of  hme  calculus 
occurs  in  the  upper  urinary  passages  {e.g.,  the  pelvis  of  the  kidney), 
and  has  a  crystalline  appearance  on  drying. 

[e)  Cystine  forms  the   basis   of  a  rare  calculus  which  is  of  a 
yellowish-green  colour  and  waxy  appearance. 


PLATE  XV. 


Stones  from  the  Bladder. 

Figs.  I  afid2. — Uric  acid  Calculus  -  on  section  and  outer  surface.  Fig.  3.  — Encysted 
Calculus  of  uric  acid.  The  lower  segment  was  held  firmly  in  a  saccule  near  the 
trigone  ;  the  larger  portion  projected  into  the  bladder.  A  certain  amount  of 
phosphatic  deposit  covers  the  exterior.  It  was  successfully  removed  by  a  suprapubic 
operation.     Figs.  4  and  5. — Phosphatic  Calculus. 

\_To  face  page  1230. 


PLATE  XVI. 


Oxalate  of  Lime  Calculus. 

Fig.   I. — From  the  exterior.  Fig.  2. — On  section. 


\_To  face  page  1230 


BLADDER  AND  PROSTATE  1231 

(/)  Xanthine,  or  xantliic  oxide,  occurs  very  exceptionally  as  a 
calculus  of  a  reddish  colour. 

An  encysted  calculus  is  one  which  develops  in  a  pocket  or  pouch 
connected  with  the  bladder  wall.  It  may  consist  of  any  of  the  above 
substances,  and  is  due  to  a  small  stone  hnding  its  way  into  a  sac- 
cule and  being  arrested  there.  It  grows  by  gradual  accretion  of 
new  calculous  material,  and  after  a  time  projects  into  the  vesical 
cavity.  A  typical  illustration  is  shown  in  Plate  XV.,  3,  where  the 
large'intravesical  portion  is  separated  from  the  encysted  part  by  a 
narrow  neck.  Occasionally  this  condition  is  due  to  the  decomposi- 
tion of  stagnant  urine  in  a  pouch,  and  the  calculus  is  then  phos- 
phatic  in  composition ;  it  is  not  unlikely  to  lead  to  ulceration  of  the 
sac  wall  and  extravasation  of  urine. 

Structure  of  a  Calculus. — A  calculus  usually  consists  of  the  fol- 
lowing parts:  i.  The  nucleus,  which  may  be  formed  by  a  portion 
of  blood-clot,  inspissated  mucus,  a  renal  calculus,  or  some  foreign 
substance  introduced  from  without.  2.  The  body,  which  consists 
of  superposed  layers  of  uric  acid  or  oxalate  of  Hme,  or  of  whatever 
substance  the  stone  is  composed ;  not  unfrequently  the  composition 
of  adjacent  laminaa  differs,  leading  to  what  is  known  as  an  alternat- 
ing calculus.  Each  lamina  consists  of  myriads  of  minute  crystals, 
held  together  by  vesical  mucus,  with  which  a  certain  amount  of 
phosphatic  material  is  often  mixed,  whilst  layers  of  pure  phosphatic 
deposit  may  be  interposed.  3.  The  crust  consists  of  a  variable 
amount  of  soft,  friable  phosphatic  material,  the  quantity  of  which 
is  the  measure  of  the  degree  of  chronic  cystitis  originated  by  the 
calculus;  in  some  cases  it  is  entirely  absent. 

The  Number  of  calculi  present  in  a  bladder  varies  greatly.  Some- 
times there  is  only  one ;  occasionally  a  considerable  number,  counted 
perhaps  by  hundreds,  may  exist;  in  such  circumstances  they  are 
never  of  great  size.  Multiple  calculi  are  not  unfrequently  faceted 
as  a  result  of  mutual  friction. 

The  Causes  of  vesical  calculus  must  be  looked  for  in  some  of 
those  constitutional  conditions  already  described  as  predisposing  to 
lithiasis  or  oxaluria.  They  are  very  common  in  children  during 
the  first  decade  of  life,  especially  amongst  the  lower  classes,  the 
children  of  the  rich  rarely  suffering  from  stone.  It  diminishes  in 
frequency  from  childhood  to  the  age  of  twenty-five,  and  then 
gradually  increases  until  it  is  relatively  common  in  elderly  men. 
The  condition  is  comparatively  rare  in  women,  o\^dng  to  the  fact 
that  the  shortness  and  large  size  of  the  urethra  allow  small  calculi 
to  be  much  more  readily  passed.  Possibly  the  character  of  the 
drinking-water,  or  the  amount  imbibed,  is  a  matter  of  importance, 
as  indicated  by  the  fact  that  the  occurrence  of  calculus  is  very 
unequally  distributed  in  different  parts  of  the  country;  thus,  it  is 
most  frequently  met  with  in  the  Eastern  Counties.  It  is  also  very 
common  in  India  and  Arabia,  a  fact  which  may  possibly  be  ex- 
plained bv  the  large  amount  of  fluid  withdrawn  "from  the  body  by 
perspiration. 


12  32  A   MANUAL  OF  SURGERY 

Symptoms. — The  effects  produced  by  vesical  calculi  vary  in 
different  individuals,  according  to  the  shape  of  the  stone,  and  the 
tolerance  of  the  mucous  membrane.  In  children  and  young  adults, 
where  the  parts  are  very  sensitive,  even  a  smooth  calculus  gives  rise 
to  severe  sjonptoms,  whilst  old  men  often  tolerate  a  large  stone 
without  much  inconvenience;  cceteris  paribus,  an  oxalate  of  lime 
calculius  is  always  more  irritating  than  one  composed  of  uric  acid. 
The  classical  symptoms  of  a  vesical  calculus  may  be  preceded  by  a 
history  of  the  patient  having  passed  '  gravel  '  for  a  long  time,  or  by 
an  attack  of  renal  colic,  on  the  cessation  of  which  the  calculous 
s^TTiptoms  commenced.  Sometimes  the  vesical  symptoms  do  not 
appear  for  some  time  after  the  passage  of  a  stone  into  the  bladder, 
presumably  in  consequence  of  its  small  size.  They  consist  of  pain 
in  the  perineum  and  neck  of  the  bladder,  which  radiates  to  the 
back  and  down  the  thighs,  but  is  especially  noticed  at  the  end  of 
the  penis  immediately  after  micturition.  The  stone  is  then  pressed 
down  against  the  sensitive  neck  of  the  bladder  by  the  contraction 
of  its  muscular  walls.  Increased  frequency  of  micturition  is  also 
present,  and  perhaps  hematuria  of  a  vesical  type,  though  this  is  not 
a  prominent  feature.  All  these  phenomena  are  increased  in  severity 
by  jolting,  jmnping,  or  any  form  of  exercise,  and  hence  are  more 
marked  during  the  day  than  at  night.  Occasionally  the  patient 
complains  that  the  flow  of  urine  suddenly  ceases  before  the  bladder 
has  been  completely  emptied,  and  that  some  change  in  the  position 
of  the  body  is  needed  in  order  to  allow  him  to  complete  the  act. 
In  addition  to  these  characteristic  symptoms,  he  may  suffer  from 
various  phenomena  secondary  to  the  irritability  of  the  bladder,  and 
dependent  on  the  straining  induced  by  the  calculus.  Thus,  tenes- 
mus, followed  by  piles  or  prolapsus  ani,  may  be  produced  by  sympa- 
thetic irritability  of  the  rectum,  especially  in  children ;  whilst  a 
hernia  may  also  be  caused,  and  not  unfrequently  priapism. 

The  symptoms  are  somewhat  modified  in  children,  leading  to 
irritability  of  the  bladder,  as  evidenced  by  wetting  of  their  clothes 
and  of  their  beds  at  night,  and  pulling  at  the  prepuce  and  penis. 
These  manifestations  are  very  similar  to  those  caused  by  a  tight 
foreskin,  with  which  condition,  indeed,  a  stone  is  often  associated; 
hence,  it  is  important  always  to  sound  the  bladder  of  a  child  after 
circumcision  for  phimosis. 

The  actual  Diagnosis  of  vesical  calculus  can  be  made  by  radio- 
graph}^ or  sounding.  X-ray  examination  is  conducted  in  the  usual 
fashion,  care  being  taken  to  see  that  the  rectum  is  empty.  The 
lamp  is  placed  over  the  patient's  abdomen,  with  the  rays  directed 
downwards  and  backwards,  and  the  plate  is  behind.  The  calculus 
usually  appears  as  a  shadow  immediatel}^  above  the  pubic  rami 
(Fig.  550).  In  order  to  examine  a  patient  by  sounding,  he  is  laid  on 
a  couch  with  the  head  low,  and  the  buttocks  raised  on  a  pillow 
placed  beneath  them.  The  bladder  should  always  contain  a  few 
oimces  of  fluid,  so  as  to  obliterate  any  folds  produced  by  laxity  of 
the  mucous  membrane,  as  well  as  to  facilitate  the  introduction  of 


BLADDER  AND  PROSTATE 


1233 


the  instrument;  the  usual  antiseptic  precautions  as  to  surgeon's 
hands,  patient's  penis,  instrument,  and  lubricating  material,  are  of 
course  rigidly  enforced.  A  sterilized  sound  of  suitable  size,  warmed 
and  lubricated  by  some  antiseptic  preparation,  is  then  gently 
passed  along  the  urethra,  and  the  handle  depressed  between  the 
separated  legs  so  as  to  enable  the  point  to  enter  the  bladder.  The 
handle,  which  should  be  cylindrical  in  shape  and  fluted,  with  the 
maker's  name  or  some  mark  to  indicate  the  direction  of  the  beak, 
is  then  lightly  grasped  between  the  index-finger  and  thumb,  and 
rotated  from  side  to  side,  whilst  at  the  same  time  the  whole  instru- 
ment is  drawn  forwards  or  backwards  in  the  urethra.     Each  side  of 


Fig.  550. — Radiogram  of  Vesical  Calculus  in  a  Boy. 

the  bladder  is  thus  carefully  investigated,  and,  finally,  if  no  stone  is 
detected,  the  beak  is  turned  directly  downwards,  so  as  to  examine 
the  pouch  which  often  forms  behind  a  slightly  enlarged  prostate. 
The  presence  of  a  stone  is  recognised  by  a  metallic  click,  which  can 
be  felt  and  even  heard,  when  the  end  of  the  instrument  taps  it.  The 
character  of  the  click  is  some  guide  to  the  size  and  density  of  the 
stone.  The  presence  of  two  or  more  calculi  is  indicated  by  the 
surgeon  being  able  to  touch  them  on  rotating  the  instrument  alter- 
nately to  each  side  of  the  middle  line,  or  by  seizing  one  stone  with  a 
lithotrite,  and  using  it  as  a  sound  for  the  other.  In  doubtful  cases, 
a  still  more  delicate  test  than  the  sound  is  obtained  by  passing  a 

78 


1234  A   MANUAL  OF  SURGERY 

medium-sized  tube  of  a  Bigelow's  evacuator,  and  washing  out  the 
bladder.  The  calcuH  may  by  this  means  be  sucked  out  even  from 
saccuh,  and  be  felt  to  rattle  against  the  end  of  the  instrument  when 
the  pressure  upon  the  indiarubber  bulb  is  relaxed.  When  the  calculi 
are  multiple  and  of  small  size,  they  may  be  even  removed  in  this 
way  by  an  examination  which  was  only  intended  to  be  diagnostic  in 
character.  The  surgeon  must  not  forget  that  a  hypertrophied  bladder 
with  projecting  fasciculi  may  somewhat  resemble  a  calculus,  espe- 
cially when  coated  with  phosphatic  material.  In  some  rare  instances 
a  calculus  may  be  so  completely  hidden  in  one  of  the  saccules  as  to 
render  its  detection  impossible  by  these  means.  An  encysted  cal- 
culus which  projects  into  the  bladder  is  recognised  by  being  always 
found  at  the  same  place. 

Course  of  the  Case. — A  patient  suffering  from  vesical  calculus  is 
certain,  sooner  or  later,  to  develop  symptoms  of  chronic  c\^stitis,  and 
septic  changes  in  the  urine  are  equally  sure  to  follow — possibly  as  a 
natural  sequence,  but  often  as  the  result  of  the  introduction  of  dirty 
instruments.  The  bladder  is  hypertrophied,  and  if  the  stone  is  not 
removed,  the  mucous  membrane  becomes  ulcerated,  and  the 
inflammation  extends  to  the  kidneys;  the  patient's  life  is  thus 
destroyed,  partly  by  exhaustion,  and  partly  by  septic  or  ursemic 
poisoning. 

The  Treatment  of  vesical  calculus  is  a  matter  which  has  exercised 
the  judgment  and  manipulative  dexterity  of  surgeons  for  many 
centuries.  A  large  number  of  operations  have  been  made  use  of. 
but  at  the  present  day  only  three  are  employed — viz.,  lithotrity, 
suprapubic  c^'stotomy,  and  very  uncommonly  perineal  cystotomy. 
Lithotrity  was  formerly-  conducted  in  several  stages,  the  stone 
being  crushed,  and  the  patient  allowed  to  pass  the  debris  subse- 
quently ;  this  process  was  repeated  at  intervals  of  a  few  days,  until 
the  bladder  was  clear.  Such  a  proceeding  took  a  considerable  time, 
and  was  exceedingly  painful,  irksome,  and  dangerous  to  the  patient. 
The  introduction  of  Bigelow's  evacuator  completely  revolutionized 
this  operation,  and  enables  it  to  be  completed  at  one  sitting,  con- 
stituting the  proceeding  sometimes  termed  Litholapaxy. 

Operation. — The  patient  is  carefully  prepared  by  keeping  him 
under  observation  for  a  few  days,  regulating  the  bowels,  and,  if 
possible,  reducing  any  inflammation  of  the  bladder  by  suitable  diet 
and  drugs,  and  by  washing  it  out.  On  the  preceding  night  a  dose  of 
castor  oil  is  administered,  and  an  efficient  enema  a  few  hours  before 
the  operation.  The  patient  should  be  warmly  clad,  and  the  legs 
enclosed  in  thick  worsted  stockings  reaching  nearly  to  the  groins. 
After  anaesthesia  has  been  induced,  the  head  is  kept  low,  and  a 
pillow  placed  beneath  the  buttocks,  so  as  sHghtly  to  raise  the  pelvis. 
The  bladder  is  carefully  washed  out  A\ath  some  bland  antiseptic, 
such  as  a  solution  of  boric  acid,  and  about  6  ounces  of  lotion  are 
left  within  it,  in  order  not  only  to  obhterate  all  folds  of  mucous 
membrane,  but  also  to  facilitate  the  seizure  of  the  stone,  and  to 
prevent  injury  of  the  walls  during  the  operation. 


BLADDER  AND  PROSTATE 


1235 


The  lithotrite  (Fig.  551)   is  then  introduced.     The  male  blade 

slides  easily  up  and  down  a  groove  in  the  stem  of  the  female  blade, 

and  after  the  stone  has  been  seized  the  blades  are  forcibly  pressed 

together  by  a  screw  action,  brought  into  play  by 

the  mechanism  in  the  handle,  which  can  be  put 

in   and  out  of  gear   at   will.     It   is   absolutely 

essential  that  the  instrimient  should  be  made  of 

well-tempered  steel,  so  as  to  prevent   any  risk 

of  breaking  during  the  operation.     To  introduce 

it  some  skill  is  needed,  since  the  curved  end  is 

short,  and  consequently  the  handle  must  be  well 

depressed  between  the  legs,  in   order  that   the 

beak  may  pass  under  the  pubic  arch.  The  posi- 
tion of  the  stone  is  next  ascertained  by  rotating 

the  instrument,   and  using  it  as  a  sound;   the 

blades  are  opened,  and  the  stone  caused  to  roll 

between  them  by  a  sHght  jerk  of   the   handle. 

This  is  better  than  attempting  to  pick  up  the 

calculus  by  inverting  the  blades,  and  is  less  likely 

to    injure   the    mucous    membrane.      If    fairly 

grasped,  the  blades  when  screwed  up   crush  it 

into  several  fragments,  each  of  which  is  sub- 
sequently dealt  with  in  a  similar  fashion.  If 
only  the  margin  of  the  stone   is    gripped,  the 

application  of  screw  pressure  may  cause  it  to 
slip  awa\^  and  the  manceuvre  must  then  be  care- 
fully repeated,  ^^'hen  the  surgeon  is  satisfied 
that  the  fragments  are  sufficiently  small,  the 
largest  evacuator-tube  that  can  be  safely  intro- 
duced is  passed  into  the  bladder.  To  effect  this, 
it  is  sometimes  necessary  to  incise  the  urethral 
orifice  with  a  bistoury  in  a  downward  direction. 
The  evacuator  is  attached  to  the  tube,  and  the 
bladder  thoroughly  washed  out  by  alternate  pres- 
sure upon,  and  relaxation  of,  the  rubber  bottle 
(Fig-  55-)-  By  this  means  the  fragments  of  the 
stone  are  collected  in  the  glass  receptacle  which 
forms  part  of  the  apparatus.  The  washing  is 
continued  imtil  no  more  fragments  are  heard  or 
felt  to  rattle  against  the  end  of  the  tube.  It  is 
often  necessary  to  reintroduce  the  lithotrite  in 
order  to  crush  some  larger  portions  of  the 
calculus  still  remaining;  the  old  practice  of 
withdra\\ing  small  fragments  mthin  the  grasp 
of  a  lithotrite  is  to  be  condemned.  It  is  scarcely 
necessary  to  re-sound  the  bladder  after  the 
efficient  use  of  the  evacuator.  A  certain  amount  of  bleeding  is 
indispensable  from  these  manipulations,  but  it  is  not  excessive  in 
careful  hands.     Should,  however,  considerable  bleeding  follow,  the 


H 


1236 


A   MANUAL  OF  SURGERY 


bladder  is  likely  to  become  subsequently  distended  \\ith  clots, 
necessitating  the  use  of  a  large-eyed  catheter  for  their  removal. 

After-Treatment. — The  patient  is  placed  in  bed  as  soon  as  the 
operation  is  completed,  and  kept  warm  and  quiet,  and  suitable 
measures  must  be  taken  to  combat  shock.  The  diet  is  restricted  to 
fluids  for  a  few  days,  whilst  pain,  if  complained  of,  may  be  reUeved 
by  a  little  morphia.  If  all  goes  well,  he  may  be  allowed  to  get  up 
at  the  end  of  the  week. 

Various  Sequelae  may  follow  this  operation.  Cystitis  results  partly 
from  mechanical  causes,  but  more  frequently  from  imperfect  asepsis. 
The  s^-mptoms  are  usually  subacute  in  character,  and  may  pass  away 
after  a  few  days ;  but  if  of  a  serious  ty^e,  considerable  constitutional 
disturbance  arises,  and  a  large  amount  of  viscid  muco-pus  is  excreted, 
whilst  the  urine  becomes  alkahne  and  ammoniacal.  In  such  a  case 
it  is  absolutely  essential  to  wash  out  the  bladder  once  or  twice  a  day, 


Fig. 


-EVACUATOR     IN    POSITION    IN    THE    BLADDER. 


as  if  left  to  itself  the  condition  is  very  liable  to  spread  up  to  the 
ureters,  and  may  destroy  the  patient's  life  by  suppurative  pyelone- 
phritis. Atony  of  the  bladder  is  occasionally  induced,  either  by  the 
operation  or  by  a  consequent  cystitis,  and  is  especially  common  in 
elderly  individuals.  It  must  be  treated  by  regular  and  aseptic 
catheterism.  When  the  patient's  kidneys  are  already  affected  prior 
to  the  operation,  an  acute  ascending  pyelonephritis  (p.  1198)  may 
be  originated  by  it,  perhaps  leading  to  suppression  of  urine  and 
death  from  unemia. 

Suprapubic  Lithotomy  was  formerly  looked  on  as  a  serious  pro- 
cedure with  a  high  mortality;  at  the  present  time  increasing  ex- 
perience has  shown  that  the  dangers  were  preventable,  and  that  it 
may  be  considered  a  very  successful  procedure.  The  bladder  is 
washed  out,  and  8  or  10  ounces  of  lotion  left  within  it;  the  patient 
is  then  placed  in  the  Trendelenburg  position,  with  the  pelvis  raised, 
the  intestines  being  thus  allowed  to  gravitate  to  the  postero-superior 


BLADDER  AND  PROSTATE  1237 

part  of  the  abdomen;  as  soon  as  the  abdominal  parietes  are  opened, 
air  finds  its  way  into  the  connective  tissue  behind  the  symphysis 
(ca\-um  Retzii),  and  the  peritoneum  is  thus  pressed  back. 

Operation. — The  pubes  having  been  previously  shaved,  and  the 
hypogastrium  purified,  an  incision  is  made  in  the  median  line 
reacliing  from  the  top  of  the  symphysis  upwards  for  about  2  or 
3  inches ;  the  lower  part  of  the  linea  alba  is  divided,  and  the  retro- 
pubic cellular  tissue  opened  up.  The  tense  rounded  outHne  of  the 
bladder  can  now  be  readily  detected  with  the  finger,  and  a  couple  of 
lateral  silk  sutures  or  shngs  are  passed  through  its  walls  so  as  to 
steady  it  and  prevent  its  subsequent  retraction.  An  opening  is  then 
made  into  it  in  the  middle  line  from  below  upwards,  through  which 
the  index-finger  is  passed  and  the  stone  examined.  Suitably  curved 
hthotomy  forceps  are  introduced,  and  the  stone  grasped  and  with- 
drawn. A  careful  examination  of  the  interior  of  the  bladder  is 
made,  to  ascertain  whether  any  further  calculi  are  present,  as  also 
to  investigate  the  condition  of  the  prostate,  which  may  sometimes 
be  advisably  removed  at  the  same  time.  The  after-treatment  of 
the  wound  differs  with  the  condition  of  the  bladder ;  if  it  is  infected, 
a  good-sized  drainage-tube  is  introduced,  and  the  urine  syphoned 
off,  healing  occurring  by  granulation  in  three  to  six  weeks  (see 
After-Treatment  of  Prostatectomy,  p.  1251).  If  the  bladder  is 
healthy  and  free  from  infection,  it  may  be  closed  by  sutures,  which 
only  pass  through  the  muscular  and  submucous  coats,  and  thus 
when  tied  do  not  project  into  its  cavity.  The  external  wound  may 
then  be  left  open  or  closed,  except  at  the  spot  where  a  drainage-tube 
or  gauze  wick  is  passed  down  to  the  vesical  wound,  so  as  to  allow 
exit  to  any  urine  which  may  accidentally  leak  into  the  wound.  The 
urine  is  either  drawn  off  by  a  catheter  at  regular  intervals,  certainly 
not  less  than  three  or  four  times  daily,  or  the  bladder  is  drained  by 
tying  in  a  catheter. 

Perineal  Lithotomy  is  seldom  required  at  the  present  day;  the 
procedure  described  as  perineal  cystotomy  (p.  1223)  would  be 
adopted.  The  finger  is  passed  into  the  bladder,  and  the  stone 
located.  It  is  removed  by  suitable  stone  forceps,  or  by  a  scoop  and 
the  finger.  Care  must  be  exercised  not  to  damage  the  structures  at 
the  neck  of  the  bladder,  or  pelvic  cellulitis  may  ensue;  but  this 
danger  is  little  likely  to  arise,  as  the  operation  ought  never  to  be 
undertaken  when  the  stone  is  of  large  size. 

Formerly  much  importance  was  attached  to  the  operation  of 
lateral  lithotomy,  in  which  the  stone  was  removed  through  a  perineal 
incision  which  included  the  left  lateral  lobe  of  the  prostate.  This 
procedure  is  now  entirely  superseded,  and  need  no  longer  be  de- 
scribed. 

Choice  of  Operation  for  Vesical  Calculus.  —  At  the  present  day 
lithotrity  has  been  brought  to  such  a  standard  of  excellence  that 
there  is  no  doubt  as  to  the  general  rule  which  should  be  followed — 
viz.,  that  unless  some  contra-indi cation  is  present,  all  cases  of  vesical 
calculus  should  he  treated  by  lithotrity. 


1238  A   MANUAL  OF  SURGERY 

The  Contra-indications  to  Lithotrity  are  as  follows:  (i)  Conditions 
of  the  Stone.  If  the  calculus  exceeds  i.^  inches  in  diameter,  it  is  not 
advisable  to  attempt  lithotrity,  on  account  of  the  damage  which  may 
be  inflicted  on  the  vesical  wall.  Moreover,  some  stones,  especially 
those  consisting  of  oxalate  of  lime,  are  so  hard  that  no  lithotrite  can 
crush  them.  Phosphatic  concretions,  on  the  other  hand,  are  so  soft 
that  a  lithotrite  becomes  clogged,  and  crushing  is  impracticable. 
An  encvsted  stone  will  also  preclude  lithotrity  on  account  of  its 
fixed  position.  There  is  no  objection  to  dealing  with  multiple 
calculi  by  this  means,  but  if  only  of  small  size,  they  may  be  removed 
by  simply  using  the  evacuator.  (2)  Conditions  of  the  Urethra.  The 
existence  of  an  organic  stricture,  or  an  enlarged  prostate,  may  render 
lithotrity  impracticable  from  the  impossibility  of  passing  large 
enough  instruments,  whilst  false  passages  may  make  it  exceedingly 
dilhcult.  Excessive  irritability  of  the  urethra,  as  evidenced  by  the 
occurrence  of  severe  rigors  after  instrumentation,  may  also  render 
the  operation  unadvisable.  (3)  Conditions  of  the  Bladder.  The 
existence  of  severe  cystitis  or  the  presence  of  sacculi,  as  indicated 
by  the  cystoscope,  will  usually  suggest  the  performance  of  lith- 
otomy; whilst  a  contracted  bladder,  which  will  only  hold  a  few 
ounces  of  urine,  materially  increases  the  dangers  and  difficulties  of 
lithotrity. 

Suprapubic  Lithotomy  should  be  undertaken  under  the  following 
conditions:  (i)  Where  the  stone  is  too  large  to  be  dealt  with  by 
crushing;  (2)  where  the  stone  is  encysted;  (3)  where  a  stricture  or 
enlarged  prostate  is  present,  and  it  is  often  feasible  to  remove  the 
prostate  at  the  same  time.  Suprapubic  cystotomy  is  only  absolutely 
contra-indicated  by  two  conditions — ^\iz.,  severe  septic  cystitis  and 
contraction  of  the  bladder. 

Indications  for  Perineal  Lithotomy. — (i)  When  serious  cystitis  and 
great  irritability  of  the  bladder  are  present,  the  incision  facilitating 
the  process  of  draining  and  washing  it  out ;  (2)  a  contracted  and 
hypertrophied  condition  of  the  bladder;  (3)  when  a  calculus  is 
impacted  in  the  neck  of  the  bladder. 

Calculus  in  Boys  is  a  common  occurrence.  It  must  be  remembered 
that  the  bladder  is  rather  an  abdominal  than  a  pelvic  organ  in 
children,  and  hence  suprapubic  lithotomy  is  particularly  indicated, 
except  in  the  hands  of  skilled  lithotritists.  It  has  been  shown,  how- 
ever, that  lithotrity  can  be  safely  practised,  and  many  surgeons  in 
the  East,  where  stone  is  so  common,  employ  it  as  a  routine  procedure, 
granting  that  a  No.  6  catheter  can  be  passed,  and  that  the  stone 
is  not  too  large  for  a  lithotrite  to  grasp.  Special  hthotrites  and 
evacuators  are  constructed  for  the  purpose. 

Calculus  in  the  Female. — As  already  mentioned,  vesical  calculus 
is  very  rare  amongst  women,  owing  to  the  shortness  and  greater 
size  of  the  urethra,  so  that  small  stones  passing  downwards  from 
the  kidneys  are  easily  voided.  Phosphatic  concretions  are  not  un- 
common, and  are  then  formed  around  a  foreign  body  usually  intro- 
duced by  the  patient.     Many  of  the  symptoms  are  very  similar  to 


BLADDER  AND  PROSTATE  1239 

those  in  the  male.  Treatment. — If  the  calculus  does  not  exceed 
i  to  f  inch  in  diameter,  it  can  usually  be  extracted  by  dilating  the 
urethra  with  the  linger,  the  sphincter  being  also  nicked  in  two  or 
three  places  if  necessary.  It  is  never  wise  to  divide  the  sphincter 
totally,  as  incontinence  is  almost  certain  to  follow.  For  a  somewhat 
larger  stone  lithotrity  can  be  undertaken,  whilst  for  those  of  really 
large  size  suprapubic  cystotomy  is  the  best  procedure.  It  has  been 
recommended  to  open  the  bladder  through  the  anterior  vaginal  wall, 
and  thus  remove  a  stone;  but  this  is  scarcely  desirable,  for  fear  of 
the  persistence  of  a  vesico-vaginal  fistula. 

Functional  Derangements  of  the  Bladder. 

The  act  of  micturition  is  a  complicated  proceeding,  which  for  its 
effective  performance  requires  the  due  co-ordination  of  several 
factors.  When  urine  collects  in  the  bladder,  it  is  prevented  from 
escaping  at  once  by  the  tonic  contraction  of  the  sphincter  vesicae; 
in  infants  this  is  but  little  developed,  and  hence  is  readily  overcome 
by  the  relatively  strong  detrusor  in  response  to  but  slight  intravesical 
pressure.  As  the  child  grows,  the  sphincter  becomes  better  de- 
veloped, and  is  under  more  effective  control ;  whilst  at  puberty  the 
growth  of  the  prostate  adds  to  this,  and  therefore  micturition 
loses  its  reflex  character,  and  becomes  entirely  voluntary.  Three 
chief  elements  enter  into  the  act  of  urination — -viz.,  (i)  an  apprecia- 
tion of  the  stimuli  set  up  in  the  bladder  by  its  increasing  distension, 
which  depends  on  the  sensory  nerves  having  a  free  communication 
with  the  sensorium;  (2)  as  a  result  of  this  stimulus,  the  sphincter 
vesicse  is  voluntarily  inhibited;  and  (3)  the  detrusor  muscle  is  con- 
tracted, expulsion  of  the  urins  necessarily  following.  A  volimtary 
contraction  of  the  abdominal  muscles  is  often  employed  to  assist 
in  this  expulsive  effort.  Each  of  these  muscular  elements  has  its 
own  centre  in  the  lumbar  enlargement  of  the  spinal  cord,  and  it  is 
possible  for  one  or  both  of  them  to  be  destroyed  or  weakened. 
Should  the  sphincteric  control  become  weak,  the  activity  of  the 
detrusor  may  be  relatively  increased,  and  the  bladder  contents  are 
expelled  too  frequently  (active  incontinence).  Should  the  sphinc- 
teric control  be  relatively  increased,  the  expulsive  efforts  of  the 
detrusor  will  be  hindered,  and  retention  results.  Necessarily  other 
causes  than  nervous  enter  into  the  production  of  these  two  con- 
ditions, and  hence  they  must  be  considered  separately. 

Incontinence  of  Urine. — A  patient  is  said  to  be  suffering  from 
incontinence  when  the  urine  escapes  involuntarily,  dribbling  away 
either  constantly  or  intermittently  from  the  urethra. 

I.  Active  Incontinence  (Enuresis)  is  often  present  in  young 
children,  mostly  boys,  in  whom,  as  already  indicated,  sphincteric 
control  is  not  too  well  developed.  It  results  from  some  condition 
of  increased  excitability  of  the  urinary  apparatus,  and  is  looked  on 
bv  some  as  of  a  choreic  nature.  The  chief  sources  of  irritation  are 
phimosis,  ascarides  in  the  rectum,  a  rectal  polypus,  or  urine  of  high 


I240  A   MANUAL  OF  SURGFUY 

specilic  gravity,  containing  uric  acid  crystals  in  suspension.  The 
affection  is  most  obvious  at  night,  and,  indeed,  may  only  occur 
during  sleep;  it  usually  disappears  when  adult  life  is  reached,  if  not 
cured  before,  but  has  been  known  to  persist  later.  Treatment  of  the 
nocturnal  incontinence  consists  in  the  removal  of  all  sources  of 
irritation — such  as  a  tight  foreskin ;  whilst  the  child  is  waked  from 
sleep  at  regular  intervals  in  order  to  pass  water,  so  as  to  break  him 
from  the  bad  habit.  Tonics — e.g.,  iron,  arsenic,  and  quinine — may 
be  administered,  and  tincture  of  belladonna  should  also  be  given  in 
full  doses.  He  must  not  be  allowed  to  lie  on  his  back,  or  to  eat 
or  drink  late  at  night,  but  must  be  kept  warm.  All  excitement  of 
the  sexual  senses  must  also  be  avoided. 

2.  Passive  Incontinence  is  said  to  be  present  when  the  neck  of  the 
bladder  is  relaxed,  so  that  as  soon  as  any  urine  is  secreted,  it  flows 
out  of  the  urethra — the  bladder  in  this  way  never  becoming  dis- 
tended. It  arises  mainly  from  two  causes:  (a)  Paralysis  of  the 
sphincter  vesicae,  as  a  result  of  some  injury  or  disease  of  the  spinal 
cord,  which  may  impair  its  function  either  temporarily  or  perma- 
nently. Thus,  in  severe  shock,  the  bladder  is  unconsciously  evacu- 
ated from  relaxation  of  the  sphincter ;  but  if  the  Imnbar  cord  is  not 
compressed  or  destroyed,  the  function  is  soon  regained.  Any  lesion 
involving  the  centre  for  the  sphincter  necessarily  destroys  its  future 
utility,  and  results  in  permanent  incontinence.  It  is  quite  possible 
for  the  detrusor  centre  to  be  damaged  without  injury  to  the  sphincter, 
and  in  such  a  case  distension  of  the  bladder  with  subsequent  over- 
flow supervenes.  Paralytic  incontinence  occasionally  follows  over- 
distension of  the  female  urethra  for  the  removal  of  a  calculus. 
Nothing  can  be  done  for  either  of  these  conditions,  if  permanent, 
beyond  the  application  of  a  suitable  urinal,  {b)  Mechanical  Incon- 
tinence sometimes  results  from  the  impaction  of  a  calculus  in  the 
internal  meatus,  or  from  its  dilatation  by  a  pedunculated  growth 
from  the  prostate. 

3.  False  Incontinence,  or  Distension  with  Overflow,  may  be  the 
outcome  of  an  attack  of  retention,  naturally  relieved,  or  is  due  to 
any  condition  in  which  the  outflow  of  urine  is  impeded  to  such  an 
extent  as  to  lead  to  a  certain  quantity  being  left  in  the  bladder 
after  every  act  of  micturition,  although  the  patient,  imagines  that 
the  organ  has  been  completely  emptied.  This  so-called  residual 
urine  gradually  increases  in  amount  until  the  bladder  becomes  filled, 
and  then  some  of  it  dribbles  away  involuntarily  so  as  to  wet  the 
patient's  clothes.  In  old-standing  cases  the  bladder  can  be  de- 
tected as  a  tense,  rounded  swelling  in  the  hypogastrium.  This 
condition  is  usually  met  with  in  patients  with'  neglected  stricture 
or  enlargement  of  the  prostate,  and  in  the  latter  case  the  bladder 
may  be  so  distended  as  to  contain  many  pints  of  urine.  Very 
much  the  same  state  of  things  obtains  in  paralysis  due  to  spinal 
mischief.  Treatment  must  be  directed  to  keeping  the  bladder 
emptied  by  the  regular  use  of  a  catheter,  but  it  often  remains  in  an 
atonic  state  for  some  time. 


BLADDER  AND  PROSTATE  1241 

Retention  of  Urine. — When  a  person  is  unable  to  expel  the  con- 
tents of  his  bladder,  so  that  it  becomes  distended,  retention  is  said 
to  be  present.  It  results  from  a  variety  of  conditions,  which  may 
be  classified  as  follows: 

I.  Mechanical  obstruction  which  may  involve  any  part  of  the 
urethra  or  the  neck  of  the  bladder,  the  actual  cause  varying  some- 
what with  the  age  and  condition  of  the  patient.  Thus,  in  infants 
the  commonest  cause  of  retention  is  the  narrowed  orifice  of  a  tight 
phimosis;  in  children,  an  impacted  calculus  in  the  urethra  or  a 
ligature  tied  round  the  penis ;  in  young  men,  gonorrhoea  or  one  of 
its  comphcations ;  in  young  women,  foreign  bodies  in  the  urethra 
or  bladder;  in  adult  men,  stricture;  in  adult  women,  uterine  fibroids 
or  some  uterine  condition  compressing  the  bladder  or  urethra ;  and 
in  old  men,  hypertrophy  of  the  prostate. 

2.  Nervous  lesions  may  be  responsible  for  some  cases.  Anything 
that  excites  the  sphincteric  energy  or  diminishes  the  activity  of  the 
detrusor  muscle  may  determine  retention,  and  thus  it  may  be 
brought  about  in  many  ways :  (a)  Spasm  of  the  sphincter  may  result 
irom  mental  perturbation  or  excitement,  a  person  being  unable  to 
micturate  in  the  presence  of  others;  possibly  this  is  more  evident 
in  those  who  have  been  guilty  of  masturbation,  [h]  Neurosis  is  a 
common  cause,  as  in  hysteria  or  shock ;  whilst  a  reflex  neurosis  is 
responsible  for  retention  after  injuries  or  operations,  especially  when 
the  latter  are  somewhere  in  the  neighbourhood  of  the  genital  organs, 
as  for  piles,  hernia,  varicocele,  etc.  (c)  Organic  disease  of  the 
nervous  system  produces  retention,  as  in  tabes,  disseminated 
sclerosis,  traumatic  and  neoplastic  conditions  of  the  cord,  etc. 

3.  Inflammatory  diseases  of  the  bladder  may  be  followed  by 
difficulty  in  micturition  or  even  retention,  probably  as  the  result 
of  an  interstitial  fibrosis  of  the  vesical  wall,  and  may,  perhaps, 
occur  most  frequently  after  gonorrhoeal  cystitis,  or  that  due  to  the 
B.  coli. 

4.  Retention  is  sometimes  the  outcome  of  habit  or  circumstances, 
as  in  clerks  or  school  teachers,  and  then  when  the  opportunity  to 
micturate  occurs  the  act  cannot  be  completed. 

If  left  unreHeved,  the  urine  accumulates  and  the  bladder  becomes 
distended,  as  described  at  p.  12 15,  giving  rise  to  much  pain  and  dis- 
comfort. One  of  two  conditions  is  certain  to  follow:  [a)  In  cases  of 
retention  from  stricture,  or  when  a  calculus  is  impacted  in  the 
urethra,  the  dilated  urethra  behind  the  seat  of  obstruction  gives 
way,  resulting  in  perineal  extravasation  of  urine.  If,  however,  the 
vesical  bladder  wall  has  been  weakened  as  the  result  of  ulceration, 
or  if  it  be  sacculated,  rupture  of  that  viscus  may  occur,  and  pelvic 
extravasation  may  follow,  [h)  When  the  retention  is  not  due  to 
complete  obstruction  of  the  passages,  the  distention  is  in  time  fol- 
lowed by  unconscious  overflow,  and  rehef  is  thereby  obtained,  al- 
though the  bladder  wall  passes  into  a  condition  of  atony. 

The  treatment  of  retention  necessarily  varies  with  the  cause,  as 
it  is  but  a  S3^mptom. 


1242  A   MANUAL  OF  SURGERY 

Atony  of  the  Bladder  is  the  term  applied  to  a  condition  in  which 
the  patient  is  unable  to  expel  the  contents,  not  on  account  of  any 
true  paralysis,  but  simply  from  loss  of  tone  of  the  muscular  wall. 
The  causes  are  as  for  retention,  and  the  condition  may  be  determined 
by  a  single  act  of  over-distension,  or  be  the  outcome  of  a  more 
chronic  type  of  retention.  Thus,  owing  to  the  oversight  of  a  house- 
surgeon,  it  occurred  in  a  patient  who  had  been  operated  on  for 
varicocele,  and  left  unrelieved  for  twenty-four  hours.  More  com- 
monly, however,  it  is  met  with  in  old  people  who  are  suffering  from 
retention  due  to  enlargement  of  the  prostate,  or  in  men  who  are  the 
subjects  of  stricture  of  the  urethra. 

In  the  slighter  cases  all  that  is  noticed  is  some  hesitation  or  diffi- 
culty in  commencing  the  act  of  micturition,  whilst  the  flow  itself 
is  weak,  the  urine  escaping  with  no  force,  and  often  dribbling  away 
after  the  act  is  apparently  completed.  In  bad  cases  a  considerable 
amount  of  residual  urine  may  be  left  in  the  bladder,  the  decomposi- 
tion of  which  may  lead  to  chronic  cystitis.  The  Treatment  should  be 
directed  to  removing  any  source  of  obstruction  which  exists,  whilst 
regular  catheterism  two  or  three  times  a  day  will  prevent  any  dis- 
tension of  the  bladder,  and  the  administration  of  strychnine,  phos- 
phoric acid,  and  other  tonics,  will  improve  the  expulsive  power  of 
the  viscus.  The  passage  of  a  constant  current  of  electricity  may 
also  be  employed  two  or  three  times  a  week,  to  stimulate  the  mus- 
cular fibres ;  one  electrode  is  inserted  into  the  bladder,  and  the  other 
placed  over  the  hypogastrium. 

Affections  of  the  Prostate. 

Acute  Prostatitis  arises  most  usually  as  a  sequela  of  gonorrhoea, 
either  in  its  acute  or  chronic  stage,  by  direct  extension  backwards 
of  the  inflammatory  process;  it  is  also  occasionally  met  with  as  a 
result  of  stricture  arising  from  the  irritation  of  retained  and  decom- 
posing urine,  or  from  the  passage  of  instruments.  It  is  said  to  be 
induced  by  the  application  of  cold  or  damp  to  the  perineum,  as  by 
sitting  on  cold  stones  or  damp  grass,  but  probably  this  has  been 
preceded  by  bacterial  invasion  of  the  posterior  part  of  the  urethra. 
Suppuration  follows  in  not  a  few  cases,  being  due  to  the  infection  of 
the  prostatic  folhcles  with  pyogenic  organisms.  Sometimes  merely 
one  or  two  superficial  follicles  are  affected,  causing  what  is  termed 
a  follicular  abscess  ;  occasionally  the  mischief  extends  much  more 
widely,  involving  the  whole  of  one  lobe,  or  perhaps  the  whole  organ, 
and  constituting  a  parenchymatous  abscess. 

The  Symptoms  consist  of  deep-seated  pain  referred  to  the  neck  of 
the  bladder,  with  perhaps  a  sense  of  weight  and  fulness  about  the 
perineum,  and  pain  referred  to  the  end  of  the  penis.  Micturition 
becomes  frequent  and  painful,  and  defaecation  may  cause  consider- 
able distress.  As  the  organ  increases  in  size,  the  pain  becomes 
more  and  more  severe,  and  all  movements  of  the  body,  as  also  the 
act  of  sitting,  are  increasingly  difficult.     On  rectal  examination  the 


BLADDER  AND  PROSTATE  1243 

organ  can  be  felt  enlarged,  hot,  and  tender.  Suppuration  is  likely 
to  follow,  and  retention  of  urine  may  be  thereby  induced.  A  fol- 
licular abscess  bursts  into  the  urethra  spontaneously,  or  is  ruptured 
by  the  passage  of  a  catheter  for  the  relief  of  retention ;  the  opening, 
however,  is  sometimes  of  a  valvular  nature,  and  only  a  small  portion 
of  the  pus  escapes.  The  process  may  then  continue  to  spread,  and 
the  pus  may  find  its  way  into  the  rectum,  or  come  to  the  surface 
through  the  perineum.  In  either  of  the  latter  conditions  a  rectal  or 
perineal  fistula  is  liable  to  result.  Considerable  constitutional  dis- 
turbance, and  perhaps  a  good  deal  of  fever,  are  usually  associated 
with  this  affection,  whether  suppuration  occurs  or  not.  The  forma- 
tion of  a  parenchymatous  abscess  is  always  attended  with  much 
more  acute  symptoms,  both  general  and  local.  The  organ  is  larger 
and  produces  more  rectal  irritation ;  a  considerable  quantity  of  pus 
may  form,  and  suppuration  may  extend  beyond  the  capsule  into 
surrounding  parts. 

Treatment. — The  patient  should  be  kept  in  bed  on  a  restricted 
diet,  and  the  bowels  freely  opened  by  saline  purges,  combined  with 
small  doses  of  antimony,  and  perhaps  full  doses  of  hyoscyamus. 
Local  depletion  may  be  undertaken  by  cupping  the  perineum,  or  by 
applying  ten  or  twelve  leeches  to  it.  Hot  hip-baths  are  also  very 
valuable,  and  linseed-meal  poultices  may  be  placed  on  the  perineum 
after  the  leeches  have  been  removed.  Extreme  pain  should  be 
relieved  by  the  use  of  morphia  suppositories,  and  if  the  urine  needs 
to  be  drawn  off,  a  soft  rubber  catheter  of  small  size  should  be  used. 
If  an  abscess  forms,  and  is  not  opened  by  the  passage  of  a  catheter, 
or  if  the  natural  opening  is  of  a  valvular  character,  so  that  the  cavity 
cannot  completely  empty  itself,  an  incision  must  be  made  into  it 
through  the  middle  line  of  the  perineum,  being  guided  by  a  finger 
placed  in  the  rectum ;  pus  may  not  be  reached  until  the  knife  has 
entered  to  a  depth  of  about  2  inches.  Urine  will  sometimes  escape 
from  this  opening,  and  may  continue  to  do  so  for  some  considerable 
time.  If  gonorrhoea  is  also  present,  suitable  treatment  must  be 
adopted  in  order  to  check  the  discharge.  When  the  abscess  is 
pointing  in  the  rectum,  it  may  be  wise  to  open  it  from  that  cavity ; 
but  every  effort  must  be  made  to  avoid  this  contingency,  as  a  recto- 
urethral  fistula  may  result. 

Chronic  Prostatitis  is  perhaps  one  of  the  most  common  causes  of 
chronic  gleet  after  gonorrhoea.  It  is  sometimes  left  as  a  sequela  of 
an  acute  attack,  or  may  arise  as  a  result  of  stricture. 

The  Symptoms  produced  by  it  are  a  sense  of  weight  and  fulness 
about  the  perineum,  combined  with  irritability  of  the  bladder,  and 
pain  referred  to  the  extremity  of  the  penis  at  the  end  of  micturition, 
owing  to  the  bladder  contracting  upon  the  hypersemic  and  sensitive 
organ.  A  glairy  discharge  of  viscid  material,  similar  in  appearance 
to  uncooked  white  of  egg  {prostatorrhoea),  is  often  present,  whilst 
fine  threads  of  mucus  are  usually  seen  floating  in  the  urine,  being 
due  to  the  formation  of  mucous  casts  of  the  prostatic  ducts.  On 
examination  through  the  recttun,  the  organ  can  be  felt  enlarged 


1244  A   MANUAL  OF  SURGERY 

and  tender,  and  the  vesicuke  are  usually  in  the  same  condition. 
Chronic  suppuration  may  follow,  the  abscess  bursting  into  the 
urethra  or  rectum,  or  pointing  in  the  perineum. 

The  Diagnosis  from  tuberculous  disease  can  usually  be  made  by 
careful  attention  to  the  history  and  physical  signs. 

Treatment  consists  in  counter-irritation  of  the  surface  of  the 
perineum,  as  by  blisters  or  iodine  paint,  care  being  taken  that  the 
reagent  employed  does  not  extend  either  to  the  anus  or  scrotum. 
Belladonna  suppositories  may  be  of  value,  whilst  the  occasional 
passage  of  a  cold  metal  bougie  may  do  good.  In  suitable  cases, 
where  a  long-standing  gleet  is  present  with  no  suspicion  of  suppura- 
tion, a  cure  may  occasionally  be  brought  about  by  the  administra- 
tion of  iodide  of  potassium,  or  of  the  liq.  ferri  perchloridi  (H^xv.  or 
more,  t.d.s.),  combined  with  sulphate  of  magnesia.  The  local  ap- 
plication of  a  solution  of  nitrate  of  silver  by  a  porte-caustique  is 
also  sometimes  recommended,  but  probably  the  best  treatment  con- 
sists in  forcible  dilatation  of  the  prostatic  urethra,  as  suggested  by 
Oberlander,  the  follicles  being  thereby  emptied  of  their  secretion; 
massage  of  the  prostate  per  rectum  against  a  sound  held  in  position 
may  also  be  useful.  Should  an  abscess  form,  it  is  incised  through 
the  perineum. 

Tuberculous  Disease  of  the  Prostate  is  usually  met  with  as  a  result 
of  extension  from  similar  disease  in  the  epididymis,  the  seminal 
vesicles  being  also  invaded;  occasionally,  however,  it  may  arise  as  a 
primary  affection.  In  either  case,  it  rapidly  spreads  to  the  bladder, 
and  thence  to  the  ureters  and  kidneys.  The  prostate  is  found  to 
contain  caseous  masses  in  the  early  stages,  but  later  on  these  break 
down,  leading  to  extensive  ulceration,  and  sometimes  the  organ  is 
riddled  with  ragged  cavities.  The  symptoms  are  those  of  irritability 
of  the  neck  of  the  bladder,  combined  with  pain  referred,  perhaps,  to 
the  end  of  the  penis,  or  mainly  noticed  in  the  back  or  perinemn. 
Haematuria  is  occasionally  produced,  whilst  pyuria  is  almost  con- 
stant. The  urine  is  feebly  acid  or  neutral,  and,  on  examination 
of  the  pus  which  is  deposited  on  standing,  the  tubercle  bacillus  may 
be  detected.  Rectal  examination  will  demonstrate  an  irregular 
enlargement  of  the  organ,  whilst  if  the  vesiculae  are  invaded  they 
can  also  be  felt. 

Treatment  consists  in  attending  to  the  general  health,  and  the 
administration  of  tonics ;  vaccination  with  tuberculin  may  prove  of 
some  value.  Possibly,  if  the  disease  is  not  too  extensiv^e,  benefit 
may  be  derived  from  scraping  away  the  tuberculous  tissue  through 
a  perineal  incision. 

Prostatic  Calculi  are  of  unfrequent  occurrence,  being  usually  met 
with  in  cases  of  chronic  prostatitis,  especially  that  resulting  from 
stricture  of  the  urethra  or  previous  attacks  of  gonorrhoea.  They 
are  generally  multiple,  and  of  small  size,  consisting  mainly  of 
carbonate  of  lime,  i  hey  develop  primarily  in  the  glandular  crypts, 
and  may  remain  embedded  in  the  organ,  giving  rise  to  but  little 
inconvenience.    When  large  and  protruding  from  the  gland  into  the 


BLADDER  AND  PROSTATE  1245 

urethra,  symptoms  of  obstruction  to  the  flow  of  urine  are  produced, 
whilst  on  passing  a  catheter  or  sound  a  distinct  click  or  grating  may 
be  noticed.  In  the  latter  case,  great  irritability  of  the  neck  of  the 
bladder  is  induced.  Sometimes  a  number  of  them  are  found  in 
a  pouch  or  pocket,  formed  by  the  amalgamation  of  several  of  the 
crypts.  Diagnosis  can  be  effected  in  some  instances  by  radiography, 
the  calculi  casting  shadows  usually  a  little  below  the  brim  of  the; 
pelvis.  It  is  in  some  instances  possible  to  remove  the  calculi 
through  the  urethra,  but  more  frequently  a  perineal  incision  is 
required. 

Enlargement  of  the  Prostate  (or,  as  it  used  to  be  termed,  senile 
hypertrophy)  is  a  condition  rarely  seen  under  fifty  years  of  age, 
characterized  by  a  chronic  persistent  overgrowth  of  the  organ,  which 
results  in  interference  with  the  act  of  micturition,  and  may  finally 
destroy  life  by  inducing  secondary  changes  in  the  bladder  and 
kidneys  by  prolonged  backward  pressure.  As  to  causation,  but  little 
is  known ;  it  is  not  apparently  attributable  to  excessive  sexual  indul- 
gence. It  may  attain  a  considerable  size,  perhaps  constituting  a 
tumour  as  large  as  one's  fist  and  weighing  200  grammes,  the  average 
normal  weight  of  the  prostate  being  about  18  grammes.  It  may  be 
of  hard  or  soft  consistence,  and  in  the  latter  case  is  extremely 
vascular.  The  vascularity  varies  from  time  to  time,  and  the  patient 
is  liable  to  sudden  attacks  of  congestion,  which  aggravate  the 
symptoms.  On  section  the  organ  may  appear  to  be  homogeneous 
and  of  the  same  texture  throughout,  but  most  commonly  it  consists 
of  a  nrnnber  of  firm  rounded  masses,  sharply  defined,  and  held  to- 
gether by  a  certain  amount  of  connective  tissue.  Outside  these  is 
an  ill-defined  layer  of  stretched  (and  sometimes  atrophied)  muscular 
tissue,  containing  a  few  glandular  elements,  but  continuous  with  the 
stroma,  and  constituting  the  true  capsule  of  the  organ.  Still  further 
out  is  the  extrinsic  sheath,  derived  from  the  pelvic  fascia  (mainly 
recto-vesical) ;  it  consists  of  two  layers,  between  which  are  the  veins 
of  the  prostatic  plexus. 

Histologically,  an  enlarged  prostate  consists  of  an  overgrowth  of 
the  glandular  tissue,  sometimes  diffuse,  more  frequently  in  the  form 
of  multiple  adenomata,  set  in  a  connective-tissue  basis  developed 
from  the  prostatic  stroma  of  muscle  fibres.  Cystic  changes  are  not 
unusually  observed  in  these  adenomata.  Occasionally  a  few  fibro- 
myomata  may  develop,  but  they  are  decidedly  uncommon. 

The  changes  induced  in  connection  with  an  enlarged  prostate  are 
numerous  and  important.* 

1.  The  prostatic  sheath  of  pelvic  fascia  becomes  thickened  and 
condensed,  thereby  preventing  any  downward  expansion  of  the 
organ,  and  directing  its  enlargement  upwards. 

2.  The  close  connection  between  the  capsule  and  the  sheath, 
which  is  so  marked  a  feature  in  the  normal  anatomy  of  the  organ, 
is  profoundly  modified,  so  that  it  becomes  easy  to  enucleate  the 
gland  in  its  entirety  from  its  surroundings. 

*  Vide  '  The  Surgical  Anatomy  of  the  Normal  and  Enlarged  Prostate,'  by 
J.  W.  Thompson  Walker,  Med.-Chir.  Trans.,  vol.  Ixxxvii. 


1246 


A   MANUAL   OF  SURGERY 


3.  The  relations  to  the  bladder  wall  are  also  much  altered. 
Normally,  the  sphincter  (Fig.  553,  S.V.)  is  interposed  between  the 
prostate  and  the  vesical  mucosa.  As  the  gland  enlarges,  this  rela- 
tion may  persist  (Fig.  554),  and  although  the  bladder  base  is  raised 
up,  the  growth  is  extravesical,  and  the  sphincter  muscle  covers  over 
the  enlargement.  More  frequently,  however,  the  gland,  as  it  en- 
larges, insinuates  itself  between  the  sphincter  and  internal  meatus, 
constituting  an  intravesical  enlargement  (Fig.  555).  This  is  gener- 
ally most  marked  in  the  middle  line  behind,  constituting  the  so- 
called  'middle  lobe'*  (Fig.  556);  but  it  may  involve  the  whole 
gland,  which  projects  into  the  bladder  as  a  collar-like  enlargement 
around  the  meatus,  whilst  sometimes  one  or  both  of  the  lateral 
lobes  are  chiefly  affected  in  this  manner.  The  gland  also  pushes 
backwards  between  the  seminal  vesicles,  which  in  time  are  dis- 


FiG.  553 


Fig. 


554- 


Fig.  555. 


P'iGS.  553-555. ^Diagrams  to  illustrate  Relation  of  the  Prostate  to 
THE  Sphincter  Vesica  (S.V.). 

In  Fig.  553  the  prostate  is  supposed  to  be  of  normal  size,  and  the  sphincter  hes 
above  it;  in  Fig.  554  the  prostate  is  enlarged,  but  has  no  intravesical  pro- 
jection or  '  middle  lobe,'  and  hence  the  sphincter  retains  its  normal  rela- 
tion; in  Fig.  555,  the  most  common  type  of  prostatic  enlargement,  a  well- 
marked  intravesical  projection  or  middle  lobe  exists,  the  sphincter  being 
displaced  backwards  by  this  development. 

placed  from  their  connection  with  the  back  of  the  bladder,  and  con- 
stitute a  posterior  relation  with  the  enlarged  organ.  It  is  interest- 
ing to  note  that  this  overgrowth  involves  mainly,  if  not  entirely, 
the  upper  part  of  the  gland,  and  that  the  portion  below  the  veru- 
montanum  is  rarely  affected,  so  that  the  openings  of  the  ejaculatory 
ducts  are  not  displaced  backwards. 

4.  The  changes  produced  in  the  prostatic  urethra  and  neck  of  the 
bladder  vary  considerably  in  different  cases.  The  length  of  the 
urethra  is  always  increased,  perhaps  by  2  or  3  inches,  or  even  more. 
Some  amount  of  obstruction  to  the  outflow  of  urine  is  universal.  In 
rare  instances  it  may  be  due  to  an  adenoma  becoming  pedunculated, 
and  projecting  downwards  into  the  urethra  as  a  polypus.  Occa- 
sionally the  base  of  the  middle  lobe  becomes  narrowed,  probably 
as  the  result  of  constriction  by  a  band  of  longitudinal  muscle  fibres 

*  Students  must  remember  that  in  the  normal  pi  estate  there  is  no  middle 
lobe,  and  that  the  structure  thus  named  is  caused  by  an  abnormal  overgrowth 
or  projection  from  one  of  the  lateral  lobes. 


BLADDER  AND  PROSTATE 


1247 


passing  down  on  either  side  from  the  ureteral  orifice  to  the  meatus; 
the  middle  lobe  thereby  becomes  more  or  less  pedunculated,  and 
may  be  moveable,  constituting  a  ball-valve  which  determines  re- 
tention, or  else  wedging  open  the  internal  meatus  and  causing  incon- 
tinence. As  a  rule  the  outflow  of  urine  is  hindered  by  the  '  prostatic 
bar,'  caused  by  the  projection  of  the  middle  lobe,  which  also  hinders 
the  entrance  of  a  catheter.  When  both  lateral  lobes  are  enlarged 
symmetrically,  the  lumen  of  the  urethra  is  diminished  from  side  to 
side,  being  narrow  or  chink-like  instead  of  triangular,  but  its  ver- 
tical measurements  are  increased.  Asymmetrical  enlargement,  of 
course,  displaces  the 
urethra  to  one  or  other 
side. 

5.  The  effect  of  an  en- 
larged prostate  on  the 
bladder  is  important. 
The  obstruction  to  the 
outflow  of  urine  leads  to 
increased  expulsive  ef- 
forts on  its  part,  and 
consequently  the  wall 
becomes  thickened  and 
hypertrophied.  This  in- 
volves the  muscular 
fibres,  which  stand  out 
prominently  as  rounded 
fasciculi,  and  the  mucous 
membrane  may  project 
outwards  between  them 
as  hernial  protrusions, 
constituting  saccules  in 
which  urine  may  stag- 
nate and  decompose, 
and  even  phosphatic  p^^  ^^g — Enlarged  Prostate  with  a  Large 
concretions  form.  Intravesical  Portion.     (From  College  of 

In  almost  every  case       Surgeons'  Museum.) 
the    enlarged    prostate 

projects  more  or  less  into  the  vesical  cavity,  either  as  a  collar-like 
mass  around  the  internal  meatus,  or  as  one  or  more  rounded  out- 
growths. This  is  necessarily  associated  with  a  pouching  backwards 
of  the  lowest  part  of  the  bladder  {prostatic  pouch),  which,  being 
below  the  level  of  the  meatus,  does  not  become  emptied  during  the 
natural  process  of  micturition,  and  in  which  residual  urine  is  there- 
fore able  to  collect  and  remain. 

Cystitis  is  very  likely  to  follow,  either  by  infection  from  within  or 
from  the  use  of  unsterilized  instruments,  and  then  the  bladder  wall 
becomes  inflamed;  ammoniacal  decomposition  of  the  urine  follows, 
and  renal  complications  may  ensue  (either  hydronephrosis  or  pyo- 
nephrosis), which  will  determine  a  fatal  issue. 


A   MANUAL  OF  SURGERY 


The  Symptoms  \'ary  somewhat  with  the  nature  and  position  of 
the  enlargement.  The  patient  at  hr^t  iinds  some  difficulty  in  mic- 
turition, especially  at  the  commencement  of  the  act;  straining  often 
hinders  rather  than  assists.  The  stream  is  not  necessarily  smaller 
than  formerly,  but  is  projected  with  less  force.  Gradually  irrita- 
bility of  the  bladder  ensues,  and  the  patient  has  to  pass  water  very 
frequently,  a  trouble  especially  noticed  during  the  night.  Some 
degree  of  pain  and  a  sense  of  weight  and  fulness  about  the  perineum 
are  also  experienced,  whilst  tenesmus,  and  even  hernia,  may  be 
subsequent!}'  induced  by  the  straining.     Intermittent  attacks  of 

increased  pain  and  diffi- 
culty in  micturition 
occur  from  time  to 
time,  being  generally 
induced  by  exposure  to 
cold  and  wet,  and  pre- 
simiably  due  to  conges- 
tion of  the  prostate. 
After  lasting  for  a  few 
days  the  more  acute 
symptoms  slowly  dis- 
appear, if  judiciously 
treated. 
-^°-  As  the  obstruction 
increases,  a  certain 
amount  of  residual  urine 
remains  within  the 
bladder  after  each  act 
of  micturition,  the  vesi- 
cal muscles  in  time  los- 
ing power  and  becoming 
atonic.  Well-marked 
distension  and  atony  of 
the  bladder  ensue  at 
length  in  neglected 
cases,  the  urine  drib- 
bling away  and  wetting 
the  clothes,  whilst  de- 
composition of  the  retained  fluid  follows,  and  causes  cystitis  \\ath  in- 
creasing vesical  irritation  and  muscular  spasm.  The  urine  becomes 
alkahne  after  a  time,  containing  muco-pus  and  phosphates,  the  result 
of  chronic  cystitis.  This,  if  untreated,  is  certain  to  lead  to  hvdro- 
nephrosis  and  pyelonephritis.  The  general  health  of  the  patient  is 
slowly  undermined  by  the  constant  irritation  produced  by  this 
process,  as  also  by  toxic  absorption,  and  the  final  chapter  may  be 
ushered  in  by  sx-mptoms  of  uraemia  from  the  mischief  inflicted  on 
the  kidnej^s. 

Occasionally  the  early  symptoms  may  pass  unnoticed  for  a  con- 
siderable time,  the  patient  imagining  that  the  frequent  calls  to  pass 


Fig.    557. — Enlarged    Prostate    after     Re- 
moval BY  Suprapubic  Operation. 

The  catheter  has  been  placed  in  the  urethra. 
I,  The  so-called  middle  lobe,  or  intravesical 
projection  behind  the  internal  meatus;  2  and 
2fl,  the  lateral  lobes;  3,  indicates  the  nodular 
adenomatous  masses  which  constitute  the  bulk 
of  the  swelling. 


BLADDER  AND  PROSTATE 

^^^  1249 

tte  bhridfr  °^  ''^f  '^*'''''  *""  evidences  of  disease.    In  such  cases 
pete^^^SS^Z^fblTrf  *'"'''''■  ^"^  "^^  <=ond.tion  uns:  ! 

fu^7.s?„?i^v9^^^^^ 

condition  anS  the  effect  of  thl"*P'?K  '"  *°'"?*™«  a  troublesome 
senous  a„dlei^^!„t^*el*'l\"c  s'^f-^^oT^^  ^^  -^^ 

tio^':f?re*f,^';ttTSaS:?r^'^r?""- 

of  the  ureth^rnd  «ctr,P'"T^^  age'of  the' mlien''t'?h'"""'""*'™ 
irritability  of  the  bladdpr  h„  „,vi,t^  j  j  patient,  the  increasing 
hinders  i/ther  than  M™  til   ^    1  ""^  '^''^-  **=  '^"^^  *=»*  straining 

a  finger  in  the  rectum    r^nn^'  *^^^.  ^^^  size,  as  recognised  by 
rectum,  the  obstrtti^l^t^rteS!'  XcSf^Sr^cti 


Fig.  558.— Catheter  Coude  and  Bicoude. 

blrri:?'at't"necrSVhe'Sfa':,7  '"'=  ''T°5'^-  '"-"-'>  -  '^^ 
times  with  difficulty  oasserf  '''^'^'^e'-  is  easily  detected,  and  some- 
prostate,  see  rrisl^  *''"  diagnosis  from  cancer  of  the 

ord'^frTTOVhe'bMdTfrot  h'"'"''  "  ^^^"'"  catheterism,  in 
this  the  /atient  may  otnt  tau"htt°d"7fr  Wmslf  X^'*'  ^"^ 

and  bars  the  onward  DrXJfff^^'-P?^""*'  '"=™=^='  *e  urethra, 
shape.  The  sweon  ihoflH  tT,  f  '"strument  of  the  ordinary 
bicoude  liZ  -/li  I,  T^  therefore  use  a  catheter  coude  or 
tt  ustf^fenfh  Lpe '  ae'rd'ol  fv  r-'\^'™ght  instrument  o 
an  angle,  hke  an  el^?w  so  as  to  enlbleV'to  '"1*  °'  '^""ij'j'  l'™*  ^^^ 
tion;  or  he  may  emnlov  an  F^Jn  T  \  '".""^e  over  the  obstruc- 

of  which  istown  out  a  httfe  foS?™"'''''''^"^*'=ter, 

utilize  the  silye™rostati   catheter  ^Cr^i^'T  '*'  '"T'  "  "^^  "^'^ 
than  usual,  denrLim?  it  well  K.f '        }:  "*  [""^er  and  more  curved 

pubic  arch.     \?Sc?er  me  hod  Ts"adop?ed  'fo'  f ""  ''^"'"^  the 
Since  with  a  little  slHll  fh^^^    ?    5  adopted,  no  force  is  requ  red 

the  obstruetio  "and    nter  tL  Sadder    "Ff""^"*  ^""-  P^^"°>»<i 
taken  to  ensure  the  effiei^!;?  "^^^^7 rS^Z^'J^ 


I250  A  MANUAL  OF  SURGERY 

ployed,  and  it  should  be  remembered  that  as  a  general  rule  large 
rather  than  small  instruments  will  pass  more  easily. 

During  the  first  fortnight  of  catheter  life  the  patient  must  be 
cart full\-  guarded  from  cold  and  exposure,  to  avoid  the  occurrence 
of  constitutional  disturbance.  Not  unfrequently  a  certain  amount 
of  fever  (to  which  the  name  of  Catheter  Fever  was  given  by  the  late 
Sir  Andrew  Clark)  is  produced,  which  either  passes  off  in  the  course 
of  a  few  da3's,  or  may  increase,  together  with  symptoms  of  chronic 
cystitis,  running  on  to  a  fatal  issue  at  the  end  of  three  or  four 
weeks.  The  origin  of  this  condition  is  still  somewhat  doubtful;  it 
probably  arises  from  the  absorption  of  micro-organisms  or  their 
products  from  the  urethra,  or  from  the  use  of  dirty  instruments, 
but  possibly  reflex  nervous  disturbance  plays  some  part  in  its  pro- 
duction. The  only  treatment  required  in  the  simpler  cases  is  to 
keep  the  patient  warm  in  bed,  to  limit  his  diet,  to  administer  quinine 
and  perhaps  opium,  and  to  keep  the  bowels  well  open. 

Luring  the  continuance  of  catheter  life,  the  patient  must  be 
warned  to  live  quietly,  and  abstain  from  all  excesses,  especially  as 
regards  eating  and  drinking;  sexual  excitement  should  be  avoided, 
and  horse-exercise  forbidden;  precautions  must  also  be  taken  to 
ensure  protection  from  cold  and  damp.  The  administration  of 
alkalies  is  desirable  if  the  urine  is  highly  acid,  so  as  to  diminish  the 
irritability  of  the  bladder. 

Under  such  a  regime,  it  is  possible  that  the  patient  may  live  in 
comparative  comfort  perhaps  for  years,  the  progress  of  the  affection 
being  entirely  checked  in  some  instances.  In  others,  the  patient 
suffers  from  intermittent  attacks  of  congestion  of  the  prostate,  with 
increased  pain  and  irritability  of  the  bladder,  and  augmented  diffi- 
culty in  micturition.  The  introduction  of  a  catheter  is  then  ver\- 
likely  to  cause  bleeding,  but  a  few  days'  rest  in  bed,  hot  baths  and 
the  administration  of  ergot,  usually  bring  about  considerable  im- 
provement. If  there  is  much  difficulty  in  passing  a  catheter,  it 
may  be  wise  to  tie  it  in  for  a  time,  or  even  suprapubic  aspiration 
may  be  required.  The  progress  of  the  case  depends,  to  a  large 
extent,  upon  the  bladder  remaining  free  from  septic  contamination, 
and  the  surgeon  must  realize  and  impress  upon  his  patient  that  such 
is  generally  due  to  infection  from  without,  and  hence  the  most 
scrupulous  care  must  be  taken  to  sterilize  all  instruments  before  and 
after  use.  In  cases  where  the  relief  given  by  regular  catheterism  is 
but  temporary,  and  the  irritability  of  the  bladder  or  the  amount  of 
residual  urine  increases  seriously,  or  the  patient  wishes  to  be  freed 
from  the  wearisome  necessity  of  regular  and  perhaps  frequent 
catheterism,  operation  for  removal  of  the  enlarged  organ  may  be 
recommended. 

Prostatectomy  was  originally  practised  by  McGill  of  Leeds  many 
years  ago,  but  it  has  only  been  established  as  a  successful  and  emi- 
nently practicable  procedure  for  a  few  years,  and  that  mainly  by  the 
energy  of  Mr.  P.  J .  Frcyer.  There  has  been  much  discussion  as  to 
whether  the  whole  prostate  is  removed  from  its  fascial  sheath  in  this 
precedure,   or  merely   an   intraglandular   enucleation    perfoimed. 


BLADDER  AND  PROSTATE  1251 

TIlis  probably  depends  largely  on  the  technique;  either  procedure 
IS  possible,  and  in  the  more  exaggerated  cases  there  is  not  much 
to  choose  between  the  two,  as  the  enlarged  organ  is  entirely  adeno- 
matous, and  the  intrinsic  capsule  is  thinned  and  atrophic.  The 
surgeon's  aim,  however,  should  be  directed  towards  the  complete 
removal  of  the  organ,  the  line  of  cleavage  being  placed  between 
what  we  have  described  as  the  capsule  and  the  fascial  sheath.  Two 
methods  of  approach  are  possible— viz.,  from  the  perineum  or  by 
the  suprapubic  route.  Personally,  we  are  at  one  with  the  maioritv 
of  surgeons  in  preferring  the  latter. 

Suprapubic  Prostatectomy.— If  there  is  much  cystitis,  the  bladder 
must  be  carefully  prepared  for  a  few  days  by  keeping  the  patient  in 
bed  and  washing  it  out  with  a  mild  antiseptic,  or  even  possibly  by 
draining  it.     At  the  time  of  operation  it  is  again  irrigated,  and  some 
6  ounces  or  so  of  boric  acid  lotion  left  in  it.     The  patient  is  placed 
m  the  Trendelenburg  position,  and  the  usual  suprapubic  incision 
made  into  the  bladder.     The  vesical  wall  is  by  some  anchored  to 
the  abdominal  parietes  by  a  deep  silkworm  gut  stitch  on  either  side, 
so  that  it  shall  not  be  unduly  torn  or  displaced  in  the  subsequent 
manipulations ;  this  step  is  not  essential,  although  the  introduction 
of  a  silk  slmg  through  the  bladder  wall  on  either  side  is  desirable. 
The  portion  of  the  prostate  projecting  into  the  bladder  is  now  care- 
fully examined  and  its  removal  commenced.     The  index  and  middle 
fingers  of  the  left  hand  (which  is  covered  with  a  sterilized  india- 
rubber  glove)  are  introduced  into  the  rectum  so  as  to  steady  and 
push  forwards  the  prostate.     The  right  index-finger  tears  through 
the  mucous  membrane  behind  the  projecting  median  lobe  or  collar 
thus  passing  between  it  and  the  displaced  sphincter  vesicce.     It  will 
often  be  found  an  easy  matter  to  pass  the  finger  round  the  enlarged 
organ  and  enucleate  it;  the  larger  the  prostate,  the  more  easily  this 
is  effected;  but  when  it  is  comparatively  small  and  hard,  enuclea- 
tion may  be  difficult.     In  this  procedure  the  ejaculatory  ducts  are 
torn  across,  as  also  the  vessels  which  enter  and  leave  the  gland  on 
either  side.     The  urethra  is  either  removed  entirely,  or  the  lower 
portion  of  it  is  detached  and  left  behind.     The  prostate  when  free 
m  Its  sheath  remains  either  in  one  mass,  or  not  unfrequently  separ- 
ates into  two  halves,  which  can  be  peeled  off  the  urethra  and 
removed  separately  from  the  bladder. 

This  enucleation  is  attended  by  remarkably  little  bleeding  in  the 
majority  of  cases,  and  even  when  at  all  free  it  can  be  quickly  re- 
strained by  irrigating  the  cavity  and  bladder  with  hot  sahne  or  boric 
acid  solution  through  a  catheter.  A  large  rubber  tube  is  passed  into 
the  bladder  and  stitched  in  the  lower  angle  of  the  wound,  the  upper 
end  of  which  is  closed  by  deep  sutures.  The  wound  is  covered  with 
a  few  layers  of  cyanide  gauze,  and  over  this  absorbent  wool  is  placed 
m  sufficient  quantity  to  take  up  the  urine  secreted.  Morphia  is 
often  needed  to  combat  the  pain  and  spasm  that  supervene,  and 
it  is  advisably  given  as  a  suppository,  or  as  a  starch  and  laudanum 
enema.  The  subsequent  treatment  varies  somewhat.  Probably 
the  best  method  is  to  dress  the  wound  with  gauze  and  wool,  which 


1252  A   MANUAL  OF  SURGERY 

are  renewed  every  four  or  six  hours  as  may  be  required.  The 
amount  of  dressing  required  is  large,  and  the  expense  is  consider- 
able. Some  surgeons  employ  Irving's  apparatus,  a  glass  cap  which 
fits  closely  over  the  wound,  kept  in  place  by  elastic  bands  round 
the  body,  and  draining  into  tubes  which  carry  away  the  urine  to 
a  bottle  between  the  legs.  This  appliance  keeps  the  patient  dry, 
and  saves  the  expense  of  dressing;  but  it  keeps  the  patient  on  his 
back,  it  presses  on  the  wound  and  lower  abdomen,  and  probably 
it  hinders  the  healing  process  somewhat.  The  bladder  is  irrigated 
daily  through  the  suprapubic  incision,  and  blood  and  small  sloughs 
will  escape  for  some  days.  As  soon  as  the  suprapubic  wound  is 
protected  by  a  layer  of  granulations,  the  tube  should  be  with- 
drawn, and  the  urine  allowed  to  escape  or  to  collect  in  the  bladder. 
A  catheter  is  passed  about  the  end  of  the  first  week,  and  the  bladder 
washed  out  through  it.  The  patient  is  allowed  up  in  an  arm-chair 
as  soon  as  possible  to  avoid  pulmonary  complications.  Not  unfre- 
quently  he  will  commence  to  pass  urine  naturally  in  about  a  fort- 
night or  three  weeks,  and  subsequently  the  function  will  be  main- 
tained in  a  normal  fashion. 

In  Perineal  Prostatectomy  a  median  staff  is  passed,  and  then  the 
membranous  urethra  and  apex  of  the  prostate  are  exposed,  either 
by  an  antero-posterior  or  transverse  incision  in  the  perineum.  The 
fascial  sheath  of  the  prostate  is  torn  through  or  divided  by  the  knife, 
and  enucleation  is  then  carried  out  by  the  finger,  assistance  being 
derived  by  pressing  the  bladder  downwards  from  above  the  pubes. 
It  is  claimed  that  the  urethra  is  less  damaged  in  this  procedure,  but 
its  advantages  are  not  apparent. 

If  the  patient  refuses  operation,  or  if  his  general  condition  pre- 
vents it  from  being  undertaken  with  safety,  and  catheterism  is 
insufficient  to  give  relief  to  his  symptoms,  a  permanent  fistula  either 
above  the  pubes  or  through  the  perineum  must  be  established, 
necessitating  the  use  of  a  portable  urinal.  This  is  effected  by  intro- 
ducing a  trocar  and  cannula  into  the  bladder,  and  leaving  it  there 
until  a  sufficient  track  has  been  formed. 

Cancer  of  the  Prostate  occurs  in  elderly  men,  but  is  more  common 
than  was  formerly  supposed ;  it  is  usually  of  a  scirrhous  type,  though 
sometimes  it  is  of  a  soft  nature;  in  either  form  it  early  progresses 
beyond  the  limits  of  the  capsule.  The  symptoms  produced  are  at 
first  similar  to  those  caused  by  simple  enlargement  of  the  prostate; 
but  the  progress  of  the  case  is  much  more  rapid,  the  amount  of 
pain  and  discomfort  is  much  greater,  and  the  pain  is  often  referred 
to  the  back  of  the  thighs  and  down  the  legs.  Later  on  hematuria 
may  occur.  On  rectal  examination  a  hard  mass  is  readily  detected, 
fixed  more  or  less  to  surrounding  parts,  and  perhaps  with  outlying 
nodules  distinct  from  the  main  mass;  secondary  deposits  may  be 
found  in  the  lumbar  and  abdominal  glands  on  palpating  the  abdo- 
men. Occasionally  phenomena  referable  to  pressure  on  the  abdom- 
inal vessels  and  nerves  arise,  and  the  symptoms  of  general  cachexia 
soon  manifest  themselves.  Palhative  treatment  alone  can  be 
adopted  in  the  majority  of  cases. 


CHAPTER  XLL 
AFFECTIONS  OF  THE  URETHRA  AND  PENIS. 

Affections  of  the  Urethra. 

Congenital   Malformations. — ^Total  Absence,   or  Occlusion,   of  the 

urethra  has  been  met  with,  the  urine  under  such  circumstances 
being  sometimes  retained,  and  leading  to  dilatation  of  the  bladder, 
ureters,  and  kidneys,  a  condition  rapidly  fatal,  even  if  the  child  be 
born  alive.  In  a  few  cases  the  urachus  remains  patent,  and  a  con- 
genital u.rinary  fistula  is  established  at  the  umbilicus,  whilst  in 
others  the  cloacal  condition  persists,  the  rectum  communicating 
with  the  bladder  (Fig.  526). 

Epispadias  is  a  deformity  in  which  the  urethra  is  partially  or 
wholly  exposed  along  the  upper  surface  of  the  penis.  According 
to  Sir  Henry  Morris,  it  is  not,  properly  speaking,  a  division  or 
deficiency  in  the  upper  wall  of  the  urethra,  but  in  its  floor,  which 
has  been  transposed  to  the  dorsum  by  torsion  of  the  penis.  '  It  is 
thus,  in  fact,  a  hypospadias  reversed — i.e.,  upside  down.'  In  rare 
instances  the  external  meatus  is  situated  just  above  the  glans, 
which  is  cleft  and  deeply  grooved  superiorly.  More  commonly  the 
urethra  opens  at  the  root  of  the  penis,  just  in  front  of  the  symphysis, 
and  in  such  patients  the  organ  is  always  rudimentary  and  stunted. 
Complete  epispadias  is  only  present  when  associated  with  extro- 
version of  the  bladder  (p.  1216).  The  incomplete  form  has  been 
treated  with  success  by  the  use  of  reversed  flaps  dissected  up  from 
the  side  of  the  penis.  For  details  of  the  operations  on  this  and  the 
following  conditions,  see  larger  text-books  on  operative  surgery. 

Hypospadias,  or  defective  development  of  the  lower  wall  of  the 
urethra,  is  a  much  more  com,mon  malformation  than  the  foregoing. 
Three  varieties  are  described.  In  {a)  hypospadia  glandis  the  open- 
ing of  the  urethra  corresponds  to  the  position  usually  occupied  by 
the  fraenum,  and  is  thus  directed  downwards  instead  of  forwards. 
The  prepuce  in  these  cases  is  always  voluminous,  and  hangs  like  a 
hood  over  the  glans,  which  is  bent  down  over  the  orifice.  (&)  Hypo- 
spadia penis  is  characterized  by  the  urethra  opening  somewhere 
along  the  under  surface  of  the  body  of  the  penis,  which  is  often 
small  and  stunted.     Considerable  discomfort  may  arise  in  the  act 

1253 


1254  A   MANUAL  OF  SURGERY 

of  micturition,  owing  to  the  urethral  orifice  looking  downwards;  it 
is  also  sometimes  so  small  as  to  require  incision  and  dilatation, 
(c)  Complete  hypospadias,  or  hypospadia  perinealis,  is  a  somewhat 
complicated  condition,  in  which  the  lower  wall  of  the  urethra  is 
defective  as  far  back  as  the  perineum,  the  scrotiun  being  cleft,  and 
thus  resembling  the  vulva.  The  penis  is  always  small,  imperfectly 
developed,  and  bound  down  by  adhesions  between  the  scrotal  seg- 
ments, looking  not  unlike  a  hypertrophied  cHtoris,  and  late  descent 
of  the  testes  is  common.  Under  such  circumstances  it  is  not  sur- 
prising that  the  sex  of  the  child  has  been  mistaken,  and  not  a  few 
cases  are  on  record  where  it  has  been  educated  as  a  female  until  the 
age  of  eighteen  or  twenty. 

In  the  incomplete  varieties,  where  the  deformity  is  slight  and  the 
urethral  opening  well  in  front  of  the  scrotum,  no  interference  is 
necessary;  but  where  it  encroaches  on  the  scrotum,  causing  incon- 
venience and  discomfort,  and  threatening  to  prevent  effective  sexual 
intercourse  in  the  future,  the  restoration  of  the  urethra  may  be 
attempted  by  the  use  of  flaps  obtained  from  either  side,  or  from  the 
redundant  prepuce.  In  the  complete  form  the  penis  must  first  be 
liberated  from  its  adhesions  and  set  free ;  the  integument  lining  the 
scrotal  cleft  is  then  dissected  up  and  turned  inwards  to  form  the 
posterior  part  of  the  urethra,  whilst  the  lateral  halves  of  the  scrotum 
are  brought  together  with  sutures;  the  anterior  portion  of  the 
urethra  mav  then  be  dealt  with  as  for  the  incomplete  variety. 

Traumatic  Laceration  of  the  Urethra  usually  results  from  violence 
apphed  directly  to  the  perineum,  as  by  falhng  astride  a  stile,  fence, 
or  beam;  it  has  also  been  caused  by  severe  jolting  in  the  saddle,  or 
by  a  kick  in  the  perineum.  In  fractures  of  the  pelvis  it  may  be 
produced  by  a  spicule  of  bone  puncturing  the  canal,  and  the  mem- 
branous portion  is  that  generally  affected.  The  whole  circumfer- 
ence of  the  urethra  may  be  involved,  the  two  segments  being  entirely 
disconnected,  or  only  a  portion  may  be  ruptured,  and  that  most 
frequently  the  floor. 

The  Symptoms  consist  of  pain  in  the  perineum  and  shock,  fol- 
lowed by  great  distension  of  the  scrotum  from  haemorrhage,  whilst 
blood  trickles  from  the  urethral  orifice.  If  the  patient  is  able  to 
restrain  himself  from  passing  water,  and  is  successfully  treated,  no 
extravasation  of  urine  results,  since  the  lesion  is  below  the  sphincter 
vesicae;  if,  however,  he  attempts  to  micturate,  the  urine  finds  its 
way  into  the  perineal  and  scrotal  tissues.  Whether  the  rupture  is 
complete  or  not,  an  organic  stricture  of  considerable  density  is 
almost  certain  to  follow,  and  great  difficulty  is  subsequently  ex- 
perienced in  keeping  it  dilated. 

Treatment. — In  the  slighter  cases,  where  it  is  probable  that  the 
mucous  membrane  has  alone  been  torn,  and  there  is  no  perineal 
swelling,  the  patient  should  be  kept  quiet  in  bed,  and  no  attempts 
made  at  instrumentation.  If  urinary  infection  of  the  wound 
occurs,  and  an  abscess  forms,  it  can  be  dealt  with  by  incision  at  a 
later  date. 


AFFECTIONS  OF  THE   URETHRA  AND  PENIS  1255 

Where,  however,  it  is  thought  that  the  urethra  is  partially  or 
wholly  divided,  no  temporizing  measures,  such  as  tying  in  a  catheter, 
even  if  that  be  possible,  should  be  adopted.  An  incision  ought  to 
be  made  at  once  into  the  perineum  so  as  to  expose  the  divided  ends 
of  the  urethra,  which  it  is  the  surgeon's  aim  to  unite.  The  blood- 
clot  is  removed,  bleeding  points  are  secured,  and  if  the  ends  of  the 
urethra  can  be  identified,  a  soft  catheter  is  introduced  into  the 
bladder,  and  they  are  sutured  together  around  it  with  fine  catgut. 
When  the  ends  are  much  torn,  it  is  wise  to  cut  away  the  bruised  ex- 
tremities so  as  to  have  clean,  smooth  surfaces  to  deal  with.  Under 
any  circumstances,  the  catheter  must  be  kept  in  for  five  or  six  days, 
if  possible,  and  subsequently  an  instrument  should  be  passed  every 
day  for  some  time. 

If  a  catheter  cannot  be  introduced,  or  if  extravasation  has  oc- 
curred, free  incisions  must  be  made  into  the  scrotum  and  perineum 
to  give  exit  to  the  blood  and  urine,  and  to  expose  the  seat  of  injury. 
A  catheter  is  passed  as  far  as  possible,  and  its  point  felt  for,  cut 
down  on,  and  guided  into  the  bladder;  a  prolonged  attempt  under 
anaesthesia  may  be  necessary  to  accomplish  this,  and  even  then  it 
is  useless  to  attempt  to  stitch  up  the  urethra,  as  the  sutures  are 
certain  to  cut  out.  Occasionally,  and  especially  if  treatment  has 
been  delayed,  the  swelling  of  the  parts  is  so  great  as  to  render  the 
passage  of  a  catheter  impossible.  The  patient  must  then  be  put  to 
bed  for  a  few  days  until  the  blood-clot  has  disappeared,  the  urine 
in  the  meantime  escaping  through  the  perineal  wound;  but  as  soon 
as  possible  another  attempt  must  be  made.  When  once  the  catheter 
is  passed,  it  must  be  retained  for  several  days,  so  as  to  establish 
the  continuity  of  the  tube. 

Foreign  Bodies  are  sometimes  found  in  the  urethra,  usually  con- 
sisting of  a  portion  of  a  catheter,  pipe-stem,  or  in  children  a  piece 
of  slate-pencil.  Their  presence  gives  rise  to  partial  or  complete 
obstruction  to  the  flow  of  urine,  followed  by  ulceration  of  the 
mucous  membrane,  the  formation  of  a  peri-urethral  abscess,  or  even 
extravasation.  They  are  readily  detected  on  the  passage  of  a  sound 
or  catheter,  and  may  be  removed  by  suitable  forceps  if  situated 
near  the  orifice.  Should  this  fail,  the  urethra  may  be  incised  and 
the  body  extracted;  a  troublesome  urinary  fistula  is  apt  to  follow 
this  proceeding,  even  when  the  wound  in  the  urethra  has  been  care- 
fully sutured. 

A  pin  is  sometimes  introduced  voluntarily  into  the  urethra,  and 
is  not  easily  removed,  since  it  has  usually  been  pushed  in  head- 
foremost. The  following  manceuvre  is  necessary  in  order  to  re- 
move it:  The  point  is  made  to  penetrate  the  floor  of  the  urethra 
and  skin  by  a  sharp  push  on  the  head  from  behind.  The  body  is 
pulled  out  until  the  head  catches  against  the  mucous  membrane, 
and  then  the  direction  of  the  pin  can  be  changed,  so  that  the  head 
presents  at  or  towards  the  meatus. 

Impacted  Calculus  is  a  not  unfrequent  cause  of  retention  in 
children.     It  can  usually  be  felt  through  the  walls  of  the  canal. 


1256  A   MANUAL  OF  SURGERY 

The  symptoms  and  treatment  are  much  the  same  as  for  foreign 
bodies.  When  near  the  neck  of  the  bhidder,  it  should  be  pushed 
back  into  that  viscus,  if  possible,  and  treated  by  lithotrity. 

Simple  Urethritis  may  arise  from  a  variety  of  causes  apart  from 
gonorrhoea— f.g.,  the  presence  in  the  female  of  an  irritating  vaginal 
clischarge,  such  as  leucorrhoea,  and  possibly  due  to  the  B.  coli.  It 
also  occurs  after  the  passage  of  an  instrument  or  of  a  calculus,  and 
is  occasionally  excited  in  gouty  individuals  by  highly  acid  urine, 
charged  presumably  with  spiculated  crystals  of  uric  acid.  The 
symptoms  are  much  the  same  as  those  of  gonorrhcea,  but  the  dis- 
charge is  thinner  in  character,  and  on  microscopical  examination 
no  gonococci  are  detected.  The  treatment  consists  in  the  adminis- 
tration of  alkalies  and  saline  purgatives,  all  forms  of  alcohol  being 
interdicted.  In  more  severe  cases  oleo-balsams  may  be  prescribed, 
and  even  mild  injections. 

Polypoid  Tumours,  similar  in  character  to  the  caruncle  met  with 
in  the  urethra  of  women,  have  been  observed  at  the  orifice  of  the 
male  urethra.  They  are  red,  vascular,  and  sometimes  exceedingly 
painful,  and  are  best  dealt  with  by  excision,  followed  by  the  applica- 
tion of  the  galvano-cautery,  so  as  to  stop  the  bleeding,  which  is 
always  copious.  If  of  large  size,  the  base  may  be  ligatured  and 
the  growth  cut  away. 

Epithelioma  of  the  urethra  is  usually  secondary  to  some  other 
malignant  development  in  the  neighbourhood — e.g.,  of  the  prostate. 
Occasionally,  however,  it  is  primary,  and  then  frequently  the  sequela 
of  an  old  stricture.  It  constitutes  a  hard  swelling  of  the  urethra, 
which  infiltrates  surrounding  parts,  and  there  is  usually  some  dis- 
charge of  blood  and  pus  from  the  meatus.  Micturition  is  consis- 
tently painful,  and  the  introduction  of  an  instrument  increases  both 
the  pain  and  bleeding ;  it  generally  passes  easily,  but  the  irregularity 
of  the  surface  of  the  growth  can  be  recognised.  Examination  by 
the  urethroscope  (p.  144)  is  desirable  in  such  cases.  Amputation 
of  the  whole  penis  is  usually  required. 

Stricture  of  the  Urethra. — By  stricture  of  the  urethra  is  meant  a 
condition  in  which  the  onwarcl  passage  of  urine  is  hindered,  owing 
to  some  change  in  the  walls  of  the  urethra,  which  prevents  them 
from  dilating.  When  at  rest,  the  urethra  is  merely  a  potential 
can?l,  the  walls  of  which  are  in  complete  apposition,  and  it  is  only 
converted  into  a  tube  when  urine  is  passing  along  it.  When,  owing 
to  some  change  in  the  structure  of  its  walls,  this  functional  dilata- 
tion is  impracticable,  the  patient  is  said  to  suffer  from  stricture. 
Three  forms  of  stricture  are  described — viz.,  the  spasmodic,  con- 
gestive, and  organic. 

Spasmodic  and  Congestive  Strictures  frequently  co-exist,  although 
either  congestion  or  spasm  may  be  the  predominant  feature  in  any 
particular  case.  Thus,  in  acute  gonorrhoea  the  mucous  membrane 
often  becomes  engorged  and  thickened  to  such  an  extent  as  to  inter- 
fere with  the  act  of  micturition.  Spasm  is  the  chief  element  under 
the  following  conditions:  (i)  When  a  patient,  suffering  from  slight 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS 


1257 


organic  stricture,  is  exposed  to  wet  or  cold,  especially  after  heavy 
drinking,  (2)  as  a  result  of  catheterism;  and  (3)  from  perineal  irrita- 
tion of  the  urethra,  as  by  a  blow  or  kick  in  this  region,  or  from 
pro  onged  riding  on  a  bicycle  with  a  badly-fitting  saddle  or  on  horse- 
back. 1  emporary  retention  is  the  usual  result  of  any  of  these  con- 
aitions  and  as  a  rule,  no  treatment  is  required  beyond  placing  the 
patient  m  a  hot  bath,  and  unloading  the  lower  bowel  by  the  use  of 
a  large  warm  enema.  If  such  fails,  catheterism  will  be  necessary, 
and  must  be  conducted  with  the  greatest  gentleness,  owing  to  the 
congested  and  lacerable  condition  of  the  mucous  membrane.  Full- 
sized  soft  instruments  should  first  be  used,  and  will  usually  succeed: 
It  not,  a  silver  instrument  must  be  substituted. 

Organic  Stricture  is  the  term  appHed  to  an  undilatable  condition 
ot  the  urethra,  resulting  from  the  development  of  cicatricial  tissue 
withm  its  walls. 

The  Causes  of  organic  stricture  are:  [a)  The  long  continuance  of  a 
T+u-'"  2'^?''''^®'  following  gonorrhoea,  or  the  frequent  recurrence 
ot  tills  alfection.  Chronic  inflammations  are  always  characterized 
by  a  tendency  to  sclerosis  of  the  tissues  involved,  and  the  urethra 
is  no  exception  to  this  rule,  its  walls  under  these  circumstances  be- 
coming thickened,  indurated,  and  contracted,  [b]  The  cicatrization 
ot  a  urethral  chancre,  or  of  an  uker  caused  by  the  impaction  of  a 
stone,  or  the  contraction  produced  by  the  healing  of  a  urethral 
abscess  may  also  lead  to  stenosis,  (c)  The  most  intractable  forms 
ot  stricture  are  those  due  to  cicatrization  after  rupture  or  laceration 
of  the  urethral  wall. 

The  usual  Situation  is  within  the  bulb— i.^.,  just  in  front  of  the 
triangular  ligament;  but  the  orifice  and  body  are  not  unfrequently 
attected  It  occurs  in  the  membranous  portion  only  as  a  result  of 
traumatism,  and  never  in  the  prostatic.  To  find  more  than  two 
strictures  m  any  particular  case  is  unusual,  although  three  or  four 
have  been  met  with. 

Various  terms  are  apphed  to  a  stricture  according  to  the  physical 
conditions  present;  thus,  it  is  termed  annular,  if  it  involves  the 
whole  lumen  of  the  urethra;  bridled,  if  it  affects  only  a  portion  of 
the  circumference  of  the  tube.  A  ribbon-shaped  stricture  is  one  in 
which  a  considerable  extent  of  the  wall  is  contracted  (i.e.,  as  if  a 
ribbon  had  been  tied  around  the  urethra).  It  is  termed  tortuous, 
It  the  resulting  passage  is  not  straight;  indurated,  if  the  walls  are 
very  hard  and  thickened;  and  resilient,  when  the  stricture,  though 
readily  dilated,  rapidly  re-contracts.  The  terms  impassable  and 
impermeable  are  appHed  to  strictures  through  which,  on  the  one 
nana,  a  surgeon  is  unable  to  pass  an  instrument,  or  along  which, 
on  the  other  hand,  urine  cannot  find  its  way;  it  is  doubtful  whether 
the  latter  condition  ever  occurs,  whilst  the  number  of  impassable 
strictures  met  with  by  the  surgeon  diminishes  with  his  experience 
and  ability  m  passing  instruments. 

The  Symptoms  of  urethral  stricture  vary  according  to  the  case. 
Ihe  patient  generally  complains  of  difficulty  in  the  act  of  micturi- 


1258  A   MANUAL  OF  SURGERY 

tion,  the  stream  becoming  small,  and  perhaps  forked  or  twisted. 
It  takes  a  longer  time  than  usual  to  empty  the  bladder,  and  even 
when  apparently  successful  a  few  drops  of  urine  may  trickle  away, 
wetting  the  patient's  clothes.  Irritability  of  the  viscus  follows, 
leading  to  frequent  attempts  to  pass  water  at  short  intervals  during 
the  day  and  night.  The  urine  under  these  circumstances  often 
becomes  alkaline,  and  loaded  with  muco-pus  and  phosphates.  As 
the  obstruction  increases,  more  and  more  residual  urine  is  left  in 
the  bladder,  which  may  in  time  form  a  tense,  rounded,  dull  swelling 
in  the  hypogastrium.  The  quantity  of  urine  trickling  away  also 
increases,  so  that  the  patient's  garments  are  always  wet,  giving  him 
an  unpleasant  urinous  odour.  A  certain  amount  of  gleety  discharge 
is  present,  whilst  if  the  individual  takes  an  excess  of  alcohol,  or  is 
exposed  to  wet  and  cold,  complete  retention  may  ensue.  Some- 
times the  onset  of  svTiiptoms  is  so  insidious  that  such  an  attack  of 
retention  is  the  first  marked  feature  in  the  case. 

The  Pathological  Conditions  arising  from  a  stricture  are  best  con- 
sidered under  the  following  live  headings:  (i)  The  tireihra  anterior  to 
the  stricture  is  usually  in  a  perfectly  normal  state,  although  possibly 
the  orifices  of  false  passages  may  be  seen.  A  few  granulations  are 
sometimes  present,  projecting  at  the  commencement  of  the  stricture. 

(2)  The  stricture  itself  is  charactewzed  by  the  development  of  fibro- 
cicatricial  tissue  immediately  under  the  mucous  membrane,  and 
intimately  adherent  to  it.  It  extends  for  a  variable  distance,  and 
is  often  associated  with  a  good  deal  of  peri -urethral  iniiltration. 

(3)  The  urethra  behind  the  stricture  is  dilated,  and  the  mucous  mem- 
brane velvety  and  friable ;  the  orifices  of  the  lacunae  and  other  glands 
are  somewhat  enlarged  and  more  than  usually  evident,  and  perhaps 
ulceration  may  be  present  around  them.  In  the  later  stages  the 
inflammation  may  extend  to  the  peri-urethral  tissue  owing  to  lym- 
phatic absorption,  or  perhaps  to  the  escape  of  a  few  drops  of  urine; 
a  perineal  abscess  then  results,  leading  subsequently  to  perineal 
fistuL'e.  When  the  obstruction  becomes  almost  absolute,  this  por- 
tion of  the  urethra  may  give  way,  leading  to  extravasation  of  urine 
into  the  perineum  and  scrotum.  (4)  The  bladder  invariably  mani- 
fests considerable  changes  in  structure.  At  first  the  vesical  wall 
undergoes  a  compensatory  hypertrophy  of  its  muscular  elements 
and  is  thickened,  in  order  to  overcome  the  obstruction  to  the  onward 
passage  of  urine  (Fig.  559).  The  lattice-work  arrangement  of  the 
muscular  bands  becomes  coarse,  thickened,  and  evident,  causing 
the  vesical  wall  to  assume  a  fasciculated  appearance.  As  the  pres- 
sure increases,  the  mucous  membrane  protrudes  between  the  mus- 
cular fasciculi,  giving  rise  to  sacculation;  it  is  also  thickened  and 
congested  as  a  result  of  chronic  cystitis ;  the  superficial  veins  become 
varicose,  and  haematuria  may  be  caused  by  their  rupture,  whilst 
ulceration  may  also  occur.  The  urine  becomes  alkaline  and  decom- 
poses, containing  muco-pus  and  phosphates.  It  is  likely  to  stagnate 
in  any  sacculi  which  exist,  and  may  then  determine  the  formation 
of  phosphatic  concretions;  or  the  walls  of  the  saccuH  ulcerate,  and 


AFFECTIONS  OF  THE   URETHRA   AND  PENIS 


1259 


after  a  time  perforation  and  extravasation  of  urine  into  the  cellular 

tissue  lead  to  a  fatal  issue.  Occasionally  the  bladder,  instead  of 
being  thickened,  is  dilated  and  atonic,  with  very  thin  walls.  (5)  Con- 
sequent on  the  changes  in  the  bladder,  the  conditions  already 
described  as  hydronephrosis,  pvonephrosis,  or  pyelonephritis  may 
develop,  partly  as  the  result  of" the  backward  pressure,  and  partly 
from  the  extension  of  septic 
matter  along  the  ureter  to  the 
pelvis  of  the  kidney  and  calyces. 

Physical  Examination. — The 
actual  diagnosis  of  a  stricture 
can  only  be  coniirmed  by  a  care- 
ful physical  examination  of  the 
urethra,  which  is  usually  made 
bj^  the  introduction  of  a  full- 
sized  catheter  or  a  solid  bougie 
— e.g.,  No.  9  or  10  (English) — 
so  as  to  ascertain  where  the 
obstruction  is  situated.  If  this 
cannot  be  passed,  smaller  instru- 
ments, and  even  filiform  bougies, 
are  inserted  until  one  is  found 
which  will  enter  the  bladder. 

A  great  variety  of  catheters  is 
in  use ;  in  old  days  onh^  metal  in- 
struments were  obtainable,  and 
even  now  the  silver  catheter  is 
the  favourite  with  many  sur- 
geons of  eminence.  In  selecting 
such  an  instrument,  care  must 
be  taken  that  it  is  suitably 
curved,  and  that  the  '  eye  '  is 
sufficiently  large  and  bevelled 
inwards,  so  that  no  proj  ecting  rim 
lacerates  the  urethral  mucous 
membrane.  The  great  advan- 
tages of  the  metal  instrument 
are  that  it  is  easily  kept  aseptic, 
and  that  the  point  can  be  located 

and  thus  guided  more  readily  along  the  urethra.  Of  late  years 
many  different  fonns  of  flexible  catheters  have  been  introduced, 
and  are  now  extensively  employed,  inasmuch  as  they  give  rise  to 
less  irritation  than  those  made  of  metal.  The  objections  to  them 
are  that  the  materials  of  which  they  consist  are  readily  attacked 
and  injured  by  antiseptics,  whilst  they  are  less  easily  directed 
through  a  stricture  on  account  of  their  flexibility,  it  being  impossible 
to  know  with  certainty  the  situation  of  the  point.  Probably  the 
best  means  of  sterilizing  a  soft  instrument  is  to  expose  it  to 
the  action  of  steam,  which  should  be  made  to  act  not  only  on  the 


Fig.  559. — Double  Stricture  of  the 
Urethra.     (College  of  Surgeons' 

Museum.) 

Glass  rods  have  been  passed  under  the 
strictures.  The  bladder  is  somewhat 
dilated,  and  its  walls  are  thick  and 
hypertrophic,  and  with  commencing 
sacculation. 


i26o  A   MANUAL  OF  SURGERY 

exterior,  but  also  inside  the  tube;  many  appliances  to  obtain  this 
object  have  been  devised.  Failing  this,  they  may  be  syringed 
through  with  i  in  20  carbolic  lotion  and  allowed  to  soak  for  a 
while  in  a  I  in  2,000  sublimate  solution;  or  they  may  be  kept 
aseptic  by  hanging  or  lying  in  an  atmosphere  charged  with  formalin 
vapour,  by  placing  a  few  tabloids  charged  with  this  substance  in  the 
bottom  of  a  jar  in  which  they  are  suspended.  Amongst  the  best 
flexible  instruments  are  the  indiarubber  or  Jacques'  catheter  (the 
distal  end  of  which  beyond  the  eye  should  be  solid  and  not  hollow), 
the  English  or  gum-elastic  catheter,  the  French  olive-headed  or 
catheter-a-boule,  and  others  made  of  silk-web  coated  with  shellac, 
etc.  Some  varieties  are  now  polished  and  prepared  inside  as  well 
as  out,  and  these  should,  if  possible,  always  be  selected. 

Bougies  or  solid  instruments  are  preferred  b}'  some  surgeons  for 
the  examination  and  treatment  of  strictures.  Those  known  as 
Lister's  bougies  are  the  best,  consisting  of  solid  metal  rods,  curved 
like  catheters,  the  bulbous  ends  of  which  are  three  sizes  smaller  than 
the  shanks,  thus  enabling  each  instrument  passed  to  prepare  the 
way  for  the  next.  Flexible  bougies  are  also  made,  whilst  for  find- 
ing a  way  through  a  tight  and  tortuous  stricture  a  filiform  bougie, 
made  of  whalebone  or  catgut,  or  a  long  graduated  whip-lash  bougie 
may  be  employed ;  in  the  latter  variety,  the  fine  end  is  passed  through 
the  stricture,  and  coils  up  in  the  bladder,  whilst  the  thicker  portion 
is  thus  brought  to  bear  on  the  stricture. 

In  order  to  introduce  a  silver  catheter  or  bougie,  the  patient  is  laid 
on  his  back,  the  surgeon  standing  on  his  left  side.  The  umbilicus 
should  always  be  exposed,  as  also  the  upper  parts  of  the  thighs. 
The  meatus  and  end  of  the  penis  are  washed  with  a  i  in  2,000 
solution  of  sublimate,  as  also  the  surgeon's  hands.  The  catheter, 
which  has  been  previously  sterilized,  warmed,  and  covered  with 
sterilized  or  antiseptic  oil  or  grease,  is  taken  in  the  right  hand,  and 
inserted  into  the  urethra,  with  the  handle  directed  over  the  left  thigh 
and  slightly  downwards.  The  point  of  the  instrument  is  guided  as 
far  as  the  perineum,  and  then  the  handle  is  carried  round  to  the 
middle  line  of  the  body  towards  the  umbilicus ;  it  is  gently  raised 
to  the  vertical,  the  penis  being  held  in  the  left  hand,  and  finally 
depressed  between  the  patient's  thighs,  the  so-called  tour-de-maitre. 
The  catheter  finds  its  way  along  the  urethra  into  the  bladder  rather 
bv  its  own  weight  than  by  any  forcible  action  of  the  surgeon.  The 
chief  points  at  which  difficulty  may  be  experienced  are:  {a)  The 
orifice,  which  may  be  small  and  contracted ;  {h)  the  lacuna  magna, 
which  is  avoided  by  keeping  the  point  of  the  instrument  against 
the  floor;  and  (c)  the  opening  in  the  triangular  ligament,  which  is 
best  entered  by  keeping  the  point  against  the  upper  wall  of  the 
canal. 

Some  authorities  recommend  that  the  patient  should  stand  up, 
with  the  back  resting  against  a  wall  or  firm  support,  the  surgeon 
sitting  in  front,  and  manipulating,  it  is  said,  with  greater  accuracy. 
The  objections  to  this  position  are:  (a)  The  habihty  of  the  patient 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS  126 1 

to  faint,  and  {b)  the  existence  of  greater  muscular  tension  than 
obtains  in  the  horizontal  posture. 

When  a  flexible  instrument  without  a  stilette  is  used,  it  is  passed 
by  pressing  the  point  on  with  a  little  rotatory  movement  until  the 
bladder  is  reached,  withdrawing  a  little,  and  pushing  on  again,  if 
any  obstruction  is  met.  In  some  instances,  however,  the  use  of  a 
stilette  is  absolutely  necessary. 

The  cliief  Dangers  of  catheterism  are  as  follows:  i.  A  considerable 
degree  of  shock  is  sometimes  experienced,  especially  in  sensitive  in- 
dividuals, and  if  an  instrument  has  not  been  passed  before.  It  may 
be  ob\dated  to  a  large  extent  by  first  introducing  about  |  drachm  of 
the  5  per  cent,  solution  of  cocaine  into  the  urethra. 

2.  Hcemorrhage  may  be  induced  by  laceration  or  abrasion  of  the 
mucous  membrane,  even  though  no  false  passage  has  been  made; 
it  is  best  avoided  by  gentleness  and  the  use  of  well-finished  instru- 
ments. In  spite  of  these  precautions,  when  the  mucous  membrane 
is  soft  and  congested,  and  in  many  cases  of  stricture,  some  bleeding 
cannot  be  avoided.  It  is  rarely  sufficient  to  call  for  special  treat- 
ment, but  if  very  abundant  may  be  arrested  by  the  pressure  of  an 
instrmnent  tied  in  or  by  injections  of  hazeline. 

3.  False  passages  are  frequently  produced  in  the  treatment  of 
strictures.  The  point  of  the  instrument  is  most  likely  to  leave  the 
canal  at  some  spot  in  the  floor,  travelling  for  a  variable  distance, 
according  to  the  force  employed,  under  the  mucous  membrane, 
occasionally  re-entering  the  dilated  urethra  behind  the  stricture, 
which  it  avoids  altogether,  or  perforating  the  posterior  wall  of  the 
bladder  by  tunnelhng  under  the  prostate,  an  accident  which  can 
only  occur  in  unskilful  hands.  The  occurrence  of  a  false  passage  is 
indicated  by  the  sudden  onward  movement  of  the  instrument,  com- 
bined mth  pain  and  haemorrhage ;  the  point  is  usually  deflected  from 
the  middle  line,  as  is  plainly  seen  by  the  obliquity  of  the  rings  at 
the  end  of  the  shaft ;  no  urine  comes  unless  the  urinary  passages  are 
opened  behind  the  stricture.  On  rectal  examination,  the  instru- 
ment can  be  felt  out  of  the  middle  line,  and  nearer  the  rectum  than 
is  normal,  and  in  some  exceptional  cases  has  even  been  found  in  it. 
False  passages  are  not  necessarily  matters  of  great  importance,  but 
when  extensive  may  lead  to  peri-urethral  suppuration  and  extrava- 
sation of  urine.  If  the  urine  is  very  offensive,  grave  infective 
troubles  may  arise,  even  threatening  life.  Thus  in  one  case  seen 
recently  the  unfortunate  patient  suffered  subsequently  from  gan- 
grene of  the  penis,  necessitating  its  almost  complete  removal,  in 
spite  of  the  fact  that  a  free  incision  was  made  through  the  perineum 
into  the  urethra,  and  the  urine  was  drained  away. 

4.  Inflammatory  phenomena  may  be  lighted  up  in  the  prostate, 
and  acute  epididymitis  induced  by  extension  along  the  vas  deferens; 
these  are  always  due  to  infection. 

5.  Urinary  Fever,  or,  as  it  is  sometimes  termed,  urethral  or 
catheter  fever,  is  always  liable  to  develop  as  a  result  of  the  intro- 
duction of  instruments.     It  may  occur  as  a  solitary  rigor  even  in 


1262  A   MANUAL  OF  SURGERY 

indi\iduals  with  healthy  urinary  organs,  but  is  much  more  fre- 
quently observed  in  those  with  damaged  kidneys.  As  to  its  causa- 
tion, there  has  been  much  discussion,  but  there  can  now  be  little 
doubt  that  it  is  essentially  infective  in  origin.  Possibly  the  instru- 
ment employed  may  be  dirty,  or  the  urethra  itself  contains  infec- 
tive material,  especially  in  its  deeper  parts.  It  is  quite  sufficient 
for  a  slight  abrasion  to  occur  near  the  neck  of  the  bladder,  to  allow 
of  the  absorption  either  of  toxins  or  of  bacteria,  and  then  general 
phenomena  show  themselves  at  once.  If  merely  toxic  products  are 
absorbed,  probably  a  passing  febrile  condition,  such  as  one  or  more 
rigors,  will  develop,  wath  no  more  serious  phenomena;  but  if  bac- 
teria find  their  way  into  the  submucous  tissues,  they  are  likely  to 
develop  rapidly  in  the  h-mphatics,  extending  to  the  bladder  and 
thence  up  the  ureters  ow-ing  to  the  continuity  of  l}Tnphatic  supply, 
giving  rise  finally  to  pyelonephritis  (p.  1197).  Formerly  reflex  con- 
gestion of  the  kidneys  was  thought  to  be  an  important  factor  in 
these  cases;  probably  the  congestion  w'hich  occurs  is  due  to  the 
direct  irritation  of  bacteria,  and  is  not  of  nervous  origin. 

The  clinical  manifestations  vary  considerably,  according  to  the 
character  of  the  case  and  the  type  of  infection,  {a)  The  simplest 
form  consists  in  the  development  of  a  single  rigor,  the  temperature 
perhaps  running  up  to  105°  F. ;  the  patient  shivers  and  feels  very  ill, 
complaining  of  headache,  but  when  the  temperature  falls  he  soon 
recovers,  and  within  a  few  hours  is  all  right  again,  {b)  Sometimes 
the  temperature  does  not  fall  to  the  normal  after  the  initial  rigor, 
but  remains  elevated  a  few  degrees  for  a  day  or  two,  and  there  may 
even  be  a  repetition  of  the  rigor.  The  patient,  however,  recovers 
perfectly,  and  no  permanent  hami  is  done,  (c)  In  the  more  serious 
cases  the  symptoms  of  pyelonephritis  supervene,  and  are  very  likely 
to  prove  fatal,  the  patient  perhaps  d3-ing  in  seven  or  eight  days. 
{d)  General  pysemia  may  appear  as  a  complication  of  the  last  con- 
dition, {e)  In  patients  who  are  commencing  the  regular  passage  of 
catheters  for  enlarged  prostate  a  series  of  phenomena  develop,  which 
have  been  already  alluded  to  (p.  1250),  and  though  often  mild,  are 
of  a  similar  nature.  (/)  Finally,  suppression  of  urine  may  accom- 
pany any  of  the  conditions  alluded  to  above. 

Treatment. — Whenever  it  seems  probable  that  the  kidneys  are 
damaged,  the  greatest  care  must  be  taken  in  order  to  avoid"  infec- 
tion. The  instruments  employed,  whether  bougies  or  catheters, 
must  be  thoroughly  sterihzed,  and  it  would  also  be  well  to  irrigate 
the  urethra  with  a  mild  antiseptic  lotion.  It  is  better  to  use  soft 
instruments,  if  possible,  rather  than  silver  ones,  as  the  latter  give 
rise  to  more  irritation  than  the  former,  and  are  more  hkely  to 
abrade  the  mucous  membrane. 

For  the  single  rigor  following  catheterism,  the  patient  must  be 
kept  \varm,  plenty  of  hot  diluent  drinks  given,  and  quinine  (2  grains) 
administered.  If  the  febrile  s\-mptoms  continue,  the  skin  and  bowels 
are  freely  acted  on,  and  a  milk  diet  prescribed,  although  a  certain 
amount  of  stimulant  may  be  given  if  necessary;   all  operative 


AFFECTIONS  OF  THE   URETHRA   AND  PENIS  1263 

measures  must  be  avoided,  unless  it  is  essential  to  relieve  obstruc- 
tion, as  they  are  almost  invariably  fatal.  Should  suppression  of 
urine  ensue,  the  loins  should  be  cupped  in  the  hope  of  reheving 
renal  congestion,  a  free  action  of  the  bowels  obtained  by  the  use  of 
watery  purgatives,  and  the  patient  made  to  sweat  freely,  either  by 
the  use  of  hot-air  baths  or  by  the  injection  of  pilocarpine.  If  the 
urinar}'  secretion  is  not  quickly  re-established  [i.e.,  in  forty-eight 
hours),  the  surgeon  should  perform  nephrostomy  {i.e.,  opening  and 
draining  the  renal  pehas)  without  delay,  selecting  for  operation  the 
kidney  which  appears  to  be  most  tender;  it  may  be  necessary  to 
incise  both  kidneys  (p.  1199).  Uraemic  symptoms  may  sometimes 
be  reheved  by  copious  and  repeated  intravenous  injections  of  saline 
solution,  which  encourage  diuresis  and  a  watery  diarrhoea. 

The  Treatment  of  Passable  Strictures  is  conducted  either  by  dilata- 
tion or  by  a  cutting  operation  (internal  or  external  urethrotomy). 

Treatment  by  Dilatation  is  effected  in  various  ways,  according 
to  the  nature  of  the  stricture  and  the  urgency  of  the  symptoms. 
Where  the  obstruction  is  not  serious,  and  an  instrument  can  be 
easily  passed,  gradual  dilatation  should  always  be  employed;  this 
consists  in  the  use  of  instruments  once  or  twice  a  week,  steadily 
increasing  in  size  until  a  No.  12  is  reached.  If  the  intervals  are 
too  short,  the  urethra  may  become  irritated,  spasm  be  induced,  and 
the  lumen  of  the  canal  temporarily  diminished  in  size;  by  keeping 
the  patient  quiet  for  a  few  days  on  a  bland  diet,  and  the  bowels 
freely  open,  the  spasm  disappears.  In  cases  where  time  is  an  object, 
rapid  dilatation  may  be  undertaken  by  the  passage  of  several  sizes 
of  bougie  at  one  sitting ;  for  this  purpose,  Lister's  instruments  are 
particularly  useful.  Where  only  a  very  small  catheter  can  be  intro- 
duced, and  that  with  difficulty,  continuous  dilatation  may  be  adopted 
by  keeping  the  patient  in  bed,  and  tying  in  the  small  instrument 
for  forty-eight  hours  or  more,  at  the  expiration  of  which  period  a 
catheter  several  sizes  larger  can  be  substituted.  This  in  turn  may 
be  tied  in  if  the  patient  can  bear  it ;  but  the  presence  of  a  catheter 
within  the  urethra  for  any  length  of  time  is  not  always  tolerated, 
and  mav  give  rise  at  the  end  of  two  or  three  days  to  considerable 
constitutional  disturbance  and  fever.  Forcible  dilatation  is  a  plan 
which  has  now  but  few  advocates.  It  consists  in  the  passage  of  an 
instrmnent,  the  shaft  of  which  is  made  in  two  portions,  which  can 
be  separated  from  one  another  in  such  a  way  as  to  destroy  the  stricture 
either  by  distension  or  rupture  of  its  substance.  It  is  but  little  used, 
on  account  of  the  great  tendency,  when  cicatrization  is  complete,  to 
the  formation  of  an  even  more  intractable  stricture  than  before. 

By  whichever  of  these  methods  dilatation  is  accompHshed,  it  is 
essential  that  either  the  surgeon  or  the  patient  should  subsequently 
pass  an  instrument  through  the  stricture  at  first  every  week  or  two, 
and  then  at  longer  intervals,  to  overcome  the  tendency  to  re-con- 
traction which  is  ever  present. 

The  Treatment  of  Passable  Stricture  by  a  Cutting  Operation  is  con- 
ducted either  by  excision  or  by  internal  or  external  urethrotomy. 


1264 


A   MANUAL  OF  SURGERY 


Excision  is  certainly  the  ideal  treatment,  the  urethra  being  thereby 
restored  to  a  normal  condition.  It  has  now  been  frequently  under- 
taken and  with  great  success  in  strictures  of  the  deeper  permeal 
portion  of  the  urethra;  it  is  not  so  satisfactory  when  the  penile 
urethra  is  involved.  Fully  an  inch  of  the  tube  may  be  excised,  and 
the  ends  sutured  together  over  a  catheter.  The  corpus  spongiosum 
must  be  detached  from  its  surroundings  to  permit  of  this.  Sutures 
are  introduced  in  the  upper  wall  first ;  then  the  catheter  is  placed  in 
position,  and  the  remainder  of  the  stitches  inserted. 

Internal  Urethrotomy  is  a  valuable  means  of  treatment  when 
rightly  employed,  but  in  careless  or  inexperienced  hands  may  be 
attended  with  considerable  danger.  It  has  been  performed  either 
by  passing  an  instrument  through  the  stricture,  and  dividing  it  from 
behind  forwards,  or  by  passing  an  instrument  down  to  the  stricture, 
and  dividing  it  from  before  backwards.  Ihe  latter  plan  of  treat- 
ment, though  recommended  by  some  skilled  authorities,  is  not  an 
operation  which  commends  itself  to  our  judgment,  inasmuch  as  it 
is  almost  impossible  to  gauge  the  amount  of  tissue  divided.  The 
former  plan  of  incising  a  stricture  from  behind  forwards  is,  of  course, 
only  called  for  under  special  circumstances,  since  if  the  urethrotome 


Fig.   560. — Civiale's  Urethrotome.     (Down  Brothers.) 

can  be  passed  through  a  stricture,  ordinary  dilatation  is  in  the 
majority  of  cases  practicable.  It  is  useful,  however,  {a)  in  the 
treatment  of  very  old  and  dense  cartilaginous  strictures,  as  also 
{b)  for  resilient  strictures,  and  (c)  when  the  urethra  is  excessively 
irritable.  It  should  only  be  employed  when  the  obstruction  is 
situated  in  the  anterior  two-thirds  of  the  urethra,  and  never  when 
septic  contamination  of  the  urine  is  present.  Many  forms  of  ure- 
throtome have  been  devised,  but  perhaps  the  most  useful  is  that 
known  as  Civiale's  (Fig.  560),  which  can  only  be  used  for  a  stric- 
ture which  will  admit  the  passage  of  a  No.  5  catheter.  The  end  is 
bulbous,  and  contains  a  hidden  knife,  worked  by  means  of  a  button 
in  the  handle.  The  instrument  is  passed  through  the  stricture,  the 
cutting  blade  projected,  and  by  withdrawing  it  the  cicatricial  tissue 
is  notched  to  such  an  extent  as  to  allow  a  full-sized  catheter  to  be 
inserted  at  once,  and,  if  possible,  tied  in.  Where  the  deeper  part  of 
the  urethra  is  being  dealt  with,  the  incision  should  be  made  along 
the  roof  so  as  to  avoid  the  bulb.  Care  must  be  taken  not  to  cut 
beyond  the  limits  of  the  cicatricial  tissue,  otherwise  ha;morrhage, 
peri-urethral  suppuration,  or  even  extravasation  of  urine,  may 
ensue.     It   is   also   advisable   to   sterilize  the   urethra   as   far  as 


AFFECTIONS  OF  THE   URETHRA   AND  PENIS  1265 

possible  by  washing  it  out  with  weak  antiseptic  solutions  before 
operating. 

External  Urethrotomy,  or  Syme's  Operation,  is  required  under  cir- 
cumstances similar  to  those  needing  internal  urethrotomy,  if  the 
stricture  is  situated  in  the  posterior  third  of  the 
urethra,  but  is  chiefly  employed  where  perineal 
fistulae  are  present.  It  is  performed  by  passing 
a  special  shouldered  staff  (Stone's,  Fig.  561),  the 
distal  end  of  which  is  small  enough  to  traverse  IS        h 

the   stricture,    and   grooved  in  the  middle  line,  ||       « 

whilst  the  shaft  of  the  instrument  is  of  larger  size,  |°       ^ 

and  ends   abruptly,   so   that   the  shoulder  rests  I  \     I 

against  the  face  of  the  stricture ;  the  groove  extends  V  /     q 

on  to  the  larger  portion  for  about  J  inch.  The 
patient  is  then  placed  in  the  lithotomy  position, 
and  the  surgeon,  seated  opposite  the  perineum, 
which  is  shaved  and  well  purified,  incises  it  in  the 
middle  line,  carrving  his  dissection  carefully  down- 
wards so  as  to  reach  the  groove  in  the  staff  behind 
the  stricture.  The  knife  is  then  carried  forwards 
to  the  anterior  extremit}'  of  the  groove,  and  inas- 
much as  it  extends  on  to  the  shaft  of  the  instru- 
ment, the  stricture  is  completel}''  divided.  Any 
fistulae  which  exist  are  laid  open  into  the  median 
wound,  and  thoroughly  scraped  and  purified.  A 
full-sized  soft  catheter  is  then  passed  into  the 
bladder,  through  either  the  penis  or  the  perineum, 
according  to  circumstances,  and  retained  in  posi- 
tion for  some  days,  the  urine  being  syphoned  off 
in  the  usual  way,  whilst  the  perineal  wound,  after 
all  hemorrhage  has  been  stopped,  is  packed  with 
strips  of  antiseptic  gauze,  and  allowed  to  heal  by 
granulation.  The  catheter  is  removed  early  or 
late  according  to  the  amount  of  general  disturb- 
ance caused  thereby,  and  subsequentl}'  a  full- 
sized  instrument  can  be  passed  into  the  bladder 
daily. 

The  Treatment  of  Impassable  Stricture  varies 
according  to  whether  or  not  the  condition  is  com- 


pHcated  with  retention  of  urine. 

If  no  retention  is  present,  it  is  possible  that  the  /f  6 

inability  to  pass  an  instrument  is  due  to  some  ^  ^ 

temporary  spasm  or  congestion  induced  by  errors 
of  diet  or  drink,  or  perhaps  by  exposure  to  cold. 
Hence  the  patient  should  rest  in  bed  for  a  few  days,  his  bowels 
be  well  opened,  the  diet  regulated,  and  a  mixture  containing  some 
alkaline  purgative  and  tincture  of  henbane  administered.  Further 
attempts  at  instrumentation  should  then  be  made,  if  necessary, 
under  an  anaesthetic,  and  if  the  stricture  still  remains  impassable, 

80 


1266 


A   MANUAL  OF  SURGERY 


Wheelhouses  operation  (Fig.  562)  is  indicated.  This  consists  in 
incising  the  urethra  in  front  of  the  constriction,  tracing  the  passage 
backwards,  and  dividing  it.  A  Wheelhouse's  straight  staff  with  a 
median  groove  and  a  blunt  hook  at  the  end  is  inserted  down  to  the 
stricture,  and  the  urethra  opened  just  in  front  of  it  by  cutting  down 
on  the  groove.  The  staff  is  then  twisted  round,  the  upper  end  of 
the  incision  drawn  up  by  the  projection  of  the  hook,  and  the  sides 
of  the  urethra  held  apart  with  artery  forceps.  The  orifice  of  the 
stricture  is  thus  exposed,  and  granulations  may  often  be  seen  pro- 
jecting from  it.  A  fine  probe-pointed  director  can  generally  be  in- 
sinuated along  the  urethra  through  the  stricture,  which  is  then 
divided.     A  full-sized  instrument  is  passed  into  the  bladder  and 

retained  for  a  few  days,  whilst 
the  wound  is  allowed  to  heal 
by  granulation. 

\lretention  of  urine  is  present 
in  a  case  of  impassable  stric- 
ture, no  time  must  be  lost. 
If  seen  at  an  early  stage,  and 
the  svTnptoms  are  not  urgent, 
the  patient  is  given  a  hot  bath, 
and  the  bowels  are  opened 
by  a  warm  enema,  whilst  a 
moderate  dose  of  opium  or 
preferably  a  morphia  supposi- 
tory is  administered.  If  the 
urine  is  not  passed  naturally 
in  the  bath,  and  the  bladder 
is  becoming  distended,  being 
felt  in  the  lower  part  of  the 
abdomen,  suprapubic  aspira- 
tion, or  puncture  with  a  trocar  and  cannula,  should  be  under- 
taken, and  temporary  rehef  thus  obtained.  Probably,  when  ten- 
sion has  been  removed  from  the  posterior  part  of  the  urethra,  a 
catheter  will  be  introduced  without  much  difficulty.  Failing  this, 
aspiration  may  be  several  times  resorted  to,  but  it  is  generally 
wiser  to  open  the  urethra  in  front  of  or  behind  the  stricture,  and 
dram  the  bladder,  since  the  risks  of  inflammatorv  troubles,  extrava- 
sation of  urine,  dangerous  pressure  upon  the  ki'dnevs,  and  urinary 
infiltration  along  the  lines  of  puncture,  are  thereby  lessened. 

Cock's  Operation,  or  Perineal  Section,  is  sometimes  adopted  when 
no  guide  can  be  passed  into  the  bladder  (Fig.  563).  The  patient  is 
placed  in  the  lithotomy  positi(jn,  and  the  situation  of  the  mem- 
branous urethra  ascertained  by  inserting  the  index-finger  into  the 
rectum.  A  median  perineal  incision  is  then  made,  and  after  divid- 
ing the  cutaneous  structures,  the  surgeon  plunges  the  scalpel  boldly 
in  towards  the  apex  of  the  prostate,  guided  by  his  finger  in  the 
rectum.  He  must  keep  strictly  in  the  middle' line,  so  as  to  avoid 
the  important  vascular  and  other  structures  which  are  so  abundantly 


Fig.  562. — Wheelhouse's  Operation 
FOR  Impassable  Stricture.  (Bryant's 
'  Surgery.') 


AFFECTIONS  OF  THE   URETHRA   AND  PENIS 


1267 


present  in  the  perineum.  As  soon  as  the  urethra  is  opened,  a  gush 
of  urine  often  escapes;  the  upper  urethral  wall  should  not  be 
damaged  with  the  knife,  for  fear  of  opening  up  the  deep  pelvic 
cellular  tissue. 

This  operarion  may  be  tolerably  simple  if  the  urethra  behind  the 
stricture  is  chlated,  as  is  not  uncommonly  the  case ;  but  sometimes 
it  is  extremely  difhcult,  especially  if  the  urethra  has  been  displaced 
laterally.  If  the  stricture  is  not  situated  too  far  from  the  incision, 
it  IS  always  wise  to  complete  the  operation  by  dividing  it,  and  a 
full-sized  catheter  can  then  be  passed  into  the  bladder,  and  the 
perineal  wound  allowed  to  granulate.  If  the  stricture  cannot  be 
dealt  with  during  the  operation,  and  is  of  a  dense  cartilaginous 
nature,  a  tube  is  inserted  into  the  bladder  through^the  perineum  ; 
probably  at  the  end  of 
a  few  days  the  tissues 
will  yield  sufficiently 
to  allow  of  the  pass- 
age of  a  catheter,  or 
Wheelhouse's  opera- 
tion can  be  subse- 
quently adopted. 

The  chief  complica- 
tions of  stricture  other 
than  those  already 
mentioned  are  peri- 
urethral abscess,  per- 
ineal fistula,  and  extra- 
vasation of  urine. 

A  Peri-Urethral  Ab- 
scess is  due  either  to  a 
limited  extravasation 
of  urine,  or  to  the  absorption  of  infective  material  through  an 
ulcerated  surface.  It  is  indicated  by  the  formation  of  a  hard,  brawny 
swelling  in  the  perineum  or  above  the  scrotum,  which  is  tender  to  the 
touch.  As  it  approaches  the  surface,  fluctuation  can  be  detected,  and 
the  skin  over  it  becomes  congested  and  oedematous.  Constitutional 
disturbance  and  fever  of  an  asthenic  type  are  also  present.  Left  to 
itself,  it  bursts  and  usually  gives  rise  to  a  perineal  sinus  or  fistula 
discharging  either  pus  or  urine  mixed  with  pus.  One  or  many  of 
these  fistulae  may  occur  (Fig.  564),  and  the  openings  are  not 
limited  to  the  perineum,  but  may  also  be  found  in  the  thighs 
buttocks,  or  even  the  groins.  In  chronic  cases,  the  scrotal  or 
penneal  tissues  become  infiltrated  and  of  an  almost  cartilaginous 
consistency. 

Diagnosis. — Every  abscess  in  the  scrotum  or  perineum  is  not 
necessarily  associated  with  stricture,  for  simple  irritation  of  the 
skin  may  lead  to  a  superficial  abscess;  suppuration  in  the  lacunge 
or  Cowper's  glands,  may  follow  gonorrhoea;  a  prostaric  or  ischio- 
rectal abscess  may  point  in  the  perineum;  whilst  the  injury  inflicted 


Fig.  563. — Cock's    Operation  of  Perineal 
Section.     (Bryant's  '  Surgery.') 


1268 


A   MANUAL  OF  SURGERY 


by  the  passage  of  instruments,  or  the  existence  of  false  passages, 
may  lead  to  a  similar  result. 

The  Treatment  of  a  Perineal  Abscess  consists  in  the  application  ol 
fomentations  during  the  early  stages;  as  soon  as  pus  is  present,  it 
should  be  let  out  through  a  free  incision,  and  it  is  often  advisable 
to  take  the  opportunity  of  dealing  radically  with  the  stricture  by 
section  at  the  same  time.  Perineal  tistulai  can  rarely  be  cured 
without  operation,  since,  although  the  stricture  may  be  completely 
dilated,  the  discharge  of  urine  and  pus  continues.  Under  these  cir- 
cumstances Syme's  or  Wheelhouse's  operation  is  the  proper  treat- 
ment. 

Extravasation  of  Urine  is  a  condition  due  to  a  solution  of  con- 
tinuity of  the  urethral  walls,  allowing  the  urine  to  find  its  way  into 
the  perineal  and  scrotal  tissues.  It  usually  results  from  over-dis- 
tension of  the  urethra  behind  a  neglected"  stricture ;  during  sorne 
violent  effort  at  micturition,  the  patient  experiences  severe  pain 


Fig.  564. — Perineal  Fistul^e.      (Bryant's  '  Surgery.') 

and  a  sensation  as  if  something  had  given  way  in  the  perineum, 
followed  by  a  feeling  of  rehef .  This,  however,  is  of  short  duration, 
as  it  is  soon  succeeded  by  the  local  and  constitutional  effects  of 
extravasation.  Occasionally  the  onset  of  symptoms  is  more  gradual, 
being  preceded  by  a  peri-urethral  abscess,  which  bursts  into  the 
urethra;  at  each  act  of  micturition  the  ca\aty  becomes  more  and 
more  distended  with  urine ;  finally  the  wall  yields,  resulting  in  diffuse 
extravasation.  The  same  phenomena  are  produced  in  cases  of 
traumatic  laceration  of  the  urethra  if  the  patient  attempts  to  empty 
his  bladder. 

The  membr;mous  urethra  is  almost  alwpvs  the  site  of  the  rupture, 
the  urine  finding  its  way  subsequently  through  the  anterior  layer 
of  the  triangular  hgament,  and  being  guided  towards  the  anterior 
abdominal  wall  by  the  arrangement  of  the  fascise.  The  root  of  the 
penis,  covered  by  its  appropriate  muscles,  lies  in  an  interfascial  cul- 
de-sac,  formed  by  the  anterior  layer  of  the  triangular  ligament  above, 
and  the  deep  layer  of  the  perineal  fascia  (or  fascia  of  Colles)  below; 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS  1269 

these  two  layers  are  continuous,  passing  round  the  transversus 
perinei  muscles,  and  are  both  attached  laterally  to  the  ischio-pubic 
rami.  Into  this  space  the  urine  finds  its  way,  after  the  anterior 
layer  of  the  triangular  ligament  has  yielded,  and  owing  to  the  fact 
that  its  passage  backwards  and  laterally  is  checked  by  the  attach- 
ment of  the  fascic-e,  it  is  necessarily  forced  forwards,  infiltrating  in 
order  the  perineum,  scrotmn,  and  body  of  the  penis.  If  more  ex- 
tensive, it  travels  along  the  spermatic  cords  to  the  anterior  abdom- 
inal parietes,  its  passage  downwards  into  the  thighs  being  pre- 
vented by  the  attachment  of  the  deep  layer  of  the  superficial  fascia 
of  the  abdomen  to  the  fascia  lata  just  below  Poupart's  ligament. 
In  the  most  severe  cases  the  urine  may  even  find  its  way  as  far  as 
the  axillae. 

The  Effects  of  extravasation  of  urine  are  always  serious.  Pos- 
sibly, if  the  urine  were  pure  and  aseptic,  part  of  it  might  be  ab- 
sorbed; but  even  then  prolonged  infiltration  of  the  tissues  is  likely 
to  result  in  suppuration  and  sloughing.  In  cases  of  stricture,  how- 
ever, the  urine  is  almost  certain  to  be  foul  and  alkaline,  and  hence 
wherever  it  tra\'els  it  gives  rise  to  a  gangrenous  celluHtis.  The 
parts  at  first  become  infiltrated  and  brawny,  but  soon  emphysem- 
atous crackling  and  putrefaction  are  observed,  owing  to  necrosis 
of  the  cellular  tissue.  The  congested  and  oedematous  skin  turns  to 
a  dusky  purple  or  black  colour,  and  finally  gives  way  or  separates, 
allowing  exit  to  a  mixture  of  pus,  urine,  and  decomposing  slough 
of  a  most  offensive  and  penetrating  odour.  The  superficial  loss  of 
substance  may  be  so  extensive  as  to  lay  bare  both  testicles,  and 
even  the  body  of  the  penis,  or  part  of  the  anterior  abdominal  wall. 
The  inflammatory  process  is  necessarily  associated  with  severe  con- 
stitutional disturbance,  at  first  characterized  by  liigh  fever  and  a 
quick,  bounding  pulse;  but  later  on  the  temperature  may  become 
subnormal,  and  the  patient  profoundly  collapsed  from  toxaemia. 

The  Treatment  consists  in  early  and  free  incisions,  so  as  to  give 
exit  to  the  urine  and  pus,  and  to  prevent,  if  possible,  the  sloughing 
of  the  skin  and  subcutaneous  tissues.  Every  part  that  the  urine 
has  infiltrated  must  be  dealt  with  in  this  way;  thus  the  perineum 
should  be  incised  in  the  middle  fine ;  the  scrotum  is  similarly  di\'ided, 
if  need  be,  down  to  the  urethra,  the  testicles  being  laid  on  either  side, 
but,  if  possible,  this  should  be  avoided.  The  penis  should  be  incised, 
if  necessary,  on  either  side  of  the  urethra,  and  along  the  dorsal 
surface.  It  is  often  possible  to  expel  a  large  portion  of  the  urine, 
especially  in  the  scrotum,  by  firmly  squeezing  the  infiltrated  tissues. 
A  full-sized  catheter  must  be  passed  into  the  bladder,  and  to  effect 
this  the  urethra  has  often  to  be  laid  open  and  the  stricture  divided; 
perineal  drainage  is  always  preferable  for  these  cases.  The  parts 
should  be  subsequently  dusted  over  with  iodoform,  and  dressed  with 
waim  antiseptic  appHcations— e.g'.,  a  charcoal  or  carbohc  hnseed 
poultice,  or  boracic  fomentations.  Frequent  hip-baths  should  be 
employed,  and,  if  practicable,  a  continuous  sitz-bath  would  be  the 
very  best  means  of  treating  the  case.     As  soon  as  the  wounds 


I270  A  MANUAL  OF  SURGERY 

become  clean,  they  should  be  dressed  in  the  ordinary  way  to  allow 
them  to  granulate.  The  general  health  of  the  patient  must  of 
course  be  attended  to,  plenty  of  easily  assimilated  nourishment, 
stimulants,  and  quinine  being  administered. 

Urinary  Fistulse  are  most  commonly  found  in  the  perineiun, 
scrotum,  or  body  of  the  penis.  They  usually  result  from  peri- 
urethral suppuration  in  connection  with  a  stricture,  but  are  occa- 
sionally due  to  other  causes — e.g.,  a  lacunar  abscess  after  gonorrhoea, 
or  a  prostatic  abscess.  They  vary  much  in  size  and  number;  when 
the  result  of  a  stricture,  many  may  be  present  (Fig.  564),  and  great 
infiltration  of  the  surrounding  tissues  is  usually  produced.  The 
Treatment  of  perineal  fistulse  has  been  already  in  measure  described, 
external  urethrotomy  being  necessary  if  a  stricture  exists.  Occa- 
sionally the  perineal  wound  does  not  close  after  such  an  operation, 
even  when  the  stricture  has  been  divided;  the  edges  of  the  fistula 
should  then  be  pared,  and  the  wound  brought  together  by  deep 
quilled  sutures.  A  catheter  should  be  kept  in  the  bladder  for  a  few 
days,  and  the  urine  regularly  drawn  off  after  its  removal. 

When  of  small  size,  and  situated  either  in  the  perineum  or  the 
penis,  cure  may  be  determined  by  cauterizing  the  passage  either 
with  a  probe  coated  with  nitrate  of  silver  or  by  a  galvano-cautery, 
but  in  other  cases  some  form  of  urethroplasty  is  necessary. 

Affections  of  the  Penis. 

Phimosis,  when  complete,  is  a  condition  in  which  the  prepuce  is 
so  long,  and  the  orifice  so  narrow,  that  it  cannot  be  retracted  behind 
the  corona.  It  is  usually  Congenital  in  origin,  and  may  exist  to 
such  a  degree  as  to  render  micturition  impossible.  More  frequently 
the  opening  is  a  very  small  one  (pinhole  prepuce),  permitting  mic- 
turition, but  leading  to  irritability  of  the  bladder  from  the  obstruc- 
tion. In  such  cases  the  prepuce  is  usually  adherent  to  the  glans, 
and  considerable  irritation  is  caused  by  the  retention  of  the  smegma 
secreted  by  Tyson's  glands;  this  may  collect  and  become  so  in- 
spissated as  to  give  rise  to  definite  concretions.  The  child  pulls  at 
the  foreskin,  owing  to  the  itching  produced,  and  thus  the  symptoms 
of  vesical  calculus  may  be  simulated.  Attacks  of  balanitis  are  also 
frequent,  and  should  the  prepuce  be  withdrawn,  paraphimosis  is 
almost  certain  to  follow.  If  allowed  to  remain  untreated  long 
enough,  distension  of  the  bladder,  and  even  hydronephrosis,  may 
supervene.  Not  only  is  this  condition  in  itself  a  cause  of  irritation 
to  the  individuals  affected,  but  it  is  often  provocative  of  masturba- 
tion ;  moreover,  it  is  certain  to  aggravate  the  symptoms  of  venereal 
disease,  and  there  is  but  little-  doubt  that  it  acts  as  a  predisposing 
cause  to  epithelioma  of  the  penis.  Phimosis  also  occurs  as  an  Ac- 
quired condition,  resulting  from  the  cicatrization  of  venereal  sores. 

The  Treatment  of  phimosis  consists  in  circumcision.  Other 
methods  have  been  suggested — e.g.,  dilatation  of  the  prepuce,  and 
merely  slitting  it  up — but  they  are  not  satisfactory. 


AFFECTIONS  OF  THE   URETHRA  AND  PENIS 


1271 


Circumcision  should  always  be  performed  on  children  with  a  long 
prepuce  within  the  first  year  of  Hfe,  since  at  that  time  the  parts  are 
but  shghtly  de\-eloped,  the  operation  is  a  trifling  one,  and  but  little 
inconvenience  is  subsequently  experienced;  the  longer  it  is  post- 
poned, the  more  troublesome  does  it  become.  The  best  method  of 
operating  is  as  follows:  The  dorsal  aspect  of  the  prepuce  is  put  on 
the  stretch  by  grasping  it  on  either  side  of  the  median  line  with  a 
pair  of  catch  forceps ;  a  director  is  then  introduced  between  it  and 
the  glans,  and  held  exactly  in  the  middle  line,  and  the  prepuce  slit 
up  with  a  curved  pointed  bistoury  or  scissors.  The  lateral  halves  are 
now  separated  from  the  glans,  adhesions,  if  necessary,  being  broken 
down ;  this  must  be  very  thoroughly  attended  to,  so  as  to  enable  all 
retained  smegma  to  be  removed,  and  the  corona  glandis  defined. 
The  redundant  preputial  tissue,  both  skin  and  mucous  membrane,  is 
cut  away  on  each  side  by  scissors,  special  attention  being  directed 
to  the  removal  of  sufficient  tissue  on  the  under  side  to  prevent  the 
unsightly  projection  so  frequently  seen 
just  below  the  fraenum.  In  adults 
several  vessels  will  bleed  and  require  to 
be  ligatured,  especially  that  in  the 
fraenum,  but  in  a  child  the  haemorrhage 
is  trifling.  Having  carefully  trimmed 
up  the  edges,  and  snipped  off  all  ragged 
corners,  so  as  to  render  the  margins  of 
the  wound  regular,  catgut  sutures  are 
inserted  to  prevent  any  raw  surface 
being  left  exposed;  in  children  only  a 
few  are  required,  but  possibly  a  con- 
siderable number  in  adults;  a  continu- 
ous suture  should  never  be  employed. 
The  wound  is  dressed  with  strips  of 
gauze,  and  around  this  a  wisp  of  sterile 
wool,  retained  in  adults  by  a  narrow 
bandage.  Considerable  after-trouble  is  sometimes  experienced  from 
nocturnal  erections,  which  may  be  so  marked  and  prolonged  as  to 
tear  through  the  stitches;  to  control  this  the  patient's  bowels  should 
be  freely  opened,  and  he  should  be  kept  on  a  low  and  unstimulating 
diet,  and  bromide  of  potassium  or  other  sedatives  administered. 
The  stitches  are  usually  removed  at  the  end  of  five  days,  and  the 
parts  are  then  dusted  over  with  a  mixture  of  powdered  boric  acid, 
zinc  oxide,  and  starch,  so  as  to  reduce  their  sensitiveness. 

When  a  phimosed  prepuce  is  completely  retracted,  the  patient 
often  finds  it  impossible  to  replace  it,  thus  giving  rise  to  a  condition 
known  as  Paraphimosis.  It  is  due  to  the  narrow  orifice  of  the 
prepuce  getting  behind  the  corona,  and  is  characterized  by  great 
oedema  and  congestion,  not  only  of  the  exposed  mucous  membrane, 
but  also  of  the  glans  itself.  If  left  untreated,  ulceration  takes  place 
along  the  line  of  constriction,  and  the  parts  become  fixed  in  their 
deformed  position,  the  vessels  sooner  or  later  accommodating  them- 


FiG.  565. — Reduction  of 
Paraphimosis. 


1272  A   MANUAL  OF  SURGERY 

selves  to  the  new  conditions,  and  the  cedema  slowly  disappearing. 
In  some  cases  sloughing  of  the  glans  may  occur. 

Treatment  consists  in  forcible  replacement  of  the  prepuce.  This 
is  accomplished  by  grasping  the  penis  between  the  first  and  second 
fingers  of  each  hand,  and  compressing  the  glans  penis  with  the 
thumbs  so  as  to  empty  the  vessels  and  diminish  the  amount  of 
oedema  present,  and  thus  reduce  its  size  (Fig.  565).  At  the  same 
time  the  fingers  draw  the  prepuce  forwards,  and  thus  finally  reposi- 
tion is  eft'ected.  When  the  redema  of  the  prepuce  is  very  marked, 
it  should  be  punctured  in  several  places  to  permit  the  escape  of 
serum  and  diminish  the  tension,  previous  to  reduction  as  just 
described.  In  more  advanced  cases  reposition  becomes  impossible, 
and  then  the  narrow  constricting  band  caused  by  the  orifice  of  the 
prepuce  must  be  divided  on  the  dorsal  aspect.  This  \\'ill  free  the 
parts,  which  can  be  subsequently  drawn  forvvards,  and  after  the 
oedema  has  been  reduced  by  apphing  lotio  plumbi  for  a  few  days, 
circumcision  may  be  advantageously  undertaken. 

Balanitis,  or  inflammation  of  the  glans,  may  be  simple  in  nature, 
arising  from  want  of  cleanliness  in  a  person  with  a  long  foreskin,  but 
more  frequently  is  associated  with  gonorrhoea  or  soft  chancres.  The 
under  surface  of  the  prepuce  is  often  involved,  and  then  the  term 
Balano-posthitis  is  sometimes  applied  to  it.  A  muco-purulent  or 
purulent  discharge  escapes  from  under  the  prepuce,  which  is  often 
swollen  and  oedematous.  Occasionall3^  when  a  considerable  degree 
of  phimosis  exists,  the  luider  surface  of  the  prepuce  may  become 
ulcerated,  and  even  perforated;  whilst  in  very  neglected  cases,  and 
especially  if  phagedena  is  present,  the  prepuce  will  slough,  and 
allow  the  glans  to  protrude,  usually  through  its  upper  surface. 

Treatment. — In  simple  cases,  all  that  is  required  is  to  cleanse  the 
parts  thoroughly  by  washing  beneath  the  foreskin,  and  then  apply 
lead  lotion  on  lint  between  the  glans  and  the  prepuce;  but  when 
there  is  much  discharge,  and  the  foreskin  is  long  and  swollen,  or  if 
perforation  is  threatening,  the  prepuce  must  be  slit  up,  and,  after  the 
parts  have  been  restored  to  a  healthy  state,  the  redundant  tissues 
should  be  cut  away  bv  a  modified  circumcision. 
For  SoJt  Chancre  and  Syphilis,  see  pp.  149  and  155. 
Herpes  not  uncommonly  affects  the  prepuce  and  glans.  It  may 
result  from  simple  local  irritation,  more  especially  in  gouty  indi- 
viduals ;  but  is  most  frequently  seen  in  patients  who  have  suffered 
from  syphilis,  and  is  then  likely  to  be  somewhat  intractable.  It 
manifests  itself  as  a  crop  of  small  vesicles  on  a  hyperaemic  base, 
wliich  become  abraded,  leaving  a  number  of  small  ulcers.  It  is 
preceded  by  pain  of  a  neuralgic  type,  and  accompanied  by  much 
itching  and  irritation.  The  only  treatment  required  is  to  keep  the 
parts  clean  and  dust  them  o\'er  with  powdered  oxide  of  zinc  and 
starch.  In  the  majority  of  cases  the  disease  lasts  from  a  week  to  ten 
days.  During  the  healing  of  the  herpetic  ulcers,  a  patient  is  very 
liable  to  be  inoculated  with  the  virus  of  either  the  soft  chancre  or 
syphilis  if  he  exposes  himself  to  the  risk  of  infection. 


AFFECTIONS  OF  THE   URETHRA  AND  PENIS 


1273 


Warts  often  arise  on  the  penis  in  the  shape  of  red,  vascular 
excrescences,  usually  pedunculated,  and  sometimes  of  considerable 
size.  They  are  met  with  most  frequently  as  a  sequela  of  gonorrhoea, 
and  must  be  carefully  distinguished  from  mucous  tubercles.  The}^ 
should  be  treated  by  snipping  them  away  with  scissors,  and  cauter- 
izing the  base  with  a  galvano-cautery.  The  X  rays  are  also  useful 
in  their  removal  when  very  extensive. 

Horns  are  also  occasionally  seen  arising  from  the  body  of  the  penis. 
They  are  of  the  usual  sebaceous  type,  as  described  at  p.  409,  and 
should  be  excised. 

Epithelioma  of  the  penis  rarely  arises  except  in  patients  who  are 
the  subjects  of  congenital  phimosis  or  possess  long  foreskins,  and 
hence  it  is  stated  that  the  disease  is  unknown  amongst  the  Jews. 
It  usually  commences  in  the 
sulcus  behind  the  corona 
glandis,  and  rapidly  spreads  to 
the  surrounding  parts,  mani- 
festing itself  either  as  an  irregu- 
lar, papillated,  wart-like  out- 
growth, or  as  a  diffuse  infiltra- 
tion, ulcerating  early,  and 
leading  to  considerable  de- 
struction of  tissue  (Fig.  566). 
At  first  the  tumour  is  mainly 
beneath  the  prepuce,  which  be- 
comes distended,  producing  a 
sanious  discharge,  which  con- 
tains epithelial  cells  as  well  as 
pus  corpuscles ;  but  as  the  case 
progresses,  the  prepuce  itself 
is  attacked,  and  even  per- 
forated. Later  on  the  body 
of  the  penis  is  invaded,  and, 
owing  to  its  great  vascularity, 
the  disease  makes  rapid  progress.  The  inguinal  glands  are  early 
affected,  but  when  the  body  of  the  penis  is  involved,  the  lumbar 
glands  are  also  implicated. 

The  Diagnosis  of  epithelioma  from  warts  is  easily  made  by  con- 
trasting the  infiltration  of  the  base  produced  by  the  former  with 
the  soft  and  normal  condition  of  the  glans  in  the  latter  affection. 

The  Treatment  of  epithehoma  consists  in  amputation  of  the  penis 
whenever  the  disease  is  sufficiently  Hmited  to  lead  to  the  hope  that 
it  can  be  eradicated.  When  confined  to  the  distal  end  of  the  organ, 
the  operation  may  possibly  be  performed  through  the  body;  but 
it  is  much  more  logical  and  more  in  accord  with  modern  scientific 
dicta  to  remove  the  whole  organ. 

Amputation  through  the  body  of  the  penis  is  an  operation  of  but  Httle 
difficulty.  The  skin  around  the  organ  is  divided  by  a  circular 
incision,  and  retracted  a  little.     The  corpora  cavernosa  are  then 


Fig.    566. — Epithelioma      of      Penis 
(King's  College  Hospital  Museum.) 


1274  ^   MANUAL  OF  SURGERY 

cut  through,  and  the  corpus  spongiosum  divided  half  an  incJi  lower 
down.  Bleeding  is  then  arrested  by  securing  the  divided  vessels; 
live  ligatures  are  usually  required,  viz.,  one  for  the  artery  to  the 
corpus  cavernosum  on  either  side,  one  for  each  dorsal  artery,  and 
one  for  the  artery  to  the  septum.  The  fibrous  sheaths  of  the 
corpora  cavernosa  are  then  overstitched,  so  as  to  close  the  vascular 
spaces,  and  the  urethra  split  on  its  inferior  aspect  for  about  a  centi- 
metre. The  skin  on  the  under  side  of  the  penis  is  similarly  incised 
in  a  longitudinal  fashion,  and  the  urethral  mucous  membrane  is 
then  stitched  to  it.  The  remainder  of  the  incision  is  closed  in  the 
usual  way. 

Anipulation  of  the  ivhole  penis  is  a  more  serious,  but  very  successful, 
operation.  The  patient  is  placed  in_the  lithotomy  position,  and  the 
perineum,  after  being  shaved  and  purified,  incised  freely  in  the 
middle  line.  The  corpus  spongiosum  is  traced  backwards,  and 
divided  at  such  a  level  as  to  allow  the  mucous  membrane  lining  the 
proximal  portion  of  the  urethra  to  be  stitched  to  the  skin  at  the 
posterior  angle  of  the  incision.  The  corpora  cavernosa  are  freed 
from  their  connections,  and  separated  at  their  origins  from  the 
ischio-pubic  rami  by  the  knife  or  suitable  raspatories.  An  elliptical 
incision  is  then  made  round  the  root  of  the  penis,  the  dorsal  vessels 
are  divided  and  secured,  and  the  suspensory  ligament  cut  through. 
The  penis  can  then  be  drawn  forwards,  and  by  a  few  final  touches 
of  the  knife  completely  removed.  All  bleeding  points  are  ligatured, 
and  the  anterior  wound  closed  by  a  continuous  suture  in  the  middle 
line,  a  drainage-tube  being  placed  in  the  perineal  portion  for  a  few 
days.  The  results  of  this  operation  have,  on  the  whole,  been  very 
satisfactory,  and  by  the  use  of  a  suitable  contrivance  the  patient 
need  not  assume  the  sitting  posture  in  order  to  micturate.  He  will 
require  to  carry  about  with  him  a  small  metal  funnel,  bevelled  to  fit 
the  perineum,  and  with  a  spout  directed  forwards.  An  excellent 
one  was  extemporized  by  a  patient  from  the  rose  of  a  watering-can, 
the  perforated  top  having  been  removed  and  the  edges  smoothed 
and  bevelled. 


CHAPTER  XLII. 

AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  AND 
SEMINAL  VESICLES. 

Congenital  Affections  of  the  Testis. — ^It  is  scarcely  necessary  to  state  that  the 
testicles  are  not  developed  in  the  scrotum,  but  from  the  posterior  wall  of  the 
abdominal  cavity,  so  that  they  lie  at  first  behind  the  peritoneum  close  to  the 
kidneys.  The  body  of  the  gland  arises  from  the  so-called  genital  ridge,  which 
is  covered  by  columnar  epithelial  cells,  and  lies  to  the  mesial  side  of  the  Wolffian 
body.  The  vasa  efferent!  a  are  developed  from  the  tubules  of  the  latter  struc- 
ture, coming  into  relation  at  a  later  date  with  the  seminal  tubules;  the  vas 
deferens  is  formed  by  the  Wolffian  duct. 

Occasionally  the  body  of  the  testis  is  entirely  absent,  whilst  a  few  cases  are 
on  record  of  absence  or  deficiency  of  the  vas.  Very  rarely  two  testicles  have 
been  developed  on  one  side,  and  have  both  found  their  way  into  the  scrotum 
{polyorchism) . 

The  passage  of  the  testis  from  the  abdominal  cavity  to  the  scrotum  takes 
place  at  about  the  end  of  the  eighth  month  of  intra-uterine  life.  '  The  guber- 
naculum  testis  is  the  active  agent  in  bringing  about  the  descent  of  the  testis. 
This  is  a  band  of  involuntary  muscular  fibres  which  traverses  the  inguinal  canal, 
and  establishes  important  connections  both  within  and  without  the  abdominal 
cavity.  Below,  three  main  attachments  of  the  gubernaculum  may  be  recog- 
nised, viz. :  {a)  to  the  abdominal  wall ;  {b)  to  the  pubis ;  (c)  to  the  bottom  of  the 
scrotum.  Above,  the  gubernacular  fibres  are  chiefly  connected  with  the 
testicle ;  but  many  of  them  are  also  attached  to  the  peritoneum  on  the  posterior 
wall  of  the  abdomen.  By  the  traction  which  the  gubernaculum  exerts  on  the 
testicle,  the  descent  of  that  organ  is  brought  about.  By  the  portion  attached 
to  the  abdominal  wall  the  testicle  is  pulled  down  to  the  internal  abdominal  ring, 
the  pubic  portion  drags  it  through  the  inguinal  canal,  whilst  the  scrotal  part 
finally  leads  it  into  the  scrotum. 

'  The  formation  of  the  processus  vaginalis  is  accounted  for  in  the  same  way. 
Some  of  those  gubernacular  fibres  which  are  inserted  into  the  peritoneum  drag 
down  the  peritoneal  diverticulum  which  lines  the  inguinal  canal  and  scrotum, 
and  prepares  the  way  for  the  testicle.'  (Cunningham's  '  Manual  of  Anatomy,' 
second  edition,  1896;  vol.  i.,  pp.  426,  427.) 

Two  chief  forms  of  malposition  of  the  testis  are  described,  arising  either  from 
its  incomplete  or  abnormal  descent. 

I.  Incomplete  Descent  or  Retention  of  the  Testis. — The  testis  may  remain  in 
the  abdominal  cavity  attached  to  the  abdominal  wall  by  a  mesorchium  [vetentio 
abdominalis) ;  more  frequently,  it  is  found  just  within  the  internal  abdominal 
ring  {retentio  iliaca) ;  but  most  commonly  it  occupies  the  inguinal  canal,  or  lies 
just  outside  of  it  {retentio  inguinalis) .  The  organ  in  the  latter  position  is  freely 
mobile,  being  readily  pressed  up  towards  the  abdominal  cavity.  The  Causes  of 
this  condition  must  be  looked  for  mainly  in  some  abnormal  attachment  of  the 
gubernaculum,  or  possibly  in  the  existence  of  intra-uterine  peritonitis.  Less 
commonly  a  contracted  condition  of  the  external  abdominal  ring,  or  an  unduly 
large  epididymis,  may  determine  its  occurrence. 

1275 


1276  A   MANUAL  OF  SURGERY 

The  condition  is  easily  recognised  by  the  absence  of  the  testicle  in  the 
scrotum,  and  in  the  inguinal  variety  the  organ  can  usually  be  detected  as  a 
small  moveable  swelling  about  the  size  of  a  horse-bean,  giving  the  character- 
istic testicular  sensation  on  pressure.  The  scrotum  on  the  affected  side  is 
imperfectly  developed. 

In  any  of  these  varieties  a  late  descent  of  the  testis  may  occur,  usually 
accompanied  by  a  congenital  hernia,  possibly  of  an  interstitial  type. 

'2.  Malposition  of  the  Testis, — Two  distinct  forms  are  described  ;  (a)  Ectopia 
Perincalis. — In  this  variety  the  testis  finds  its  way  into  the  perineum,  slipping 
along  the  groove  between  the  thigh  and  the  scrotum.  It  may  exist  as  a  con- 
genital condition,  being  then  due  to  the  contraction  of  an  accessory  band  of 
gubernacular  fibres;  or  it  may  happen  in  consecjuence  of  a  late  descent  of  the 
testicle,  owing  to  atrophy  of  the  scrotum.  It  always  causes  considerable  incon- 
venience to  the  patient,  especially  on  sitting  or  riding,  {b)  Ectopia  Cruralis. — 
The  testicle  here  lies  on  the  inner  side  of  Scarpa's  triangle,  in  the  region  of  the 
saphenous  opening.  It  is  said  to  escape  along  the  crural  canal ,  but  more  prob- 
ably it  passes  down  the  inguinal  canal  as  usual,  and  then  finds  its  way  over 
Poupart's  ligament  to  this  situation,  guided  by  a  second  accessory  band  of 
gubernacular  tissue.  When,  as  not  uncommonly  happens,  a  congenital  hernia 
also  exists,  it  may  travel  outwards  to  the  anterior  superior  spine,  being  directed 
there  by  the  arrangement  of  the  fasciae,  as  in  a  femoral  hernia  (extra-parietal 
interstitial  hernia,  p.  1093). 

In  cases  of  retained  or  misplaced  testis  the  spermatogenic  function  of  the 
o  gan  is  rarely  developed,  or  at  most  merel}^  for  a  year  or  two  about  the  age  of 
twenty.  Pain  is  not  unfrecjucntly  complained  of,  coming  on  in  bouts  which 
last  for  a  short  time  and  then  disappear,  probably  due  to  slight  injuries  or 
torsion.  Fibrosis  of  the  testis  follows  in  time,  and  total  degeneration  is  the 
ultimate  outcome.  If  only  one  organ  is  affected,  but  little  harm  follows;  but 
if  both  are  involved,  the  individual  is  probablv  sterile. 

Complications  of  a  Retained  or  Misplaced  Testicle. — Any  of  the  conditions  to 
be  described  hereafter  in  this  chapter  may  involve  a  retained  or  misplaced 
testicle,  just  as  if  it  were  in  the  scrotum,  and  give  rise  to  considerable  trouble, 
especially  when  the  organ  is  lying  in  close  proximity  to  the  peritoneum.  A 
testis  misplaced  or  retained  in  the  inguinal  canal  is  much  exposed  to  injury,  and 
a  subacute  traumatic  orchitis  often  occurs.  It  is  stated  that  such  organs  are 
very  prone  to  become  the  seat  of  malignant  disease  at  a  later  period  of  life,  but 
the  accuracy  of  this  statement  is  a  little  doubtful. 

Treatment. — Taking  into  consideration  the  discomfort  occasioned  by  this 
condition,  as  well  as  the  risk  arising  from  the  tendency  to  mahgnant  disease, 
there  can  be  little  doubt  that  the  best  method  of  treatment  is  the  removal  of 
the  testicle.  Many  operations  have  been  devised  with  the  idea  of  placing  the 
organ  in  its  normal  position  in  the  scrotum,  but  the  majority  of  such  methods 
have  proved  useless,  owing  to  the  defective  length  of  the  spermatic  vessels  and 
cord ;  moreover,  the  traction  and  handling  required  to  draw  the  organ  down 
into  the  scrotum  may  determine  the  occurrence  of  fibrotic  changes,  even  if  they 
are  not  already  present.  Some  authors  advise  the  replacement  of  the  organs  in 
the  abdominal  cavity  in  patients  before  the  age  of  twenty-three,  but  it  is 
doubtful  whether  much  value  is  to  be  attached  to  such  a  suggestion. 

Another  condition  met  with  congenitally  is  Inversion  of  the  testis,  the  epi- 
didymis lying  in  front,  and  the  body  of  the  organ  behind.  It  is  of  no  clinical 
significance,  except  that  in  careless  hands  the  testis  may  be  injured  whilst 
tipping  a  hydrocele. 

Torsion  of  the  Spermatic  Cord  results  in  acute  strangulation  of  the  testis. 
The  cause  still  remains  unknown,  but  several  of  the  cases  recorded  have  been 
associated  with  late  descent  of  the  testicle,  and  others  have  been  attributed  to 
twists  and  strains.  The  symptoms  are  tolerably  characteristic:  the  patient 
complains  of  an  acute  sickening  pain  in  the  testis  which  persists  until  gangrene 
has  supervened,  and  may  then  disappear;  it  is  accompanied  by  a  certain 
amount  of  pyrexia,  and  the  appearance  of  a  tumour,  either  in  the  inguinal 
region  or  in  the  scrotum.  The  testicle,  slightly  enlarged,  is  felt  below,  and 
above  it  a  larger  mass,  consisting  of  the  twisted  cord  and  the  congested  and 


AFFECTIONS  OF  THE  TESTIS,  CORD.  SCROTUM,  ETC.      1277 

swollen  epididymis.  In  some  cases  the  latter  swelling  has  been  crepitant, 
owing  to  the  development  of  gases  due  to  its  putrefaction.  The  condition  is 
very  likely  to  be  niistaken  for  a  strangulated  hernia,  which  it  closely  resembles; 
but  the  presence  of  fever,  and  the  absence  of  abdominal  distension  and  of  faecal 
vomiting,  are  important  distinctive  signs;  moreover,  constipation,  though  often 
present,  is  never  absolute.  If  the  testis  is  situated  in  the  scrotum,  the  cord 
and  inguinal  canal  are  found  to  be  clear ;  whilst  if  in  the  canal,  the  afiEected  side 
of  the  scrotum  is  empty.  The  only  Treatment  possible  is  exploration  and 
removal  of  the  inflamed  or  gangrenous  testis  and  cord,  unless  the  case  is  seen 
very  early,  when  it  may  be  feasible  to  untwist  it. 

Injuries  of  the  Testis  and  Cord, — Contusion  is  a  very  common  form 
of  injury.  It  arises  from  blows,  kicks,  squeezes,  and  the  like,  and  is 
always  associated  with  immediate  pain  of  a  most  sickening  and  in- 
tense character,  which  is  not  only  experienced  in  the  testicle,  but  also 
radiates  along  the  cord  towards  the  loins  and  back,  and  down  the 
front  of  the  thigh.  Severe  shock  accompanies  the  pain,  and  may  be 
so  profound  as  to  lead  to  a  fatal  issue.  A  well-marked  traiunatic 
orchitis  often  follows,  and  this  may  in  turn  induce  atrophy  of  the 
organ,  although  the  same  condition  sometimes  occurs  without  much 
evidence  of  inflammation,  as  a  result  of  thrombosis  and  occlusion  of 
the  spermatic  vessels.  A  haematocele  is  also  induced  by  a  sub- 
cutaneous lesion  of  this  nature.  Treatment  consists  in  keeping  the 
patient  in  the  recumbent  posture  with  the  scrotum  well  raised,  and  in 
applying  fomentations  or  an  icebag. 

Penetrating  Wounds  or  Punctures  are  uncommon  except  as  a  result 
of  surgical  treatment  {e.g.,  tapping  a  hydrocele).  A  certain  amount 
of  haemorrhage  usually  follows,  whilst  the  immediate  lesion  is  asso- 
ciated with  severe  testicular  pain.  If  the  wound  becomes  infected, 
the  tubules  are  likely  to  protrude,  and  a  hernia  testis  may  result.  All 
that  is  ordinarily  required  is  to  purify  the  parts  and  allow  them  to 
heal;  sutures  should  not  be  inserted  into  the  tunica  albuginea,  if 
there  is  any  doubt  as  to  the  wound  being  sterile.  If  the  gland  is 
totally  disorganized,  castration  must  be  undertaken. 

Hsematocele,  or  a  localized  collection  of  blood  in  the  tunica 
vaginalis  or  cord,  is  a  common  result  of  injuries. 

I.  Hsematocele  o£  the  Tunica  Vaginalis  arises  from  traumatism, 
such  as  a  sudden  blow  or  severe  strain,  and  occasionally  follows  the 
tapping  of  a  hydrocele  if  a  superficial  vessel  has  been  ruptured  or 
punctured,  or  if  the  body  of  the  testis  has  been  wounded;  it  may, 
however,  be  due  to  general  oozing  from  dilated  capillaries  in  the 
serous  membrane  owing  to  the  sudden  relief  of  tension.  It  also 
occurs  more  or  less  spontaneously  in  connection  with  malignant 
disease.  The  History  generally  given  is  that  the  patient  was  seized 
with  a  sudden  sickening  pain  in  the  testicle,  which  became  quickly 
enlarged  without  any  evidence  of  inflammation.  If  blood  is  ex- 
travasated  at  the  same  time  into  the  scrotum,  the  integument  be- 
comes discoloured  in  the  course  of  a  few  days  owing  to  a  diffusion  of 
the  blood  pigment.  At  first  the  swelling  is  smooth  and  fluctuating, 
exactly  resembling  a  hydrocele,  except  in  the  absence  of  trans- 
lucency;  but  owing  to  a  deposit  of  fibrin  on  the  walls  from  the 
coagulation  of  the  blood,  it  becomes  hard  and  firm  in  a  short  time. 


1278  A   MANUAL  OF  SURGERY 

closely  simulating  a  solid  tumour.  In  slight  cases  the  blood  is 
entirely  absorbed,  but  when  the  effusion  is  considerable  the  coagu- 
lum  is  likely  to  persist.  On  laying  open  such  a  swelling,  the  testicle 
is  usually  found  in  a  healthy"  state,  whilst  the  enlarged  tunica  is 
occupied  by  some  blood-stained  brownish-yellow  fluid,  and  sur- 
rounded by  a  mass  of  fibrinous  coagulum,  part  of  which  is  deposited 
in  laminae  upon  the  walls,  and  part  remains  as  shreddy  masses  pro- 
jecting into  its  lumen.  In  very  chronic  cases  the  walls  of  the  tunica 
become  thick  and  indurated,  and  may  even  undergo  calcareous 
changes.  Suppuration  is  sometimes  met  with  as  a  result  of  auto- 
infection.  The  Diagnosis  of  a  haematocele  in  the  earlier  stages  is 
easily  made;  but  when  it  has  solidified  it  can  only  be  suspected  by 
the  history,  and  by  the  exclusion  of  other  sources  of  enlargement, 
whilst  an  exploratory  incision  or  puncture  is  often  necessary  to  settle 
the  diagnosis.  Treatment. — When  the  patient  is  seen  soon  after  the 
injury,  he  must  be  kept  at  rest,  the  parts  elevated,  and  evaporating 
lotions  applied ;  whilst  if  the  effusion  is  large,  removal  of  a  portion 
by  aseptic  tapping  will  expedite  the  process  of  absorption.  In  more 
chronic  cases  it  may  be  necessary  to  lay  the  cavity  open  and  remove 
its  contents,  whilst  in  the  later  stages,  if  the  tunica  has  become 
thick  and  indurated,  and  the  testis  atrophied,  castration  may  be 
advisable. 

2.  Haematoceleof  the  Cord  is  but  rarely  seen.  It  is  due  to  the  rup- 
ture of  one  of  its  vessels,  as  a  result  of  injury  or  strain.  A  swelling 
of  considerable  size  rapidly  forms,  extending  along  the  cord  from  the 
inguinal  region  to  the  scrotum,  but  the  testis  remains  free  and  unim- 
pHcated.  Such  a  condition  may  be  mistaken  for  an  omental  hernia, 
but  on  careful  examination  the  tumour  is  felt  to  be  more  uniform  in 
consistency,  more  rounded  in  outline,  and  even  semi-fluctuating.  It 
is  irreducible  and  without  impulse,  whilst  the  history  of  the  case  will 
assist  the  surgeon  in  making  a  correct  diagnosis,  treatment  in  the 
early  stages  consists  in  the  appHcation  of  evaporating  lotions,  and 
later  on,  if  the  blood-clot  is  not  absorbed,  the  cavity  may  be  laid  open 
and  the  coagulum  removed. 

Rupture  of  the  Vas  Deferens  has  resulted  from  excessive  strain ;  it 
is,  however,  very  rare,  not  more  than  half  a  dozen  cases  being  on 
record.  It  may  affect  the  intra-abdominal  portion  of  the  vas,  and 
then  gives  rise  to  haemorrhage  from  the  urethra,  together  with  some 
amount  of  fever  and  hypogastric  pain,  leading  possibly  to  atrophy  of 
the  organ.  Rupture  of  the  scrotal  portion  is  followed  by  enlargement 
of  the  testis,  and  perhaps  scrotal  haemorrhage.  This  was  associated 
in  a  case. under  our  observation  with  haemorrhage  from  the  urethra 
on  attempting  coitus  shortly  after  the  accident,  and  subsequently 
with  severe  pain  and  swelling  of  the  testis  produced  by  the  same  act, 
but  atrophy  did  not  follow.  If  it  occasions  any  inconvenience,  it  is 
best  treated  by  castration. 

Inflammatory  Affections  of  the  Testis  may  be  chiefly  confined  at 
their  onset  either  to  the  body  of  the  organ  or  to  the  epididymis;  in 


AFFECTIONS  OF  THE  TESTIS.  CORD,  SCROTUM,  ETC.      1279 

the  former  case  the  term  Orchitis  is  applied  to  it,  in  the  latter 
Epididymitis  ;  as  the  case  progresses  both  portions  are  involved  in 
the  process;  either  condition  may  be  acute  or  chronic. 

Acute  Orchitis  most  frequently  results  from  injury,  but  it  is  also 
met  with  as  a  primary  affection  in  gouty  and  rheumatic  individuals, 
sometimes  arising  spontaneously;  or  it  may  follow  mumps,  typhoid, 
or  other  eruptive  fevers,  as  a  result  of  metastasis,  whilst  it  is  always 
to  some  extent  associated  with  epididymitis.  In  mumps  it  may  pre- 
cede the  parotid  lesion,  or  may  even  occur  without  it. 

The  testicle  becomes  considerably  enlarged,  exceedingly  painful, 
and  tender  to  the  touch.  The  shape  of  the  organ  is  more  or  less 
globular  (Fig.  567,  A),  whilst  the  pain  is  of  a  pecuUarly  sickening 
character,  extending  upwards  along  the  course  of  the  cord  towards 
the  back  and  loins.  The  scrotal  integuments  become  red  and  in- 
filtrated, and,  o\\'ing  to  the  acuteness  of  the  process,  more  or  less 
adherent  to  the  coverings  of  the  gland.     A  plastic  or  serous  effusion 


Fig.  567. — Diagrammatic  Sections  of  (A)  Orchitis,  (B)  Epididymitis, 
AND  (C)  Hydrocele  of  Tunica  Vaginalis. 

T,  Testis;  E,  epididymis;  HY,  hydrocele. 

into  the  tunica  vaginalis  is  sometimes  present,  giving  rise  to  what  is 
known  as  an  '  acute  hydrocele.'  Some  constitutional  disturbance 
accompanies  the  process,  the  temperature  being  elevated  two  or  three 
degrees,  whilst  vomiting  and  constipation  are  marked  symptoms.  It 
is  unusual  for  suppuration  to  ensue,  but  an  abscess  occasionally 
forms,  and  then,  after  the  pus  has  been  let  out,  a  hernia  testis  may 
follow.  Atrophy  is  a  more  common  sequela,  especially  in  adults, 
being  caused  by  constriction  of  the  vessels  and  tubules,  owing  to 
organization  of  the  inflammatory  exudation. 

Acute  Epididymitis  is  almost  always  due  to  the  extension  of  an 
inflammatory  process  from  the  urethra,  the  usual  cause  being  gonor- 
rhoea; it  occasionally  follows  the  passage  of  instruments  or  the 
lodgment  of  a  calculus ;  or  it  may  be  secondary  to  a  suppurative 
prostatitis,  unconnected  \vith  gonorrhoea.  It  is  ushered  in  by  pain 
in  the  inguinal  region  and  perhaps  in  the  hypogastrium  along  the 
course  of  the  vas  deferens,  which  soon  extends  to  the  scrotimi. 


i28o  A   MANUAL  OF  SURGERY 

The  testicle  becomes  enlarged,  but  its  shape  is  that  of  an  elongated 
oval,  somewhat  flattened  laterally.  The  ep'didymis  is  readily  felt 
as  a  crescentic  swelling,  partially  overlapping  the  gland  in  all  direc- 
tions, and  in  its  concavity  the  rounded  outline  of  the  anterior  wall 
of  the  testis  can  usuallv  be  distinguished  (Fig.  567,  B),  or  the  tunica 
vaginalis  distended  with  fluid.  The  scrotum  is  red,  (edematous,  and 
adherent  to  the  testis,  whilst  the  cord  is  infiltrated,  enlarged,  and 
tender.  The  same  constitutional  symptoms  are  met  with  as  in 
orchitis.  Suppuration  is  perhaps  more  common  than  after  the  latter 
affection,  since  the  condition  is  usually  due  to  a  suppurating  in- 
flammation of  the  deeper  parts  of  the  urethra;  but  it  is  a  rare 
complication.  Atrophy  of  the  testis  is  a  not  unfrequent  result  in 
cases  which  are  not  efficiently  treated,  the  plastic  material  exuded 
into  the  epididymis  being  organized  into  fibro-cicatricial  tissue,  and 
constricting  the  spermatic  vessels ;  an  acute  attack  of  double  epididy- 
mitis may  in  this  way  render  the  individual  sterile. 

The  Treatment  of  both  these  conditions  in  the  acute  stage  consists 
in  keeping  the  patient  in  bed,  with  the  scrotum  supported  on  a  small 
pillow.  The  part  is  assiduously  fomented,  except  when  the  case  is 
seen  verv  early,  an  icebag  or  Leiter's  coil  being  then  employed.  ' 
Leeching  should  not  be  utilized,  as  the  triangular  leech-bites  are  very 
liable  to  become  irritated  and  infected,  and  never  heal  well  in  the 
scrotum;  if  local  abstraction  of  blood  appears  desirable,  one  or  more 
of  the  scrotal  veins  may  be  punctured;  the  haemorrhage  is  easily 
arrested  bv  elevating  the  part.  Pain,  if  severe,  may  be  mitigated 
by  a  hot  sitz-bath,  or  by  morphia  suppositories.  As  regards  general 
treatment,  the  patient,  after  a  preliminary  dose  of  calomel,  is  kept 
on  a  fluid,  unstimulating  diet,  whilst  alkaline  purgatives  are  ad- 
ministered, with  the  addition  of  tincture  of  henbane  or  opium  as  a 
sedative;  if  the  pulse  is  hard  and  the  temperature  high,  vinum  anti- 
monialis  in  lo-minim  doses  is  also  beneficial.  When  the  acute  stage 
is  passed,  the  organ  usually  remains  enlarged,  and  for  a  time  some- 
what tender ;  it  is  then  best  treated  by  strapping  with  lead  plaster,  or 
with  the  emplastrum  ammoniaci  cum  hydrargyro.  This  must  be 
continued  until  all  signs  of  thickening  and  induration  have  dis- 
appeared. 

Subacute  or  chronic  forms  of  inflammation  are  also  met  with  affect- 
ing the  testis  or  epididymis,  either  as  a  consequence  of  the  above,  or 
resulting  primarilv  from  blows  or  strains.  The  characteristic  enlarge- 
ment is  readilv  detected,  associated  with  a  certain  amount  of  tender- 
ness. A  useful  diagnostic  point  between  the  chronic  epidid\Tnitis 
follo\\'ing  gonorrhoea  and  that  due  to  syphilis  is  that  the  former 
usually  involves  the  globus  minor,  and  the  latter  is  almost  limited 
to  the  globus  major.  The  condition  is  best  treated  by  strapping, 
and  perhaps  the  administration  of  small  doses  of  mercury  and  iodides 
mav  assist  in  the  absorption  of  th^^  inflammatory  prf)ducts.  Chronic 
orchitis  is  very  similar  to  the  enlargement  produced  by  syphihs, 
from  which,  indeed,  it  can  only  be  distinguished  by  the  absence  of 
a  syphilitic  history. 


AFFECTIONS  OF  THE  TESTIS,   CORD,   SCROTUM,   ETC.     1281 


Tuberculous  Disease  of  the  Testis  {Syn.  :  Tuberculous  Sarcocele, 
Chronic  Tuberculous  Orchitis). — This  affection  is  most  commonly 
seen  in  young  adults  with  a  distinct  tuberculous  history,  but  it  also 
occurs  in  otherwise  healthy  indi\iduals.  It  may  commence  as  a 
primary  affection  of  the  epididymis,  or  may  be  secondary  to  tuber- 
culous disease  elsewhere. 

Pathological  Anatomy. — The  process  originates  in  the  connective 
tissue  of  the  epididymis,  and  runs  its  usual  course,  at  first  consisting 
merely  of  miliary  elements  deposited  around  the  vessels,  which  by 
their  coalescence  and 
caseation  lead  to  the 
formation   of    cheesy 
masses,  and  these  at 
a    later  stage  may 
emulsify  and  give  rise 
to  abscesses.     It  may 
be  limited  to  any  one 
part  of  the  epidid\Tnis 
(most  often  the  globus 
major),  or  may  widely 
infiltrate  its  substance, 
causing  a  general  en- 
largement (Fig.  568). 
In  the  latter  case  it 
early  tends  to  spread, 
either  into  the  body 
of  the  testis  or  along 
the  vas  deferens.   The 
corpus    Highmori- 
anum    becomes    first 
involved  b}-  a  similar 
deposit, and  finally  the 
intertubular    connec- 
tive tissue  of  the  gland;  this  is  always  associated  with  overgrowth 
of  the  epithehum  in  the  tubuH  seminiferi,  the  cells  after  a  time 
undergoing  fatty  degeneration,  and  perhaps  to  such  an  extent  that, 
on  microscopic  section,  the  normal  appearance  of  the  organ  has 
entirelv  disappeared.     An  abscess  may  form  within  it,  and  find  its 
wav  to  the  surface  by  burrowing  through  the  tunica  albuginea,  the 
visceral  and  parietal  layers  of  the  tunica  vaginaHs  having  previously 
become  adherent.     After  the  pus  has  escaped,  a  hernia  testis  is 
likely  to  develop.     If  the  process  extends  upwards  along  the  cord, 
the  vas  is  mainly  impHcated,  becoming  perceptibly  thickened,  the 
other  structures  of  the  cord  being  but  little  affected.     The  disease 
spreads  along  the  vas  on  the  outside  of  the  bladder  to  the  vesiculse 
seminales  and  prostate,  and  may  even  involve  the  base  of  the  bladder, 
the  ureters,  and  kidneys.     Lastly,  general  dissemination  of  tuber- 
culous disease  mav  occur,  and  it  is  a  curious  fact  that  meningeal 
mischief  is  not  very  uncommonly  associated  with  genital  tuberculosis. 

81 


Fig.   56S.— 1 


-Tuberculous  Disease  of  Testis, 
mainly  involving  the  epididymis  and  cord. 
(King's  College  Hospital  Museum.) 


1282  A   MANUAL  OF  SUJiGHRY 

Clinical  Signs. — The  disease  is  generally  unilateral,  although  the 
other  testicle  often  becomes  involved  at  a  somewhat  later  date.  Its 
onset  may  be  abrupt  or  gradual;  in  the  former  case  the  attack  simu- 
lates an  acute  orchitis,  but  at  the  end  of  a  few  weeks,  although  the  pain 
subsides,  the  swelling  persists,  being  followed  by  the  development  of 
abscesses  containing  cheesy  pus.  In  the  more  chronic  cases,  one  or 
more  hrm  and  indurated  nodules,  which  are  free  from  tenderness, 
are  felt  in  the  epididymis,  but  more  often  the  whole  of  this  structure 
is  found  to  be  enlarged  imd  thickened,  forming  a  painless  crescentic 
swelling,  surrounding  the  posterior  half  of  the  body  of  the  testis,  from 
which  it  is  usually  separated  by  a  deep  groove  or  sulcus.  The  epi- 
didymis is  nodular  and  craggy  to  the  feel,  and  may  be  of  unequal 
consistency,  areas  of  softening  being  interposed  between  portions 
which  are  distinctly  hard.  The  vas  is  early  thickened,  whilst  the 
other  structures  of  the  cord  are  but  little  involved;  the  thickening 
is  more  or  less  nodular,  and  almost  beaded  in  its  consistency.  The 
body  of  the  testis  may  be  involved  and  enlarged,  the  line  of  demarca- 
tion between  it  and  the  epididymis  becoming  indistinct.  Testicular 
sensation  remains  as  long  as  any  nonual  glandular  tissue  exists,  but 
effusion  into  the  tunica  vaginalis  is  not  usual.  When  suppuration 
occurs,  the  pain  increases,  especially  if  the  abscess  is  in  the  substance 
of  the  organ.  As  it  finds  its  way  to  the  surface,  the  skin  becomes 
adherent  to  the  testis,  and  is  red  and  congested.  Gradually  fluctua- 
tion manifests  itself,  and  the  escape  of  the  pus  may  be  followed  by  a 
hernia  testis.  An  abscess  forming  in  connection  with  the  epididymis 
is  less  painful,  and  may  attain  considerable  dimensions  before  it 
bursts;  it  never  gives  rise  to  a  hernia  testis.  Extension  of  the 
disease  to  the  seminal  vesicles  causes  no  characteristic  symptoms, 
and  is  only  detected  on  rectal  examination ;  when,  however,  the  base 
of  the  bladder  and  prostate  are  affected,  considerable  dysuria  and 
irritability  of  the  bladder  are  induced. 

The  differential  diagnosis  is  discussed  at  p.  1296. 

Treatment. — If  seen  in  the  very  early  stage,  when  only  a  small 
nodule  exists  in  the  epididymis,  it  is  possible  that  residence  at  the 
seaside  or  at  a  suitable  sanatorium,  combined  with  constitutional 
treatment  (perhaps  vaccination  with  tubercuHn)  and  local  strapping 
to  induce  venous  congestion,  may  lead  to  its  disappearance.  If  ap- 
parently limited  to  one  portion  of  the  epididymis,  the  disease  may  be 
dealt  with  by  the  conservative  measure  of  incision,  curetting,  and 
applying  pure  carbolic  acid;  but  such  is  seldom  feasible,  since  the 
disease  is  seldom  sufficiently  localized. 

If  the  whole  epididymis  is  enlarged  and  solid,  and  the  body  of  the 
testis  more  or  less  normal,  epididymectomy  may  be  undertaken.  In 
this  procedure  the  tuberculous  mass  is  freed  from  the  body  of  the 
organ,  the  spermatic  vessels  lying  on  the  inner  side  are  carefully 
guarded,  and  the  vas  is  dissected  out  and  cleared  as  high  as  possible. 
The  presence  of  an  abscess  or  sinus  is  no  contra-indication,  since  it 
merely  involves  a  somewhat  freer  removal  of  scrotal  integument. 
Should  foci  exist  in  the  body  of  the  testis,  they  are  likely  to  atrophy 


AFFECTIONS  OF  THE  TESTIS,  CORD.  SCROTUM,  ETC.       1283 


subsequently,  or  they  can  be  scraped  out  at  a  later  date.  In  this  way 
the  function  of  the  gland  as  the  producer  of  a  valuable  internal 
secretion  can  be  retained,  although  its  use  as  a  generative  organ  is 
lost — a  retention  the  more  important  owing  to  the  likelihood  of  the 
other  testis  being  subsequently  invaded.  If  the  vas  is  thickened  at 
the  external  abdominal  ring,  it  need  not  deter  the  surgeon  from 
operating,  even  if  the  ve  .icuhe  are  enlarged,  since  tuberculous  disease 
is  not  like  cancer;  if  the  great  bulk  of  the  mischief  is  removed, 
Nature  can  frequently  eliminate  any  small  portion  that  remains.  In 
such  cases  the  inguinal  canal  should  be  freely  opened,  and  the  vas 
traced  backwards  and  divided.  In  one  case  thus  dealt  with,  the 
bladder  was  distended  with  boracic  lotion,  the  patient  placed  in  the 
Trendelenburg  position,  and  the  vas  fol- 
fowed  back  along  the  side  of  the  bladder 
nearly  as  far  as  the  seminal  vesicles. 
For  tuberculous  disease  of  the  seminal 
vesicles,  see  p.  1297. 

Castration  (p.  1296)  is  reserved  for  cases 
where  the  testis  is  disorganized,  and  its 
value  as  a  secreting  gland  totally  de- 
stroyed. Of  course  the  cord  is  also  re- 
moved after  division  as  high  up  as  possible. 

Syphilitic  Disease  of  the  Testicle. — The 
testicle  may  become  affected  by  syphilis, 
either  in  the  late  secondary  or  in  the 
tertiary  stage;  most  commonly  it  results 
from  the  acquired  variety,  but  occasion- 
ally is  met  with  in  the  inherited. 

Secondary  Syphilitic  Epididymitis  is  not 
very  frequently  seen.  It  occurs  in  the 
form  of  a  chronic  enlargement  of  the 
epididymis,  associated  perhaps  with  a 
hydrocele,  about  six  to  twelve  months  after  infection.  The  case  is 
very  similar  to  a  simple  chronic  epididymitis,  but  the  nodular 
thickening  mainly  involves  the  globus  major,  and  is  usually  sym- 
metrical.    It  readily  disappears  on  the  administration  of  mercury. 

Tertiary  Syphilitic  Orchitis  is  observed  at  a  much  later  period  of 
the  disease,  even  twenty  or  thirty  years  after  infection.  It  is  not  un- 
frequently  bilateral.  Pathologically,  it  resembles  the  majority  of 
tertiary  manifestations  in  consisting  of  a  diffuse  infiltration  accom- 
panied by  overgrowth  of  the  connective  tissue.  If  the  process  affects 
equally  the  whole  organ,  the  ordinary  syphihtic  sarcocele  or  sclerosis 
of  the  testis  results ;  if  it  is  more  locaH^ed  in  its  distribution,  the 
gummatous  variety  is  said  to  be  present  (Fig.  569).  The  former 
affection  is  much  more  common  than  the  latter. 

In  the  tertiary  syphilitic  sarcocele,  the  body  of  the  testis  is 
primarily  involved,  and  becomes  evenly  enlarged  and  stony  hard. 
It  is  globular  in  outline,  frequently  accompanied  by  a  hydrocele, 
and  the  normal  testicular  sensation  early  disappears.     The  same 


Fig.  569. — Tertiary  Syphi- 
litic Disease  of  Testis 
with  Gumma  of  the  Body. 
(Treves'  '  Surgery.') 


1284  A  MANUAL  OF  SURGERY 

process  occasionally  extends  to  the  epididymis  and  cord.  Suppura- 
tion is  exceedingly  rare.  On  section  the  characteristic  appearance 
of  a  testicle  has  entirely  vanished;  the  tunica  albuginea  is  much 
thickened,  and  extending  from  it  through  the  substance  of  the  organ 
are  bands  of  connective  tissue,  representing  the  normal  septa;  in 
bad  cases  the  gland  substance  is  almost  comj)letely  destroyed. 

In  the  gummatous  variety  a  similar  condition  involves  the  greater 
part  of  the  organ,  but  in  addition  one  or  more  gummatous  foci  are 
present.  On  section  they  appear  as  yelkn\-ish-\vhite  masses,  fairly 
well  defined,  and  since  the  central  portions  are  non-vascular,  they 
undergo  the  usual  degenerative  changes,  becoming  soft  and  diffluent. 
If  the  gumma  comes  to  the  surface,  the  skin  may  give  way,  and  a 
deep  syphilitic  ulcer  with  a  sloughy  base  like  wet  wash-leather 
results.  Hernia  testis  very  rarely  follows  such  an  occurrence.  The 
clinical  features  of  the  gummatous  variety  are  at  first  similar  to 
those  of  the  former,  but  after  a  time  one  portion  of  the  organ 
becomes  prominent  and  painful,  and  as  this  increases  in  size  the 
central  parts  become  soft  and  fluctuating,  and  finalh'  yield,  giving 
exit  to  the  characteristic  gummy  contents.  Under  suitable  treat- 
ment the  swelling  in  each  of  these  varieties  may  disappear  entirely, 
leaving  the  testicle  either  of  normal  size  or  atrophied;  but,  as  in 
tuberculous  disease,  its  functional  utility,  if  not  entirety  destroyed,  is 
probably  impaired  considerably. 

For  the  differential  diagnosis,  see  p.  1295. 

Treatment  consists  in  the  administration  of  iodide  of  potassium 
and  mercury,  whilst  the  hydrocele  may  be  tapped,  and  the  organ 
strapped  or  supported  by  a  suspender.  If  a  gummatous  ulcer  is 
produced,  it  may  be  possible  to  excise  the  greater  portion  of  the 
characteristic  slough  at  its  base;  but  in  all  cases  it  should  be  dressed 
wath  lint  or  gauze  steeped  in  lotio  nigra  or  some  other  mercurial 
preparation. 

Hernia  Testis  is  the  term  applied  to  a  protrusion  of  the  substance 
of  the  gland,  more  or  less  infiltrated  with  granulation  tissue,  through 
an  opening  in  the  tunica  albuginea  and  skin  of  the  scrotum.  It 
arises  from  various  causes,  such  as  a  septic  penetrating  wound  of 
the  testis,  acute  suppurative  orchitis,  or  from  a  chronic  abscess, 
whether  simple  or  tuberculous  in  nature.  It  is  rarely  produced  by 
the  breaking  down  of  a  gumma,  o\Wng  to  the  extensive  infiltration  of 
the  organ  with  fibro-cicatricial  tissue,  and  necessarily  it  never  follows 
suppuration  in  the  epididymis.  It  is  always  preceded  by  a  condition 
of  increased  pressure  within  the  tunica  albuginea,  and  consequently 
as  soon  as  an  aperture  is  formed  in  this  membrane,  its  natural 
elasticity,  allowing  of  its  contraction,  forces  a  portion  of  its  contents 
out  of  the  opening ;  this  may  even  proceed  to  such  an  extent  as  to 
cause  the  whole  of  the  substance  of  the  gland  to  protrude,  the  tunica 
albuginea  being  practically  turned  inside  out.  A  mass  resembling 
granulation  tissue  is  then  seen  to  project  through  an  opening  in  the 
scrotum;  it  is  often  somewhat  pedunculated  or  mushroom-like  in 
shape,  possibly  overhanging  the  margins  of  the  skin,  but  in  less 


AFFECTIONS  OF  THE  TESTIS.  CORD,  SCROTUM,  ETC.      1285 


advanced  cases  the  integument  may  be  distinctly  undermined. 
A  considerable  discharge  of  pus  usually  accompanies  it.  The 
condition  must  be  distinguished  from  the  fungating  growth  which 
occasionally  results  from  malignant  disease  of  the  organ,  when  the 
protrusion  consists  of  tumour  substance,  with  no  trace  of  testicular 
tissue. 

The  Treatment  of  hernia  testis  usually  consists  in  extirpation  of 
the  organ,  especially  when  it  is  affected  by  tuberculous  disease.  In 
simple  cases  healing  of  the  wound  may  be  obtained  by  keeping  the 
part  aseptic,  and  applying  pressure  by  means  of  a  pad  of  gauze. 
In  other  cases  it  may  be 
possible  to  separate  the 
protruding  mass  from  the 
surrounding  skin,  and  after 
paring  the  edges  of  the 
wound,  to  bring  them  to- 
gether by  sutures,  and  thus 
bury  the  gland  substance, 
which,  however,  remains 
projecting  from  the  opening 
in  the  tunica  albuginea. 
Such  proceedings  are  sel- 
dom very  satisfactory. 

Tumours  of  the  Testis 
are  generally  malignant  in 
character,  only  one  non- 
malignant  form  being  at 
all  common,  viz.,  fibro- 
cystic disease,  or  adenoma 
testis. 

Fibro-Cystic  Disease 
{Syn. :  Adenoma  Testis, 
Cystic  Sarcocele).  —  This 
condition  is  characterized 
by  the  formation  of  a 
tumour  of  variable  size, 
scattered  through  the  sub- 
stance of  which  are  numerous  cystic  cavities,  lined  with  cuboidal  or 
stratified  epithehum.  These  cj^sts  are  usually  rounded,  but  occa- 
sionally tubular  in  shape,  and  may  communicate  with  one  another; 
they  contain  serous  fluid  and  sometimes  intracystic  growths.  They 
are  surrounded  by  connective  tissue,  the  amount  and  character  of 
which  vary  greatly  in  different  cases.  It  consists  mainly  of  simple 
fibrous  tissue,  but  it  is  very  common  to  see  cartilaginous  nodules 
(Fig.  570,  2)  and  mjrxomatous  foci  scattered  through  its  substance, 
and  is  very  prone  after  a  time  to  undergo  a  malignant  transformation. 
According  to  Bland-Sutton  and  Eve,  these  tumours  arise  from  the 
remains  of  the  Wolffian  body  or  mesonephros,  which  is  almost 
always  normally  represented  in  the  neighbourhood  of  the  globus 


Fig.  570. — Fibro-Cystic  Disease   of  the 
Testis.  (College  of  Surgeons'  Museum.) 

I,  Body  of  testis  spread  out  over  the 
growth;  2,  nodules  of  cartilage  contained 
in  the  growth. 


1286  A    MANUAL  OF  SURGERY 

major  of  the  cpididxTnis  by  tlu.-  structure  known  as  tlie  organ  of 
Giraldes  (paradidymis).  Otlicrs  look  on  the  disease  as  a  teratoma. 
The  testicle  can  be  found  in  most  cases  spread  out  in  a  thin  layer 
over  the  tumour  substance  (Fig.  570,  i). 

Clinical  Signs. — This  condition  is  met  with  in  young  adults,  and 
may  possibly  be  attributed  to  an  injury.  The  organ  steadily 
becomes  enlarged,  but  this  gives  rise  to  no  inconvenience  except  by 
its  size  and  weight.  It  is  round  in  outline  and  elastic  in  consistency, 
the  cord  remaining  unaffected  unless  malignant  disease  supervenes. 
When  of  great  size,  the  skin  of  the  scrotum  may  ulcerate.  The 
case  runs  a  chronic  course,  and  even  should  the  growth  become 
malignant,  the  change  of  type  only  appears  late  in  the  disease. 

Treatment  consists  in  removal  after  an  exploratory  incision  has 
dt'monstrated  the  nature  of  the  growth. 

Other  non-malignant  tumours  have  been  described,  such  as  chon- 
droma, osteoma,  fibroma,  myxoma,  etc.,  but  they  are  exceedingly 
uncommon,  if  they  occur  at  all  apart  from  sarcoma  or  fibro-cystic 
disease. 

Sarcoma  oJ  the  Testis  commences  in  the  body  of  the  organ,  either 
within  the  first  decade  of  life  or  between  the  ages  of  thirty  and  forty, 
and  is  sometimes  a  sequela  of  late  or  imperfect  descent.  It  is  usually' 
a  soft,  round-celled  growth,  taking  on  the  form  of  a  lympho-sarcoma ; 
in  other  cases  it  is  harder,  and  of  the  nature  of  a  fibro-sarcoma. 
Frequently  cartilaginous  nodules  are  incorporated  in  its  substance, 
and  patches  of  myxomatous  tissue  or  cystic  degeneration  from 
haemorrhage  are  also  seen.  As  already  stated,  it  is  sometimes  second- 
ary to  fibro-cystic  disease.  It  originates  in  the  connective-tissue 
elements  of  the  organ,  the  glandular  substance  being  early  destroyed. 
It  appears  as  a  rounded  swelling,  and  at  first  its  outline  is  irregularly 
smooth ;  as  the  disease  progresses,  however,  it  may  become  nodulated 
from  the  development  of  cysts.  The  tumour  may  attain  very  large 
dimensions,  but  the  cord  and  scrotal  tissues  only  become  affected  in 
the  later  stages,  and  then  ulceration  and  the  formation  of  a  fungus 
testis  occasionally  follow  with  involvement  of  the  inguinal  Ivmphatic 
glands.  Secondary  growths  are  always  found  in  the  lymphatic 
glands  which  lie  over  the  bifurcation  of  the  aorta  and  vena  cava,  and 
thence  the  disease  is  disseminated  locally  and  may  cause  severe  pain 
by  involvemient  of  the  nerve  roots  of  the  lumbar  plexus,  or  give  rise 
to  visceral  deposits.  There  are  but  few  subjective  s\Tnptoms  at  first, 
a  feeling  of  weight  and  dragging  being  alone  experienced,  whilst 
testicular  sensation  is  soon  lost ;  but  at  a  later  date,  when  the  cord  is 
involved,  pain  and  cachexia  become  very  marked.  The  Course  of 
these  cases  is  slow  up  to  a  certain  point,  but  the  tumour  may  then 
rapidly  increase  in  size,  spreading  along  the  cord  to  the  interior  of  the 
abdomen  even  in  the  course  of  a  few  weeks,  thereby  rendering  re- 
moval utterly  impossible,  although  it  would  have  been  easily  prac- 
ticable at  an  earlier  period.  Treatment  consists  in  the  extirpation  of 
the  growth  with  the  testis  as  early  as  possible,  the  cord  being  divided 
high  up. 


AFFECTIONS  OF  THE  TESTIS.  CORD,  SCROTUM,  ETC.       1287 

Carcinoma  of  the  Testis  is  usually  of  the  encephaloid  type,  and 
arises  in  the  body  of  the  organ  as  a  soft  rapidly-growing  tumour, 
which  soon  extends  to  tlie  tissues  of  the  cord,  and  contracts  adhesions 
to  the  scrotum;  ulceration  and  the  formation  of  a  fungating  mass 
follow,  whilst  secondary  deposits  are  found  in  the  abdominal  and 
inguinal  glands  as  in  sarcoma,  and  sometimes  in  the  viscera.  It  is 
impossible  to  distinguish  a  carcinoma  from  a  sarcoma  of  the  testis  by 
cKnical  signs,  since  it  usually  occurs  at  the  same  period  of  adult  life, 
and  very  rarel}^  in  children.  Very  rapid  growth,  and  early  enlarge- 
ment of  the  cord  and  haiiphatic  glands,  point  to  cancer  rather  than 
sarcoma.  The  only  Treatment  is  removal  of  the  diseased  organ, 
including  the  spennatic  cord,  as  high  as  possible,  and  the  incision 
mav  advisabl}'  be  carried  up  along  the  line  of  the  iliac  vessels  with 
stripping  aside  of  the  peritonemn  and  its  contents  so  as  to  allow  of 
the  exposure  of  the  bifurcation  of  the  aorta  and  the  removal  of  any 
enlarged  glands  in  that  position — a  serious  addition  to  the  operation, 
but  essential,  if  the  patient's  life  is  to  be  saved.  The  outlook  is  any- 
thing but  favourable,  and  becomes  still  less  so  if  the  glands  in  the 
groin  are  involved. 

Hydrocele. — ^Any  collection  of  fluid,  other  than  pus  or  blood,  in 
the  neighbourhood  of  the  testis  or  cord  is  teraied  a  hydrocele.  The 
fluid  usually  consists  of  seriun,  but  in  some  forms  spermatozoa  are 
also  present,  and  in  rare  cases  it  may  consist  of  chyle  or  a  similar 
milkv  fluid  (chylous  hydrocele).  Two  chief  varieties  are  described, 
according  to  whether  the  testis  or  the  cord  is  involved. 

I.  In  Hydrocele  of  the  Testis  the  fluid  is  contained  in  the  tunica 
vaginalis  (vaginal  hvdrocele) ,  or  exists  as  a  circumscribed  swelling  in 
its  neighbourhood  (encysted  hydrocele). 

I.  A  Vaginal  Hydrocele  is  one  in  which  there  is  an  accumulation 
of  fluid  in  the  tunica  vaginalis,  and  the  following  varieties  may  be 
differentiated : 

{a)  Acute  Hydrocele  occurs  in  conjunction  with  acute  inflammation 
of  the  testis  or  epididymis.  The  effusion  of  fluid  is  never  abundant, 
and  is  often  only  made  out  on  careful  examination ;  at  first  it  consists 
of  plasma,  as  in  all  acute  inflammations  of  a  serous  membrane,  and 
is  therefore  spontaneously  coagulable.  It  may  become  chronic,  or 
may  disappear  entirely,  perhaps  leaving  a  few  adhesions. 

(b)  A  Congenital  Hydrocele  occurs  in  cases  in  which  the  funicular 
process  is  stdl  patent.  The  general  signs  of  a  vaginal  hydrocele,  as 
described  below,  are  present,  but  the  fluid  can  be  returned  by 
pressure  into  the  abdominal  cavity.  It  is  rarely  seen  in  others  than 
infants,  and  may  be  treated  by  the  application  of  evaporating  lotion 
to  the  scrotum,  whilst  a  light  truss  or  woollen  support  is  placed  over 
the  inguinal  canal,  as  for  congenital  hernia.  It  is  often  associated 
with  phimosis,  which  should,  of  course,  be  dealt  with  by  circum- 
cision. If  it  persists,  it  may  be  treated  by  operation  as  for  congenital 
hernia,  to  which,  indeed,  it  frequently  leads. 

(c)  An  Infantile  Hydrocele  is  due  to  non-obliteration  of  the  funicu- 


1288  A  MANUAL  OF  SURGERY 

lar  process  of  peritoneum,  except  at  its  upper  extremitv.  It  pre- 
sents the  signs  of  an  ordinary  acquired  hydrocele,  the  fluid,  however, 
extending  along  the  cord,  even  into  the  inguinal  canal.  Its  treat- 
ment is  the  same  as  for  an  acquired  hydrocele. 

(d)  A  Bilocnlar  Hydrocele  is  one  in  which  there  is  an  additional 
loculus  within  the  abdominal  cavity,  communicating  by  a  neck  of 
variable  size  with  the  distended  tunica  vaginahs.  It  is  due  to  a 
persistence  of  the  intra-abdominal  portion  of  the  funicular  process 
between  the  peritoneum  and  internal  abdominal  ring ;  this  becomes 
distended  with  fluid,  and  the  collection  burrows  downwards  in  front 
and  by  the  side  of  the  bladder  towards  the  pelvis.  A  similar  condi- 
tion occurs  in  the  female,  arising  in  the  upper  part  of  the  canal  of 
Nuck. 

[e)  Acquired  Vaginal  Hydrocele  is  the  most  common  variety. 
Causes. — It  may  arise  in  middle-aged  persons  without  any  apparent 
cause,  but  is  usually  associated  with  chronic  orchitis.  A  hydrocele 
almost  always  accompanies  a  tertiary  syphilitic  enlargement  of  the 
organ,  but  is  uncommon  in  tuberculous  or  malignant  disease. 
Hydrocele  is  very  frequently  seen  in  those  who  dwell  in  hot  climates, 
probably  as  the  results  of  a  lax  and  pendulous  condition  of  the 
scrotum  and  testicles;  in  India  natives  always  support  the  scrotum. 
The  tunica  is  usually  thickened  and  hypersemic,  and  that  covering 
the  testis  may  be  pitted  and  scarred.  Here  and  there  thick  plaques 
of  fibrous  material  are  \asible,  sometimes  yello\\4sh  from  fatty 
degeneration,  sometimes  calcified,  or  even  cartilaginous  or  osseous. 

Signs. — Vaginal  hydrocele  appears  as  a  rounded  pyriform  swelHng 
in  the  scrotum,  which  extends  for  a  variable  distance  along  the  cord. 
Its  tension  differs  with  the  amount  of  fluid  present,  and  with  the 
thickness  of  its  walls;  it  is  generally  elastic,  and  with  obvious 
fluctuation.  The  cord  is  felt  distinctly  above  the  rounded  upper 
part  of  the  tumour,  and  the  testis  is  generally  situated  posteriorly 
(Fig.  567,  C),  although  it  projects  forwards  into  the  cavity,  and  is 
thus  not  readily  detected.  Its  position  may  be  ascertained  by 
pressure  over  it,  when  the  characteristic  testicular  sensation  is 
produced.  On  holding  a  light  close  to  the  scrotum,  the  tumour  is 
seen  to  be  translucent,  and  the  position  of  the  testicle  can  also  be 
demonstrated.  In  old-standing  cases  when  the  walls  have  become 
exceedingly  thick,  the  translucency  will  be  lost.  Occasionally,  when 
inflammation  has  existed,  adhesions  may  form  between  the  testis 
and  the  anterior  wall,  and  irregularity  in  the  shape  of  the  tumour  is 
thereby  induced,  or  the  cavity  may  be  divided  into  compartments 
by  fibrous  bands  or  septa. 

As  a  result  of  traumatism,  subcutaneous  rupture  of  a  hydro- 
cele has  occurred,  leading  to  increased  swelHng  of  the  part,  and 
perhaps  cedema  of  scrotum  and  penis;  the  parts  become  bruised, 
but  after  a  time  the  swelling  diminishes,  and  perhaps  a  spontaneous 
cure  follows. 

It  is  scarcely  necessarv  to  mention  that  there  is  no  impulse  on 
coughing,  and  that  the  tumour  is  dull  on  percussion.     When  the 


AFFECTIONS  OF  THE  TESTIS,  CORD.  SCROTUM,  ETC.      1289 

distension  is  very  great,  its  weight  causes  a  dragging  pain ;  the  penis 
becomes  buried  in  the  swelling,  and  ec2;ema  of  the  scrotum  may 
result  from  the  urine  trickling  over  it.  The  fluid  in  the  sac  is 
yellowish  or  straw-coloured;  its  specific  gravity  varies  from  1015  to 
1025 ;  it  contains  a  large  amount  of  albumen,  especially  fibrinogen. 
In  old-standing  cases  cholesterine  may  also  be  present. 

The  Treatment  of  vaginal  hydrocele  is  palHative  or  radical. 
Palliative  treatment  consists  in  tapping  the  cavity  and  removing  the 
fluid,  the  patient  being  subsequently  directed  to  wear  a  suspender, 
and,  where  inflammation  of  the  testis  exists,  to  apply  coohng  lotions. 
For  chronic  orchitis  strapping  of  the  testis  may  be  required. 

In  order  to  tap  a  hydrocele,  the  tumour  must  be  firmly  grasped  in 
the  palm  of  the  left  hand,  and  the  skin  over  its  anterior  wall  purified 
and  made  tense.  A  spot  at  the  antero-inferior  margin  is  then 
selected,  as  free  from  vessels  as 
possible,  and  a  fine  sterihzed  trocar 
and  cannula  inserted  almost  direct- 
ly upwards,  so  as  to  pass  in  front 
of  the  body  of  the  testis  (Fig.  571). 
The  site  selected  for  tapping  must, 
of  course,  vary  with  the  position  of 
the  testicle,  which  should  be  pre- 
viously demonstrated.  The  fluid 
having  been  withdrawn,  the  can- 
nula is  removed  and  the  puncture 
covered  with  wool  and  collodion. 
The  condition  usually  recurs  after 
a  longer  or  shorter  period,  and  the 
operation  may  then  be  repeated. 
If  a  dirty  instrument  is  employed, 
inflammation,  and  even  suppura- 
tion, may  follow,  whilst  if  a  vessel 
or  the  body  of  the  testis  is  punc-  Fig.  571 
tured,  a  haematocele  may  result. 

Radical  treatment  consists  in  in- 
jection of  the  cavity,  or  excision  of 
the  lining  membrane,    (i.)  Injection 

of  the  cavitv  after  tapping  has  long  been  a  favourite  method.  Many 
different  reagents  have  been  employed,  such  as  port  ^\'ine,  tincture  of 
iodine,  solution  of  corrosive  sublimate  (i  in  500),  or  glycerine  of 
carboHc  acid.  Perhaps  the  best  is  the  tincture  of  iodine,  but  that 
contained  in  the  British  Pharmacopoeia  is  not  strong  enough,  and 
the  old  Edinburgh  tincture,  which  is  nearly  the  same  strength  as  the 
Hn.  iodi,  B.P.,  should  be  emploj^ed.  The  amount  used  varies  with 
the  size  of  the  hydrocele,  but  for  one  of  moderate  dimensions  it  mil 
suffice  to  inject,  after  tapping,  2  drachms  of  the  tincture,  and  after 
manipulating  it  well  ^vithia  the  cavity,  a  part,  say  i  drachm,  is 
allowed  to  escape.  Smart  mflammatory  reaction  follows,  and  a 
cure  may  result,  probably  from  obHteration  of  the  vaginal  space 


•Method  of  Tapping  a 
Hydrocele. 

Te,  Testis ;  Ep,  epididiTnis ; 
Hy,  hydrocele. 


I290 


A  MANUAL  OF  SURGERY 


by  tlie  formation  of  adhesions.  In  a  certain  ]iert;entage  of  cases 
failure  may  be  expected,  and  this  is  more  likely  to  ha])pen  if  too 
weak  an  irritant  has  been  employed,  or  if  the  hydrocele  is  a  chronic 
one  \\nth  thick  and  indurated  walls,  or  has  been  tapped  on  several 
previous  occasions,  (ii.)  The  open  method  of  operation  is  now 
generally  adopted,  and  is  particularly  recommended  in  large  and 
chronic  cases.  The  hydrocele  is  cut  down  on  through  an  incision 
in  the  upper  part  of  the  scrotum,  and  the  tunica  vaginalis  isolated 
from  the  superjacent  structures.  The  cavity  is  opened,  and  the 
parietal  portion  of  the  tunica  snipped  away  with  scissors  close  to 
the  testicle.  A  number  of  vessels  will  need  to  be  ligatured;  a 
drainage-tube  is  inserted,  and  the  wound  closed  in  the  ordinary 

wa3^     The  results  of  this  practice  are 
most  satisfactory. 

When  the  sac  is  not  too  largi>,  and  the 
tunica  supple  and  uninfiltrated,  it  often 
suffices  to  turn  it  inside  out,  and  stitch 
its  edges  to  the  back  of  the  epidid}Tiiis. 
In  infants  hydrocele  is  by  no 
means  uncommon,  and  may  be,  but 
is  not  always,  of  the  congenital  type. 
The  communication  is  sometimes  very 
small,  so  that  reduction  is  impractic- 
able, although  on  lying  up  the  cavity 
slowly  empties ;  it  is  desirable  to  make 
certain  as  to  this  point  before  under- 
taking treatment.  If  the  sac  com- 
municates with  the  peritoneal  cavity, 
it  may  be  treated  as  a  hernia  by  truss 
pressure,  or  more  satisfactorily  by 
operation.  If  no  communication  exists, 
many  cases  get  well  spontaneously, 
but  as  a  useful  placebo  the  scrotum  may 
be  painted  over  frequently  with  a  lotion 
of  chloride  of  ammonium  (grs.  x. 
ad  si.  mixed  with  rectified  spirit  and 
water) ;  faihng  this,  acupuncture  may  be  tried,  the  fluid  being 
allowed  to  escape  into  the  scrotal  tissues;  in  the  few  cases  in  which 
this  fails,  an  open  operation  (incision  with  drainage  or  partial 
removal  of  the  sac)  will  be  required. 

2.  Encysted  Hydrocele  of  the  testis  occurs  in  two  main  forms, 
according  to  whether  it  arises  in  connection  with  the  epididymis 
or  the  bodv  of  the  testis. 

{a)  Encysted  Hydrocele  of  the  Epididymis  exists  usually  as  a  rounded 
globular  sweUing,  tense  and  elastic  in  consistency,  and  translucent. 
It  is  situated  above  the  body  of  the  testis,  and  close  to  the  head  of 
the  epididymis  (Fig.  572 ) .  As  a  rule,  it  does  not  attain  a  size  greater 
than  that  of  the  body  of  the  testis  itself,  so  that  it  may  appear  as  if 
a  double  testicle  was  present ;  the  hydrocele  is,  of  course,  devoid  of 


Fig.  572. — Encysted  Hydro- 
cele       OF        Epididymis. 

■^  (College  of  Surgeons' 
Museum.) 


AFFECTIONS  OF  THE  l^ESTIS,  CORD,  SCROTUM,  ETC.       1291 

testicular  sensation.  Less  frequently  it  may  attain  considerable 
dimensions,  even  projecting  below  and  around  the  testicle  which, 
though  enveloped  by  it,  is  quite  distinct  from  it.  The  fluid  con- 
tained within  these  cysts  is  usually  milky  and  opalescent  in  appear- 
ance, owing  to  an  admixture  of  semen;  under  the  microscope 
spemiatozoa,  either  hving  or  dead,  can  be  demonstrated ;  on  account 
of  this  it  is  sometimes  termed  a  spermatocele.  The  specific  gravity 
is  lower  than  that  of  ordinary  hydrocele  fluid,  and  there  is  but  little 
albumen.  The  origin  of  these  cysts  has  given  rise  to  much  dis- 
cussion. They  are  of  a  very  different  nature  to  the  ordinary 
vaginal  hydrocele,  or  even  to  the  encysted  hydrocele  of  the  cord, 
since  the  walls  are  not  lined  with  endothehum,  but  with  cuboidal 
or  columnar  epithehum.  They  are  probably  due  either  to  a  dilata- 
tion of  one  or  more  of  the  vasa  efferentia  testis,  or  more  frequently 
to  distension  of  some  of  the  foetal  relics  always  found  near  the  head 
of  the  epididymis,  especially  of  those  known  as  Kobelt's  tubes; 
these,  as  also  the  vasa  efferentia  testis,  are  derived  from  the  tubules 
of  the  Wolffiian  body,  differing,  however,  from  them  in  not  becoming 
attached  to  the  body  of  the  testis  (Fig.  72,  p.  230).  They  are  thus 
homologous  with  the  parovarian  cysts  found  in  the  female.  Smaller 
pedunculated  cysts  containing  clear  serum  are  sometimes  met 
with  in  this  region,  arising  from  a  distension  of  the  hydatid  of 
Morgagni,  which  is  developed  from  the  remains  of  the  Miillerian 
duct. 

Treatment  is  conducted  along  the  same  hues  as  for  vaginal  hydro- 
cele, viz.,  by  tapping  as  a  palHative  measure,  and  injection  or  ex- 
cision in  order  to  establish  a  radical  cure. 

{h)  Encysted  Hydrocele  of  the  Tunica  Albuginea  is  a  condition  rarely 
seen,  consisting  of  a  small  collection  of  serous  fluid  beneath  the 
visceral  portion  of  the  tunica  vaginalis.  It  is  probably  due  to 
dilatation  of  lymphatic  spaces,  and  has  absolutely  no  clinical  sig- 
nificance. 

IL  Hydrocele  of  the  Cord  occurs,  as  already  described,  in  connec- 
tion with  the  congenital  and  infantile  varieties  of  vaginal  hydrocele. 
If  limited  to  the  cord,  it  exists  in  one  of  two  forms,  the  encysted  or 
the  diffuse. 

I.  Encysted  Hydrocele  of  the  Cord  arises  from  imperfect  obHtera- 
tion  of  the  funicular  process  of  peritoneum,  the  patent  portion 
becoming  distended  with  fluid  and  giving  rise  to  a  cavity  lined  ^yith 
endothehum.  It  is  usually  detected  as  a  rounded  elastic  swelHng, 
occupying  the  inguinal  canal,  moving  freely  up  and  down  within 
it.  The  upper  border  is  sharply  limited,  and  in  favourable  cases 
translucency  can  be  demonstrated.  On  fixing  the  testicle  the  cyst 
is  no  longer  moveable.  The  fluid  contained  within  it  is  identical 
in  nature  with  that  in  a  vaginal  hydrocele.  In  the  female  a  similar 
condition  arises  from  imperfect  obhteration  of  the  canal  of  Nuck, 
giving  rise  to  what  is  known  as  a  hydrocele  of  the  round  ligament. 
Treatment  consists  in  removal  of  the  fluid  by  tapping,  or,  if  a  more 
radical  proceeding  is  necessary,  by  injection  or  excision. 


1292 


A   MANUAL  OF  SURGERY 


2.  Diffuse  Hydrocele  of  the  Cord  is  but  rarely  seen.  It  results 
from  a  diffuse  cedema  of  its  cellular  tissue,  and  presents  on  ex- 
amination a  fusiform  or  sausage-shaped  tumour,  which  extends 
along  the  cord  for  a  variabk'  distance. 

The  term  Chylous  Hydrocele  is  applied  to  a  distension  of  the  tunica 
vaginalis  with  chylous  fluid,  recognised  by  being  milky  in  appear- 
ance, and  under  the  microscope  seen  to  consist  of  a  fatty  emulsion. 
Several  modes  of  origin  have  been  suggested,  but  none  are  very 
satisfactory.  In  one  case  under  our  care,  a  series  of  dilated  Utti- 
phatics  filled  with  a  similar  fluid  extended  upwards  from  the  testicle 
to  the  inguinal  canal. 

Varicocele. — A  varicose  condition  of  the  pampiniform  plexus 
(Fig.  ^y_^)  is  very  commonly  met  with  in  young  men,  but  seldom  in 

those  of  advanced  age,  except  when  it  has 
become  chronic,  or  is  due  to  mahgnant 
disease, of  the  kidney  (p.  121 1).  It  usually 
occurs  in  individuals  with  a  lax  and  pen- 
dulous scrotmn,  and  is  often  associated 
with  masturbation,  which  induces  abnor- 
mal vascularity  of  the  testis.  The  fact 
that  it  sometimes  develops  in  quite  young 
boys  suggests,  however,  that  there  is  some 
congenital  condition  associated  with  it. 
It  may  also  be  caused  by  the  pressure  of  a 
truss  applied  for  the  relief  of  a  hernia.  It 
is  almost  invariably  on  the  left  side,  and 
the  reasons  given  for  this  are  as  follows: 
{a)  The  left  testis  usually  hangs  lower  than 
the  right,  and  hence  the  spermatic  veins 
are  longer  and  exposed  to  greater  blood 
pressure.  {b)  The  left  spermatic  vein 
opens  into  the  left  renal  vein  at  right 
angles,  and  no  valve  is  present  at  the 
orifice,  whilst  that  on  the  right  side  opens 
obliquely  into  the  vena  cava  and  is  valved.  (c)  The  presence 
of  the  sigmoid  flexure  on  the  left  side  of  the  body,  and  its  dis- 
tension by  accumulated  fseces  as  a  result  of  constipation,  may  lead 
to  pressure  on  the  abdominal  portion  of  the  left  spermatic  vein. 

A  varicocele  is  characterized  by  the  presence  of  a  soft  irregular 
swelling  in  the  scrotum,  which  is  somewhat  p^-ramidal  in  shape, 
the  main  mass  being  below  and  slightly  overlapping  the  testis,  and 
the  apex  above.  It  consists  of  dilated  and  tortuous  veins,  the  out- 
lines of  which  can  often  be  seen  through  the  skin  (Fig.  574).  They 
impart  a  sensation  to  the  finger  which  has  been  likened  to  a  collec- 
tion of  worms  in  a  bag;  there  is  a  distinct  impulse  down  the  veins 
on  coughing.  On  assuming  the  recumbent  posture  the  swelling 
almost  disappears,  owing  to  the  vessels  being  emptied  of  their  con- 
tained blood;  if  pressure  is  subsequently  applied  over  the  external 


Fig.  573.  — ^Varicocele. 
(Treves'  'Surgery.') 


AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  ETC.      1293 

abdominal  ring,  and  the  patient  allowed  to  stand,  the  tumour  re- 
appears, lining  from  below  upwards.  A  sensation  of  weight  and 
pain  usually  accompanies  a  varicocele,  whilst  severe  neuralgia  of 
the  testis  may  be  induced.  It  is  a  frequent  source  of  seminal  emissions, 
and  may  result  in  testicular  atroph}'.  Phlebitis  is  liable  to  follow 
an  injury,  and  may  lead  to  a  spontaneous  cure;  if  one  of  the  dilated 
veins  is  ruptured,  severe  hcemorrhage  ensues,  causing  a  diffuse 
li;ematocelc  of  the  cord.  In  favourable  cases  the  condition  dis- 
appears spontaneously. 

The  Diagnosis  of  varicocele  is  easily  made,  the  only  condition  foi 
which  it  is  likely  to  be  mistaken  being  an  omental  hernia ;  the  differ- 
ence between  the  two  conditions  has  been  discussed  at  p.  1095. 

The  Treatment  of  slight  cases  of  varicocele  consists  in  supporting 
the  testicle  and  scrotum  by  means  of  a  well-fitting  suspender,  whilst 


Fig.  574. — Large  Varicocele  in  a  Patient  aged  35  Years,  who  had  used 
No  Support  for  Many  Years. 

the  patient  is  also  instructed  to  bathe  the  parts  with  cold  water  night 
and  morning,  and  to  take  such  measures  as  shall  ensure  a  daily 
action  of  tha  bowels. 

Radical  Treatment  by  excision  of  the  veins  is  advisable  in  neuralgic 
cases,  where  atrophy  of  ths  testis  is  threatening,  or  in  order 
to  fit  the  patient  for  admission  into  any  of  the  pubhc  services. 
The  operation  is  conducted  as  follows:  The  pubic  region  having 
been  shaved  and  purified,  an  incision  i|  inches  long  is  made  in  the 
direction  of  the  cord,  with  its  centre  a  little  below  the  external 
abdominal  ring.  The  structures  of  the  cord  are  raised  on  the 
fingers,  and  the  coverings  divided,  so  as  to  expose  the  spermatic 
veins  at  their  upper  end.  Two  main  branches  are  usually  found  in 
this  situation,  but  occasionallv  there  is  onty  one.  These  are  cleaned 
and  carefully  isolated  from  the  other  structures  of  the  cord,  and  a 
ligature  is  apphed  to  them  at  the  external  abdominal  ring.     The 


1294  A   MANUAL  OF  SURGERY 

vessels  are  now  clamped  with  a  pair  of  Spencer  Wells  forceps 
below  the  ligature,  and  divided  between  it  and  the  forceps.  The 
lower  end,  grasped  by  the  forceps,  is  stripped  downwards,  so  as  to 
free  the  pampiniform  plexus  from  the  other  elements  of  the  cord, 
and  the  dissection  can  be  carried  nearly  as  far  as  the  epididymis  by 
drawing  the  testicle  up  into  the  wound.  The  lower  end  of  the  veins 
is  ligatured  in  one  or  two  portions  and  divided.  By  this  means  the 
whole  varicocele  is  removed.  If  the  scrotmn  is  pendulous,  and  the 
testicle  hangs  low,  it  may  be  advisable  to  raise  it  by  tying  the  upper 
and  lower  ligatures  together,  care  being  taken  not  to  pull  them  off 
in  so  doing;  perhaps  it  is  wiser  to  introduce  a  suture  through  the 
divided  ends  of  the  veins  above  and  below,  which  are  purposely  left 
long.  The  wound  is  then  closed  without  a  drainage-tube,  and 
dressed  as  usual.  The  patient  is  kept  in  the  recumbent  posture  for 
a  fortnight,  until  organization  has  occurred  in  the  di\'idtd  ends  of  the 
veins,  and  a  finn  cicatrix  has  formed.  This  method  of  treatment  is 
infinitely  superior  to  that  often  practised  of  exposing  the  veins  in  the 
scrotum,  since  a  wound  in  the  groin  always  heals  much  more  readily 
than  one  in  the  scrotum ;  whilst  it  is  easier  to  dissect  the  veins  out 
from  above,  where  only  one  or  two  trunks  exist.  The  venous  return 
after  the  operation  is  maintained  by  the  vein  or  veins  running  with 
the  artery  to  the  vas  in  the  posterior  portion  of  the  cord.  Occasion- 
ally, if  the  removal  of  veins  has  been  too  complete,  a  hydrocele 
develops  subsequently,  owing  to  the  passive  congestion  of  the  testis. 
It  is  usually  unnecessary  to  remove  any  scrotal  integument,  although 
it  is  often  redundant;  but  after  the  wound  is  soundly  healed,  the 
dartos  may  be  stimulated  daily  by  brushing  the  scrotum  with  a 
clothes-brush. 

Neuralgia  of  the  Testis  is  characterized  by  the  organ  becoming 
exquisitely  tender  and  painful,  although  apparently  healthy.  It 
usually  occurs  in  young  adults  of  nervous  temperament,  or  in 
middle-aged  gouty  men.  It  is  not  uncommonly  associated  with 
a  varicocele.  The  pain  is  usually  paroxysmal  in  character,  and  very 
intractable.  Treatment  must  be  directed  mainly  to  the  general 
health,  consisting  in  the  administration  of  nerve  tonics,  such  as  iron 
and  quinine,  whilst  locally  sedatives,  e.g.,  belladonna  and  aconite, 
may  be  applied.  It  is  also  advisable  that  a  suspender  should  be 
worn. 

Atrophy  of  the  Testis  results  from  several  causes:  (i.)  It  may  be 
due  to  a  congenital  arrest  of  development,  as  met  with  in  displace- 
ment or  late  descent,  (ii.)  It  is  most  frequently  the  consequence  of 
inflammatory  affections,  either  of  the  body  or  epidid\Tnis,  o\\ang  to 
the  cicatricial  contraction  caused  thereby  leading  to  compression  of 
the  vessels.  It  occasionally  follows  the  metastatic  orchitis  of  mimips, 
especially  in  adults,  whilst  it  is  also  due  to  syphilitic  disease,  (iii.)  It 
arises  from  impaired  nutrition,  as  after  the  di\dsion  of  the  supplying 
arteries  in  operations  for  varicocele  or  hernia,  or  from  compression 
of  the  cord  by  closing  the  inguinal  canal  too  finnly  in  the  operation 
for  the  radical  cure  of  hernia.     It  appears,  however,  that  division  of 


AFFECTIONS  OF  THE  TESTIS,  CORD.  SCROTUM,  ETC.      1295 

the  spermatic  vessels  alone  will  not  suffice  to  determine  atrophy,  if 
the  artery  to  the  vas  with  its  accompanying  veins  and  nerves  are 
preserved  intact,  (iv.)  Chronic  congestion  of  the  organ,  as  by  a 
varicocele,  may  induce  atrophy;  whilst  (v.)  sexual  excesses  are  also 
stated  to  lead  to  it.  If  unilateral,  it  is  of  comparatively  little  impor- 
tance ;  but  where  both  organs  are  affected,  sterility  is  sure  to  result, 
and  the  patient,  if  previously  young  and  healthy,  is  likely  to  become 
depressed  in  spirits  and  melancholic.  This  may  be  due  in  part  to 
mental  causes,  but  also  in  measure  to  the  absence  of  seminal  secre- 
tion, the  re-absorption  of  which  into  the  system  is,  according  to 
Brown-Sequard,  an  important  factor  in  the  maintenance  of  a  vigorous 
state  of  mind  and  body. 

General  Diagnosis  of  Scrotal  Tumours. 

When  a  patient  presents  himself  for  examination  with  a  swelhng 
in  the  scrotum,  the  surgeon  has  to  decide  whether  it  is  a  hernia,  a 
hydrocele,  a  haematocele,  a  varicocele,  or  a  sohd  enlargement  of  the 
testis,  and,  if  the  latter,  of  what  nature.  The  first  point  to  which 
attention  is  directed  is  the  condition  of  the  cord  immediately  below 
the  external  ring.  If  this  is  of  normal  si2;e  and  consistency,  hernia 
and  diffuse  hydrocele  of  the  cord  are  thereby  excluded,  whilst  the 
existence  of  a  rounded  tense  swelHng,  moveable  within  the  canal, 
but  becoming  fixed  on  holding  the  testis,  indicates  that  an  encysted 
hydrocele  of  the  cord  is  probably  present.  When,  however,  the 
cord  is  more  or  less  masked,  further  examination  speedily  deterrnines 
whether  a  hernia  or  a  diffuse  hydrocele  or  haematocele  of  the  cord 
exists,  since  the  former  is  often  reducible,  has  an  impulse  on  cough- 
ing, and  is  rounded  or  nodular  in  outline,  and  the  latter  are  sausage- 
shaped,  always  irreducible,  and  semi-fluctuating. 

When  the  swelhng  is  purely  scrotal,  inspection  and  manipulation 
will  at  once  decide  if  it  is  a  varicocele,  by  its  characteristic  feel,  by 
its  disappearance  on  assuming  the  recumbent  posture,  and  filling 
again  from  below  on  standing  up.  If  the  swelling  is  rounded  in 
outhne,  the  next  point  to  be  determined  is  whether  it  is  solid  or  fluid. 
If  fluid,  it  is  probably  a  hydrocele,  or  the  early  stage  of  a  hemato- 
cele; the  translucency  of  the  former,  and  the  sudden  appearance  and 
non-translucency  of  the  latter,  should  suffice  to  demonstrate  its 
nature.  It  is  possible  that  the  hydrocele  is  merely  a  secondary  com- 
phcation,  and  hence  no  final  opinion  should  be  given  until  it  has  been 
tapped,  and  the  condition  of  the  body  of  the  testis  investigated.  If 
however,  a  solid  mass  exists  in  the  scrotum,  it  is  either  a  hemato- 
cele in  its  later  stages,  or  some  form  of  sarcocele,  whether  simple, 
syphilitic,  tuberculous,  or  neoplastic.  A  hcematocele  is  possibly  recog- 
nised by  its  history,  and  by  there  being  a  fluid  centre  to  the  swelling, 
surrounded  by  solidified  tissue.  Chronic  orchitis  and  syphilitic 
enlargement  of  the  testis  are  so  much  alike  as  to  render  diagnosis 
always  uncertain  in  the  absence  of  a  distinct  syphihtic  history;  but 
if  the  swelling  is  extremely  hard,  with  a  smooth  and  regular  outline. 


I2g6  A   MANUAL  OF  SURGERY 

without  testicular  sensation,  limited  to  the  body  of  the  testis,  and 
accompanied  by  a  hydrocele,  it  is  probably  syphilitic.  Tuberculous 
disease,  on  the  other  hand,  occurs  more  frequently  in  younger  in- 
dividuals than  does  the  syphiHtic  variety,  whilst  the  epididymis 
is  usually  first  attacked,  becoming  nodulated,  the  cord  is  early 
implicated,  l^drocele  is  rare,  suppuration  is  frequent,  and  testicular 
sensation  remains  till  the  body  of  the  testis  is  disorganized.  Tumours 
always  impart  a  distinct  sense  of  weight  to  the  hand,  quite  different 
to  that  noticed  in  tul^erculous  or  syphilitic  disease;  if  a  simple 
tumour  is  present,  it  is  rounded,  slow  in  growth,  and  the  cord  is 
unaffected.  Malignant  disease  is  characterized  by  rapid  growth, 
more  severe  pain,  and  early  implication  of  the  structures  of  the  cord 
and  of  the  lumbar  lymphatic  glands.  The  enlargement  of  both 
testes  is  in  favour  of  tubercle  or  syphilis  rather  than  of  malignant 
disease.  A  certain  small  number  of  cases  will  remain  where,  in 
spite  of  every  care,  the  nature  of  the  mass  is  still  a  matter  of  doubt ; 
in  such  the  diagnosis  cannot  be  established  without  puncture  or 
an  exploratory  incision. 

Whilst  weighing  carefully  the  local  conditions,  we  must  not  omit 
thoroughly  to  investigate  and  appreciate  the  general  history  and 
condition  of  the  patient,  his  age,  appearance,  previous  habits  and 
illnesses,  etc.  At  the  same  time,  an  examination  of  the  internal 
organs  should  be  made  to  ascertain,  as  far  as  possible,  the  existence 
or  not  of  concurrent  disease — e.g.,  tuberculous  disease  of  the  lungs 
or  kidneys,  or  secondary  malignant  deposits. 

Castration  is  required  for  many  different  conditions,  which  have 
been  already  described — e.g.,  for  malposition,  tuberculous  disease, 
old-standing  hsematoceles,  and  simple  or  malignant  tumours.  The 
operation  is  conducted  as  follows :  The  pubes  and  perineum  having 
been  previously  shaved  and  purified,  the  surgeon,  standing  on  the 
same  side  of  the  patient  as  the  organ  to  be  removed,  makes  an 
incision  down  to  the  testis.  If  large  and  adherent  to  the  scrotal 
tissues,  the  incision  must  necessarily  involve  the  scrotum,  but 
wherever  practicable  it  is  wise  to  avoid  the  scrotal  integuments, 
making  the  incision  over  the  cord.  It  should  always  extend  up- 
wards as  far  as  the  external  abdominal  ring,  so  as  to  enable  the 
structures  of  the  cord  to  be  divided  high  up — a  most  important 
matter  in  tuberculous  and  mahgnant  disease;  the  inguinal  canal 
can  then  also  be  closed,  if  necessary.  The  testis  or  tumour  is 
enucleated  from  its  surroundings,  and  the  cord  isolated  and  divided 
as  high  as  possible,  after  transfixing  and  securety  ligaturing  it  with 
silk.  Some  surgeons  prefer  to  separate  the  tissues  of  the  cord,  and 
to  take  them  up  individually,  but  this  is  a  matter  of  little  import- 
ance. The  stump  should  not  be  allowed  to  slip  back  into  the  canal 
until  all  bleeding  has  completely  stopped,  and  it  has  been  suggested 
that  the  cut  end  of  the  vas  should  be  touched  with  pure  carbolic 
acid  as  a  precautionary  measure.  All  bleeding  points  in  the  scrotum 
are  now  secured  by  ligature,  and  these  may  be  numerous;  the 
wound  is  closed  by  sutures,  a  drainage-tube  being  inserted  in  the 


AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  ETC.       1297 

scrotum,  and  by  choice  coming  to  the  surface  at  the  upper  end  of 
the  wound — that  is,  as  far  from  the  perineum  as  possible. 

In  the  performance  of  double  castration,  it  is  recommended  to 
make  two  crescentic  incisions  from  side  to  side,  so  as  to  include 
between  them  a  portion  of  the  scrotal  integument,  in  order  to  reduce 
the  subsequent  redundancy  of  unnecessary  tissue. 

Affections  of  the  Vesiculse  Seminales. 

Acute  Vesiculitis  is  not  often  met  with,  but  sometimes  arises,  in  association 
with  prostatitis,  as  a  comphcation  of  gonorrhoea.  It  is  characterized  by  deep- 
seated  pain  in  the  perineum,  together  with  irritabihty  of  the  neck  of  the  bladder 
and  increased  frequency  of  micturition.  Defaecation  becomes  painful,  and  on 
examination  of  the  rectum  the  vesiculae  can  be  felt  enlarged  and  tender.  If 
suppuration  ensues,  an  abscess  forms,  which  usually  bursts  into  the  rectum,  but 
sometimes  into  the  bladder  or  peritoneal  cavity.  As  a  rule,  the  condition  dis- 
appears pari  passu  with  the  gonorrhoea;  but  when  suppuration  has  supervened, 
it  is  advisable  to  open  the  abscess  by  a  deep  incision  through  the  perineum, 
guided  by  a  finger  in  the  rectum. 

Subacute  or  Chronic  Vesiculitis  is  not  uncommon,  the  latter  condition  being 
often  associated  with  prostatitis,  and  one  of  the  most  frequent  causes  of  gleet. 
Seminal  emissions  and  priapism  may  be  caused  by  it,  and  the  enlarged  organ 
can  be  felt  through  the  rectum.  A  good  deal  of  pain,  often  referred  to  the 
back,  is  experienced.     The  treatment  is  the  same  as  for  chronic  prostatitis. 

Tuberculous  Disease  attacks  the  vesiculae  seminales  as  a  result  of  extension 
from  the  testis  along  the  vas,  being  almost  always  associated  with  similar  dis- 
ease of  the  prostate  and  base  of  the  bladder.  The  organs  can  be  felt  enlarged, 
and  if  suppuration  occurs,  the  abscess  may  burst  into  the  rectum  or  bladder,  or 
possibly  into  both,  a  recto-vesical  fistula  being  thereby  developed.  It  is 
possible  to  reach  the  vesiculae  through  a  semilunar  incision  in  the  perineum, 
displacing  the  rectum  backwards,  and  the  bladder  and  prostate  forwards,  or 
from  behind  by  removing  the  coccyx  and  part  of  the  sacrum,  as  in  Kraske's 
operation.  When  exposed,  complete  excision  is  sometimes  possible,  or  an 
opening  is  made  into  them,  and  the  cheesy  contents  scooped  out. 

Affections  of  the  Scrotum. 

Injuries  of  the  Scrotum. — Contusions  and  blows  give  rise  to  ecchymosis, 
which  niay  be  so  extensive  as  to  warrant  the  term  hcBWiatoma  scroti  which  has 
been  applied  to  it. 

Incised  wounds  may  affect  the  skin  and  subcutaneous  tissues,  or  may  lay 
open  the  tunica  vaginalis,  with  or  without  protrusion  of  the  testicle.  All  that 
is  needed  in  such  cases  is  to  render  the  wound  aseptic,  and  to  deal  with  it  on 
general  principles.  Considerable  destruction  of  scrotal  tissue  may  be  repaired 
by  transplantation  of  flaps  from  the  inguinal  region,  or  by  grafting  according 
to  Thiersch's  method. 

Cellulitis  of  the  Scrotum  most  commonly  results  from  extravasation  of  urine, 
for  which  see  p.  1268.  It  may  occasionally  arise  from  other  causes,  and  leads 
to  great  constitutional  disturbance,  usually  of  an  asthenic  type,  and  often  to 
considerable  sloughing ;  the  testes  may  be  exposed  when  the  sloughs  come  away, 
or  may  even  be  involved  in  the  same  process.  As  a  general  rule  repair  is  very 
active  in  the  scrotum. 

(Edema  of  the  Scrotum  is  usually  due  to  dropsy,  being  often  associated  with 
general  anasarca  and  ascites.  It  may  attain  considerable  dimensions.  Acute 
inflammatory  cedema  of  the  scrotum  is  a  term  sometimes  applied  to  erysipelas 
affecting  this  region,  on  account  of  the  absence  of  the  vivid  red  colour  usually 
caused  by  that  affection.  Considerable  oedema  is  always  present,  and  gan- 
grene of  the  skin  may  result.     A?  soon  as  the  gangrene  becomes  limited,  it 

82 


1298  A   MANUAL  OF  SURGERY 

should  be  excised,  and  the  margins  of  the  wound  brought  together  by  sutures, 
or  allowed  to  heal  by  granulation. 

Scrotal  FistulSB  arc  usually  due  to  the  bursting  of  abscesses  in  connection 
with  the  urethra  (see  I'erineal  Abscess). 

Sinuses  of  the  Scrotum  are  often  found  in  connection  with  tuberculous  or 
s\-phditic  disease  of  the  testicle. 

Eczema  of  the  Scrotum  is  a  troublesome  affection,  giving  rise  to  great  pruritus 
ami  irritation.  It  results  from  the  presence  of  pediculi,  but  the  more  chronic 
forms  occur  amongst  workers  in  tar  and  paraffin,  and  also  in  chimney-sweeps, 
being  due  to  the  constant  irritation  of  the  corrugated  scrotal  integument  by 
dirty  clothes.  It  is  characterized  by  the  presence  of  warty  outgrowths,  and 
not  unfrequently  runs  on  to  epithelioma,  originating  the  condition  known  as 
chimnev-siveep's  or  paraffin  cancer.  The  usual  characteristics  of  such  a  new 
growth  are  present,  and  in  some  of  the  deeper  cells  particles  of  soot  have  been 
demonstrated.  The  inguinal  glands  are  usually  involved,  but  not  till  late,  and 
the  progress  of  the  case  is  slow.  The  only  treatment  which  can  be  adopted  is 
complete  removal,  together  with  the  inguinal  glands. 

For  Elephantiasis  Scroti,  see  p.  362. 


CHAPTER  XLIII. 
SURGERY  OF  THE  FEMALE  GENITAL  ORGANS.* 

Affections  of  the  Vulva. — Injuries  to  the  External  Genitalia  may 

arise  from  direct  violence,  or  during  parturition  from  the  forcible 
expulsion  of  the  head.  In  the  non-pregnant  condition  the  results 
differ  but  little  from  other  similar  lesions,  and  require  no  special 
treatment  or  consideration.  Occasionally  a  kick  or  a  fall  on  a  stick 
or  paling  may  result  in  laceration  of  the  recto-vaginal  septum.  The 
wound  is  usually  contused,  and  the  margins  irregular,  so  that  im- 
mediate suture  is  unlikely  to  succeed.  The  parts  are  therefore  kept 
clean  by  frequent  douches  and  allowed  to  granulate,  and  the  loss 
of  substance  is  in  that  way  often  made  good;  should  a  fistula  persist, 
a  plastic  operation  will  be  subsequently  necessary.  Of  course,  if 
the  original  injury  is  a  clean  incision,  immediate  operation  to  close 
the  defect  is  desirable. 

In  the  pregnant  state  or  when  large  varicose  veins  are  present,  an 
injury  to  the  vulva  may  result  in  serious  haemorrhage  if  there  is  an 
external  wound,  or  in  the  formation  of  a  large  hcematoma.  The 
labium  becomes  much  swollen  and  firm  to  the  touch,  o\ving  to  the 
coagulation  of  the  blood;  suppuration  often  follows,  especially  if  the 
injury  is  associated  with  a  superficial  abrasion.  Treatment. — If  the 
hsematoma  should  hinder  parturition,  it  may  be  necessary  to  incise 
it  at  once  and  turn  out  the  blood-clot.  Under  other  circumstances 
it  may  be  treated  by  the  application  of  cooling  lotions ;  but  should 
it  persist  or  if  suppuration  ensues,  operation  will  be  required;  the 
cavity  is  opened,  emptied  and  packed  with  gau2;e  to  ensure  healing 
by  granulation. 

Varix  of  the  vulva  is  not  unfrequently  associated  with  a  similar 
condition  in  the  legs,  or  may  sometimes  arise  as  a  result  of  block- 
ing of  the  external  iliac  vein,  owing  to  the  opening  up  of  collateral 
branches.  One  or  two  veins  may  become  enlarged,  often  running 
transversely  across  the  Mons  Veneris,  or  large  bunches  of  veins  may 

*  It  is  impossible  in  a  work  of  this  size  to  include  more  than  a  comparatively 
brief  notice  of  the  more  important  gynaecological  conditions  which  encroach  on 
the  domain  of  the  general  surgeon.  As  a  means  of  distinction  we  have  con- 
sidered that  all  vaginal  operations,  etc.,  are  purely  gynaecological,  whilst  those 
necessitating  abdominal  section  belong  as  much  to  the  general  surgeon  as  to 
the  gynaecologist.     Vulval  lesions,  of  course,  may  come  under  the  care  of  either. 

1299 


I300  A   MANUAL  OF  SURGERY 

form  in  tlic  labia.  Pregnancy  usually  aggravates  this  condition  to 
an  alanning  degree,  and  a  very  slight  injur\'  may  determine  a  rup- 
ture of  the  veins.  Treatment. — If  troublesome  and  causing  much 
pruritus  or  irritation,  the  veins  may  be  excised  under  careful  anti- 
septic precautions. 

Vulvitis,  or  inflammation  of  the  lining  membrane  of  the  vestibule, 
is  due  to  uncleanliness,  gonorrhcjea,  or  to  irritating  discharges  coming 
from  above.  It  is  characterized  by  injection  of  the  mucous  mem- 
brane, by  itching  or  smarting  pain,  especially  on  walking,  and  a 
secretion  of  mucus  or  muco-pus,  causing  the  labia  to  stick  together. 
The  mucous  follicles  may  become  affected,  and  a  localized  abscess 
result,  situated  either  immediately  beneath  the  mucous  membrane 
or  in  the  substance  of  the  labium.  The  treatment  consists  in  the  use 
of  warm  and  mild  astringent  or  antiseptic  lotions  to  purify  the  part 
{e.g.,  lotio  plumbi),  sitting  in  hot  water  being  most  beneficial.  At 
the  same  time  the  patient  is  kept  quiet,  and  the  bowels  are  opened 
by  a  saline  purge.  When  a  follicular  abscess  forms,  it  should  be 
incised  through  the  mucous  membrane  and  its  cavity  stuffed  with 
a  small  portion  of  dressing.  A  labial  abscess  should  be  freely  opened 
at  any  spot  where  it  is  threatening  to  point,  and  the  cavity  packed 
with  gauze  to  ensure  healing  from  the  bottom. 

Vaginitis  may  be  secondary  to  vulvitis,  or  associated  with  an  in- 
flammatorv  affection  of  the  uterus.  As  a  primary  lesion  it  is  most 
commonly  due  to  injury,  such  as  the  injection  of  too  hot  water,  or 
the  presence  of  a  foreign  body — e.g.,  a  badly-fitting  and  retained 
pessary,  or  awkward  or  violent  coitus.  Vaginitis  is  not  generally 
a  marked  feature  in  gonorrhoea.  The  s\anptoms  are  a  sense  of  heat 
and  pain,  frequent  and  painful  micturition,  and  a  free  muco-purulent 
leucorrhoea.  Complications  may  arise  from  extension  upwards  to 
the  uterus  and  tubes.  Treatment  consists  in  warm  soothing  injec- 
tions in  acute  cases,  together  with  hot  hip-baths ;  in  the  more  chronic 
types  astringent  injections  are  required. 

Cysts  of  the  Labia  are  occasionally  seen,  being  due  to  the  blocking 
of  the  duct  of  a  mucous  follicle,  or  of  the  more  specialized  vulvo- 
vaginal glands  (glands  of  Bartholin) ;  they  may  attain  considerable 
dimensions,  and  must  be  freely  dissected  out  if  causing  any  incon- 
venience. 

Various  other  tumours  of  the  vulva  occur — e.g.,  elephantiasis, 
epithelioma,  etc.,  but  have  no  special  peculiarities. 

Affections  of  the  Round  Ligament  are  not  very  uncommon.  Non- 
obliteration  of  the  canal  of  Nuck  leads  to  the  appearance  of  a  con- 
genital inguinal  hernia,  which  is  very  frequent  in  girls  and  young 
unmarried  women.  In  the  operation  required  for  its  cure  the  round 
ligament  is  included  in  the  ligature  which  encircles  the  neck  of  the 
sac.  A  hydrocele  of  the  round  ligament  is  due  to  a  partial  oblitera- 
tion of  the  same  structure,  the  patent  portion  becoming  distended 
with  a  serous  exudation.  It  presents  as  a  tense,  rounded  swelling 
just  below  the  external  abdominal  ring  or  in  the  inguinal  canal,  and 
is  treated  by  dissecting  it  away.     Occasionally  cases  of  bilocular 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1301 

hydrocele  are  met  with,  in  wliich  an  external  cavity  communicatee, 
with  a  large  pehic  collection  of  fluid  enclosed  in  a  serous  membrane. 
Tumours  of  the  round  ligament  are  unusual,  but  occur  in  the  fonii 
of  lymphangioma  and  fibro-myoma.  An  interesting  instance  of  the 
latter  was  seen  in  a  woman  who  was  also  the  subject  of  uterine 
fibro-myomata  necessitating  hysterectomy.  The  tumour  of  the 
round  ligament  was  as  large  as  an  orange. 

Uterine  Displacements. — ^The  maintenance  of  the  uterus  in  its 
nomial  position  of  slight  anteversion  is  due  to  the  associated  influ- 
ence of  many  diverse  factors.  Displacements  are  caused  by  many 
lapses  from  the  normal  condition — e.g.,  lack  of  support,  as  by  rup- 
ture of  the  perineum,  increased  pressure  from  above,  increased 
weight  of  the  uterus,  as  from  subinvolution  after  pregnancy,  chronic 
inflammation  or  the  presence  of  tumours,  the  traction  of  adhesions 
resulting  from  pelvic  cellulitis,  etc.  The  most  common  displace- 
ments are  forwards,  constituting  anteversion  or  anteflexion ;  back- 
wards, in  the  form  of  retroversion  or  retroflexion;  and  downwards, 
giving  rise  to  prolapse  or  procidentia. 

It  is  unnecessary  to  enter  into  the  symptoms  and  ordinary  treat- 
ment of  these  conditions;  but  the  operative  treatment  of  them 
requires  notice. 

Anterior  displacements  require  no  external  operative  treatment. 

Posterior  displacements  are  not  unfrequently  dealt  with  by  opera- 
tions through  the  anterior  abdominal  wall.  Two  chief  methods  are 
employed — viz.,  shortening  the  round  hgaments  and  hysteropexy. 
Shortening  of  the  round  ligaments  can  be  undertaken  as  an  extra-  or 
as  an  intra-peritoneal  procedure,  (i.)  Alexander's  operation  is  extra- 
peritoneal, and  suitable  only  for  uncomplicated  cases.  The  inguinal 
canal  on  each  side  is  exposed  and  the  external  obHque  slit  up;  the 
round  ligament  is  identified,  isolated,  drawn  taut,  and  the  slack 
portion  cut  away;  the  posterior  end  is  then  fixed  in  the  canal  by 
sutures,  which  also  serve  to  close  it;  the  external  oblique  is  also 
carefully  sutured,  (ii.)  In  the  intra-abdominal  operation  a  com- 
plete investigation  of  the  pelvic  viscera  is  possible.  A  small  median 
incision  is  made;  the  round  ligament  on  either  side  is  isolated, 
doubled  over,  and  stitched  to  itself  so  as  to  remove  all  slackness. 
This  latter  operation  is  probably  much  the  more  satisfactory  of  the 
two.  Of  course,  the  additional  use  of  a  suitable  pessary  may  be 
desirable. 

A  still  more  satisfactory  measure  consists  in  detaching  the  slack 
round  ligament  from  its  connections,  and  drawing  it  on  either  side 
through  a  small  incision  about  2  centimetres  from  the  middle  line 
through  the  peritoneum  and  rectus  muscle,  including  its  anterior 
sheath.  The  two  loops  are  then  sutured  together  across  the  middle 
line  in  front  of  the  line  of  union  of  the  two  muscular  segments  of 
the  abdominal  wall.  A  few  stitches  are  inserted  to  prevent  the 
hgaments  from  retracting.  The  uterus  is  thus  fixed  forwards  in  a 
normal  position  and  condition. 

Hysteropexy  {ventro-fixation),  or  the  fixation  of  the  uterus  to  the 


1302 


A   MANUAL  OF  SURGERY 


anterior  abdominal  wall,  is  a  procedure  that  must  be  cautiously 
undertaken  in  married  patients  who  liave  not  reached  the  climac- 
teric. An  incision  2  or  3  inches  in  lengtli  is  made  inunediately 
abo\-c  the  symphysis,  and  the  fundus  uteri  is  drawn  forwards  by  a 
volsellum.  Three  silkworm  gut  stitches  are  inserted  through  the 
abdominal  parietcs  and  peritoneum,  and  also  througli  the;  body  of 
the  uterus  just  posterior  to  its  axis.  1  he  stitches  should  include 
about  I  inch  of  the  uterine  wall  in  their  grasp,  and  go  about  -J  inch 
deep.  On  drawing  them  tight,  the  uterus  is  fixed  forwards  against 
the  abdominal  wall  and  contracts  adhesions.  In  some  cases  it  may 
be  desirable  to  scarify  the  uterine  wall  before  tying  the  stitches,  so 


Fig.  575. 


Fig.  576. 


Fig.  577. 


Fig.  575. — -Incision  for  Repairing  Ruptured  Perineum. 

Fig.  576. — ^Vaginal  Flap  dissected  up  from  Recto-vaginal  Septum  and 

DRAWN  Forwards.     (Some  of  the  sutures  are  introduced.) 
Fig.  577.— Operation  for  Repairing  a  Ruptured  Perineum  completed. 

as  the  better  to  determine  adhesions.  As  a  general  rule  the  ad- 
hesions stretch  somewhat,  and  hence  allow  a  certain  degree  of  play, 
but  without  the  likelihood  of  a  return  of  the  displacement. 

Prolapse  of  the  Uterus  is  most  commonly  associated  with  a  rup- 
tured perineum  and  chronic  metritis.  The  anterior  vaginal  wall 
often  gives  way  first  and  brings  down  the  bladder,  causing  consider- 
able dysuria  or  vesical  irritabihty;  and  then  the  uterus  itself  de- 
scends, and  may  even  protrude  from  the  vulva,  the  vagina  being 
turned  inside  out,  and  its  walls  becoming  dry  like  skin,  and  perhaps 
ulcerated  from  persistent  irritation.  Treatment  varies  according  to 
the  condition  present  and  with  the  causes.  The  uterus,  if  enlarged 
and  inflamed,  may  need  to  be  curetted  so  as  to  diminish  its  bulk  and 
weight.     The  perineum,  if  defective,  must  be  repaired  by  one  of  the 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1303 

many  forms  of  perineoplasty  now  in  vogue.  Possibly  the  introduc- 
tion of  a  suitable  pessary  may  suffice  to  keep  the  uterus  in  place  for 
a  sufficient  time  to  allow  the  uterine  supports  to  regain  their  tone. 
In  some  cases  hysteropexy  will  be  indicated,  but  in  the  worst  forms 
vaginal  hysterectomy,  combined  with  some  operation  to  diminish 
the  size  of  the  vaginal  canal,  may  be  required. 

The  operation  for  repairing  a  ruptured  perineum  necessarily  varies 
with  the  extent  and  completeness  of  the  tear.  Obstetricians  should 
always  endeavour  to  stitch  up  these  ruptures  immediately  after 
labour,  as  the  parts  are  then  very  insensitive,  owing  to  the  stretching 
which  they  have  suffered,  and  patients  are  very  loth  to  undergo  a 
secondary  operation  soon  after.  The  plan  usually  adopted  for 
remedying  a  defect  which  does  not  quite  extend  to  the  anus  is  indi- 
cated in  Figs.  575-577.  An  incision  is  made  skirting  the  posterior 
vulval  margin,  and  extending  forwards  on  either  side  to  the  ter- 
minations of  the  nymphge.  By  deepening  this  the  posterior  vaginal 
wall  can  be  separated  from  the  rectum,  great  care  being  taken  not  to 
encroach  on  either  cavity,  and  the  flap  thus  produced  is  drawn  for- 
wards. The  wound  is  then  stitched  up  transversely,  and  an  effective 
perineal  body  produced.  A  more  extensive  intravaginal  operation 
is  needed  when  the  rent  involves  the  anal  orifice. 

Uterine  Tumours. 

Fibro-myomata  are  by  no  means  uncommon,  developing  during 
sexual  activity,  and  causing  symptoms  partly  from  their  location  in 
the  uterus,  partly  from  the  size  which  they  may  attain.  Any  part 
of  the  uterus  may  be  affected  primarily,  but  they  generally  originate 
in  the  substance  of  the  wall,  and  that  usually  the  posterior  wall ;  if 
they  remain  in  this  relation,  they  are  known  as  interstitial  or  intra- 
mural fibroids  (Fig.  578,  i).  When  they  are  situated  near  the  inner, 
or  outer  uterine  wall  they  may  project  either  into  the  uterine  or 
peritoneal  cavities,  constituting  the  submucous  (2)  or  subserous  (3) 
fibroids.  Occasionally  they  become  pedunculated,  and  then  a.  fibroid 
poly  pits  of  the  uterus  may  develop,  and  project  through  the  os  into 
the  vagina,  where  it  may  undergo  strangulation  or  torsion,  and  may 
slough  away  or  become  acutely  inflamed.  A  pedunculated  sub- 
serous fibroid  may  similarly  become  twisted  or  inflamed,  and  then 
may  either  slough,  or  may  gain  adhesions  elsewhere — e.g.,  to  the 
omentum,  and  finally  become  separated  from  the  uterus. 

The  actual  structure  of  these  tumours  varies  slightly,  but  they  are 
all  more  or  less  of  a  fibro-myomatous  nature — i.e.,  they  consist  of 
muscle  fibres  similar  to  those  of  the  uterus,  with  a  varying  amount 
of  fibrous  stroma  and  bloodvessels.  Occasionally  they  are  very  hard 
and  not  specially  vascular ;  in  other  cases  they  are  softer  and  more 
vascular,  and  then  usually  grow  more  quickly.  They  are  surrounded 
by  a  capsule  of  varying  density,  which  is  often  the  seat  of  many 
enlarged  veins,  and  if  these  are  ulcerated  into,  considerable  haemor- 
rhage follows.     The  uterus  generally  becomes  hyperaemic  and  en- 


1304 


A   MANUAL  OF  SURGERY 


larged,  and  the  mucous  membrane  thickened;  not  unfrequently 
endometritis  is  present,  and  the  inflammation  may  spread  u])  to  tlie 
tubes,  causing  pyosalpinx. 

Various  secondary  changes  may  occur  in  uterine  libroids.  They 
may  become  (ledematous,  or  undergo  cystic  degeneration,  as  a  result 
of  defective  nutrition,  and  that  generally  in  young  people;  iibro- 
cystic  disease  of  the  uterus  is  thereby  determined.  Occasionally  in 
old  women,  where  the  evolution  of  the  growth  has  long  ceased,  cal- 
careous degeneration  occurs,  and  the  growth  is  converted  into  a  stony 
mass.  In  younger  women  a  somewhat  similar  change  may  be 
present,  and  the  fibroid  becomes  hard,  but  not  stony.  The  exist- 
ence of  this  condition  must  be  remembered  in  connection  with  the 

radiographic  examination  of  the 
pelvis,  as  circular  shadows  of  a 
perplexing  nature  may  be  produced 
by  these  tumours.  Injiammatio-n 
and  pyogenic  infection,  with  per- 
haps abscess  formation,  may  follow 
abrasion  of  the  mucous  membrane 
with  a  sound,  and  sloughing  of  the 
growth  may  result  either  from  an 
inflammatory  attack  or  from  de- 
fective blood-supply.  It  is  pos- 
sible that  sarcoma  may  supervene 
in  some  few  cases,  but  the  associa- 
tion is  not  yet  absolutely  proven. 

The  Symptoms  vary  much  in 
different  cases,  but  are  mainly 
those  of  haemorrhage  and  pressure. 
Hcemorrhage  occurs  either  as  a  pro- 
longation of  the  normal  menstrual 
periods  (menorrhagia),  or  as  a 
chronic  and  persistent  effusion  of 
-Diagram  OF  Uterus  WITH  blood  (metrorrhagia).  It  may  be 
FiBRo-MYOMATA.  abseut  in  subserous  and  interstitial 

I,  Interstitial  fibroid;  2,  submucous  fibroids,   and  is  most  marked  in 
fibroid;  3,  subserous  fibroid.  the  submucous  variety,  in  which 

the  endometrium  is  congested  and 
succulent.  The  amount  of  blood  lost  may  drain  the  patient,  who 
looks  anamic  and  dehydrated.  There  may  be  but  Httle  pain  in 
the  subserous  variety,  unless  the  growth  becomes  twisted  or  im- 
pacted in  the  pelvis.  When  the  tumour  projects  upwards  into  the 
abdomen  nothing  but  a  sense  of  weight  is  experienced  unless  the  size 
is  so  great  as  to  encroach  seriously  on  the  viscera.  When  the  growth 
is  mainly  pelvic,  and  especially  when  a  fibroid  of  the  cervix  extends 
sideways  into  the  broad  ligament,  or  when  impaction  occurs,  the 
s\Tnptoms  may  be  extremely  distressing.  Vesical  irritability  may  be 
marked,  and  micturition  may  be  painful  and  difficult.  Tenesmus 
or  constipation  may  arise  from  pressure  on  the  rectum ;  hydrone- 


F1G.578 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1305 

phrosis,  when  the  ureters  are  compressed;  and  severe  neuralgic  pain 
down  the  leg,  should  the  pelvic  nerves  be  encroached  on.  The 
presence  of  a  polypoid  submucous  growth  is  likely  to  cause  violent 
expulsive  contraction  of  the  uterus. 

riie  Diagnosis  is  made  by  palpation,  digital  examination,  and  the 
use  of  the  sound.  Bimanual  examination  should  reveal  the  size  and 
shape  of  the  uterus,  and  much  useful  information  can  often  be  ob- 
tained by  a  combined  vaginal  and  rectal  examination.  The  sound 
will  demonstrate  the  increased  length  of  the  uterine  canal,  which  is 
often  in  addition  t\\'isted. 

The  Prognosis  has  to  be  considered  carefully  in  every  case  before 
determining  for  or  against  operative  treatment.  The  majority  of 
the  cases  improve  at  the  menopause,  the  growth  shrinking  and  the 
haemorrhage  ceasing;  exceptions  to  this  rule  are,  however,  not  un- 
known. It  is  therefore  obvious  that  if  the  patient  is  approaching 
the  climacteric  and  the  symptoms  are  not  grave,  it  may  be  advisable 
to  wait  for  that  event.  On  the  other  hand,  if  the  condition  occurs 
in  a  young  woman,  and  especially  if  the  haemorrhage  is  sufficiently 
severe  to  necessitate  prolonged  rest  and  more  or  less  chronic  in- 
validism, operation  is  certainly  desirable.  Of  course,  the  existence 
of  severe  haemorrhage,  or  of  symptoms  of  pelvic  pressure,  would  at 
all  ages  justify  operation. 

Treatment. — If  the  symptoms  are  not  such  as  to  warrant  opera- 
tion, all  that  is  required  is  that  the  patient  should  rest  at  the  meri- 
struail  periods,  and  that  ergot  and  iron  should  be  administered  if 
necessary. 

Operative  Treatment  consists  in  either  the  enucleation  of  the  tumour 
or  the  extirpation  of  the  uterus,  and  the  removal  of  the  ovaries  and 
tubes. 

(i)  Myomectomy,  or  the  enucleation  and  removal  of  the  tumour 
apart  from  the  uterus,  is  only  suitable  under  special  circumstances. 
When  the  growth  projects  into  the  uterus  or  vagina  as  a  polypus, 
the  vaginal  route  may  be  adopted;  the  cervix  is  dilated  if  need  be, 
and  after  incising  the  mucous  membrane  the  growth  can  be  enucle- 
ated by  the  finger.  A  subserous  fibro-myoma  can  similarly  be 
removed  without  difficulty  if  it  be  thought  desirable.  Not  unfre- 
quently  this  condition  is  met  with  in  laparotomies  for  other  condi- 
tions, and  the  surgeon  may  think  it  desirable  to  remove  the  growth. 
A  longitudinal  incision  down  to  the  capsule  and  a  sweep  round  of 
the  finger  usually  suffices  to  enucleate  the  tumour,  and  that  with 
very  little  bleeding.  Two  or  three  deep  stitches  may  be  introduced 
into  the  uterine  substance,  and  the  peritoneum  adjusted  and  apposed 
by  superficial  stitches.     No  drainage  is  required  as  a  rule. 

(2)  Abdominal  Hysterectomy  for  fibroids  is  a  most  successful  pro- 
cedure. It  may  suffice  to  remove  the  organ  through  or  above  the 
cervix  (supra-vaginal  hysterectomy),  or  it  may  be  needful  to  include 
the  cervix  in  the  mass  that  is  removed  (pan-hysterectomy).  The 
procedure  is  identical  up  to  a  certain  point,  but  the  latter  operation 
is  rather  the  longer,  and  the  dangers  are  a  little  greater. 


1306 


A   MANUAL  OF  SURGERY 


The  patient  must  be  carefully  prepared  as  for  any  other  abdom- 
inal operation  (p.  959),  but  in  addition  the  pubes  and  vulva  must 
be  shaved  and  thoroughly  purified;  the  vagina  should  be  douched 
for  some  days  previously,  and  an  antiseptic  dressing  worn,  and  if 
need  be  the  uterine  canal  should  be  curetted  and  disinfected  with 
some  powerful  antiseptic. 

After  auctisthesia  has  been  induced,  the  Trendelenburg  position  is 
adopted,  and  an  incision  of  suitable  length  made  in  the  median  line. 
The  parts  are  then  carefully  explored,  and  if  no  adhesions  exist,  an 
abdominal  cloth  is  packed  in  over  the  intestines  in  order  to  protect 
and  keep  them  from  exposure  and  injury.  If  adhesions  to  omentum 
or  gut  arc  present,  they  must  be  carefully  divided;  it  is,  of  course, 
most  desirable  that  a  complete  peritoneal  covering  should  be  secured 


Fig.  579. 


-DiAGRAM^OF  Uterus,  Vagina,  and  Broad  Ligament,  seen  from 
IN  Front. 


O.A.,  Ovarian  artery;  U.A.,  uterine  artery;  U.,  ureter.  The  dotted  lines  repre- 
sent the  division  of  the  broad  ligament  in  hysterectomy  according  to 
whether  or  not  the  ovary  is  removed.  The  continuous  dark  lines  crossing 
the  uterus  indicate  the  incisions  through  the  uterine  substance  in  supra- 
vaginal hysterectomy. 

for  any  adherent  organs;  omental  grafts  may  be  sometimes  useful 
in  this  direction.  Ihe  uterus  is  now  lifted  up  and  drawn  into  the 
incision  bv  a  Doyen's  myoma  screw  or  a  stout  volsellum. 

The  broad  ligaments  are  then  examined,  and  a  decision  made  as 
to  whether  or  not  the  ovaries  and  tubes  are  to  be  saved.  It  is  cer- 
tainly desirable  that  in  a  young  woman  an  effort  should  be  made  to 
retain  at  any  rate  one  ovary,  thereby  avoiding  the  nervous  s\Tnptoms 
often  determined  by  an  acute  artificial  menopause.  The  lines  of 
section  of  the  broad  ligament  under  these  two  conditions  are  indi- 
cated diagrammatically  in  Fig.  579. 

A  pedicle  needle  carrying  a  sufficient  length  of  well-boiled  silk  is 
carried  through  the  round  ligament  so  as  to  secure  the  ovarian  artery 
and  veins,  and  tied  as  far  away  from  the  uterus  as  possible ;  a  broad 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1307 

ligament  clamp  may  then  be  placed  in  position  close  to  the  uterus, 
so  as  to  prevent  venous  regurgitation,  and  the  broad  ligament  is 
divided  half-way  down.  It  is  often  possible  and  desirable  to  pick  up 
the  divided  end  of  the  ovarian  artery  on  the  face  of  this  section  and 
secure  it  separately,  whilst  the  little  artery  which  accompanies  the 
round  ligament  should  also  be  carefully  secured.  The  ovarian 
artery  on  the  other  side  is  next  dealt  with  in  a  similar  fashion.  A 
transverse  cut  is  now  made  across  the  front  of  the  uterus,  involving 
merely  the  serous  membrane,  and  connecting  the  two  ends  of  the 
incisions  in  the  broad  ligaments;  the  peritoneum  below  this  trans- 
verse cut  is  detached,  together  with  the  bladder,  from  the  cervix, 
and  the  intra-Hgamentary  space  is  thereby  opened  up  on  either 
side.  In  this  will  be  found  the  uterine  vessels,  and  it  may  be 
possible  to  see  and  isolate  the  uterine  artery  before  securing  it  by 
ligature.  Care  must  be  taken  in  this  part  of  the  operation  to  keep 
close  to  the  uterus,  as  the  ureter  comes  forwards  from  behind  under 
the  uterine  artery  to  reach  the  bladder,  lying  about  the  level  of  the 
OS  internum.  The  uterine  vessels  are  in  this  way  carefully  secured 
and  di\dded. 

The  uterus  is  now  merely  held  by  the  connection  between  the 
vagina  and  cervix,  and  the  peritoneal  reflection  in  Douglas's  pouch. 
If  a  supra-vaginal  operation  will  suffice,  the  surgeon  cuts  across  the 
neck  of  the  uterus  in  such  a  way  as  to  fashion  two  flaps,  and 
finally  the  peritoneum  behind  is  also  divided.  A  few  small  vessels 
will  probably  need  to  be  secured  on  the  face  of  the  uterine  stump. 
This  having  been  effected,  the  uterine  flaps  are  stitched  carefully 
together  so  as  to  bury  the  open  cervical  canal;  the  uterine  stump  is 
then  covered  in  by  uniting  the  divided  portions  of  peritoneum.  This 
line  of  sutures  is  carried  up  on  either  side  so  as  to  secure  t  he  two 
layers  of  the  broad  ligament ;  the  final  result  is  that  the  pelvic  floor 
is  covered  in  by  a  continuous  layer  of  peritoneum,  showing  a  sutured 
incision  which  runs  transversely  from  one  side  to  the  other.  The 
usual  peritoneal  toilette  follows,  and  the  abdomen  is  generally  closed 
entirety,  no  drainage  being  required. 

When  the  fibroid  tumours  involve  the  cervix,  it  may  be  necessary 
to  perform  pan-hysterectomy.  The  operation  follows  along  the 
lines  indicated  above,  up  to  the  securing  of  the  uterine  vessels.  It 
is  then  advisable  to  open  into  the  posterior  vaginal  cul-de-sa  c,  and 
enucleate  the  cervix  from  its  surroundings  from  behind  forwards, 
keeping  very  near  to  the  uterus  at  the  sides  so  as  to  avoid  the  ureters, 
and  keeping  clear  of  the  bladder  in  front.  Several  vessels  derived 
from  the  vaginal  arteries  will  require  to  be  secured  in  this  pro- 
ceeding. The  wound  in  the  pelvic  floor  is  closed  much  in  the  same 
way  as  before,  but  not  so  completely  as  regards  the  vaginal  walls, 
a  small  lamp-wick  drain  of  iodoform  gauze  being  introduced  between 
them.  The  peritoneum  is  sutured  continuously  over  the  gauze, 
and  up  on  either  side  to  the  upper  extremity  of  the  broad  ligament. 

In  both  cases  a  pad  of  antiseptic  dressing  is  maintained  over  the 
vulva  for  a  time,  and  in  pan-hysterectomy  it  is  advisable  to  douche 


i3o8  A   MANUAL  OF  SURGERY 

the  vagina  daily.  Tlie  gauze  packing  is  removed  on  tlie  third  day, 
and  another  strip  introduced.  The  results  of  this  o]X'ration  are 
most  satisfactory,  and  the  death-rate  comparatively  small. 

(3)  Double  Salpingo-obphorectomy  (removal  of  ovaries  and  tubes) 
was  at  one  time  much  ])ractised  in  the  treatment  of  uterine  fibroids, 
and  certainly  had  the  effect  of  checking  haemorrhage  and  diminishing 
their  growth  by  determining  an  artificial  menopause.  At  the  same 
time,  the  patient  is  not  relieved  of  the  incubus  of  the  growth,  and 
hence  the  operation  is  now  but  seldom  employed,  except  as  part  of 
a  complete  hysterectomy. 

Sarcoma  of  the  Uterus  is  not  of  very  common  occurrence.  It  may 
be  a  secondary  development  following  on  fibro-myomata,  or  may 
be  primary.  In  most  cases  it  occurs  as  a  solid,  firm  tumour,  con- 
sisting of  spindle  cells,  but  more  vascular  than  and  not  quite  so 
hard  as  the  majority  of  fibroids ;  in  others  it  is  of  a  softer  consistency, 
and  may  be  associated  with  myxomatous  development.  It  almost 
always  involves  the  body  of  the  organ,  the  cervix  being  unaffected; 
and  it  may  either  attack  the  mucous  membrane  primarily  as  a 
diffuse  infiltration,  or  constitute  a  more  localized  growth  in  the 
muscular  tissue.  Secondary  deposits  occur  in  the  vagina  and 
elsewhere,  and  the  case  runs  a  more  rapid  course  than  a  simple 
fibroid,  although  the  symptoms  are  much  of  the  same  type.  There 
is,  however,  more  discharge  from  the  vagina,  which  may  contain 
debris  of  the  growth,  and  becomes  somewhat  offensive.  Treatment 
consists  in  pan-hysterectomy. 

Carcinoma  of  the  Uterus  is  the  most  common  form  of  cancer  in  the 
female,  accounting  for  over  30  per  cent,  of  the  deaths  from  this 
disease.  It  follows  the  usual  lule  as  to  age,  being  uncommon  under 
thirty  years,  and  most  frequently  seen  between  the  ages  of  forty 
and  fifty.  It  generally  occurs  in  multipane,  and  is  probably 
associated  with  lacerations  of  the  cervix  and  inflammatory  erosions 
dependent  thereon.  The  site  of  origin  is  usually  the  cervix,  the 
body  being  comparatively  seldom  affected  primarily. 

Cancer  of  the  cervix  starts  (i.)  as  a  nodular  overgrowth  of  the 
glands  embedded  in  its  substance;  (ii.)  as  an  epithelioma  of  the 
vaginal  portion,  projecting  into  that  passage  as  a  malignant  papil- 
loma; or  (iii.)  as  a  diffuse  affection  of  the  cervical  epithehum  and  its 
glands,  and  hence  is  most  frequently  of  a  columnar-celled  type.  In 
all  these  cervical  forms  the  vagina  is  early  affected;  the  disease 
spreads  more  slowly  up  towards  the  body  of  the  uterus.  The 
arrangement  of  vessels  and  lymphatics  will  explain  the  fact  that 
invasion  of  the  broad  ligaments  is  early;  these  structures  become 
infiltrated  and  rigid,  fixing  the  uterus,  and  pressure  phenomena  upon 
the  rectum,  bladder,  or  pelvic  vessels  and  nerves,  will  sooner  or  later 
be  manifested.  Destructive  ulceration  follows,  and  the  bladder  or 
rectum  may  be  laid  open,  and  empty  their  contents  into  the  vagina, 
which  in  the  worst  cases  becomes  an  evil-smelhng  cloaca.  Adhesive 
inflammation  serves  to  protect  the  peritoneal  cavity,  which  is  not 
often  opened  up. 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1309 

Carcinoma  of  the  body  of  the  uterus  starts  in  the  mucous  mem- 
brane and  its  glands,  and  is  rapidly  disseminated,  infiltrating  the 
whole  cavity;  it  also  is  of  a  columnar-celled  type.  The  whole 
organ  may  become  hollowed  out  by  ulceration,  constituting  a  slough- 
ing cavity  from  which  an  abundant  hfemorrhagic  discharge  escapes. 

In  all  cases  lymphatic  dissemination  follows,  involving  the  pelvic 
glands  first,  and  later  on  the  iliac,  and  possibly  even  the  inguinal. 
Compression  of  the  ureters  may  cause  hydronephrosis;  the  iliac 
vessels  may  be  compressed  and  lead  to  oedema  of  the  legs,  and  pul- 
monary embolus  secondary  to  venous  thrombosis  has  been  known 
to  cause  death.     General  dissemination  to  the  viscera  is  not  common. 

The  chief  Symptoms  of  uterine  cancer  are  pain,  haemorrhage,  and 
an  offensive  discharge.  Pain  is  unfortunately  not  an  early  manifes- 
tation in  most  cases,  and  hence  the  disease  has  often  gained  a  good 
hold  before  the  patient  comes  under  observation.  As  soon  as  the 
body  of  the  organ  is  attacked,  or  the  extra-uterine  cellular  tissue,  it 
begins  to  trouble  the  patient;  it  is  of  an  aching,  gnawing,  or  boring 
character,  and  in  the  later  stages  may  be  so  appalling  in  its  severity 
as  to  necessitate  the  injection  of  huge  doses  of  morphia.  As  a 
general  rule,  it  is  most  marked  when  there  is  comparatively  little 
destructive  ulceration.  Referred  and  sympathetic  pains  in  back, 
breasts,  and  legs  are  also  much  complained  of.  The  haemorrhage 
may  at  first  be  merely  an  exaggeration  of  normal  menstrual  periods, 
but  later  on  the  loss  of  blood  is  often  continuous  and  may  be  asso- 
ciated with  a  discharge  of  horribly  offensive  muco-pus  and  cancerous 
debris.  The  appearance  of  a  haemorrhagic  discharge  after  the 
menopause  should  always  determine  a  careful  local  examination  of 
the  pelvic  viscera.  Loss  of  flesh,  debility,  and  the  ordinary  phe- 
nomena of  a  cancerous  cachexia,  are  gradually  developed,  and  to 
these  may  be  added  special  symptoms  due  to  implication  of  the 
bladder  and  bowel. 

On  vaginal  examination  the  physical  signs  corresponding  to  the 
type  of  disease  make  themselves  evident.  There  may  be  merely  a 
nodular  thickening  of  the  cervix;  or  an  ulcerating  papillomatous 
mass,  like  a  cauliflower,  may  project  into  the  vagina,  invading  the 
wall  of  this  tube ;  or  the  finger  may  pass  through  the  open  os  into 
a  ragged  hollow  cavity  lined  by  an  ulcerating  mass  of  new  growth. 
The  most  careful  attention  must  be  given  as  to  the  lateral  extension 
of  the  growth  into  the  broad  ligament,  whether  the  uterus  is  mobile 
or  fixed,  and  whether  the  vaginal  wall  is  much  involved,  as  it  is 
upon  these  facts  that  the  possibility  or  not  of  operation  depends. 
It  is  useless  to  attempt  removal  when  the  broad  ligaments  are 
badly  invaded,  or  if  the  vaginal  wall  is  extensively  implicated,  or 
the  uterus  firmly  fixed  to  bladder  or  rectum. 

In  early  doubtful  cases  where  the  os  is  ulcerated  to  a  slight  extent, 
a  portion  of  the  growth  should  be  snipped  away,  and  submitted  to 
microscopical  examination. 

Radical  Treatment  is  only  practicable  when  the  disease  has  not 
extended  too  far.     Formerly  gynaecologists  used  to  practise  amputa- 


I3IO  A   MANUAL  OF  SURGERY 

tion  of  the  cervix  when  the  disease  was  apparently  limited  to  this 
region.     In  the  light  of  modern  pathology  such  a  procedure  is  un- 
scientific and  insufticient,  and  clinical  experience  has  shown  that  the 
onl}'  operation  which  should  be  considered  is  complete  hysterectomy. 
Hysterectomy  for  carcinoma  uteri  may   be   performed  by  the 
vaginal  route  or  through  the  abdomen,     (i)  The  vaginal  operation 
is  possibly  a  little  safer,  but  has  the  objections  that  the  broad  liga- 
ments cannot  be  dealt  with  quite  so  satisfactorily,  and  that  should 
adhesions  exist  it  will  be  difficult  or  impossible  to  deal  with  them. 
However,  in  simple  early  cases  it  will  suffice,  and,  indeed,  when  the 
disease  is  so  extensive  as  to  need  more  than  a  vaginal  procedure, 
it  has  probably  gone  so  far  as  to  be  practically  inoperable.     For 
details  of  this  operation,  gynaecological  text-books  must  be  con- 
sulted.    (2)  A  hdominal  hysterectomy  is  the  more  scientific  procedure, 
and  should  always  be  performed  where  the  local  and  general  con- 
ditions of  the  patient  are  satisfactory.     Wertheim's  pan-hysterec- 
tomy is  the  operation  generally  adopted,  if  it  be  practicable;  it 
involves  the  removal  of  the  complete  uterus,  together  with  the  upper 
part  of  the  vagina,  the  whole  of  the  broad  ligaments,  and  the 
cellular  tissue  and  glands  along  the  iliac  vessels.     An  important 
preliminary  consists  in   a  thorough  scraping,   cauterization,   and 
disinfection  of  the  diseased  cervix.     The  operation  itself  is  con- 
ducted in  the  Trendelenburg  position  through  a  median  subumbilical 
incision,  the  intestines  being  carefully  packed  off  from  the  pelvis 
by  suitable  gauze  swabs.     The  local  condition  of  affairs  having 
been  fully  investigated,   the  ureters  are  exposed  by   an  incision 
along  the  posterior  pelvic  wall  just  behind  the  base  of  the  broad 
ligament  on   each  side.     Each  ureter  is  traced  forwards  to  the 
bladder,   and  if  this   be   done  carefully  the   blood-supply  is  not 
impaired,  and  although  the  ureters  are  isolated  they  will  not  slough. 
In  this  dissection  the  origin  of  the  uterine  artery  is  laid  bare,  and 
divided  between  ligatures,  whilst  the  broad  ligament  is  also  divided 
as  close  to  the  pelvic  wall  as  possible  after  ligaturing  the  vessels 
entering  it.     The  peritoneum  in  front  of  the  uterus  is  next  divided, 
and  the  bladder  dissected  forwards  as  far  as  the  anterior  fornix  of 
the  vagina;  a  similar  dissection  frees  the  rectum  from  the  back 
of  the  uterus,  which  is  now  merely  held  in  position  by  its  vaginal 
attachments.     This  latter  tube  is  then  secured  by  two  suitable 
right-angled  clamps,  and  divided  between  them.     Finally,  if  the 
patient's  condition  warrants  it,  the  peritoneum  is  divided  upwards 
over  the  iliac  vessels,  and  the  cellular  tissue  and  all  enlarged  glands 
removed  as  high  as  the  bifurcation  of  the  aorta.     The  cavity  left  is 
carefully  packed  with  iodoform  gauze  projecting  into  the  vagina, 
and  the  peritoneum  accurately  sutured  transversely  over  it.     The 
mortality  of  this  procedure  is  high  (20  per  cent.),  but  with  improved 
technique  this  is  diminishing.     The  chief  risks  are  infection  of  the 
peritoneal  cavity,  cancerous  dissemination,  or  injury  to  the  ureters. 
Palliative  Treatment  in  inoperable  cases  consists  in  staying  the 
haemorrhage,  keeping  the  parts  as  free  from  sepsis  as  possible,  and 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  131 1 

combating  pain  by  morphia.  In  some  cases  it  may  be  permissible 
to  curette  the  diseased  structures,  thereby  removing  protuberant 
masses  which  interfere  with  the  escape  of  the  discharge.  Radium 
is  of  considerable  value  in  these  cases  (p.  57). 

Finally,  a  word  must  be  added  to  emphasize  the  fact  that  the 
constant  association  of  this  disease  with  a  torn  and  eroded  os 
suggests  the  possibility  of  prevention  by  attending  to  such  lesions 
and  not  allowing  them  to  persist  indefinitely  without  treatment. 

Chorio-epithelioma  {Syn.:  Deciduoma  malignum,  Syncytioma  maligna,  etc.) 
is  an  interesting  condition  to  which  considerable  attention  has  been  directed 
of  late.  It  consists  of  an  overgrowth  of  the  chorionic  villi,  which  constitute  a 
soft  bleeding  tumour,  invading  and  thinning  the  uterine  wall,  and  insinuating 
itself  into  the  venous  channels,  so  that  general  dissemination  of  the  growth  is 
an  early  manifestation,  the  lungs  being  usually  involved  first.  The  growth  is  a 
soft,  succulent  papillomatous-looking  mass,  involving  the  body  of  the  uterus, 
and  not  unfrequently  the  fundus,  and  bearing  a  close  resemblance  in  structure 
and  physical  characters  to  a  vesicular  mole;  in  fact,  it  may  be  looked  on  as  a 
malignant  form  of  this  structure.  The  characteristic  histological  feature  is  the 
presence  of  large  syncytial  cells  derived  from  the  outer  layers  of  the  chorionic 
villi,  which  appear  as  masses  of  protoplasm,  containing  many  dark  nuclei;  in 
addition  to  these  are  many  smaller  cells,  irregular  in  shape,  unusually  rich  in 
glycogen,  and  in  which  division  by  karyokinesis  is  the  rule.  It  is  unusual  to 
be  able  to  demonstrate  typical  chorionic  villi  in  the  mass,  but  the  peculiar  cells 
are  exactly  similar  in  nature  to  those  which  occur  in  the  villi.  Ovarian 
changes  are  not  unfrequently  observed,  in  the  shape  of  multiple  cysts,  due  to 
degeneration  of  the  corpora  lutea. 

The  clinical  features  of  a  chorio-epithelioma  are  tolerably  characteristic. 
Occasionally  the  disease  follows  a  normal  pregnancy,  and  is  apparently 
due  to  the  persistence  of  a  portion  of  the  placental  tissue,  which  takes  on 
malignant  action  of  this  peculiar  type.  In  the  great  majority  of  cases,  how- 
ever, it  is  preceded  by  a  miscarriage  at  a  fairly  early  date,  and  perhaps  a 
vesicular  mole  of  some  size  is  removed.  The  hasmorrhagic  discharge  does  not 
cease,  but  continues  and  may  become  exaggerated.  Retention  of  placental 
tissue  is  usually  diagnosed,  and  as  a  rule  the  uterus  is  curretted;  if  on  micro- 
scopic examination  of  the  scrapings  the  characteristic  cells  of  a  chorio- 
epithelioma  are  found,  no  delay  is  permissible,  but  the  uterus  must  be  removed 
at  once.  Should  the  case  be  left,  the  hasmorrhagic  discharge  increases,  the 
uterus  becomes  enlarged ,  and  evidences  of  secondary  deposits  appear,  especially 
in  the  lungs.  The  nature  of  this  growth  is  very  malignant,  and  the  patient 
quickly  succumbs.  Treatment  consists  in  abdominal  hysterectomy,  which 
should  include  the  ovaries,  and  if  the  case  is  taken  before  dissemination  has 
occurred,  there  is  good  hope  of  success. 


Affections  of  the  Fallopian  Tubes. 

Pyosalpinx,  or  an  accumulation  of  pus  in  the  Fallopian  tube,  is 
the  result  of  an  inflammation  of  its  lining  walls  (salpingitis) ,  due  to 
infection  either  with  gonococci  (the  commonest  cause),  or  with 
pyogenic  organisms  spreading  from  an  infected  uterus  after  a  mis- 
carriage or  confinement,  or  occasionally  with  the  tubercle  bacillus. 
The  process  is  usually  chronic  or  subacute;  if  it  should  commence 
acutely,  the  symptoms  are  so  blended  with  those  of  the  accompany- 
ing uterine  or  peritoneal  inflammation  as  to  be  scarcely  distinguish- 
able. Both  tubes  are  usually  affected,  and  it  is  not  uncommon  for 
suppuration'to  spread  to  and^involve  the  ovary. 


I3I2  A   MANUAL  OF  SURGERY 

The  inflammation,  whether  acute  or  chronic,  usually  results  in 
blocking,  and  ]ierhaps  complete  and  permanent  closure,  of  both  ends 
of  the  tube;  the  abdominal  ostium  may  be  closed  by  fibrin  or  by 
the  adhesion  of  the  hmbriated  extremity  to  surrounding  viscera. 
Distension  of  the  tube  follows,  and  it  frequently  becomes  elongated 
and  tortuous  (Fig.  580) ;  it  may  contain  a  considerable  quantity  of 
pus,  which,  though  containing  organisms  at  first,  may  in  time 
become  sterile,  the  germs  dying  out.  The  distended  tubes  gain 
adhesions  to  surrounding  parts  as  a  result  of  plastic  peritonitis,  and 
the  abscess  may  burst  either  into  the  vagina,  into  one  of  the  sur- 
rounding viscera  (bladder,  rectum,  or  small  intestine),  or  into  the 
general  peritoneal  cavity. 

Tuberculous  pyosalpinx  is  due  to  an  infection  of  the  mucous  mem- 
brane of  the  tube,  which  may  be  primary,  the  organisms  reaching  the 


Fig.  580. — Pyosalpinx,  showing  the  Fallopian  Tube  bent  over  on 
ITSELF.     (King's  College  Hospital  Museum.) 

I,  Ovary;  2,  uterine  end  of  tube. 

part  through  the  blood-stream,  or  secondary  to  uterine  or  peritoneal 
tuberculosis;  the  latter  is  the  more  common.  Both  tubes  are 
generally  affected,  and  either  become  distended  with  curdy  pus, 
which  may  undergo  caseation  or  calcification,  or  constitute  solid 
fibroid  masses  with  encapsuled  caseous  foci,  embedded  in  a  dense 
mass  of  adhesions.  If  the  disease  is  primary,  it  may  spread  out- 
wards through  the  abdominal  ostium  to  the  peritoneal  cavity,  and 
give  rise  to  a  tuberculous  peritonitis  which  commences  as  a  pelvic 
affection  and  may  be  shut  off  by  adhesions  from  the  general  cavity. 
Clinical  History. — In  the  acute  stage,  which  is  generally  seen  in 
gonorrhceal  and  septic  cases,  the  symptoms  arc  practically  those  of 
pelvic  peritonitis.  The  patient  lies  in  bed  with  the  knees  drawn 
up;  the  temperature  is  raised,  and  there  may  be  one  or  more  rigors ; 
the  lower  part  of  the  abdomen  is  intensely  tender,  and  vaginal 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  13 13 

examination  reveals  little  but  a  generalized  painful  rigidity  and 
infiltration  of  all  the  parts.  This  condition  may  persist  and  pelvic 
suppuration  result,  an  abscess  developing  either  within  the  peri- 
toneal ca\'ity,  or  in  and  around  the  broad  ligament,  and  bursting 
either  externally  or  into  one  of  the  viscera.  More  frequently  the 
acute  phenomena  gradually  subside,  and  the  patient  then  begins 
to  manifest  the  signs  of  a  clironic  salpingitis,  which  in  the  majority 
of  cases  constitute  the  initial  symptoms.  Pain  is  perhaps  the  chief 
manifestation,  and  this  is  sometimes  of  a  continuous  dragging  type, 
referred  to  the  back  and  increased  on  any  exertion,  or  it  may  only 
be  noticed  to  any  extent  at  the  periods.  Not  unfrequently  the 
patient  is  laid  up  for  a  week  or  ten  days  at  a  time  with  these 
phenomena.  If  many  adhesions  are  present,  micturition  and 
defalcation  may  also  be  very  painful.  The  patient  is  unable  to 
take  much  exercise,  and  may  walk  in  a  peculiarly  cautious  manner, 
bending  forwards  so  as  to  relax  the  abdominal  muscles,  and  possibly 
guarding  the  lower  abdomen  with  her  hands.  All  these  symptoms 
are  increased  at  the  menstrual  periods,  which  are  profuse  and 
prolonged,  and  accompanied  by  some  rise  of  temperature.  When 
a  well-marked  collection  of  pus  is  present,  a  hectic  type  of  tempera- 
ture may  persist,  and  the  patient  shows  signs  of  toxaemia.  The 
bursting  of  the  abscess  into  the  vagina  or  one  of  the  viscera  may 
cure  the  case,  if  a  sufficient  exit  to  the  pus  is  thereby  provided. 
Vaginal  examination  demonstrates  the  enlarged  and  tender  tubes; 
the  uterus  itself  loses  some  or  all  of  its  mobility,  and  the  vaginal 
vault  may  feel  hard  and  rigid. 

Treatment  in  the  acute  cases  consists  of  rest  in  bed,  fomentations 
to  the  abdomen  and  hot  vaginal  douches,  together  with  opium,  if 
need  be,  for  the  pain.  In  the  great  majority  of  cases  the  only 
treatment  is  removal  of  the  tubes,  but  this  should  be  delayed,  if 
possible,  until  the  acute  symptoms  have  passed.  It  may  be  a 
simple  procedure,  or  an  operation  of  the  greatest  difficulty,  accord- 
ing to  the  number  and  nature  of  the  adhesions  present.  It  must 
be  remembered  that,  although  the  pus  in  an  old-standing  case  is 
likely  to  be  sterile,  one  cannot  rety  on  this  occurrence,  and  hence 
every  precaution  must  be  taken  to  guard  against  infection.  It  may 
be  possible  in  some  cases  to  save  one  or  both  ovaries,  and  this  is 
certainly  desirable  in  order  to  protect  the  patient  from  the  dis- 
comforts of  an  acute  menopause.  In  a  few  favourable  cases  the 
pus  can  be  reached  through  the  vaginal  vault,  and  an  intra-peri- 
toneal  operation  is  thereby  avoided;  but  the  indications  must  be 
very  clear  and  precise  before  this  method  of  approach  is  adopted. 

Hydrosalpinx  is  a  condition  in  which  the  Fallopian  tube  is  dis- 
tended with  a  mucoid  secretion,  due  to  the  existence  of  a  chronic 
inflammation  which  has  extended  from  the  uterus,  and  led  to  the 
closure  of  the  abdominal  and  vaginal  openings  of  the  tube.  A 
collection  of  considerable  size  may  result,  and  needs  to  be  dealt 
with  by  laparotomy. 

Tubal  Gestation  'is  a  condition  in  which  the  impregnated  ovum 

83 


1314  A   MANUAL  OF  SURGERY 

commences  to  develop  in  tlie  Fallopian  tube  instead  of  in  the  uterus. 
The  causes  of  this  condition  are  quite  unknown,  but  it  may  be  due 
to  a  kink  or  twist  of  the  tube,  whereby  the  onward  passage  of  the 
ovum  is  prevented.  Ectopic  gestation  also  occurs  within  the  peri- 
toneal cavity  or  in  connection  with  the  ovary,  but  these  conditions 
are  looked  on  as  always  secondary  to  a  primary  tubal  gestation,  the 
foetus  having  escaped  from  the  tube.  Any  part  of  the  tube  maybe 
affected,  and  hence  three  forms  are  described,  viz.,  (i)  the  interstitial 
or  tubo-uterine,  where  the  growth  encroaches  on  the  uterine  wall; 
(2)  the  true  tubal;  and  (3)  the  tubo-ovarian  or  infundibular,  where 
the  outer  end  of  the  tube  is  affected. 

The  muscular  wall  of  the  tube  stretches  and  at  first  becomes 
hypertrophied;  the  mucous  lining  is  turgid  and  congested,  and 
transformed  into  a  decidual  membrane.  In  time  the  muscle  fibres 
disappear  and  are  replaced  by  fibrous  tissue,  and  at  the  placental 
site  atrophy  occurs,  so  that  sooner  or  later  rupture  of  the  tube 
follows,  and  then  the  ovum  either  escapes  into  the  abdomen  or  into  the 
substance  of  a  broad  ligament,  and  may  die  or  continue  its  develop- 
ment, the  placenta  in  the  latter  case  gaining  a  fresh  attachment  to 
intestines  or  other  structures.  Concurrently  with  these  changes  in 
the  tube,  the  uterus  enlarges  and  becomes  lined  by  a  decidual  mem- 
brane, but  is  relatively  much  smaller  than  usual ;  at  five  months  it 
is  a  third  smaller  than  in  an  intra-uterine  pregnancy,  and  at  full 
term  is  about  4  to  6  inches  long.  Not  unfrequently  the  rupture  of 
a  tubal  gestation  is  accompanied  by  the  discharge  of  a  complete 
cast  of  the  uterus,  from  which  a  lochial  secretion  escapes  for  a  time, 
and  which  undergoes  involution. 

The  clinical  history  of  an  ectopic  gestation  varies  very  much  in 
different  cases.  Occasionally  it  occurs  in  a  young  and  healthy 
primipara,  and  then  is  due  to  some  congenital  defect  of  the  tube; 
more  commonly  it  is  seen  in  women  who  have  already  borne  children 
or  have  had  some  preceding  trouble,  suggesting  the  existence  of 
pelvic  adhesions  or  of  old  salpingitis.  Not  unfrequently  there  is  a 
history  of  a  preceding  period  of  sterility,  and  then  a  period  is  missed, 
the  woman  not  suspecting  the  existence  of  pregnancy.  There  may 
be  some  amount  of  pelvic  pain  of  a  crampy  nature,  and  a  discharge 
of  a  blood-stained  character,  suggesting  the  onset  of  an  abortion.  In 
most  cases  the  general  signs  of  pregnancy  are  absent,  since  the 
patient  comes  under  observation  at  too  early  a  period  for  their 
development;  but  if  the  condition  persists,  they  may  be  noticed, 
though  somewhat  atypical ;  the  breasts  are  enlarged ;  vomiting  may 
occur;  but  the  menses  are  not  always  completely  stopped.  Exam- 
ination in  the  early  stages  might  indicate  the  presence  of  a  well- 
defined  moveable  mass  on  one  side  of  the  uterus,  constituted  by  the 
enlarged  tube. 

In  the  early  months  the  great  danger  is  that  of  rupture  of  the  tube, 
and  possibly  death  from  haemorrhage.     Two  forms  are  described: 

I.  Primary  Intraperitoneal  Rupture  usualty  occurs  about  the  sixth 
to  the  eighth  week.     The  tube  gives  way  before  the  increasing  tension 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1315 

of  the  ovum,  and  looks  almost  as  if  torn  in  half.  Severe  haemorrhage 
follows,  and  the  patient  cither  succumbs,  or  recovers  to  suffer, 
perhaps,  from  a  similar  condition  a  few  days  later.  Occasionally 
the  bleeding  is  less  severe,  the  attacks  recurring  and  being  associated 
with  faintness;  a  localized  pelvic  haematocele  is  likely  to  result. 
In  a  few  cases  the  ovum  regains  a  vascular  connection  in  the 
abdomen  and  continues  its  development,  but  generally  the  pregnancy 
comes  to  an  end  and  the  ovum  dies.  The  symptoms  are  alarming  in 
the  extreme.  The  patient  is  seized  with  severe  cutting  intra- 
abdominal pain  which  is  referred  to  the  pelvis,  and  becomes  white, 
faint,  and  collapsed.  The  lower  part  of  the  abdomen  is  exquisitely 
tender,  and  the  muscles  are  held  rigid  and  tense.  The  actual 
presence  of  blood  in  the  peritoneal  cavity  can  rarely  be  demon- 
strated, but  the  amount  lost  is  often  very  great.  If  the  patient 
survives,  she  is  left  in  a  feeble  condition,  and  often  suffers  from 
pyrexia  for  some  days,  whilst  the  pain  gradually  diminishes.  A 
recurrence  of  the  bleeding  may  bring  the  patient  into  the  direst 
peril;  but  if  it  does  not  recur,  absorption  commences  and  may 
progress  uninterruptedly,  or  a  pelvic  hsematocele  may  result,  and 
this  may  persist  indefinitely  or  undergo  suppurative  changes  and 
require  operation. 

2.  Primary  Extraperitoneal  Rupture  occurs  when  the  chief  develop- 
ment has  been  downwards  and  inwards  between  the  layers  of  the 
broad  ligament.  The  catastrophe  is  in  these  cases  somewhat  later 
than  in  the  fortner  class,  rupture  being  delayed  sometimes  till  the 
seventh  to  the  twelfth  week.  The  loss  of  blood  is  necessarily  not 
so  great,  and  the  general  s3''mptoms  are  less  severe.  On  vaginal 
examination  the  blood  tumour  can  probably  be  detected  by  the  side 
of  the  uterus.  The  ovum  usually  dies,  and  the  blood  may  be 
absorbed;  but  not  uncommonly  infection  supervenes  and  an  abscess 
forms;  in  other  cases  a  secondary  rupture  into  the  peritoneal 
cavity  follows,  being  associated  with  the  ordinary  symptoms  of 
this  condition. 

Comparatively  few  ectopic  pregnancies  continue  after  the  fourth 
month,  but  should  the  ovum  escape  the  earlier  dangers  that  surround 
it,  its  development  may  continue  either  in  the  tube  (very  rare)  or  in 
the  abdominal  cavity.  The  usual  phenomena  of  pregnancy  are 
present,  but  with  modifications.  The  breasts  are  less  full  than 
usual ;  the  movements  of  the  child  under  the  abdominal  wail  may 
be  unnaturally  obvious  to  the  naked  eye;  the  abdomen  is  asym- 
metrically enlarged,  and  the  long  axis  may  even  be  transverse; 
palpation  of  the  foetus  may  be  unduly  easy,  and  the  placental 
souffie  exaggerated  or  misplaced.  At  full  term,  or  possibly  a  month 
or  two  before  it,  a  foiTn  of  spurious  labour  occurs,  followed  usually 
by  the  death  of  the  foetus.  The  abdominal  swelling  diminishes  in 
size,  and  the  uterus  undergoes  involution  with  a  lochial  discharge. 
The  foetus  becomes  encapsuled,  and  may  be  either  mummified, 
calcified  (then  constituting  a  lithopedion),  or  transformed  into 
adipocere;  or  suppuration  sometimes  ensues,  and  the  disintegrated 


[3i6  A   MANUAL  OF  SURGERY 

foetus  may  iind  its  way  out  tlirough  abscesses  which  burst  into 
the  hollow  \'iscera  or  externally. 

Treatment  of  a  Ruptured  Tubal  Gestation.^ — In  these  cases  the 
danger  to  the  patient  is  that  of  hcemorrhage,  and  it  is  obvious  that 
the  rules  guiding  us  elsewhere  apply  here — viz.,  that  the  bleeding 
point  should  be  exposed  and  the  torn  vessels  secured.  Owing  to  the 
fact  that  the  ha.'morrhage  is  concealed,  it  is  possible  for  the  patient 
to  pass  into  such  a  condition  of  collapse  as  to  render  operative  treat- 
ment almost  impracticable.  In  such  cases  it  may  be  feasible  to 
improve  her  condition  by  the  infusion  of  salt  solution,  so  as  to  justify 
operation.  In  other  cases  where  the  patient  has  had  one  attack  of 
haemorrhage  from  which  she  is  recovering,  the  question  of  operation 
is  quite  open  to  discussion:  on  the  one  hand  are  the  facts  that  no 
further  trouble  need  arise,  and  that  the  hematocele  may  be  absorbed ; 
on  the  other  hand  the  haemorrhage  may  recur,  or  the  hsematocele 
may  suppurate.  It  is  probable  that  operation  in  all  cases  is  per- 
fectly sound  advice,  especially  as  one  cannot  be  always  certain  that 
the  ovum  is  dead  (although  the  passage  of  a  cast  of  the  uterus  is 
suggestive),  and  its  continued  development  in  the  peritoneal  cavity 
is  most  undesirable.  In  careful  aseptic  hands  the  risks  of  operation 
are  very  small.  It  goes  almost  without  saying  that  if  a  diagnosis 
of  tubal  gestation  is  made  prior  to  rupture,  the  tube  should  be  at 
once  removed. 

Operation  for  intraperitoneal  rupture  must  not  be  delayed :  possibly 
it  may  be  wise  to  commence  intravenous  infusion  before  opening 
the  abdomen,  and  to  allow  an  assistant  to  continue  the  process 
during  its  performance.  The  patient  is  placed  in  the  Trendelen- 
burg position;  a  median  incision  is  made  above  the  pubes;  an 
abundant  escape  of  blood  and  clots  is  likely  to  follow,  but  the 
hand  is  thrust  firmly  down  so  as  to  distinguish  the  uterus,  and 
thence  passes  to  the  ruptured  tube,  which  must  be  grasped  by 
the  uterine  attachment  and  a  haemostatic  clamp  at  once  applied;  the 
other  end  is  then  sought  for.  The  intervening  portion  is  removed, 
and  the  bases  securely  ligatured.  The  intraperitoneal  clots  may 
be  swabbed  away  or  left  according  to  the  condition  of  the 
patient,  and  the  abdomen  either  closed  entirely  or  a  drainage- 
tube  inserted.  The  subsequent  treatment  is  that  for  all  forms  of 
haemorrhage. 

The  operation  for  an  extraperitoneal  rupture  is  slightly  different 
in  its  chciracters,  since  it  is  usually  not  undertaken  for  haemorrhage, 
but  in  order  to  remove  the  products  of  gestation,  to  relieve  the 
patient  from  pain,  or  to  prevent  a  long  and  tedious  convalescence 
whilst  the  hematocele  is  absorbing.  The  possibility  that  infection 
may  have  already  reached  the  sac  must  not  be  lost  sight  of.  A  median 
laparotomy  is  performed  in  the  Trendelenburg  position,  and  the 
viscera  securely  walled  off  by  sterile  gauze.  Intestinal  adhesions 
may  be  present,  and  must  be  cautiously  loosened  so  as  to  expose  the 
sac  of  the  haematocele.  This  may  give  way  during  the  manipula- 
tions to  separate  the   intestine,  or  may  need  to  be  incised,  or  is 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1317 

tapped  with  a  trocar.  The  mass  is  then  isolated,  its  vessels  tied, 
and  complete  removal  follows;  or  it  may  be  necessary  to  evacuate 
the  contents  and  drain  or  pack  the  cavity,  especially  when  the  blood 
has  burrowed  deeply  into  the  pelvis  between  the  layers  of  the 
broad  ligament. 

When  suppuration  has  occurred,  the  abscess  must  be  treated  on 
the  same  lines  as  are  followed  in  the  treatment  of  a  pelvic  peri- 
tonitis. It  may  be  possible  to  open  and  drain  from  the  vagina,  or 
the  abscess  may  have  to  be  dealt  with  from  above. 

For  the  treatment  of  ectopic  gestation  which  persists  after  the 
fourth  month,  we  must  refer  readers  to  larger  text -books. 

Primary  Cancer  of  the  Fallopian  Tube  commences  in  the  mucous 
membrane,  and  is  likely  to  run  a  rapid  course,  leading  to  early 
dissemination  of  the  disease  through  the  peritoneal  cavity  if  the 
abdominal  ostium  is  patent.  The  ovary  is  not  unfrequently  affected 
in  this  way,  and  careful  examination  may  be  required  to  demon- 
strate that  the  primary  lesion  is  in  the  tube. 

Cysts  of  the  Ovary  and  Broad  Ligament. 

Many  different  forms  of  cyst  are  developed  in  this  region,  and 
their  origin  from  an  embryological  standpoint  has  been  already 
alluded  to  (p.  230).  The  following  classification  may,  however,  be 
useful : 

I.  Cysts  directly  connected  with  the  Ovary. 

1.  True  ovarian  cyst,  single,  multiple,  or  proliferating. 

2.  Paroophoritic  cyst  with  papillomatous  developments. 

3.  Corpus  luteum  cj^sts. 

4.  Ovarian  dermoid  or  teratoma. 

5.  Malignant  ovarian  cyst  (usually  carcinomatous). 

6.  Ovarian  hydrocele. 

II.  Cysts  of  the  Broad  Ligament. 

1.  Parovarian  cysts. 

2.  Cysts  of  Kobelt's  tubes. 

3.  Cyst  of  Gartner's  duct. 

4.  Fallopian  tube  cysts.  - 

5.  Lymphangiomatous  developments. 

True  Ovarian  Cysts,  or,  as  they  should  perhaps  be  better  termed, 
the  cysto-adenomata  of  the  ovary,  are  usually  multilocular  swellings, 
involving  one  or  both  ovaries  (more  commonly  the  former),  and 
arising  from  the  tubular  ingrowths  of  the  ovarian  epithelium  or  froni 
the  Graafian  follicles.  As  the  swelling  increases,  the  walls  between 
the  loculi  thin  out  and  may  be  absorbed;  but  the  usual  appearance 
is  that  shown  in  Fig.  581,  where  rounded  cyst-like  masses  are  seen 
projecting  within  the  larger  cyst,  which  has  been  laid  open.  The 
fluid  is  of  a  tenacious  character,  somewhat  similar  in  type  to  mucin, 
and  usually  of  a  yellowish- white  colour;  if  haemorrhage  has  taken 
place  into  the  cyst,  the  colour  is  of  course  modified. 

The  size  of  these  cysto-adenomata  varies  enormously;  they  may 


I3i8 


A   MAXl'AI.  or  SURGFAiV 


be  small  as  an  orange,  or  large  enough  to  compress  the  abdominal 
contents  and  interfere  seriously  with  respiration.  The  largest  cyst 
of  this  type  we  have  dealt  with  contained  32  pints  of  fluid;  the 
patient  was  65  inches  in  circumference,  and  her  legs  were  dripping 
with  dropsy;  she  had  been  unable  to  lie  down  in  bed  for  many 
months.  The  walls  of  the  growth  vary  in  thickness  and  substance ; 
sometimes  there  is  a  considerable  mass  of  newly-formed  epithelial 
tissue,  which  in  time  would  undergo  degeneration  and  form  fresh 
cysts.  The  cyst  is  covered  externally  with  peritoneum,  and  possibly 
adhesions  to  omentum  or  intestine  may  be  present.  The  broad 
ligament  and  Fallopian  tube  become  stretched  by  the  traction  and 


Fig.  581. — Proliferating   Cysto-adenoma   of   the   Ovary.     (King's 
College  Hospital  Museum.) 

The  main  cyst  has  been  laid  open  to  show  the  smaller  cysts  which  project  into 

its  cavity. 

weight  of  the  mass  and  constitute  a  well-marked  pedicle,  which 
contains  the  nutrient  vessels. 

Paroophoritic  Cysts  are  very  similar  in  character  to  the  above,  but 
contain  intracystic  papillomatous  developments  (Fig.  582),  which 
not  unfrequently  burrow  through  the  cyst  wall,  and  may  invade  the 
peritoneal  cavity,  and  hence  are  semi-malignant.  The  primary 
growth  may  be  uni-  or  multi-locular,  and  in  some  cases  large  thin- 
walled  cysts  develop  containing  cauliflower-like  excrescences  of 
considerable  size,  which  are  covered  with  columnar  epithelium. 

Corpus  Luteum  Cysts  are  usually  multiple  and  not  of  great  size, 
though  occasionally  they  may  be  found  as  large  as  a  fist.  The  fluid 
contained  within  is  more  or  less  thick,  and  dark  in  colour  from  blood 
extravasation,  and  the  lining  wall  shows  a  definite  overgrowth  of 


SURGERY  OF  THE  FEMALE  GENFFAL  ORGANS 


1319 


lutein  cells.  The  association  of  this  type  of  overgrowth  with 
decidiioma  malignum  has  been  already  mentioned. 

For  Ovarian  Dermoids  or  Teratomata,  see  p.  22S.  An  ovarian 
demioid  is  usually  unilocular;  it  may  manifest  its  presence  at  an 
early  age,  or  not  until  middle  life ;  it  grows  slowly,  and  is  very  liable 
to  attacks  of  partial  torsion,  which  ma}^  finally  become  complete. 

Ovarian  Hydrocele  is  a  condition  rarely  observed,  in  which  the 
ovary  lies  in  a  pouch  in  the  broad  ligament,  the  mouth  of  which 
becomes  closed  through  the  development  of  adhesions,  so  that  a 
collection  of  fluid  can  occur  outside  the  ovary.  It  is  not  likely  to 
attain  great  dimensions. 

Parovarian  Cysts  result  from  distension  with  fluid  of  the  par- 
ovarium or  organ  of  Rosenmiiller,  which  in  reality  is  the  atrophied 


Fig.  582. — Cyst  of  Ovary  (Paroophoritic)  with  Proliferating  Papillo- 
matous Intra-cystic  Growths.     (King's  College  Hospital  Museum.) 

remnant  of  the  Wolffian  body,  traces  of  which  can  often  be  seen  in 
the  broad  ligament.  As  the  cyst  gradually  increases  in  size,  the 
layers  of  the  broad  ligament  are  separated,  and  the  ovary  and  tube 
are  pushed  up  and  stretched  over  the  growth,  which  usually  burrows 
deeply  into  the  pelvis  by  the  side  of  the  uterus.  The  cyst  is  gener- 
ally unilocular,  thin-walled,  and  contains  a  clear  limpid  fluid.  Its 
method  of  development  explains  the  fact  that  it  has  no  pedicle. 

Cysts  of  Kobelt's  Tubes  (Fig.  583)  are  frequently  seen,  and  are  of 
little  significance.  It  is  quite  unusual  for  them  to  become  large 
enough  to  cause  s^Tnptoms. 

Clinical  History. — -It  is  unnecessary  to  discuss  here  in  extenso  the 
symptoms  which  arise  in  the  earlier  stages  when  an  ovarian  cyst  is 


I320  A   MANUAL  OF  SURGERY 

small  and  intrapelvic.  Suffice  it  that  some  disturbance  of  men- 
struation may  occur,  usually  in  the  direction  of  menorrhagia,  and 
that  there  may  be  a  sense  of  intrapelvic  pressure  or  pain,  and 
possibly  some  interference  with  the  bladder  or  rectum;  the  latter 
may  be  more  marked  in  the  broad  ligament  cysts  than  in  the  true 
ovarian. 

The  patient  is  most  likelv  to  come  under  observation  when  the 
growth  has  emerged  from  the  pelvis  and  become  abdominal,  and 
possibly  she  may  have  noticed  that  the  swelling  appeared  first  on 
one  side.  As  it  increases  in  size,  it  becomes  more  mesial,  and 
pushes  up  under  the  anterior  abdominal  wall,  usually  displacmg 
the  intestines  backwards  and  towards  the  sides  of  the  abdomen. 
Hence  on  inspection  the  projection  of  the  growth  can  often  be  seen, 
and  there  is  no  bulging  of  the  flanks  such  as  occurs  in  ascites. 
Percussion  elicits  a  dull  note  over  the  swelling,  though  the  margms 
may  be  overlapped  by  intestine  and  give  a  semi-resonant  note; 
the  flanks  are  resonant,  whereas  in  ascites  the  anterior  abdommal 
wall  is  resonant,  and  the  flanks  and  sides  dull.     Very  little  or  no 

modification  in  the  per- 

„,--  "  cussion  note  occurs  on 

'i^'          --'  /^  changing  the  position 

'■■  from    the     dorsal     to 

-  \  the   lateral  decubitus, 

\  whereas  in  ascites  this 

\  produces     a     marked 

alteration.     On  palpa- 


..^  ,  t.^  — ^    tion  the  outhne  of  the 

^  '^  cyst    may    be     easily 

Fig.  583.— Cysts  of  Kobelt's  Tubes.     (King's   tangible,  and  it  may  be 

College  Hospital  Museum.)  felt  passing  down  into 

I.  Fallopian  tube;  2,  fimbriated  extremity  of  Fallo-   the  pelvis.  A  tap  some- 

pian  tube;  3,  ovary;  4,  Kobelt's  cysts.  times  produces  a  fluid 

thrill,  which  is  most 
marked  in  the  unilocular  parovarian  cysts,  and  often  absent  in  the 
multilocular  variety,  unless  the  front  of  the  mass  is  constituted  by  a 
single  large  loculus.  It  may  be  possible  to  demonstrate  that  the  mass 
is  mobile,  especially  on  bimanual  examination.  The  growth  is  usually 
found  to  drag  the  uterus  upwards,  and  does  not  project  down  into 
the  fornices ;  hence  the  vagina  often  appears  to  be  very  long,  and 
the  cervix  is  sometimes  difficult  to  reach.  The  uterus  may  be 
displaced  laterally. 

Pressure  symptoms  of  various  types  arise,  such  as  impaired  diges- 
tion and  constipation,  leading  to  interference  with  nutrition, 
emaciation  and  debility;  redema  of  the  legs  is  caused  by  pressure 
on  the  vena  cava;  the  subcutaneous  veins  of  the  abdominal  wall 
become  prominent;  and  respiration  may  be  considerably  em- 
barrassed. Should  even  a  small  ovarian  cyst  become  impacted 
in  the  pelvis,  all  the  evidences  of  pressure  may  be  at  once 
exaggerated,  and  both  rectum  and  bladder  are  irritable. 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1321 

Complications  of  various  types  ensue,  and  may  quickly  jeopardize 
the  patient's  life,  (i.)  Injlammation  arises  from  a  variety  of  causes 
— e.g.,  traumatism  or  partial  torsion;  or  germs  may  gain  access 
from  some  neighbouring  viscus — e.g.,  the  appendix  or  Fallopian  tube. 
The  trouble  may  be  of  a  slight  and  localized  character,  and  then 
merely  a  few  adhesions  are  developed;  or  it  may  be  a  deep  paren- 
chymatous affection,  followed  by  suppuration.  The  usual  phe- 
nomena of  intra-abdominal  inflammation  are  manifested:  the 
patient  complains  of  pain,  and  lies  with  the  legs  drawn  up;  the 
temperature  is  raised;  vomiting  and  possibly  constipation  are 
present;  and  on  palpation  the  growth  is  tender,  increased  in  size, 
and  possibly  less  easily  defined.  If  pus  forms,  it  may  escape  into 
the  peritoneal  cavity  or  one  of  the  hollow  viscera.  Even  if  recovery 
follows,  extensive  adhesions  may  ensue  and  lead  to  serious  conse- 
quences. 

(ii.)  Torsion  of  the  cyst  is  predisposed  to  by  the  existence  of  a 
well-marked  elongated  pedicle,  and  is  most  often  seen  in  connection 
with  dermoids;  it  is  impossible  in  the  presence  of  extensive  ad- 
hesions. It  is  probably  determined  by  irregular  contractions  of 
the  abdominal  muscles,  and  the  final  disturbance  may  be  caused 
by  definite  traumatism.  From  the  fact  that  in  acute  cases  the 
pedicle  is  found  twisted  on  itself  two  or  three  times,  it  is  obvious 
that  slight  attacks  must  have  preceded  the  final  outbreak  of 
symptoms,  and  many  of  the  slighter  attacks  of  inflammation  (usually 
supposed  to  be  peritonitic  in  type)  are  probably  of  this  nature. 
Finally,  the  torsion  becomes  so  severe  that  the  circulation  in  the 
cyst  ceases,  and  strangulation  ensues.  An  aseptic  peritonitis 
follows,  and  unless  relief  is  given  in  time  death  from  generalized 
peritonitis  and  intestinal  paralysis  follows.  The  cyst  becomes 
enlarged  and  engorged  with  blood;  hsemorrhage  may  occur  into  its 
substance,  and  gangrene  is  likely  to  follow.  The  symptoms  may 
come  on  suddenly  after  some  effort,  or  there  may  be  no  obvious 
cause.  Pain  of  a  severe  character  is  complained  of,  followed  by 
shock ;  the  tumour  is  obviously  increased  in  size,  tense  and  tender ; 
vomiting  and  constipation  suggest  the  existence  of  an  acute  in- 
testinal obstruction,  and  if  the  case  is  not  seen  till  late  and  there 
is  no  definite  history  of  a  cyst  to  be  obtained,  a  diagnosis  may 
be  difficult  or  impossible  apart  from  an  exploratory  operation. 

(iii.)  Rupture  of  the  cyst  may  be  spontaneous  from  gradual 
thinning  of  the  walls,  or  due  to  traumatism.  The  results  vary 
with  the  contents.  A  sudden  rupture  leads  to  severe  pain  and 
shock ;  this  may  be  followed  by  inflammatory  phenomena  and  peri- 
tonitis if  the  contents  are  of  a  sticky  colloidal  character,  but,  when 
limpid  and  serous,  the  fluid  may  be  absorbed,  and  no  harm  follows. 
The  cyst  itself  collapses,  and  is  likely  to  develop  adhesions,  but  the 
secreting  substance  persists,  and  the  cavity  may  fill  up  again. 

It  is  impossible  to  discuss  fully  here  the  Diagnosis  of  ovarian 
cystomata,  and  it  must  suffice  to  point  out  that  the  passage  of  a 
catheter  eliminates  the  question  of  a  distended  bladder;  that  careful 


1322  A  MANUAL  OF  SURGERY 

attention  to  the  percussion  phenomena,  both  in  the  dorsal  and 
lateral  decubitus,  should  suffice  to  determine  the  existence  or  not 
of  ascites ;  and  that  vaginal  examination  and  the  passage  of  a  uterine 
sound  should  eliminate  uterine  conditions  that  might  be  mistaken. 
Before  the  introduction  of  a  sound  it  is  of  course  essential  to  exclude 
the  possibility  of  pregnancy.  The  absence  of  changes  in  the  cervix 
uteri  and  in  the  breasts,  the  non-existence  of  a  uterine  souffle  on 
auscultation,  or  of  a  history  of  amenorrheea,  morning  sickness,  etc., 
should  suffice  to  determine  the  absence  of,  this  latter  condition. 

Treatment  for  nearly  all  varieties  of  ovarian  cvst  is  the  operation 
of  Ovariotomy,  first  performed  in  1809  by  Dr.  Ephraim  McDowell  in 
Danville,  Kentuckj^  and  that  with  success.  The  essential  idea  of 
the  operation  is  the  removal  of  the  cyst,  and  this  may  be  accom- 
plished either  with  or  without  tapping.  The  size  of  the  growth 
will  to  some  extent  determine  whether  or  not  it  should  be  tapped, 
but  there  are  some  conditions  where  it  is  unnecessary  {e.g.,  in  small 
cysts),  and  others  where  it  is  undesirable  {e.g.,  dermoid  cysts,  and 
the  proliferating  papillomatous  forms) ;  in  these  latter  there  may 
be  active  cells  in  the  fluid  contents,  and  the  escape  of  these  into  the 
peritoneal  cavity  (and  it  is  not  always  possible  to  prevent  such 
escape)  may  result  in  infection  of  the  peritoneum  with  these  cells, 
and  a  new  development  of  some  form  of  epithelial  growth  may 
ensue. 

Operation. — The  patient  is  prepared  in  the  usual  way,  the 
abdominal  wall  being  purified  and  the  vulva  shaved;  but  unless 
there  is  some  objectionable  discharge,  there  is  no  need  to  douche  or 
pack  the  vagina.  The  Trendelenburg  position  may  be  advisably 
adopted,  as  it  enables  the  surgeon  to  deal  with  the  pedicle  of  the  cyst 
more  easily.  An  incision  is  made  in  the  middle  line  above  the  pubes, 
and  the  anterior  wall  of  the  cyst  is  exposed.  The  finger  or  hand  is 
swept  round  in  order  to  ascertain  whether  or  not  there  are  any 
adhesions ;  if  present,  it  may  be  possible  to  deal  with  them  at  this 
stage,  but  more  usually  it  is  easier  to  detach  them  later  on.  A 
Spencer  Wells  trocar  is  then  thrust  into  the  cyst,  and  as  the  fluid 
escapes,  the  relaxed  wall  is  grasped  by  forceps  and  drawn  up  out  of 
the  incision  so  as  to  prevent  the  fluid  getting  into  the  peritoneal 
cavity.  This  end  is  not  always  attained,  as  the  cyst  wall  is  some- 
times so  soft  and  friable  that  it  splits  and  bursts,  and  any  attempt 
to  grasp  it  with  forceps  leads  to  an  increased  rent  in  its  substance. 
Under  these  circumstances  the  patient  can  either  be  rolled  over  on 
her  side,  and  the  contents  scooped  out  by  the  hand,  or,  possibly 
better,  the  incision  is  rapidly  increased  in  length  to  a  sufficient 
extent  to  allow  the  whole  cj^st  to  be  lifted  up  out  of  the  abdomen. 
Large  secondary  cysts  may  be  opened  b}'  the  trocar  through  the  first 
main  cyst,  but  in  doing  this  care  must  be  taken  not  to  thrust  the 
instrument  through  the  posterior  or  lateral  wall  of  the  growth. 
The  pedicle  is  now  securely  tied  off,  and  any  form  of  ligature  which 
involves  its  transfixion  will  suffice.  It  is  perhaps  wise  to  di\'ide  the 
pedicle  at  such  a  distance  from  the  ligature  that  the  main  ovarian 


SURGf-RY  OF  THE  FEMALE  GEMITAL  ORGANS  1323 

vessels  can  be  recognised  on  the  stump,  and  an  ordinary  silk  or 
catgut  ligature  can  be  separately  applied  to  each  of  these;  this  plan 
will  obviate  any  danger  that  might  arise  from  the  relaxation  or 
slipping  of  the  main  ligature.  The  other  ovary  is  then  examined 
and  dealt  with  according  to  circumstances.  The  peritoneal  cavity 
is  cleansed,  and  possibly  when  much  of  the  cyst  fluid  has  escaped 
it  may  be  desirable  to  wash  it  out  with  salt  solution,  and  the 
abdominal  incision  is  then  closed. 

Broad  ligament  cysts  (parovarian)  often  have  no  pedicle,  and  then 
must  be  enucleated  after  tapping.  The  layers  of  the  broad  liga- 
ment are  divided  in  a  suitable  manner  back  and  front ;  the  supplying 
vessels  are  secured  by  ligature;  and  the  cyst  wall  can  usually  be 
freed  from  its  surroundings  without  difficulty.  The  opening  in  the 
broad  ligament  is  subsequently  stitched  up,  and  probably  no 
drainage  will  be  required. 

An  ovarian  cyst  with  a  twisted  pedicle  is  treated  in  the  usual  way 
after  untwisting.  An  inflamed  or  suppurating  cystoma  must  be 
dealt  with  according  to  circumstances;  it  may  be  possible  to  remove 
it  en  masse,  but  incision  and  drainage  without  removal  may  have  to 
be  resorted  to. 

An  uncomplicated  ovariotomy  is  one  of  the  most  successful  major 
operations  in  surgery,  and  the  death-rate  is  now  phenomenally 
small.  The  presence  of  adhesions  and  other  complications  of  course 
adds  to  the  gravity  and  increases  the  death-rate. 

Solid  Tumours  of  the  Ovary  are  not  very  common,  and  consist 
of  carcinoma,  sarcoma,  or  myo-fibroma.  Carcinomata  are  solid  or 
cystic;  they  grow  rapidly,  and  early  involve  surrounding  parts, 
producing  a  generalized  carcinomatous  infection  of  the  peritoneal 
cavity  with  ascites.  Bland-Sutton*  has  pointed  out  that  in  the 
majority  of  cases  cancer  of  the  ovary  is  secondary  rather  than 
primary,  and  that  the  causative  lesion  may  be  found  in  the  intes- 
tine. Fallopian  tube,  or  breast.  Sarcomata  are  usually  more  or  less 
firm,  and  of  the  spindle-celled  type,  thereby  closely  simulating 
the  myo-fibromata ;  in  the  former,  however,  the  growth  is  more  rapid, 
and  ascites  is  more  likely  to  be  present.  In  all  these  cases  extirpa- 
tion should  be  practised,  if  possible. 

Salpingo-odphoreetomy,  or  removal  of  the  ovary  and  its  tube,  is 
required  in  many  conditions — e.g.,  small  solid  or  cystic  tumours, 
hydro-  or  pyo-salpinx,  and  sometimes  for  dealing  indirectly  with 
inoperable  carcinoma  mammae.  The  operation  may  be  simple  in 
the  extreme,  or  one  of  the  greatest  difficulty  if  many  adhesions  are 
present.  The  Trendelenburg  position  is  adopted;  the  usual  mesial 
incision  is  made;  the  ovary  is  secured,  and  silk  ligatures  are  carried 
through  the  broad  ligament  and  tied  above  and  below  to  secure  the 
ovarian  vessels.  After  removal  of  the  tube  and  ovary,  it  is  ad- 
visable to  secure  separately  the  chief  vessels  on  the  face  of  the 
stump.  Adhesions  are  dealt  with  as  may  be  required. 
*  British  Medical  Journal,  January  4,  1908. 


CHAPTER   XLIV. 

AMPUTATIONS. 

By  the  term  Amputation  is  meant  the  removal  of  some  portion  of  the  body 
which  is  injured  or  diseased  to  such  a  degree  as  to  endanger  the  patient's  Hfe, 
or  to  preclude  any  hopes  of  its  restoration  to  a  normal,  or  even  useful,  condition. 
In  this  chapter  we  shall  merely  deal  with  the  operation  as  applied  to  the 
extremities,  amputations  of  organs  such  as  the  breast  and  penis  having  been 
described  elsewhere.  Necessary  limitations  of  space  force  us  to  treat  the 
subject  somewhat  briefly. 

Methods  of  Amputations. — Since  the  introduction  of  anaesthesia,  the  methods 
employed  for  the  purpose  of  removing  limbs  have  been  almost  revolutionized  ; 
there  is  now  no  necessity  to  hurry  through  the  operation,  and  hence  many  new 
proceedings,  and  these  sometimes  of  a  most  complicated  nature,  have  been 
devised.  They  are  in  the  main  merely  modifications  of  three  cardinal  operations 
— the  circular,  the  racquet-shaped,  and  the  flap. 


Fig.  584.^ — Circular  Amputation  for  the 
Arm,  showing  Flap  of  Skin  turned  back, 
AND  Knife  applied  for  Division  of  the 
Muscles. 


Fig.  585.  —  Section  of 
Parts  after  Circular 
Amputation. 

A,  Skin  and  subcutaneous 
fat;  B,  muscles;  C, bone. 


The  Circular  Amputation  (Fig.  584),  although  formerly  much  employed,  is 
now  but  little  used ;  in  it  the  skin  and  subcutaneous  tissues  are  divided  around 
the  whole  circumference  of  the  limb  by  a  circular  sweep  of  the  knife.  These  are 
then  retracted  or  dissected  back  like  a  cuff,  and  the  superficial  muscles  divided 
in  a  similar  manner.  The  soft  parts  are  again  further  retracted,  and  the  deeper 
muscles  divided,  allowing  the  bone  to  be  cleared  and  sawn  through  at  a  still 
higher  level.  The  end  of  the  bone  is  thus  placed  at  the  apex  of  a  conical  hollow 
(Fig.  585),  and  can  be  completely  covered  over;  the  vessels,  moreover,  are 
divided  transversely.     The  stump  is  not  very  shapely,  and  after  a  time,  owing 

1324 


AMPUTATIONS 


1325 


to  the  shrinking  of  the  soft  parts,  the  cicatrix  is  likely  to  become  attached  to  the 
bone.  The  arm  is  almost  the  only  situation  in  which  a  pure  circular  operation 
is  ever  undertaken  at  the  present  day;  but  a  modified  form  is  still  occasionally 
utilized  elsewhere.  Thus,  one  or  two  vertical  incisions  may  be  associated  with 
the  circular  cut,  in  order  to  facilitate  the  removal  of  the  bone  at  a  higher  level, 
as  in  disarticulation  of  the  hip-joint  by  Furneaux  Jordan's  method  (p.  1340). 

The  Racquet-shaped  Method  (Fig.  590,  A  and  C)  is  very  similar  to  the  last- 
described  modification  of  the  circular.  In  it  an  oval  incision  is  made  around 
the  limb  with  one  end  pointed,  and  if  necessary  prolonged  upwards  to  form,  as 
it  were,  the  handle  of  the  racquet.  This  method  is  useful  for  removing  fingers 
and  toes,  and  is  also  employed  at  the  hip  and  shoulder  joints. 

A  somewhat  similar  operation  is  known  as  the  Elliptical  or  Oval  Method.  In 
it  an  oval  incision  is  made  around  the  limb;  the  lower  or  distal  portion  is  then 
dissected  up  so  as  to  enable  the  amputation  or  disarticulation  to  be  completed 
at  a  level  a  little  below  the  proximal  end.  The  free  convex  border  of  the  flap 
is  then  turned  over,  and  fitted  into  the  concavity  of  the  wound. 


Fig.  586. — Amputation  of  the  Thigh 
BY  Lister's  Flap  and  Circular 
Method. 


Fig.  587. — Lateral  View  of  the 
Same  Operation  with  the 
Skin  Flaps  Dissected  Back. 


A  indicates  the  anterior  flap;  B,  the  posterior,  which  is  half  the  length  of 
the  anterior ;  C,  the  line  of  division  of  the  muscles,  which  is  performed  by 
circular  sweeps  of  the  knife. 

The  Flap  Method  is  that  chiefly  made  use  of  at  the  present  day  in  amputating 
through  the  shafts  of  the  long  bones.  It  was  formerly  performed  by  transfixion 
in  order  to  save  time ;  but  the  bulk  of  muscles  included  in  the  flaps,  and  the  fact 
that  the  vessels  and  nerves  are  often  sliced  longitudinally,  render  this  an 
undesirable  proceeding.  Hence  it  has  been  discarded,  and  the  flaps  are  now 
usually  marked  out  superficially,  and  then  raised  by  dissection.  As  a  rule,  they 
consist  merely  of  skin,  subcutaneous  tissue,  and  deep  fascia,  a  little  muscle 
being  perhaps  included  towards  the  base. 

The  best  method  of  amputating  in  muscular  parts,  such  as  the  thigh,  is  that 
known  as  the  Modified  Flap  and  Circular  (Figs.  586  and  587),  which  was  origin- 
ally suggested  by  Lord  Lister.  In  this  two  rectangular  flaps  with  the  corners 
rounded  off  are  raised  on  opposite  sides  of  the  limb,  the  length  of  the  anterior 
being  two-thirds  of  the  diameter  of  the  limb  at  the  point  at  which  it  is  proposed 


1326 


A   MANUAL  OF  SURGERY 


to  divide  the  bone,  and  the  posterior  flap  half  the  length  of  the  anterior.  These, 
consisting  merely  of  skin  and  subcutaneous  tirsues,  are  dissected  up;  the 
muscles  are  then  divided  circularly,  being  retracted  for  another  half-diameter. 
The  advantages  of  the  flap  and  circular  methods  are  thus  combined.  In 
cutting  the  flaps  it  is  most  essential  that  they  should  not  taper,  but  should 
remain  the  same  breadth  throughout,  the  corners  being  merely  rounded  off. 


General  Remarks  on  Amputations. 

Certain  important  details  must  always  be  attended  to  by  the  operator  when 
selecting  an  amjiutation  suitable  for  any  particular  case. 

I.  A  Sufficient  Covering  is  necessary  in  order  to  protect  the  end  of  the  bone 
from  injurious  pressure.     If  the  skin  were  not  contractile,  and  if  the  muscles 

did  not  retract,  it  would 
suffice  to  provide  two 
flaps,  each  equal  to  half 
the  diameter  of  the  limb 
at  the  point  of  section  of 
the  bone;  but  owing  to 
the  contractility  and  re- 
traction of  living  tissues, 
it  is  essential  to  allow  at 
least  a  diameter  and  a 
half,  and  sometimes  two 
diameters;  in  non-mus- 
cular parts  the  former 
may  suffice,  but  in  fleshy 
parts,  especially  when 
amputating  low  down  in 
the  thigh,  where  the 
range  of  muscular  con- 
traction is  much  greater, 
the  latter.  It  is  usually 
a  matter  of  some  signifi- 
cance whence  the  flaps 
are  derived ;  thus,  a  single 
flap,  e.g.,  a  long  anterior 
or  posterior,  is  not  to  be 
recommended  owing  to 
the  difficulty  of  main- 
taining its  nutrition. 
Equal  flaps  are  used  in 
parts  like  the  arm,  where 
the  end  of  the  stump  will 
not  be  exposed  to  pres- 
sure. Generally,  how- 
ever, one  flap  is  cut  longer 
than  the  other,  as  in  the 
case  of  the  modified  flap 
and  circular,  the  longer 
flap  being  taken  from 
that  side  of  the  limb  which  has  the  better  blood-supply.  Teale's  amputation 
(Fig.  588)  consists  in  raising  a  long  square  anterior  flap,  equal  in  breadth  and 
length  to  half  the  circumference  of  the  limb  at  the  point  of  section  of  the  bone, 
and  including  everything  down  to  the  bone.  The  posterior  flap  is  similar  in 
nature  to  the  anterior,  but  only  a  quarter  of  its  length.  The  free  end  of  the 
anterior  flap  is  doubled  over,  and  accurately  stitched  to  the  posterior.  The 
advantages  claimed  for  this  operation  are  that  the  vessels  are  cut  long,  and  thus 
the  nutrition  of  the  flaps  is  secured,  whilst  a  covering  nearly  equal  to  two 
diameters  of  the  limb  is  provided.  The  great  objection  to  the  method  consists 
in  the  amount  of  the  limb  which  has  to  be  sacrificed  on  account  of  the  length 


The 


5. — Teale's  Amputation.    (Treves' 
'  Operative  Surgery.') 

smaller   block   indicates   how   the   flaps   ; 
brought  together. 


AMPUTATIONS  1327 

ot   the   anterior   flap,  and   hence  it  is   rarely  employed.     Occasionally   the 
covering  is  derived  irom  the  sides  of  the  limb  (amputation  by  lateral  flaps). 

2.  The  Cicatrix  should  be  situated  away  from  the  end  of  the  bone,  especially 
in  the  lower  extremity,  where  the  weight  of  the  body  has  to  rest  upon  the 
stump. 

3.  A  Dependent  Opening  is  desirable  for  purposes  of  drainage,  and  to  ensure 
this  the  anterior  llap  is  often  made  longer  than  the  posterior.  This,  however,  is 
not  such  an  important  matter  since  the  introduction  of  aseptic  methods. 

4.  All  these  objects  should  be  attained  with  as  little  sacrifice  of  the  limb  as 
possible,  since  the  higher  the  operation,  the  greater  the  shock  to  the  patient. 

As  to  the  operation  itself,  the  greatest  care  must  be  taken  to  maintain 
Asepsis,  since  muscular  and  fascial  planes  have  been  freely  opened,  and  possibly 
the  medullary  cavity  of  the  bone  exposed ;  the  dangers  of  infection  under  such 
circumstances  are  obvious.  Haemorrhage  is  prevented  by  previous  exsanguina- 
tion  of  the  limb  by  elevating  it  for  two  or  three  minutes,  and  then  applying 
an  elastic  tourniquet.  In  the  leg  a  piece  of  rubber  tubing  may  be  employed, 
Samway's  tourniquet  being  perhaps  the  best.  In  the  arm,  however,  paralytic 
symptoms,  usually  involving  the  musculo-spiral  nerve,  have  followed  the  use  of 
such  appliances,  especially  when  made  of  solid  rubber;  a  fiat  elastic  bandage 
carried  several  times  around  the  limb,  and  secured  by  a  knot  or  with  a  safety- 
pin,  is  all  that  is  needed.  Should  the  tourniquet  have  to  be  applied  close  to  the 
area  of  operation,  it  must,  of  course,  be  first  sterilized ;  it  is  also  advisable  to 
protect  the  skin  over  which  it  is  placed  by  a  few  layers  of  gauze.  After  the  limb 
has  been  removed,  the  main  vessels  are  at  once  ligatured,  both  artery  and  vein 
being  separately  tied.  It  is  well  to  isolate  and  draw  them  down  for  a  little 
distance,  so  as  to  make  sure  that  they  have  not  been  buttonholed.  Any  other 
vessels  which  can  be  seen  are  tied  before  the  tourniquet  is  removed.  An  assis- 
tant should  for  a  time  be  ready  to  control  the  main  trunk  after  releasing  it  from 
the  tourniquet.  In  some  cases  it  may  be  impracticable  or  undesirable  to  apply 
a  tourniquet,  and  then  the  main  vessels  may  be  temporarily  controlled  by 
digital  compression  at  some  suitable  spot  whilst  the  amputation  is  completed. 
All  bleeding  points  are  rapidly  secured  by  pressure  forceps  and  subsequently 
tied,  and  the  main  trunks  isolated,  and  clamped  or  ligatured  before  division. 

For  special  methods  of  controlling  the  haemorrhage  in  amputation  through 
the  hip-joint,  see  p.  1339. 

Attention  has  already  been  drawn  to  the  necessity  of  not  tapering  the  flaps, 
but  of  cutting  them  square,  the  corners  alone  being  rounded.  In  dissecting 
then:  up,  the  deep  fascia  should  be  included  with  the  flap,  and  the  blade  of  the 
knife  always  turned  towards  the  part  which  is  to  be  removed,  so  that  the  under 
surface  of  the  flap,  ana  with  it  the  nutrient  vessels,  shall  not  be  scored .  Whilst 
dividing  the  muscles,  the  flaps  must  be  carefully  guarded  by  the  hands  of 
assistants.  Before  sawing  the  bone,  it  is  recommended  that  the  periosteum 
should  be  retracted  for  some  distance,  so  as  more  efficiently  to  provide  for  its 
nutrition;  this  plan  should  certainly  be  adopted  for  the  humerus  and  femur. 
Any  irregular  bony  spicules  left  after  sawing  should  be  trimmed  off  with 
cutting  pliers.  Attention  must  next  be  directed  to  the  main  nerves  and  to  any 
tendons  which  lie  exposed  in  the  wound,  all  such  structures  being  cut  short, 
the  nerves  as  high  as  possible.  It  is  always  well  to  cover  in  the  end  of  the  bone 
by  stitching  the  stripped-up  periosteum  and  subsequentl}'^  the  muscles  together 
over  it.  and  the  little  extra  time  expended  in  the  introduction  of  these  buried 
stitches  will  be  well  repaid  in  the  increased  shapeliness  of  the  stump.  The 
incision  in  the  skin  is  usually  closed  by  a  continuous  suture,  and  provision  made 
for  drainage  from  one  of  the  angles  of  the  incision.  The  dressing  is  applied  in 
such  a  way  as  to  draw  the  flaps  down  over  the  end  of  the  bone,  and  a  splint  is 
generally  necessary  in  order  to  control  the  upper  ends  of  the  divided  muscles 
and  to  keep  them  from  spasmodic  contractions. 

The  chief  Complications  likely  to  arise  in  the  subsequent  course  of  the  case 
are  shock,  reactionary  hasmorrhage,  and  those  which  result  from  infection ;  these 
conditions  and  their  treatment  have  been  described  elsewhere. 

In  a  Healthy  Stump  the  end  of  the  bone  is  rounded,  and  the  medullary  cavity 
closed  by  a  layer  of  compact  tissue.  The  divided  muscles  and  tendons  are  either 


1328 


A   MANUAL  OF  SURGEUY 


incorporated  in  the  cicatrix,  or  gain  fresh  adhesions  to  the  bones.  The  vessels 
are  obhterated  as  far  as  the  next  patent  branches,  whilst  the  ncrv'c-ends  usually 
become  bulbous  (Fig.  123,  p.  373),  but,  if  suitably  shortened,  do  not  adhere 
either  to  the  end  of  the  bone  or  to  the  cicatrix,  and  hence  give  rise  to  no  trouble. 
A  sufficient  covering  of  non-adherent  skin  and  subcutaneous  tissue  should  form 
a  pad  for  the  protection  of  the  bones. 

Affections  of  Stumps. — («)  Necrosis  of  the  end  of  the  bone  is  sometimes  the 
result  of  carelessness  on  the  part  of  assistants,  who  can  readily  denude  it  of  its 
periosteum  by  rough  sponging,  etc. ;  it  rarely  follows  if  the  periosteum  has  been 
first  retracted  before  the  bone  is  divided ;  and  practically  never  apart  from 
infection.  A  small  annulai  sequestrum  is  usually  all  that  separates,  but  should 
the  inflammation  spread  up  the  medullary  cavity  [acute  traumatic  osteomyelitis) , 
a  more  extensive  destruction  of  bone  tissue  follows  (for  symptoms  and  treatment 
of  which  see  p.  567).  [h)  Sloughing  of  the  ends  of  the  flaps  occurs  in  debilitated 
individuals,  especiallyif  thin  skin  flaps  have  been  employed,  orif  their  nutrition 
has  been  impaired  by  trauma,  or  if  unhealthy  tissue  has  been  incorporated  in 
their  substance  by  amputating  too  close  to  the  seat  of  disease  or  injury.  The  pro- 
cess is  usually  limited  in  extent,  and  rarely  calls  for  treatment  other  than  keep- 
ing the  part  dry  and  aseptic,  the  slough  being 
then  slowly  absorbed ;  if  infection  is  present, 
the  consequences  may  be  very  serious,  even 
necessitating  re-amputation  at  a  higher  level, 
(c)  A  conical  stump  results  either  from  the  flaps 
being  cut  too  short,  or  from  the  parts  shrinking 
as  a  result  of  suppuration,  or  in  young  people 
from  continued  growth  of  the  upper  epiphyseal 
cartilage  of  the  divided  bone.  In  bad  cases  the 
bone  may  even  project  through  the  integument, 
and  necrose;  re-amputation  is  the  only  treat- 
ment, [d)  Apainful  stumplswsvL3.\\y  dwe  to  the 
adhesion  of  a  bulbous  nerve-end  to  the  cicatrix 
or  bone,  so  that  it  is  dragged  upon  at  each 
movement  of  the  limb.  The  pain  is  of  a  severe 
neuralgic  nature,  and  is  treated  by  excising  the 
bulb,  or  re-amputation,  {e)  A  spasmodic  stump 
sometimes  occurs,  being  due  either  to  irritation 
of  the  enlarged  nerve-ends,  or  to  some  central 
cause.  In  the  former  instance,  excision  of  the  bulbs  or  re-amputation  will  cure 
the  case;  in  the  latter,  the  trouble  will  persist  in  spite  of  treatment,  affecting 
fresh  groups  of  muscles  after  re-amputation. 


^^;f«,.. 


Fig.  589.  —  Incisions  for 
Amputation  of  Terminal 
Phalanx  of  Finger. 


Special  Amputations. 

Amputation  of  the  Fingers  is  frequently  required  after  machine  accidents  and 
similar  injuries,  or  in  necrosis  following  a  whitlow.  In  these  cases  it  is  often 
impossible  to  follow  any  regular  routine,  the  flaps  being  obtained  from  any 
portion  of  sound  tissue  present.  The  following,  however,  are  the  chief  plans 
adopted: 

Amputation  of  the  Terminal  Phalanx  is  usually  conducted  by  opening  the 
joint  on  the  dorsal  aspect,  and  cutting  a  palmar  flap  from  the  pulp  of  the  fi.iger 
(Fig.  589). 

No  useful  result  follows  amputation  through  the  first  inter-phalangeal  articu- 
lation, since  the  portion  left  is  practically  fixed  and  useless,  no  tendons  being 
inserted  to  govern  it.  An  operation  which  is  sometimes  advantageous  consists 
in  amputating  through  the  middle  of  the  second  phalanx,  so  as  to  leave  the 
insertion  of  the  flexor  sublimis  tendon,  the  flaps  for  such  an  operation  being 
derived  from  any  part  of  the  finger,  and  the  bone  di^•ided  by  cutting  pliers. 

Removal  of  a  finger  at  the  Metaearpo-phalangeal  Joint  is  an  operation  fre- 
quently necessary.  It  is  best  conducted  by  means  of  a  racquet-shaped  incision 
(Fig.  590,  A),  which  starts  over  the  knuckle,  extends  between  it  and  the  next 
finger,  curves  round  to  the  palmar  aspect  so  as  to  be  placed  a  little  below  the 


AMPUTATIONS 


1329 


crease  in  the  skin  at  the  root  of  the  finger  (Fig.  590,  A) ,  and  returns  in  the  same 
way  to  the  back  of  the  knuckle.  This  incision  can  be  made  with  one  sweep 
of  the  knife,  but  there  is  no  real  advantage  in  such  a  procedure.  The  articula- 
tion is  then  opened  from  behind;  the  structures  on  either  side  are  successively 
divided,  making  them  tense  b}-  rotation  of  the  finger,  and  the  flexor  tendons 
finally  cut  across.  Bleeding  points  (usually  one  on  each  side)  are  secured,  and 
the  wound  closed. 

The  question  of  remo\"ing  the  head  of  the  metacarpal  bone  is  one  which  must 
be  decided  by  the  occupation  of  the  patient;  if  he  is  a  working  man,  or  needs 
strength  of  hand,  it  should  be  left,  as  its  removal  always  causes  weakness.  In 
ladies  and  those  where  smallness  and  elegance  of  the  hand  are  required  rather 
than  strength,  it  can  be  taken  away  by  slightly  prolonging  the  incision  upwards, 
clearing  the  bone  on  either  side,  and  applying  cutting  pliers.  The  gap  between 
the  adjoining  fingers  can  in  this  way  be  almost  obliterated.  It  is  especially 
adWsable  to  do  this  in  the  case  of  the  index-finger,  since  the  head  of  the  second 


Figs.  590  and  591. — Dorsal  and  Palmar  Views  of  Hand  with 
Incisions  for  Various  Amputations. 

A,  Incision  for  amputation  of  finger  by  racquet  method ;  B,  Faraboeuf 's  method 
of  amputation,  as  applied  for  index-finger;  C,  racquet-shaped  incision  for 
disarticulation  of  thumb  at  carpo-metacarpal  joint;  D,  amputation  through 
the  wrist  by  a  long  palmar  flap.  In  all  of  these  the  continuous  black  lines 
indicate  the  portions  of  the  incisions  visible  from  the  dorsal  or  palmar 
aspects  respectively;  the  interrupted  lines,  the  portions  that  are  hidden. 

metacarpal  bone  forms  an  unsightly  projection,  and  is  very  exposed  to  injury. 
For  this  finger,  Faraboeuf's  method  (Figs.  590,  B,  and  591,  B,  and  p.  1332) 
is  often  used. 

Occasionally  the  four  fingers  and  their  attached  metacarpal  bones  have  to  be 
removed  en  bloc.  Short  equal  flaps  may  then  be  cut  from  the  front  and  back  of 
the  hand,  and  the  disarticulation  effected.  The  stump  that  remains,  although 
consisting  merely  of  the  carpus  and  thumb,  is  very  serviceable. 

Amputation  of  the  Thumb  should  never  be  undertaken  unless  absolutely  neces- 
sary, since  its  removal  seriously  impairs  the  functional  utility  of  the  hand;  as 
large  a  portion  must  be  saved  as  practicable,  so  as  to  assist  the  patient  in  grasp- 
ing. The  phalanges  may  be  removed  by  any  method  which  enables  the  bone  to 
be  covered  with  the  least  possible  sacrifice. 

When  it  is  also  necessary  to  take  away  the  metacarpal  bone,  one  of  the  two 
following  plans  should  be  adopted : 

I.  The  racquet  method  (Figs.  590,  C,  and  591,  C).  In  this  an  incision  com- 
mences in  the  intertendinous  hollow  known  as  the  tabatidre,  and  extends  along 
the  dorsum  of  the  thumb  to  the  head  of  the  metacarpal  bone,  the  oval  portion 
sweeping  round  it  at  the  level  of  the  web  when  the  thumb  is  abducted,  and  on 

84 


1330 


A  MANUAL  OF  SURGERY 


the  palmar  aspect  corresponding  to  the  oblique  crease  at  its  root.  The 
remainder  of  the  operation  resembles  that  for  removal  of  a  finger.  Care  must  be 
taken  not  to  wound  the  trunk  of  the  radial  artery  as  it  passes  through  the  base 
of  the  interosseous  space;  the  blade  of  the  knife  is  therefore  kept  closely 
applied  to  the  bone. 

2.  By  a  palmar  flap.  In  this  the  knife  is  first  carried  across  the  dorsal  aspect 
of  the  thumb,  from  the  centre  of  the  web  between  it  and  the  index-finger,  to  a 
point  on  the  palmar  surface  of  the  wrist  just  above  the  thenar  eminence.  The 
knife  is  then  rotated  so  that  its  cutting-edge  looks  outwards,  and  inserted 
deeply  through  the  ball  of  the  thumb,  transfixing  it,  so  as  to  emerge  at  the 
same  spot  in  the  centre  of  the  web  as  that  at  which  the  incision  commenced. 
A  muscular  flap  with  a  well-rounded  border  is  readily  fashioned  by  cutting 
outwards.  The  remaining  soft  parts  are  then  divided,  and  disarticulation 
completed  by  opening  the  joint.  It  is  a  prettier  and  more  showy  operation 
than  the  former,  but  otherwise  has  no  advantages. 

Amputation  through  the  Wrist-Joint  is  seldom  performed  except  for  injuries, 
and  then  the  flaps  must  be  derived  as  best  they  can  from  healthy  tissues. 

Three  chief  methods  are,  however 
described :  {a)  In  the  elliptical 
(Fig  592),  the  incision  takes  the 
form  of  an  ellipse,  the  highest 
point  being  on  the  dorsum  J  inch 
below  the  level  of  the  wrist-joint, 
and  the  lowest  in  the  centre  of  the 
palm  2  inches  below  the  former. 
On  the  ulnar  side,  the  incision 
passes  between  the  pisiform  bone 
and  the  base  of  the  fifth  meta- 
carpal, whilst  on  the  radial  side 
it  crosses  the  carpo-metacarpal 
articulation.  After  dividing  the 
cellular  tissue,  and  dissecting  up 
the  palmar  flap ,  the  j  oi nt  i s  opened 
from  the  posterior  aspect,  and  the 
disarticulation  completed.  The 
convex  end  of  the  palmar  flap  is 
fitted  into  the  concavity  of  the 
dorsum,  and  the  cicatrix  thus 
forms  a  curved  line  on  the  back  of 
the  stump,  {b)  A  long  palmar  flap 
(Fig  591,  D)  is  sometimes  utilized, 
extending  from  just  below  either 
styloid  process  down  to  about  the 
middle  of  the  metacarpal  bones, 
the  sides  of  this  flap  being  parallel  to  each  other.  The  dorsal  incision  crosses 
the  carpus  horizontally  between  the  two  extremities  of  the  former  wound 
(Fig-  590  D).  The  palmar  flap  is  then  dissected  up  so  as  to  include  only 
skin  and  subcutaneous  tissue,  with  perhaps  a  little  muscular  tissue  from  the 
thenar  and  hypothenar  eminences.  The  wrist-joint  is  opened  from  the  dorsum, 
and  the  amputation  completed  by  the  division  of  the  flexor  tendons,  (c)  In  a 
few  cases,  amputation  by  an  external  flap  may  be  desirable  (Dubreuil's 
method).  The  incision  commences  at  the  junction  of  the  middle  and  outer 
thirds  of  the  back  ol  the  wrist,  reaching  down  to  the  head  of  the  metacarpal 
bone  of  the  thumb,  terminating  at  a  point  in  the  palm  immediately  opposite 
its  commencement.  This  flap  is  dissected  up,  and  should  contain  a  certain 
amount  of  muscular  substance  from  the  thenar  eminence.  The  skin  and 
subcutaneous  tis.sues  on  the  ulnar  aspect  are  now  divided  by  a  circular  sweep 
of  the  knife  around  the  inner  side  of  the  limb.  Disarticulation  follows,  and 
the  external  flap  is  carried  inwards,  and  sutured  so  as  to  close  the  wound. 

Amputation  through  the  Forearm  is  usaally  conducted  by  means  of  a  flap 
operation,  the  flaps  being  either  equal  in  length  or  one  a  httle  longer  than  the 


Fig,  592. — Amputation   of  the    Wrist 
BY  Elliptical  Method. 

The  dark  line  indicates  the  palmar  flap, 
the  dotted  line  the  dorsal  incision. 


AMPUTATIONS 


1331 


other.  The  muscles  are  divided  circularly,  and  the  bones  should  be  thoroughly 
cleared  before  division. 

Disarticulation  at  the  Elbow-joint  is  an  operation  very  raiely  seen,  and  is 
either  undertaken  by  the  elliptical  method  or  with  a  long  anterior  flap. 

Amputation  through  the  Arm  may  be  carried  out  by  any  of  the  methods 
described,  e.g.,  the  flap,  circular,  or  modified  flap  and  circular,  the  choice  in  any 
particular  instance  being  determined  by  the  requirements  of  the  case. 

Disarticulation  at  the  Shoulder-joint. — Three  chief  methods  are  practised 
for  the  performance  of  this  operation,  viz.,  Spence's,  Larrey's,  or  that  by  means 
of  an  external  or  deltoid  flap.  In  all,  the  third  part  of  the  subclavian  artery 
may  be  controlled  by  digital  compression,  the  surgeon  endeavouring  to  leave 
the  division  of  the  main  vessels  until  the  last  stage  of  the  proceedings ;  but  it  is 
perhaps  better  to  clamp  all  the  smaller  vessels  as  soon  as  they  are  cut,  and  to 
isolate  and  tie  the  main  trunks  before  their  division. 

{a)  Spence's  operation  (Fig.  593). — ^A  preliminary  incision  similar  to  that  for 

excision  of  the  shoulder  is  first  made,  extending  downwards  and  outwards 

tlirough  the  fibres  of  the  deltoid,  from  a  point  midway 

between  the  coracoid  and  acromion  processes.     This 

passes  directly  down  to  the  bone,  and,  if  necessary,  the 

j  oint  is  at  once  opened  and  examined  prior  to  any  further 

steps  being  taken.     The  surgeon,  standing  on  the  outer 

side  of  the  limb,  then  carries  his  knife  from  the  lower 

part  of  the  incision  downwards  and  inwards  across  the 

axillary  folds  around  the  limb  to  the  point  from  which 

it  first  started,  thus  making  the  incision  racquet-shaped. 

The  skin  is  first  dissected  up  all  round  for  an  inch  or 

so,  and  then  the  muscles  on  the  inner  side,  the  deltoid 

in  part,  the  pectoralis  major,  the  coraco-brachialis  and 

biceps,  are  divided  on  the  slant,  thereby  exposing  the 

main  vessels   and   nerves.     The  vessels  may  now  be 

secured  and  divided,  and  the  nerves  isolated,  pulled 

down  and  cut  short,  or  they  may  be  left  intact  for  a 

time.     The  soft  structures  on  the  outer  side  of   the 

vertical  incision  are  next  separated  from  the  bone,  and 

then  the  outer  half  of  the  capsule,  together  with  the 

muscles  inserted  into   the   greater   tuberosity  of  the 

humerus,  and  the  long  tendon  of  the  biceps,  are  divided. 

The  inner  half  of  the  capsule  and  the  subscapularis  are 

then  cut  through  so  as  to  free  the  head  of  the  bone.     By 

retracting  the  external  flap  and  protruding  the  head 

from  its  socket,  the  posterior  part  of  the  capsule  can 

be  severed,  and  then  the  knife,  travelling  downwards 

l)etween  the  humerus  and  the  axillary  vessels,  is  made  to  cut  its  way  out,  thus 

completing  the  disarticulation,  the  vessels  and  nerves,  if  not  already  dealt  with, 

being  divided  as  the  last  step  in  the  proceeding.     If  the  knife  is  kept  close 

to  the  bone,  the  trunk  of  the  posterior  circumflex  artery  is  not  interfered  with. 
(&)  Larrey's  operation  (Fig.  594)  is  very  similar  to  the  above,  except  that  the 

vertical  incision  is  made  on  the  outer  aspect  of  the  joint,  reaching  downwards 

from  the  prominence  of  the  acromion  for  a  distance  of  about  6  inches,  the  oval 

portion  starting  from  its  centre,  and  being  directed  obliquely  downwards  and 

inwards.     The  tissues  are  reflected  on  either  side  of  the  humerus;  the  joint  is 

opened  by  a  transverse  cut  over  the  great  tuberosity,  which  also  di\ddes  the 

muscles  inserted  into  it.     The  knife  is  finally  carried  down  on  the  inner  side  of 

the  humerus  so  as  to  sever  the  vessels  last,  if  considered  desirable. 

[c)  Amputation  by  the  external  01  deltoid  flap  is  but  little  practised  the  at 
present  time.     The  flap  is  either  cut  by  transfixion,  or  dissected  up.     It  is 

U-shaped,  its  base  extending  from  the  coracoid  process  in  front  to  the  root  of 
the  acromion  behind.    A  skin  incision  is  now  made  across  the  inner  aspect  of 

the  limb,  joining  the  ends  of  the  former  incision,  and  extending  about  2  inches 
below  the  axilla.   Disarticulation  is  then  carried  out  in  the  same  way  as  in  the 

previous  methods. 


Fig.  593.— Spence's 
Amputation  at 
THE  Shoulder 
BY  Anterior  Rac- 
quet. (Treves' 
'  Operative  Sur- 
gery.') 


1332 


A  MANUAL  OF  SURGERY 


Occasionally  it  is  necessary  to  remove  the  whole  of  the  upper  limb  together 
with  the  scapula  and  outer  third  of  the  clavicle,  for  new  growths,  usually  of  a 
sarcomatous  nature,  or  for  injury.  This  so-called  Interscapulo-thoracic  Ampu- 
tation is  best  performed  according  to  Bcrgcr's  method.  An  incision  is  made 
along  the  clavicle,  and  the  middle  poition  of  this  bone  is  then  removed  so  as  to 
enable  the  surgeon  to  divide  between  ligatures  the  subclavian  artery  and  vein 
on  a  level  with  the  lower  border  of  the  first  rib.  The  anterior  flap  is  then 
formed  by  an  incision  (Fig.  595)  reaching  from  the  centre  of  the  former  and 
extending  downwards  and  otitwards  over  the  shoulder,  across  the  anterior  fold 
of  the  axilla,  and  as  far  as  the  lower  angle  of  the  scapula.  The  pectorales  major 
and  minor  are  divided  along  this  line,  thereby  exposing  the  brachial  plexus,  the 
constituent  nerves  of  which  are  severed  on  a  level  with  the  section  of  the  vessels. 
The  axillary  space  can  now  be  opened  up  along  the  outer  surface  of  the  ser- 
ratus  magnus.  The  limb  is  then  rotated  inwards  and  adducted  across  the 
trunk,  and  the  patient  drawn  well  to  the  edge  of  the  table  so  as  to  enable  the 
posterior  incision,  which  unites  the  outer  ends  of  the  two  former,  to  be  made. 
The  flap  thus  marked  out  is  dissected  up,  and  the  different  muscles  retaining 
the  scapula  in  connection  with  the  body  are  divided  one  after  the  other, 


Fig.  594. — Larrey's  Amputation 
through  the  shoulder  -  joint 
BY  External  Racquet.  (Treves' 
'  Operative  Surgery.') 


Fig.  595. — Incisions  for  the 
Interscapulo-thoracic  Am- 
putation. 


including  the  trapezius,  omo-hyoid,  levator  anguli  scapulae,  rhomboids,  and 
serratus  magnus.  These  may  be  incised  as  near  to  the  bone  as  is  thought 
compatible  with  the  total  removal  of  the  growth.  Any  remaining  fibres  are 
cut  across,  and  the  limb  is  thus  detached.  In  cases  of  new  growth  there  may  be 
a  large  number  of  vessels,  both  arteries  and  veins  requiring  ligature;  but  in  a 
healthy  limb  removed  for  injury,  none  but  the  posterior  scapular  and  supra- 
scapular will  give  any  trouble.  Naturally,  such  an  operation  is  accompanied 
by  some  amount  of  shock,  but  the  results  usually  obtained  have  been  very 
gratifying. 

Amputations  of  the  Lower  Extremity. 

Amputation  of  the  Toes  at  the  metatarso-phalangeal  articulations  is  piecisely 
similar  to  the  analogous  operation  on  the  fingers.  It  must  be  remembered  that 
the  joint  lies  as  far  behind  the  web  as  the  apex  of  the  toe  is  in  front  of  it, 
and  hence  the  incision  must  start  farther  back  than  might  be  expected. 

For  the  removal  of  the  great  toe  from  the  metatarsal  bone,  Farabcenf's  opera- 
tion is  the  best.  The  incision  (Fig.  594)  commences  over  the  head  of  the  latter 
bone,  and  well  to  the  inner  side  of  the  extensor  tendon ;  it  extends  downwards 
nearly  as  far  as  the  interphalangeal  articulation,  and  then  crosses  the  plantar 


AMPUTATIONS 


1333 


Mirlace  of  the  toe  so  as  to  reach  the  centre  of  the  web  between  it  and  the  second 
toe;  thence  the  knife  is  carried  straight  back  to  the  commencement  of  the 
incision.  These  cuts  are  deepened,  the  tendons  divided,  the  joint  opened,  and 
the  toe  removed.  It  will  then  be  found  that  an  internal  flap  remains,  which 
can  be  brought  across  the  head  of  the  metatarsal  bone,  and  covers  it  in  so  that 
the  L-shiiped  cicatrix  is  not  exposed  to  pressure. 

Amputation  of  the  great  toe  at  the  tarso-metatarsal  articulation  is  conducted 
either  by  a  racquet-shaped  incision,  or  by  dissecting  up  a  flap  from  the  inner 
side.  It  is  a  bad  operation,  leaving  a  terribly  mutilated  foot,  and  should,  if 
possible,  never  be  undertaken. 

Amputation  of  the  foot  at  the  Tarso-metatarsal  Articulation  is  performed 
either  by  Lisfranc's  or  Hey's  operation. 

Lisfyanc's  amputation  (Fig.  597)  consists  really  of  a  disarticulation,  no  bone 
being  sawn  across.  The  patient  lies  on  the  back  with  the  foot  elevated,  and 
extending  beyond  the  end  of  the  table.     On  the  right  foot  a  slightly  convex 


Fig.  596. — Farabceuf's  Am- 
P.UTATION  OF  THE  Great 
Toe.  (Treves'  _ 'Opera- 
tive Surgery.')  •  .-„ 


Fig.  597.^^Tncisions  for  Lisfranc's  Ampu- 
tation.   (Treves'-'  Operative  Surgery.') 

dorsal  incision  extending  down  to  the  bones  is  made  from  the  tip  of  the  fifth 
metatarsal  bone  on  the  outer  side  to  the  base  of  the  first  on  the  inner.  The 
plantar  flap  is  then  marked  out,  reaching  from  the  terminations  of  the  former 
incision  forwards  as  far  as  the  roots  of  the  toes,  and  being  necessarily  longer  on 
the  inner  than  the  outside  side.  On  the  left  foot  the  incisions  are  made  in  the 
opposite  direction.  This  latter  flap  is  dissected  up,  the  toes  being  fully  ex- 
tended by  an  assistant;  only  the  skin  and  subcutaneous  tissues  are  raised  for 
the  first  inch,  but  further  back  all  the  structures  in  the  sole  of  the  foot  are 
included.  The  appearance  of  the  peroneus  longus  tendon  will  indicate  that 
the  dissection  has  been  carried  back  far  enough.  Disarticulation  is  now  per- 
formed from  the  dorsal  aspect,  the  line  of  the  joints  (Fig.  598)  being  kept  in 
mind.  The  knife  is  entered  behind  the  spur  of  the  fifth  metatarsal  bone,  and 
is  at  first  directed  forwards  and  inwards  towards  the  head  of  the  first  meta- 
tarsal bone.  The  line  of  the  articulation  is  then  followed  as  far  as  the  base  of 
the  second  metatarsal,  which  projects  baclcwards  between  the  internal  and 
external  cuneiform  bones.     The  joint  between  the  first  metatarsal  and  the 


1334 


A   MANUAL  OF  SURGERY 


CHOPART 


HEY 
--LISFRAKC 


internal  cuneiform  is  now  opened  transversely  on  the  inner  side,  and  the  dorsal 
ligament  between  the  second  metatarsal  and  the  middle  cuneiform  divided. 
The  strong  interosseous  ligament  passing  between  the  internal  cuneiform  and 
the  base  of  the  second  metatarsal  is  next  severed  by  inserting  the  point  of  a 
knife  downwards  between  the  first  and  the  second  metatarsal  bones,  and  cut- 
ting backwards  towards  the  ankle,  elevating  the  handle  of  the  knife  in  order  to 
do  so.  By  grasping  the  toes  in  the  left  hand,  and  forcibly  depressing  them,  the 
remaining  ligaments  on  the  dorsal  aspect  are  divided,  and  the  disarticulation 
can  then  be  completed. 

The  plantarjflap  is  sometimes  formed  as  the  last  stage  of  the  operation, 
having  merely  been  mapped  out  in  the  first  instance.     In  such  a  case  the 

dorsal  incision  is  first  made,  the  metatarsus  dis- 
articulated, and  the  plantar  flap  cut  from  within 
outwards. 

Hey's  operation  is  essentially  similar  to  the 
above,  with  the  exception  that  the  projection 
of  the  internal  cuneiform  is  sawn  across 
(Fig.  598),  leaving  a  more  even  surface  of  bone. 
It  is  certainly  to  be  preferred  to  a  simple  dis- 
articulation. Skey  advised  that  the  three  outer 
joints  should  be  opened  as  above,  and  that  then 
the  saw  should  be  applied  so  as  to  leave  in  its 
mortice  the  base  of  the  second  metatarsal, 
whilst  the  projection  of  the  internal  cuneiform 
is  removed. 

Amputation  at  the  Mid-tarsal  Joint  {Chopart's 
amputation,  Fig.  598)  is  conducted  in  a  very 
similar  manner  to  Lisfranc's.  A  plantar  flap 
with  convex  end  is  marked  out,  reaching  on  the 
inner  side  of  the  foot  from  a  point  immediately 
behind  the  tubercle  of  the  scaphoid  forwards 
to  within  i  inch  of  the  root  of  the  toes,  and 
terminating  on  the  outer  side  on  a  level  with 
the  calcaneo-cuboid  articulation,  i.e.,  midway 
between  an  external  malleolus  and  the  spur  of 
the  fifth  metatarsal.  It  should  be  i  inch  longer 
on  the  inner  than  on  the  outer  side.  This 
plantar  flap  is  first  dissected  up,  including 
everything  down  to  the  bones,  and  then  a 
dorsal  incision  is  made  with  a  slightly  convex 
border.  The  joints  between  the  astragalus  and  scaphoid  on  the  inner 
side,  and  between  the  os  calcis  and  cuboid  on  the  outer,  are  opened  from 
above.  Disarticulation  is  completed  by  a  few  touches  of  the  knife,  and 
after  all  haemorrhage  has  been  arrested,  the  plantar  flap  is  drawn  up,  and 
united  by  sutures  to  the  dorsal.  Some  surgeons  prefer  to  fashion  the 
plantar  flap  after  opening  the  joints  from  the  dorsum. 

Chopart's  amputation  is  not,  on  the  whole,  a  very  satisfactory  proceeding, 
since  it  consists  in  the  removal  of  the  anterior  segment  of  the  arch  of  the  foot, 
the  posterior  half  being  left  without  support.  The  natural  result  of  this  is  that 
the  head  of  the  astragalus  travels  downwards,  and  presses  upon  the  anterior 
portion  of  the  stump,  causing  a  good  deal  of  pain  and  discomfort,  whilst  the  os 
calcis  is  drawn  upwards  by  the  traction  of  the  tendo  Achillis.  Formerly  it  was 
considered  that  the  resulting  deformity  was  purely  due  to  unbalanced  muscular 
traction,  and  hence  attempts  to  prevent  it  were  made  by  dividing  the  tendo 
Achi.Uis,  or  by  stitching  the  extensor  tendons  to  the  under  surface  of  the  os 
calcis.  Seeing,  however,  that  the  trouble  is  mainly  mechanical,  and  hence 
unavoidable,  it  would  perhaps  be  wiser  to  avoid  the  operation  entirely,  substi- 
tuting for  it  a  subastragaloid  amputation,  or  modifying  it  by  removing  the 
astragalus  after  the  foot  has  been  taken  away.  Tripier's  amputation  has  also 
been  utilized  to  prevent  such  displacement;  in  it  an  oblique  external  racquet  is 
made,  reaching  backwards  to  the  anterior  border  of  the  tendo  Achillis;  dis- 


FiG.  598.  —  Skeleton  of 
Foot,  showing  Level  of 
Various  Amputations. 


AMPUTATIONS  I335 

aiticulation  follows  at  the  mid-tarsal  joint,  and  then  the  os  calcis  is  sawn 
across  horizontally  on  a  level  with  the  sustentaculum  tali,  so  as  to  leave  a 
broad  base  of  support,  which  is  not  so  likely  to  become  tilted  forwards.  It  is 
but  fair  to  say,  however,  that  in  not  a  few  cases  of  Chopart's  amputation  an 
excellent  stump  remains  without  any  of  these  inconveniences. 

A  still  better  modification,*  wdiere  practicable,  is  to  remove  the  foot  on  a 
slightly  anterior  plane,  i.e.,  to  leave  the  scaphoid  on  the  inner  side,  and  to 
diNdde  the  cuboid  on  a  level  with  its  anterior  border  with  a  saw.  The  skin 
incisions  can  be  made  as  for  a  Chopart.  The  stump  left  is  longer,  and  there- 
fore controlled  more  easih^  whilst  the  attachment  of  the  tibialis  posticus  is 
maintained,  and  it  is  easy  to  give  the  peroneus  longus  an  insertion,  so  that  the 
lateral  movements  of  the  foot  are  in  great  part  preserved. 

Subastragaloid  Amputation  of  the  foot  is  occasionally  possible  in  cases  of 
injury,  where  the  astragalus  remains  uninjured.  The  best  plan  to  adopt  is  that 
known  as  Maurice  Perrin's  oval  operation.  A  racquet-shaped  incision  (Fig.  599) 
is  made,  commencing  at  the  insertion  of  the  tendo  Achillis,  and  extending  along 
the  outer  border  of  the  foot  to  a  point  immediately  behind  and  a  little  above  the 
spur  of  the  fifth  metatarsal,  from  which  it  sweeps  over  the  dorsum,  along  the 
instep,  and  after  crossing  the  sole  returns  to  the  same  spot  The  dorsal  part  of 
the  flap  is  then  dissected  up,  the  astragalo- 
scaphoid  joint  opened,  the  tendo  Achillis  - 

divided,  and  by  twisting  the  foot  inwards  ^i^-  \ 

the  joints  between  the  astragalus  and  os  »^^  '\ 

calcis  can  be  entered,  and  the  interosseous  ^^  \^^ 

ligament  severed.     By  still  further  invert-  ^^  /t"^^ 

ing  the  foot  until  it  assumes  a  position  of  ,^^fe  /    i  ^\. 

extreme  varus,  the  structures  on  the  inner         ^^^^       ^    1      ~  ^"--^..^ 
side  of  the  os  calcis  can  be  detached,  and        (^  \       /  "-nN^^^ 

by  continuing  the  same  torsion,  the  inner        ^  ^  *  a^^A   ./  ~  ^^^ai^V^ 

surface  of  the  bone  is  finally  cleared,  the  i^s^^^^s^iS^^^^^v^^Sv. ^ 

dorsal  aspect  of  the  foot  looking  down-    ^  ^  ^       ^^^^^  ^^^ 

wards.     When  the  foot  has  been  removed.    Fig.  599.-RACQUET  Incision  for 
bleeding  points  are  secured,  tendons  and      Subastragaloid  Amputation, 
nerves  cut  short,  and   the  wound,  which 

now  lies  horizontally,  is  secured  by  sutures.  A  very  firm  basis  of  support 
is  provided  by  this  operation,  and  the  stump  is  covered  by  the  skin  of  the  heel, 
which  is  accustomed  to  pressure. 

Amputation  of  the  Foot. — Syme's  amputation  consists  of  a  disarticulation  at 
the  ankle-joint,  together  with  removal  of  the  two  malleoli  and  the  articular 
surface  of  the  tibia.  The  patient  lies  on  the  back  mth  the  leg  well  elevated 
and  projecting  over  the  end  of  the  table,  the  surgeon  standing  either  below  or  a 
little  to  the  right  of  the  patient.  Having  exsanguinated  the  limb,  the  opera- 
tion is,  on  the  right  foot,  commenced  b}^  making  an  incision  from  the  tip  of  the 
external  malleolus  down  to  the  heel,  and  extending  up  to  a  point  |  inch  below 
and  behind  the  internal  malleolus  (Fig.  600,  A) .  On  the  left  side  the  incision 
is  made  in  the  opposite  direction.  For  this  purpose  a  short-handled  strong- 
bladed  knife  should  be  employed  (an  ankle-knife).  The  incision  is  directed 
slightly  back\vards,  otherwise  a  bucket-shaped  heel  flap  is  formed,  in  which 
discharges  may  collect.  The  knife  is  carried  dow-n  to  the  bone  at  the  first  cut, 
and  the  surgeon  then  proceeds  to  dissect  up  the  heel  flap  thus  marked  out  by 
inserting  his  thumb  into  the  wound,  and  partly  peehng,  partly  cutting,  the 
soft  tissues  from  the  back  of  the  os  calcis.  This  is  sometimes  a  tedious  and 
tiring  proceeding,  since  it  is  most  important  to  keep  close  to  the  bone  for  fear 
of  dividing  the  nutrient  vessels  of  the  flap  (external  and  internal  calcanean) 
The  dorsal  incision  (A^)  is  then  made,  uniting  the  ends  of  the  former  wound,  and 
carried  slightlv  forwards  so  as  to  mark  out  a  short  convex  flap.  This  is  dis- 
sected up,  and  the  ankle-joint  opened,  the  line  of  the  articulation  being  placed 
\  inch  above  the  tip  of  the  internal  malleolus.  By  di\dsion  of  the  lateral  and 
posterior  ligaments,  of  the  tendo  Achilhs,  and  of  the  few  remaining  fibrous 

*  Gaz.  des  Hdpitaux,  January  21,  1902 


1336 


A   MANUAL  OF  SURGERY 


connections  along  the  top  of  the  os  calcis,  the  foot  is  removed.  The  lower  ends 
of  the  tibia  and  fibula  are  then  cleared  and  sawn  oft  (S),  the  ends  of  the  dorsal 
flap  being  meanwhile  held  out  of  harm's  way.  The  main  vessels  are  tied,  as 
also  any  other  bleeding  points;  the  tendons  and  chief  nerves  are  drawn  down 
and  cut  short,  and  the  wound  closed  by  sutures  provision  being  made  for 
drainage  through  one  of  the  angles. 

A  much  quicker  and  prettier  method  of  performing  this  operation  consists  in 
opening  the  joint,  and  disarticulating  immediately  after  the  incisions  have 
been  made,  whilst  the  os  calcis  is  subsequently  dissected  out  of  the  heel  flap 
from  above,  keeping  the  knife  close  to  the  bone. 

Syme's  amputation  gives  excellent  results  with  only  slight  shortening,  and 
the  patient  is  able  to  walk  on  skin  which  is  already  accustomed  to  pressure.  It 
is  specially  useful  where  amputation  is  required  for  tarsal  disease,  inasmuch  as 
it  is  then  rarely  safe  to  undertake  any  of  the  partial  or  more  conservative 
methods  of  operating. 

Pirogoff's  opsration  is  one  in  which  the  posterior  portion  of  the  os  calcis  is 
sawn  off,  and  applied  to  the  under  surface  of  the  previously  sawn  ends  of  the 


Fig.  600. — Lines  of  Incision  in  Bones  and  Soft  Parts  in  Syme's  and 
Pirogoff's  Amputations. 

A,  A^,  Incisions  for  Syme's  amputation;  B,  B^,  incisions  for  Pirogoff's  amputa- 
tion (these  should  really  start  from  the  same  point  as  in  Syme's  operation, 
viz.,  the  tip  of  the  external  malleolus,  but  to  avoid  confu.sion  they  have 
been  placed  a  little  behind  it) ;  S,  section  of  tibia  and  fibula  in  Syme's 
amputation;  P,  section  of  tibia  and  fibula  in  Pirogoff's  amputation;  P^, 
line  of  section  of  the  os  calcis  in  Pirogoff's  amputation. 


tibia  and  fibula.  The  operation  here  described  is  not  strictly  that  of  Pirogoff, 
but  rather  the  modification  suggested  by  Sedillot.  The  patient  and  surgeon 
being  relatively  placed  as  for  Syme's  operation,  an  incision  is  made  extending 
from  the  same  points,  viz.,  between  the  tip  of  the  external  malleolus  and  a 
point  f  inch  below  and  behind  the  inner  malleolus,  but  instead  of  passing 
directly  downwards  it  is  carried  obliquely  forwards  (Fig.  600,  B) .  Everj^thirg 
is  divided  at  once  down  to  the  bone,  and  the  dorsal  incision  is  then  made,  being 
placed  at  right  angles  to  the  plantar  (B^).  The  ankle-joint  is  opened  from 
above  and  disarticulation  completed  ;  the  structures  to  the  side  of  and  behind 
the  joint  are  then  divided,  so  that  a  saw  can  be  applied  to  the  exposed  surface 
of  the  OS  calcis,  and  the  bone  cut  in  a  direction  more  or  less  parallel  to  that  of 
the  plantar  flap  (P^).  The  lower  ends  of  the  tibia  and  fibula  are  now  cleared, 
and  the  malleolus  and  articular  surface  sawn  off  obliquely,  the  saw-cut  being 
as  nearly  as  possible  parallel  to  that  made  through  the  os  calcis  (P).  The 
object  of  this  obliquity  is  to  enable  the  sawn  end  of  the  posterior  part  of  the 


AMPUTATIONS 


1337 


OS  calcis  to  be  brought  into  apposition  with  the  similarl}^  treated  ends  of  the 
bones  of  the  leg,  and  wired  to  them  without  any  traction  on  the  tendo  Achilhs. 
By  this  operation  a  somewhat  longer  stump  is  obtained  than  in  Syme's,  and 
the  patient  is  able  to  walk  on  the  posterior  part  of  the  os  calcis  instead  of  on 
the  sawn  ends  of  the  tibia  and  fibula.  The  operation  is  more  useful  in  cases  of 
injury  than  for  disease 

Amputations  of  the  Leg  may  be  undertaken  either  immediatel}^  above  the 
malleoli  (supramalleolar)  or  in  the  middle  third,  or  a  hand's-breadth  below  the 
knee  (site  of  election).  In  the  two  former  positions  almost  any  operation  may 
be  practised  according  to  the  needs  of  the  case,  but  perhaps  the  most  satis- 
factory is  that  by  means  of  equal  lateral  flaps,  each  of  which  is  equal  in  length 
to  one  diameter  of  the  limb,  and  consists  below  of  skin,  fat,  and  deep  fascia, 
but  for  the  upper  half  the  muscles  are  also  included  (Fig.  602,  i).  In  dividing 
the  bones,  care  must  be  taken  not  to  leave  a  sharp  projecting  edge  on  the  front 
of  the  tibia.  This  is  best  prevented  . 
by  partially  sawing  through  the  bone 
in  an  oblique  direction  from  above 
downwards,  and  when  this  has 
reached  a  little  bej^ond  its  centre, 
the  saw  is  withdrawn,  and  a  hori- 
zontal section  made,  cutting  across 
the  oblique  incision  in  such  a  way  as 
to  remove  a  wedge  of  bone  from  the 
front  of  the  tibia,  which  thus  be- 
comes suitably  bevelled .  The  fibula 
should  always  be  divided  before 
completing  the  section  of  the  tibia. 

In  the  lower  third  of  the  leg, 
Teale's  amputation  (Fig.  588)  is 
sometimes  recommended,  and  gives 
good  results. 

Amputation  of  the  Leg  at  the  Site 
of  Election  may  be  performed  either 
bj'  the  modified  flap  and  circular 
operation,  or  by  a  large  external 
flap  {Faraboeuf's  operation) .  In  the 
latter,  the  external  flap  (Fig.  601, 


Fig.  601. — Farabceuf's  Amputation  at 
THE  Site  of  Election,  a  Hand's- 
breadth  BELOW  the  Knee. 


A,  C)    which  is   U-shaped,   is  first    ^he  continuous  line.  A,  B,  C,  indicates 


the  shape  of  the  large  external  flap ;  the 
dotted  line,  B,  C,  the  incision  on  the 
inner  side  of  the  limb.  The  direction 
in  which  the  bones  are  sawn  is  also 
shown. 


marked  out  with  the  knife,  extend- 
ing I J  inches  higher  in  front  than 
behind,  and  its  length  being  equal 
to  the  diameter  of  the  limb  at  the 
point  at  which  the  bones  are  to  be 
divided.  The  incision  on  the  inner 
side  is  then  made,  extending  directly 

across  the  limb  from  a  point  i^  inches  below  the  upper  end  of  the  anterior 
horn  of  the  former  incision  to  its  posterior  extremity  (B,  C).  The 
external  flap  is  dissected  up,  commencing  anteriorly;  the  fingers  and  knife 
being  inserted  between  the  tibialis  anticus  and  the  tibia,  all  the  soft  parts 
down  to  the  bone  and  interosseous  membrane  are  divided  obliquely.  The 
anterior  tibial  artery  is  cut  long,  and  care  must  be  taken  not  to  free  the  flap 
from  the  interosseous  membrane  too  high,  for  fear  of  injuring  the  trunk  of  this 
vessel  as  it  passes  between  the  bones,  an  accident  which  would  seriously 
imperil  the  ^dtality  of  this  large  and  fleshy  mass.  The  tissues  on  the  inner  side 
of  the  limb  are  now  divided,  either  by  transfixion  or  circular  di\'ision.  The 
interosseous  membrane  and  bones  are  bared,  and  the  saw  applied  according  to 
the  method  already  described. 

Disarticulation  at  the  Knee-joint  is  a  very  useful  and  valuable  proceeding. 
The  methods  chieflv  employed  are  as  follows:  (i.)  Stephen  Smith's  operation.  01 
amputation  bv  equal  lateral  flaps.  The  inci.sions  extend  from  a  point  imme- 
diately below  the  tuberosity  of  the  tibia  backwards  in  a  semilunar  fashion,  to 


1338 


A  MANUAL  OF  SURGERY 


terminate  in  the  middle  line  behind  on  a  level  with  the  joint  (Fig.  602,  2). 
The  incision  on  the  inner  side  should  reach  a  little  lower  than  that  on  the 
outer,  in  order  to  ensure  sufficient  covering  for  the  inner  condyle,  which  is 
always  larger  than  the  outer.  The  flaps  are  dissected  up  all  round,  including 
the  subcutaneous  and  deep  fascia,  being  turned  back  in  front  like  a  collar,  so 
as  to  enable  the  surgeon  to  reach  and  divide  the  insertion  of  the  ligamentum 
patellae.  The  knife  is  now  carried  along  the  upper  margin  of  the  tibia,  separ- 
ating the  attachments  of  the  semilunar  cartilages  to  the  bones  by  dividing 
the   coronary   ligaments.     The   surrounding   muscles   and   tendons   are   cut 

through  at  the  same  level,  together  with 
the  crucial  ligaments,  and  the  leg  is  finally 
separated  by  boldly  sweeping  the  knife 
through  the  soft  parts  at  the  back  of  the 
joint,  the  flaps  being  well  retracted.  The 
popliteal  vessels  are  secured,  and  the  flaps 
drawn  together  in  the  median  line.  When 
union  has  occurred,  the  cicatrix  is  drawn 
up  behind  into  the  intercondyloid  notch  so 
that  an  excellent  hooded  covering  is  pro- 
vided for  the  lower  end  of  the  femur.  The 
chief  objection  to  the  operation  is  that  the 
upper  part  of  the  synovial  membrane  of  the 
joint  remains  intact,  and  may  become  dis- 
tended by  a  serous  effusion  through  the 
irritation  produced  by  wearing  an  artificial 
limb,  (ii.)  Amputation  can  be  undertaken 
by  a  long  anterior  flap,  the  patella  being 
left  in  situ  or  removed,  according  to  circum- 
stances. A  short  posterior  flap  is  also 
formed  and  dissected  up,  so  as  to  enable 
the  muscles  and  vessels  to  be  divided 
transversely, 

Supracondyloid  Amputation  of  the  Thigh 
is  an  operati  on  often  requisite  in  order  to  deal 
with  disease  or  injury  involving  the  knee- 
joint,  {a)  Garden's  amputation,  slightly 
modified,  is  one  excellently  adapted  to  this 
purpose.  An  anterior  flap  (Fig.  603,  A)  is 
fashioned  from  the  most  prominent  point 
of  one  condyle  to  that  of  the  other,  the 
incision  crossing  the  mid-line  in  front  half- 
way between  the  patella  and  the  tibial 
tubercle.  This  flap  is  dissected  up  in  front  of  the  patella  as  far  as  its  upper 
border.  A  short  posterior  flap  is  then  dissected  up  (Garden  made  his  posterior 
incision  horizontal).  A  transverse  cut  above  the  patella  lays  the  knee-joint 
open,  and  after  flexing  the  limb  the  lateral  and  crucial  ligaments  are 
divided.  The  hamstring  muscles,  etc.,  are  severed  by  cutting  from  \vithout 
inwards,  and  a  few  touches  of  the  knife  will  then  serve  to  disarticulate.  The 
muscles  are  retracted,  and  the  femur  divided  a  little  above  the  condyles. 
{b)  Lister's  modification  (Fig.  603,  B)  consists  in  making  a  transverse 
incision  across  the  front  of  the  limb  on  a  level  with  the  upper  border  of 
the  tubercle  of  the  tibia.  The  horns  of  this  incision  are  joined  posteriorly 
by  carrying  the  knife  downwards  at  an  angle  of  forty-five  degrees  to  the  axis 
of  the  leg.  This  flap  is  dissected  up,  and  the  whole  of  the  integuments  and 
subcutaneous  tissues  are  freed  and  retracted  like  a  cuff,  so  as  to  enable  the 
muscles  to  be  divided  circularly  just  above  the  patella.  The  saw  is  then 
applied,  and  the  bone  removed.  By  this  means  the  covering  of  the  end  of 
the  bone  is  taken  more  from  the  back  than  from  the  front  of  the  limb, 
(c)  Gritti's  operation  (Fig.  604)  is  thus  performed  :  A  large  anterior  flap  similar 
to  that  used  in  Garden's  operation  is  dissected  up,  including  the  patella,  and  a 
shorter  posterior  flap  is  then  fashioned.     The  soft  parts  are  divided  by  a  cir- 


FiG.  602. — Amputation  of  the 
Leg  by  Lateral  Flaps;  2, 
Stephen  Smith's  Amputation 

THROUGH  the  KnEE-JOINT. 


AMPUTATIONS 


1339 


cular  cut  of  the  knife,  and  the  femur  sawn  across  about  the  level  of  the  adductor 
tubercle.  The  cartilaginous  surface  of  the  patella  is  then  removed  with  the 
saw,  and  the  remaining  portion  of  the  bone  secured  by  a  silver  wire  to  the 
divided  end  of  the  femur.  Considerable  difficulty  may  be  experienced  in 
keeping  the  patella  in  accurate  apposition,  and  to  obviate  this  Stokes  recom- 
mended division  of  the  femur  at  a  slightly  higher  level — i.e.,  above  rather  than 
through  the  condyles,  [d)  Amputation  by  a  long  posterior  flap  is  sometimes 
required  in  cases  where  the  tissues  in  front  of  the  limb  have  become  disor- 
ganized from  disease  of  the  joint,  or  when  cicatrices  produced  by  a  previous 
excision  are  present.  The  posterior  flap  is  first  marked  out  and  dissected  up, 
including  merely  the  skin  and  subcutaneous  tissues.  A  transverse  incision  is 
made  across  the  limb  above  the  cicatrices  or  sinuses,  the  bone  sawn  just  above 


Fig.  603. — Incisions  for  Supra- 
coNDYLOiD  Amputation  of  the 
Thigh. 

A,  Garden's  operation;  B,  Lister's 
modification  of  the  same. 


Fig.  604. — Stokes -Gritti  Amputa- 
tion, SHOWING  Incision  in  the 
Soft  Parts  and  the  Lines  of  Sec- 
tion in  the  Femur  and  Patella. 


the  site  of  the  preceding  excision,  and  the  posterior  muscles  and  vessels  divided 
circularly.     A  very  good  stump  usually  results. 

Amputation  of  the  Thigh  may  be  conducted  by  any  of  the  general  methods 
already  described,  but  Lister's  operation,  modified  flap  and  circular  (Figs.  586 
and  587)  is  perhaps  the  best. 

Amputation  through  the  Hip-joint. — Disarticulation  at  the  hip-joint  is  always 
an  operation  of  the  greatest  gravity,  and  every  precaution  should  be  taken  to 
minimize  the  immediate  risks  by  preventing  haemorrhage  and  lessening  shock. 
No  part  of  the  body  should  be  unnecessarily  exposed,  whilst  the  head  is  kept 
low,  and  although  the  operation  must  not  be  hurried  over,  no  time  is  wasted. 

Perhaps  the  best  way  of  preventing  haemorrhage  is  to  secure  the  main  vessels 
before  dividing  them,  and  then  to  take  up  each  bleeding  point  as  it  appears ;  the 
limb  can  thus  be  removed  with  the  loss  of  merely  a  few  ounces  of  blood.  The 
only  other  plan  which  is  at  all  desirable  is  that  suggested  by  Wyeth,  of  New 
York,  which  consists  in  appl5ring  a  rubber  tourniquet  close  to  the  pelvic  brim, 
and  this  is  prevented  from  slipping  by  inserting  long  needles  immediately 
below  it.  The  limb  is  first  exsanguinated  by  elevation,  or  possibly  by  the  use 
of  an  Esmarch's  bandage.  Two  long  steel  needles,  10  inches  in  length  and 
■^-^  inch  in  thickness,  are  then  inserted,  one  on  the  outer  side  of  the  thigh  and 
one  on  the  inner.     The  former  '  is  introduced  J  inch  below  the  anterior  superior 


I340  A   MANUAL  OF  SURGERY 

spine  of  the  ilium,  and  slightly  to  the  inner  side  of  this  prominence,  and  is  made 
to  traverse  superficially  for  about  3  inches  the  muscles  and  fascia  on  the  outer 
side  of  the  hip,  emerging  on  a  level  with  the  point  of  entrance.  The  point  of 
the  second  needle  is  thrust  through  the  skin  and  tendon  of  origin  of  the  ad- 
ductor longus  muscle  |  inch  below  the  crutch,  the  point  emerging  i  inch 
below  the  tuber  ischii.  The  points  should  be  shielded  at  once  with  cork  to 
prevent  injury  to  the  hands  of  the  operator.  No  vessels  are  endangered  by 
these  skewers.  A  mat  or  compress  of  sterile  gauze  2  inches  thick  and  4  inches 
square  is  laid  over  the  femoral  artery  and  vein  as  they  cross  the  brim  of  the 
pelvis;  over  this  a  piece  of  strong  white  rubber  tubing,  J  inch  in  diameter 
when  unstretched,  and  long  enough  when  in  position  to  go  five  or  six  times 
round  the  thigh,  is  now  wound  very  tightly  around  and  above  the  fixation 
needles  and  tied.'*  By  this  means  the  limb  can  be  removed  with  very  little 
loss  of  blood. 

Formerly  but  one  operation  was  utilized  for  the  removal  of  the  limb  at  the 
hip-joint,  viz.,  by  transfixion,  the  flaps  being  cut  antero-posteriorly.  The 
great  advantage  of  this  method  was  the  rapiditj^  with  which  it  was  executed ; 

it    has,    however,    been   replaced    by 
I  ^  J         other   plans,    one    of    which    should 

I  M         always  be  adopted. 

^^  ^M  Amputation  by  an  external  racquet 

^^8        incision  (Fig.  605;  right  leg)  has  been 
^^F^       recommended  by  many  surgeons,  es- 
J^      '%      pecially  Furneaux  Jordan,  Esmarch, 
-/^  'i       ^"^  Lister,  each  of  whom  has  advo- 

:^,i;  1^^^     I  M      cated  some  slight  modification.     The 

'I  I  '%      surgeon   shoulcl  always  stand  to  the 

l\  j      outer   side   of   the   limb,   whilst   the 

/\  J       pelvis    of    the    patient   rests    at    the 

w  /    \       '^      extreme    edge    of    the    table.      The 

f         /      \      S      essential   features   of   this  operation 
''    ^  ^s4       consist  in  a  circular  division  of   the 

,^  ,..--'%       structures  down  to  the    bone   below 

^  'J        the  lesser  trochanter,  whilst  the  head 

i  S        oi  the  bone  is  disarticulated  and  re- 

I  m         moved  through  the  external  vertical 

Fig     605.  —  Amputation     through      portion    of    the    incision    extending 
T-uTT  t-Ttd  totxtt  downwaTds    from    above    the    great 

THE   rllP-JOINT.  ,  ,  .,  ,,  T,,,  -u^i. 

trochanter;  it  matters  little  whether 

On  the  right  leg  Furneaux  Jordan's      the  vertical  incision  is  made   before 

method  is  indicated ;  on  the  left  leg      or  after  the  tissues  in  the  thigh  have 

the  flaps  required  for  the  anterior      been  divided.     Perhaps  the  simplest 

racquet  operation  are  shown.  plan  of  carrying  out  this  operation 

is  as  follows:  A  circular  incision  is 
made  through  the  skin  and  subcutaneous  tissues  5  or  6  inches  below  the  great 
trochanter.  These  are  dissected  up  for  a  few  inches,  and  the  muscles 
divided  circularly  down  to  the  bone,  which  is  at  once  sawn  through.  The 
external  incision,  6  or  8  inches  long,  is  then  made,  the  tissues  being  freed 
from  the  anterior  and  posterior  surfaces  of  the  femur,  and  the  rotator  muscles 
divided  along  the  borders  of  the  great  trochanter.  The  lower  end  of  the  frag- 
ment of  the  femur  is  then  grasped  by  lion  forceps,  and  after  forcibly  flexing 
and  rotating  the  bone  inwards,  the  capsule  of  the  joint  is  laid  open  on  its 
posterior  aspect.  By  everting  the  bone,  the  anterior  part  of  the  capsule  can 
be  reached  and  incised,  and  the  attachment  of  the  ilio-psoas  muscle  severed. 
The  ligamentum  teres  is  then  divided  by  inserting  the  point  of  the  knife  into 
the  acetabulum,  and  the  head  of  the  bone  is  thus  set  free.  One  great  advan- 
tage of  this  operation  is  that  the  incisions  are  placed  as  far  as  possible  from  the 
risk  of  infection  from  the  genital  organs  and  perineum. 

In  the  majority  of  cases,  however,  the  best  method  of  amputating  at  the  hip- 


*  Wyeth,  Annals  of  Surgery,  February,  1897. 


AMPUTATIONS  1341 

joint  is  by  means  of  an  anterior  racquet  incision  (Fig.  605 ;  left  leg).  This  com- 
mences over  the  centre  of  Poupart's  ligament,  and  is  carried  down  along  the 
course  of  the  main  vessels  for  about  3  inches.  The  common  femoral  sheath  is 
exposed,  and  both  artery  and  vein  are  secured  by  double  ligature  and  divided. 
The  incision  is  then  completed ;  it  sweeps  over  the  inner  side  of  the  thigh  4  or 
5  inches  below  the  perineum  to  the  back,  and  is  brought  up  again  to  the  front 
3  or  4  inches  below  the  great  trochanter.  The  muscular  structures  in  the  outer 
liap  are  then  cut  through,  and  the  external  circumflex  artery  and  other  bleed- 
ing vessels  secured  by  pressure  forceps  en  route.  By  rotating  the  limb  inwards, 
the  insertion  of  the  gluteus  maximus  can  be  divided,  as  also  the  muscle-s 
attached  to  the  great  trochanter.  The  muscles  in  the  inner  flap  are  then 
similarly  dealt  with  after  rotating  the  limb  outwards,  the  internal  circumflex 
artery,  etc.,  being  secured.  The  capsular  hgament  is  next  divided  transversely 
and  the  head  of  the  bone  disarticulated.  Finally,  the  limb  is  rotated  forcibly 
outwards,  and  all  the  soft  parts  at  the  back  of  the  limb,  including  the  sciatic 
vessels  and  nerves,  are  divided  from  within  outwards  with  one  sweep  of  the 
knife.     The  wound  when  sutured  lies  anterio-posteriorly. 


CHAPTER  XLV. 

ANiESTHESIA.* 

The  practice  of  surgery  has  always  been  of  such  a  nature  as  to  render  some 
means  of  abolishing  the  pain  caused  thereby  a  desideratum;  but  although  in 
the  old  days  various  plans  were  adopted  to  attain  this  object,  yet  it  was  not 
until  the  end  of  the  eighteenth  century  that  any  real  advance  was  made  in 
this  direction.  In  1799  Sir  Humphry  Davy  suggested  the  possibility  of  using 
nitrous  oxide  gas  as  a  means  of  rendering  patients  anaesthetic  during  surgical 
work;  but,  as  then  employed,  it  was  so  uncertain  in  its  action  that  no  great 
benefit  was  derived  from  the  knowledge  thus  acquired,  and  many  j'ears  elapsed 
before  it  came  into  extensive  use.  The  demonstration  of  the  properties  of 
ether  in  1846  by  Long  and  Morton  in  America,  and  of  chloroform,  in  1847,  by 
Sir  James  (then  Professor)  Simpson  m  Edinburgh,  heralded  in  a  new  era  of 
surgery.  Operations,  which  before  were  scanty  in  number,  became  greatly 
multiplied,  and  at  the  present  day,  with  our  advanced  knowledge  and  experi- 
ence, and  our  constant  dependence  on  these  agents,  it  is  difficult  to  understand 
how  surgical  practice  could  have  been  conducted  without  them.  Anaesthetics 
have  enabled  the  surgeon  to  attack  almost  every  region  of  the  body,  and  in- 
stead of  operations  being  hurried  over,  in  order  to  minimize  the  patient's 
sufferings,  they  are  now  undertaken  with  much  more  deliberation,  accuracy 
being  the  great  requisite  of  the  present  day,  and  not,  as  formerly,  rapiditj'. 

Anaesthesia  may  be  produced  in  several  ways :  (i)  By  temporarily  paralyzing 
the  sensitive  nerve  endings  in  the  immediate  neighbourhood  of  the  part  to 
be  operated  upon,  either  by  freezing  or  the  application  or  the  injection  into 
the  surrounding  tissues  of  certain  chemical  substances  which  will  have  that 
effect  {local  analgesia) .  (2)  By  temporarily  suspending  the  conductivity  of  the 
main  nerve-trunks  supplying  the  affected  areas,  by  injecting  into,  or  around, 
these  nerves  chemical  substances  similar  to  those  used  in  the  former  method 
{spinal  and  regional  analgesia) .  In  neither  of  these  methods  is  the  patient 
rendered  unconscious,  as  is  the  case  in  the  two  following  plans.  (3)  By 
employing  a  volatile  substance,  and  administering  it  bv  inhalation  through  the 
nose  and  mouth  {inhalation  ancBsthesia) .  (4)  By  injecting  similar  volatile 
substances  into  the  veins,  rectum,  etc. 

I.  Local  Anaesthesia  (including  local  and  regional  analgesia)  is  utilized 
where  slight  operations  of  short  duration  are  to  be  undertaken,  or  occasionally 
in  more  serious  cases  where  the  patient  cannot  stand  a  general  anaesthetic. 
The  chemical  substances  employed  for  this  purpose  are,  with  one  exception, 
all  derived  from  or  allied  to  cocaine,  which  is  an  alkaloid  obtained  from  the 
dried  leaves  of  Erythroxylon  coca  (South  America).  Of  the  alkaloid  itself  the 
salt  most  frequently  used  is  the  hydrochlorate. 

Mucous  membranes  are  readily  anaesthetized  by  applying  a  5  or  10  per  cent, 
solution  to  them  for  about  five  or  ten  minutes,  the  insensibility  lasting  for 
about  the  same  time.     In  dealing  with  the  skin  or  deeper  tissues,  hypodermic 

*  For  the  revision  of  this  chapter  I  am  indebted  to  the  kindness  of  Dr.  Silk. 

1342 


ANESTHESIA  I343 

injections  of  the  drug  axe  relied  on,  the  anaesthesia  following  the  course  of  the 
peripheral  nerves.  The  action  of  cocaine  is  supposed  to  depend  partly  on  an 
anaemic  condition  of  the  affected  tissues  induced  by  arterial  contraction, 
partly  on  paralysis  of  the  termination  of  the  sensory  nerves.  Inflamed 
tissues  are  but  little  affected  by  it.  When  applied  hypodermically,  the  needle 
should  be  inserted  in  the  line  of  incision,  and  the  injection  diffused  equally 
along  it.  In  making  use  of  this  reagent,  it  must  always  be  remembered  that 
cocaine  has  a  distinctly  depressing  influence  upon  the  heart,  and  hence  more 
than  \  grain  should  never  be  employed.  Should  toxic  effects  be  manifested 
(as  by  pallor  of  the  face,  a  cold  clammy  sweat,  giddiness,  weak  and  rapid 
pulse),  the  patient's  head  should  be  lowered,  and  stimulants  administered. 
In  some  parts  of  the  body  it  may  be  possible  to  control  the  circulation  so  as 
to  hinder  the  general  absorption  of  the  drug.  Thus,  for  circumcision  the 
base  of  the  penis  may  be  constricted  by  an  elastic  band,  whilst  a  similar  ar- 
rangement may  be  applied  to  the  fingers  and  toes  for  small  operations,  such 
as  avulsion  of  a  toe-nail. 

The  circulation  can  also  be  controlled  to  some  extent  by  adding  a  few  drops 
of  the  I  in  i,ooo  adrenalin  solution  to  each  injection  of  the  alkaloid. 

Recent  experience  with  the  use  of  this  drug  has  demonstrated  the  fact  that 
equally  satisfactory  results  are  obtained  by  injecting  larger  quantities  of 
much  more  dilute  solutions  (i  or  2  per  cent.)  beneath,  as  well  as  all  round 
the  site  of  the  operation  {Schleich's  infiltration  method) . 

It  has  also  been  found  that  many  of  the  allies  and  derivatives  of  cocaine 
are  equally  ef6.cacious  and  much  less  likely  to  give  rise  to  toxic  symptoms. 
Of  these  substitutes  the  best  known  are  /3-eucaine,  stovame,  and  novocaine. 
Of  the  first  of  these  Barker*  recommends  the  following  formula: 

Distilled  water    .  . 

/3-eucaine 

Sodium  chloride 

One  per  mille  adrenaUn  chloride  solution 

There  are  no  toxic  effects  associated  with  this  solution,  and  as  much  as 
7  ounces  may  be  employed  in  order  to  infiltrate  the  tissues.  If  allowed  to  act 
for  thirty  or  forty  minutes,  the  parts  are  often  found  to  be  not  only  anesthetic, 
but  also  practically  bloodless.  Operations  of  gravity  can  be  performed 
without  pain,  including  such  conditions  as  strangulated  hernia,  intestinal 
obstruction,  tracheotomy,  thyroidectomy,  etc.,  when  a  general  anaesthetic 
may  be  undesirable. 

Local  anaesthesia  is  also  produced  by  freezing  the  part,  either  by  the  appli- 
cation of  ice  and  salt,  or  by  the  ether  spray,  or  with  ethyl  chloride.  The  latter 
reagent  is  now  put  up  conveniently  in  small  glass  or  thin  metal  flasks  with  a 
fine  capillary  outlet;  on  holding  the  flask  in  the  hand  a  spray  is  produced, 
which  is  allowed  to  play  upon  the  part  to  be  operated  on.  The  rapid  evapora- 
tion from  the  surface  leads  to  the  freezing  of  the  skin,  which  becomes  of  a 
dead  white  colour.  The  anaesthesia  produced  is  of  a  very  fugitive  nature,  and 
a  certain  amount  of  pain  may  be  associated  with  the  thawing  process,  but 
less  than  that  caused  by  the  ether  spray. 

Of  late  years  considerable  success  appears  to  have  attended  the  use  of  a 
mixture  of  quinine  and  urea  (quinine  hydrochlor-carbamide),  i  per  cent,  of 
the  combined  drugs,  which  is  absolutely  non- toxic  in  any  quantity,  but  rather 
apt  to  produce  undue  effusion. 

2.  For  the  production  of  regional  analgesia  not  only  must  the  nerve-supply 
of  the  part  be  known,  but  one  must  also  be  acquainted  with  the  exact  points 
of  emergence  of  the  main  nerve-trunks  from  the  deep  fascia.  Spalteholtz 
and  othersf  have  carefully  worked  out  many  of  these  points,  but  it  is  obvious 
that  the  process  is  a  very  difficult  and  complicated  one,  and  may  involve  a 

*  Brit.  Med.  Journ.,  December  24,  1904,  p.  1638;  and  Practitioner,  Sep- 
tember, 1907. 

t  Braun,  "Die  Lokalanasthesie,"  Leipzig,  1913;  Hirschel,  translated  by 
Krohn,  '  Textbook  of  Local  Anaesthesia,'  1914. 


I00"0  c.c.            = 

3-^  ounces 

0-2  gramme  = 
0-8  gramme  = 

a 

3  grams 

12 

10  minims 

1344 


A   MANUAL  OF  SURGERY 


second  or  additional  operation  on  the  same  patient.  In  any  of  these  methods 
it  is  of  prime  importance  that  the  solutions  used  should  be  absolutely  sterile. 

Spinal  Analgesia  is  a  condition  which  results  from  the  introduction  within 
the  spinal  membranes  of  some  substance  which  acts  upon  the  nerve  centres 
or  roots,  and  produces  insensitiveness  to  pain  in  the  regions  supplied  by  them. 
At  first  cocaine  was  employed  for  this  purpose,  but  the  after-affects  were  so 
troublesome  that  it  had  to  be  given  up,  and  the  substance  now  most  generally 
utilized  is  stovaine.  It  is  prepared  in  sterilized  solution  in  glass  ampoules 
(Billon)  containing  c  i  gramme  of  stovaine  with  an  equal  amount  of  glucose 
in  2  c.c.  of  sterile  water.  The  whole  or  a  part  of  this  is  injected  into  the 
cerebro-spinal  cavity. 

The  proceeding  is  very  simple  in  technique.  A  suitable  series  of  needles 
and  a  syringe  easily  sterilizable  are  provided  by  most  instrument-makers  for 
this  purpose.  Care  must  be  taken  that  no  alkali  is  used  in  the  sterilization 
of  syringe  or  needles,  as  stovaine  is  thereby  decomposed  and  becomes  inert. 


'^-!A  A-i 


\iM 


Fig.  606. — Diagram  of  Patient's  Back  in  the  Sitting  Posture,  and  Site 
OF  Injection  for  inducing  Spinal  Analgesia. 

The  pointer  merely  indicates  the  site  of  injection,  and  not  the  direction  in  which 
the  needle  must  be  inserted. 


The  patient's  back  is  purified,  and  he  is  placed  either  sitting  with  the  head 
bent  well  forwards,  or  lies  on  his  side  doubled  up.  This  position  of  flexion 
is  most  important  in  order  to  open  up  the  invertebral  spaces  posteriorly.  The 
site  usually  selected  for  the  injection  is  the  3rd  lumbar  interspace  {i.e.,  be- 
tween the  3rd  and  4th  lumbar  vertebrae),  and  this  corresponds  to  the  summit 
of  the  iliac  crests  (Fig.  606).  The  spot  is,  if  need  be,  frozen  by  chloride  of 
ethyl,  and  then  the  needle  is  introduced  in  the  middle  line,  and  passes  directly 
backwards  and  perhaps  a  little  upwards.  Some  insert  the  needle  about  i  inch 
from  the  middle  line,  and  then  it  must  also  be  inclined  a  little  inwards.  If 
correctly  placed,  the  resistance  of  the  ligamentum  subflavum  is  felt,  and  sub- 
sequently that  of  the  dura  mater.  A  successful  puncture  is  followed  by  a 
flow  of  cerebro-spinal  fluid,  tinged  at  first,  perhaps,  with  a  little  blood;  a 
drachm  or  two  may  be  allowed  to  escape,  although  the  necessity  or  desirability 
of  this  is  not  proven,  and  then  the  stovaine  solution  is  injected,  and  the  needle 
is  withdrawn.  Should  the  needle  impinge  on  bone,  it  is  wisest  to  take  it  out 
a.nd  make  a  fresh  puncture,  either  througli  the  same  interspace  or  through  the 


ANESTHESIA  1345 

next  above  or  below.  After  the  injection  the  patient  lies  back  with  a  support 
about  4  inches  high,  placed  under  the  sacrum,  so  as  to  encourage  the  diflusion 
oi  the  stovame  up  the  canal  for  a  short  distance.  This  upward  dissemination 
must,  however,  be  limited,  as  the  analgesia  is  associated  with  motor  paralysis, 
and  obviously  the  respiratory  muscles  must  not  participate  in  this. 

Analgesia  usually  develops  in  from  hve  to  twelve  minutes,  and  often  shows 
Itself  in  the  perineum  before  appearing  in  the  feet.  Gradually  it  extends  over 
the  whole  lower  extremity,  and  may  reach  to  the  umbilicus,  or  a  little  higher, 
it  is  accompanied  by  motor  paralysis  and  loss  of  the  reHexes,  but  the  patient 
may  be  conscious  of  ordinary  tactile  sensations.  A  certain  proportion  of 
failures  will  be  noted,  and  at  present  it  is  impossible  to  explain  their  occurrence. 
V\  hen  the  injection  is  successful,  the  patient  lies  quietly  during  the  operation 
with  complete  muscular  relaxation,  and  can  engage  in  conversation,  smoke  a 
cigarette,  or  read  a  newspaper.  The  administration  need  not  be  followed  by 
any  restriction  of  diet,  but  some  amount  of  headache  may  be  experienced  on 
the  same  or  the  following  day,  and  in  a  few  cases  vomiting.  After-results  in 
the  shape  of  nervous  diseases  involving  the  spinal  cord  have  been  reported  in 
a  few  instances  as  coming  on  after  a  year  or  two;  but  it  is  a  little  difficult  to 
be  certain  of  the  causal  relationship  of  the  injection. 

At  the  present  time  the  general  opinion  as  to  the  value  of  this  procedure  is 
that,  whUst  in  suitable  cases  it  may  be  employed  for  operations  below  the 
umbihcus  when  a  general  anaesthetic  is  not  desirable,  yet  as  a  routine  method 
of  inducing  anaesthesia  it  has  but  slight  advantages  over  the  ordinary  plan. 
It  is  not  always  certain;  the  injection  is  not  always  painless;  the  after-results 
are  sometimes  unpleasant;  the  patient  is  not  protected  from  nervous  shock 
and  apprehension  during  the  operation;  and  the  question  of  late  nervous 
sequelas  still  remains  to  be  decided.  On  the  whole,  its  employment  may  be 
advised  when  a  general  anaesthetic  is  undesirable  owing  to  the  condition  of 
the  patient's  heart,  lungs,  kidneys,  etc. ;  when  diabetes  is  present  in  an  aggra- 
vated form;  when  the  surgeon  is  short-handed;  and  when  very  complete 
muscular  relaxation  is  required,  as  in  dealing  with  fractures.  The  absence  of 
struggling  during  and  after  the  administration  of  a  general  anaesthetic  makes 
It  particularly  desirable  in  the  last  of  these  conditions. 

3-  General  Anaesthesia  by  Inhalation.— (i)  Nitrous  Oxide  Gas  (NO2)  is  most 
commonly  used  in  dental  work,  or  for  short  operations,  such  as  bending  a 
stiff  joint  and  breaking  down  adhesions,  the  avulsion  of  a  toe-nail,  or  the  open- 
ing of  an  abscess.  It  is  practically  safe  and  not  unpleasant,  either  in  its  use 
or  in  Its  subsequent  effects.  It  is  also  employed  in  conjunction  with  ether 
the  patient  being  first  anaesthetized  mth  gas,  and  the  condition  maintained 
by  ether.  Gas  has  also  been  recommended  for  the  removal  of  adenoids;  but 
the  general  opinion  now  obtaining  is  that,  to  perform  this  operation  satis- 
factorily, a  more  lasting  anesthetic  is  required.  The  gas  is  stored  in  a  con- 
densed and  liquefied  form  in  special  steel  cylinders,  closed  by  a  screw  which 
can  be  readily  loosened,  so  as  to  allow  the  gas  to  escape  through  a  tube  into  an 
mdiarubber  bag.  This  is  attached  to  a  closelv-fitting  face-piece,  with  a  suit- 
able arrangement  of  valves  and  stop-cocks,  by  means  of  which  the  gas  is 
allowed  to  reach  the  patient.  A  valvular  exit  for  the  expired  air  is  also  present 
(Fig.  608).  In  its  usual  method  of  administration  the  bag  is  first  filled  with 
gas,  and  then  air  is  completely  excluded  by  carefully  adjusting  the  padded 
face-piece  to  the  irregularities  of  the  face.  Some  anaesthetists,  however,  by 
means  of  a  special  apparatus  devised  by  Sir  Frederick  Hewitt,  allow  the' ad- 
ministration of  a  minute  proportion  of  pure  oxygen  at  the  same  time,  in  order 
to  prevent  the  li\ddity  of  the  face  and  the  twitching  of  the  limbs  often  present 
when  anaesthesia  is  induced  in  the  ordinary  way.  These  symptoms  of  incipient 
asphAocia  may  also  be  avoided  by  allowing  the  last  few  iB&piratioas^of-the  gas 
to  be  mixed  mth  air.  This  may  be  done  by  raising  the  face-piece,  by  opening 
the  air- valve,  or,  as  suggested  by  Dr.  Flux,  by  using  an  open  inhaler  into  which 
the  gas  is  poured.  Of  course,  in  removing  teeth  the  mouth  is  firmly  gagged 
open  prior  to  the  commencement  of  the  administration. 

(2)  Chloroform  is  perhaps  the  anaesthetic  most  generally  employed,  on  ac- 
count of  the  ease  with  which  it  can  be  administered,  although  there  can  be  but 

85 


1346  A  MANUAL  OF  SURGERY 

little  doubt  that  its  use  is  attended  with  somewhat  more  risk  than  that  of 
ether.  Much  controversy  has  arisen  as  to  whether  the  heart  is  ever  directly 
affected  by  the  drug,  or  whether  the  dangerous  symptoms  met  with  are  not 
due  to  priniary  failure  of  the  respiration.  The  experimental  evidence  on  the 
subject  is  of  a  very  conflicting  nature;  and  it  is  impossible  as  yet  to  consider 
the  question  solved.  The  Scotch  school  of  surgeons,  headed  by  Syme  and 
Lister,  has  always  maintained  that  the  breathing  alone  need  be  watched 
during  the  administration  of  chloroform,  failure  of  the  respiration  being  the 
first  danger-signal;  the  second  so-called  Hyderabad  Commission  has  sought  to 
confirm  this  view.  Many  practical  surgeons  and  anaesthetists  oppose  the 
statement,  holding  that,  although  the  respirations  may  fail  first  in  a  large 
percentage,  and  probably  a  majority,  of  fatal  cases,  yet  there  are  a  certain 
number  in  which  heart  failure  is  also  seen  as  a  result  of  the  direct  toxic  effect 
of  the  chloroform  upon  its  muscular  substance.  Certainly  in  not  a  few  instances 
of  death  during  the  administration  of  chloroform  the  heart  stops  first,  but  a 
great  distinction  must  be  drawn  between  the  deaths  which  result /rom  chloro- 
form, and  the  deaths  that  occur  during  the  administration  of  chloroform.  An 
overdose  of  chloroform,  without  doubt,  leads  to  failure  of  the  respiration;  but 
in  the  majority  of  such  cases,  if  suitable  precautions  are  adopted  sufficiently 
early,  a  fatal  result  may  be  averted.  Cases  in  which  the  heart  stops  first  are 
probably  due  to  syncope,  and  are  not  entirely  dependent  on  the  nature  of  the 
anaesthetic  administered. 

Attention  has  been  drawn  recently  to  a  condition  known  as  delayed  chloro- 
form poisoning,  which  is  chiefly  observed  in  children,  and  especially  in  cases 
where  grave  toxzemia  is  present.  It  commences  about  1 2  hours  after  the  admin- 
istration with  vomiting,  the  ejecta  usually  resembling  beef  tea,  which  persists 
in  spite  of  all  treatment,  and  the  child  becomes  drowsy,  apathetic,  and  finally 
dies  about  the  fifth  day  in  a  condition  of  coma.  Some  slight  degree  of  icterus 
may  be  noted.  The  breath  smells  of  acetone,  and  the  blood  and  urine  contain 
both  acetone  and  diacetic  acid;  these,  however,  can  often  be  detected  in 
children  after  chloroform,  and  in  some  other  conditions.*  Post-mortem  the 
•most  marked  phenomenon  is  an  intense  fatty  degeneration  of  the  liver,  and  to 
some  extent  of  other  organs;  but  Guthrie  thinks  that  the  hepatic  condition 
has  probably  preceded  the  administration  to  a  slight  extent,  and  that  the 
chloroform  was  merely  the  final  element  in  determining  the  outbreak  of  trouble. 
In  adults  a  similar  condition  arises  a  day  or  two  after  the  operation,  and  per- 
haps most  commonly  in  cases  of  grave  toxaemia,  e.g.,  suppurative  appendicitis. 
The  symptoms  are  those  of  acute  yellow  atrophy  of  the  liver,  including  per- 
sistent vomiting,  well-marked  jaundice,  delirium,  and  finally  coma.  The  liver 
is  extensively  involved,  and  undergoes  evident  degenerative  changes.  Nothing 
can  be  done  as  a  rule,  although  the  indications  are  to  reduce  the  toxic  absorp- 
tion from  the  wound  as  far  as  po.ssible,  and  to  flood  the  system  with  alkalies. 
As  a  prophylactic,  glucose  in  doses  in  i  drachm,  t.d.s.,  has  been  recommended. 
Death  is  the  usual  outcome,  and  occurs  about  the  third  day.  A  similar  con- 
dition of  hepatic  disorganization  may  also  occur  after  the  administration  of 
ether,  and,  indeed,  may  develop  irrespective  of  operative  interference  of 
any  kind. 

Chloroform  may  be  given  in  several  different  ways,  but  in  all  the  chief  points 
to  be  attended  to  are  regularity  of  dose,  and  full  admixture  with  air,  so  that  not 
more  than  4  per  cent,  of  the  vapour  is  inspired.  The  plan  so  often  employed 
of  pouring  an  unknown  quantity  of  chloroform  on  a  piece  of  lint,  folded  in  two 
or  three  layers  and  held  close  to  the  patient's  nose  and  mouth,  is  most  unscien- 
tific and  to  be  strongly  condemned.  The  Open  Method  is  that  recommended 
bv  Lord  Lister.     A  mask  reaching  from  the  root  of  the  nose  to  the  chin  is  made 

*  To  test  for  acetone,  the  urine  is  first  rendered  alkaline  by  caustic  potash. 
To  this  is  added  a  few  drops  of  a  newly  prepared  concentrated  solution  of 
sodium  nitro-prusside.  If  acetone  is  present  the  mixture  becomes  a  reddish- 
violet  colour,  which  turns  blue  on  standing,  or  yellow  on  the  addition  of  acetic 
acid.  If  a  solution  of  ferric  chloride  is  added  to  the  alkaline  urine,  a  claret 
colour  is  produced. 


ANESTHESIA  13^7 

from  the  side  of  a  towel,  and  fixed  with  a  safety-pin.  This  is  first  held  some 
incnes  above  the  patient's  nose,  and  moistened  from  the  outside  with  chloro- 
lorm  Irom  a  drop-bottle.  As  the  respiratory  passages  become  tolerant  of  the 
cirug  the  mask  is  gradually  lowered  to  touch  the  face,  and  is  kept  continually 
moistened.  At  the  end  of  two  or  three  minutes  the  respiration  increases  in 
irequency.  and  a  stage  of  excitement  may  be  reached,  during  which  the  patient 
may  sing,  shout,  or  struggle  violently.  The  anaesthetic  is  still  cautiously 
pushed,  care  being  taken  that  during  the  deep  respirations  which  follow  the 
struggling  stage  an  overdose  is  not  administered.  Complete  ansesthesia  is 
indicated  by  relaxation  of  the  muscles,  loss  of  the  corneal  reflex,  and  contrac- 
tion ot  the  pupil,  and  it  is  usually  attained  in  about  five  minutes.  As  long  as 
the  operation  lasts,  the  anaesthetist  must  endeavour  to  maintain  this  condition 
but  the  amount  needed  during  the  later  stages  is  much  less  than  at  its  com- 
mencement. Another  and  a  better  plan  is  to  employ  a  Schimmelbusch's  mask 
(^ig.  607),  over  which  are  stretched  one  or  two  layers  of  domette  or  five  or  six 
ot  gauze.  The  liquid  is  dropped  on  this  surface  in  separated  drops  at  short 
intervals,  not  m  a  continuous  stream. 

Junker's  inhaley  is  often  used  for  giving  chloroform,  especially  in  operations 
about  the  nose  and  face.  It  is  economical,  and  on  the  whole  satisfactory  In 
this  apparatus  air  is  pumped  through  a  layer  of  chloroform  to  a  face-piece  placed 
over  the  patient  s  mouth,  or  to  a  tube  passed  into  his  nose.  The  air  laden  with 
chloroform  vapour  is  inspired,  and  produces  the  usual  constitutional  effects- 


Fig.  607.— Schimmelbusch's  Mask  for  the  Administration  of 
Chloroform.     (Down  Brothers.) 

the  amount  administered  is,  to  a  certain  extent,  regulated  by  the  rapidity  with 
which  the  mdiarubber  bulb  of  the  apparatus  is  squeezed;  after  a  time  how- 
ever, the  loweied  temperature  induced  by  the  evaporation  leads  to  a  diminu- 
tion m  the  amount  of  chloroform  vapour  given  off.  Accidents  have  happened 
with  this  apparatus  from  filling  the  bottle  too  full,  or  from  having  the  india- 
rubber  tubes  fixed  to  the  wrong  nozzles;  in  either  instance  liquid  chloroform 
may  be  pumped  out  of  the  exit- tube. 

(3)  Ether  is  generally  considered  to  be  a  safer  anaesthetic  than  chloroform  in 
that  It  IS  a  cardiac  stimulant.  It  is  usually  administered  by  Clover's  apparatus 
or  by  an  open  method.  ^ 

Clover's  apparatus  (Fig.  608,  D  and  E)  consists  of  a  face-piece  similar  to  that 
utilized  for  giving  nitrous  oxide,  a  metal  receptacle  for  the  ether,  and  a  bag  In 
this  apparatus  the  air  used  in  respiration  passes  over  the  surface  of  the  ether 
contained  m  the  receptacle,  the  proportion  of  ether  inspired  being  regulated  so 
that  at  first  a  considerable  admixture  of  air  is  permitted,  whilst  later  on  ether 
vapour  m  the  proportion  of  a  third,  a  half,  or  even  tw^o-thirds,  is  inhaled  The 
chief  advantage  of  this  apparatus  is  the  ease  with  which  the'amount  of  ether 
administered  is  regulated;  but  a  distinct  disadvantage  exists  in  the  fact  that 
the  patient  breathes  his  own  expired  air  again  and  again,  and  so,  unless  care  is 
taken,  he  is  likely  to  become  cyanosed.  This  can,  however,  be  prevented  by 
removing  the  mask  occasionally,  and  giving  the  patient  a  few  breaths  of  un- 


1348 


A   MANUAL  OF  SURGERY 


mixed  air.  Another  objection  lies  in  the  amount  of  mucus  which  often  collects 
about  the  pharynx,  whilst  the  moisture  in  the  expired  air  condenses  in  the 
bag,  which  becomes  very  objectionable  unless  carefully  washed  out  after  each 
administration. 

In  the  administration  of  ether  it  is  now  usual  to  adopt  what  is  known  as  the 


Fig.  608. — Apparatus  for  the  Administration  of  Nitrous  Oxide  and 
Ether  in  Combination. 

A,  Steel  cylinders  containing  compressed  nitrous  oxide;  B,  indiarubber  bag; 
C,  three-way  stop-cock  with  valves;  D,  Clover's  ether  chamber ;  E,  face- 
piece.  If  nitrous  oxide  alone  is  administered,  D  is  omitted.  When  ether 
alone  is  used,  A  and  C  are  omitted,  and  a  smaller  bag  substituted  for  B. 


'  oras  and  ether  method,'  by  which  is  meant  that  the  patient  is  first  anaesthetized 
with  nitrous  oxide,  and  the  anaesthesia  is  continued  and  maintained  by  means 
of  ether.  If  the  Clover's  inhaler  is  to  be  used,  the  arrangement  shown  in 
Fig.  608  is  employed,  a  Clover's  ether-chamber  being  interposed  between  the 


ANMSTHESIA 


1349 


face-piece  and  the  three-way  tube  of  a  nitrous  oxide  apparatus.  The  patient  is 
first  allowed  .some  six  or  eight  full  in.sjiirations  of  nitrous  oxide  gas,  and  then  the 
ether-chamber  is  turned  to  permit  of  gradually  increasing  doses  of  ether 
vapour.  As  soon  as  symptoms  of  nitrous  oxide  narcosis  present  (twitching  of 
muscles,  irregular  stertor,  etc.),  the  gas-bag  is  detached  and  the  ordinary  ether- 
bag  substituted. 

The  advantages  claimed  for  this  '  combined  method  '  arc  that  anaesthesia  is 
induced  much  more  rapidly  (two  minutes),  and,  what  is  far  more  important, 
the  process  is  much  less  unpleasant  for  the  patient  than  when  ether  alone  is 
employed.  The  patient  is  apt  to  become  rather  livid  and  rigid,  but  these 
conditions  pass  off  in  the  course  of  a  minute  or  two. 

Of  late  years  it  has  become  the  fashion  to  administer  ether  by  what  is 
termed  the  Open  Method — i.e.,  in  much  the  same  way  as  in  the  administration 
of  chloroform.  A  Schimmelbusch's  mask  is  employed  (Fig.  607),  with  three 
or  four  layers  of  domette  or  six  or  eight  layers  of  gauze;  the  irregularities  of 
the  face  are  filled  in  with  strips  of  cotton-wool,  and  the  ether  is  dropped  on  in 
a  series  of  very  rapid  large  drops,  the  supply  being  maintained  at  much  the 
same  rate  throughout  the  whole  operation.  It  is  usual  in  this  country  to  com- 
mence with  chloroform  or  the  A.C.E.  mixture,  and  better  results  will  be  ob- 


FiG.  609. — ^Silk's  Modification  of  Rendle's  Mask.    (Down   Brothers.) 

tained  if  the  administration  is  preceded  by  an  injection  of  morphine  \  gr. 
and  atropine  -^  gr.,  given  about  an  hour  beforehand.  The  chief  objections 
to  this  plan  are  the  large  quantities  of  ether  required,  and  the  consequent 
discomfort  caused  to  the  operator  and  his  assistants.  This,  however,  can 
be  minimized  considerably  by  giving  it  in  the  semi-open  method  as  for 
A.C.E. 

(4)  To  obviate  the  depressing  effects  of  chloroform,  a  combination  known  as 
the  A.C.E.  Mixture  is  often  used,  consisting  of  alcohol,  chloroform,  and  ether, 
blended  in  the  proportion  of  one,  two,  and  three  parts  respectively.  It  may  be 
given  either  from  a  Rendle's  mask,  or  by  the  open  method  as  for  chloroform, 
but  the  latter  plan  is  only  applicable  to  children  and  weakly  individuals,  who 
require  but  little  anaesthetic.  Rendle's  mask  consists  of  an  oval  box  open  at 
one  end  and  shaped  to  fit  the  nose  and  mouth,  and  the  fundus  perforated  with 
holes  to  permit  of  the  free  entrance  of  air;  it  may  be  made  of  leather,  or  pre- 
ferably of  celluloid  or  metal  (Fig.  609).  Two  or  three  sponges  are  placed 
within  it,  and  soaked  with  the  anaesthetic,  the  patient  breathing  in  and  out  of 
the  cone.  The  inspired  air  is  thus  laden  with  the  vapour,  and  the  amount 
admitted  is  regulated  in  measure  by  covering  a  certain  proportion  of  the  inlet 
holes  with  the  hand.  The  objection  to  this  reagent  is  that  it  evaporates 
somewhat  unequally,  the  ether  coming  off  first,  and  leaving  an  excess  of 
chloroform,  which  may  be  dangerous;   this    can,  however,  be  obviated  by 


I350  A   MANUAL  OF  SURGERY 

re-moistening   the    sponges   alternately   with    the    mixture    and    with    pure 
ether, 

(5)  During  recent  years  ethyl  chloride  has  been  introduced  as  a  general 
anaesthetic  with  excellent  results.  It  may  be  used  {a)  for  short  operations  on 
the  mouth  or  nose — e.g.,  tooth-extraction  or  removal  of  adenoids,  where  a 
single  dose  is  sufficient  for  the  purpose;  {b)  for  minor  operations  elsewhere — 
e.g  ,  opening  abscesses,  reducing  fractures  and  dislocations ;  and  (c)  for  inducing 
anaesthesia,  which  can  be  maintained  by  ether,  in  prolonged  operations.  Its 
utility  is  limited  by  its  extremely  volatile  nature  and  by  the  method  which  must 
be  employed  in  its  administration.  For  this  purpose  the  bag  of  a  nitrous 
oxide  or  of  an  ether  apparatus  is  utilized  (it  has  no  action  upon  rubber) ; 
2  or  3  c.c.  are  poured  into  it,  and  the  face-piece  is  firmly  ])laced  over  the 
patient's  mouth  and  nose.  Anaesthesia  is  induced  very  rapidly,  and  recovery 
IS  equally  rapid,  but  is  rather  apt  to  be  followed  by  sickness  and  depression. 
Another  use  for  this  drug  is  as  a  preliminary  to  the  use  of  ether  or  the  A.C.E. 
mixture.  In  the  latter  case  from  8  to  10  c.c.  are  poured  upon  the  sponge  of 
a  Rendle's  mask,  and  as  soon  as  the  patient  becomes  unconscious  a  full  dose  of 
the  mixture  is  added.  An  undue  proportion  of  fatalities  have  been  recorded 
from  the  use  of  ethyl  chloride,  so  that  it  is  unwise  to  place  it  in  the  hands  of 
the  unskilled  or  inexperienced. 

4.  There  are  three  non-inhalation  methods  of  administering  ether  which 
have  proved  useful  in  certain  special  cases: 

(i)  Intravenous. — A  vein  in  the  bend  of  the  elbow  or  over  the  internal 
malleolus  is  opened  under  a  local  injection,  and  a  cannula  is  tied  in;  a  slightly 
warm  solution  of  i  part  of  ether  to  20  of  sterile  normal  salt  solution  is  allowed 
to  flow  into  the  vein  through  this  cannula  in  a  steady  but  small  stream. 
Anaesthesia  is  induced  very  rapidly,  and  is  of  a  very  satisfactory  nature,  and 
capable  of  accurate  adjustment.  To  ensure  the  steadiness  of  the  supply,  an 
apparatus  with  a  regulating  dripper,  similar  to  that  required  for  continuous 
proctoclysis  (Fig.  457),  is  requiretl. 

The  chief  objections  and  difficulties  connected  with  the  plan  are  the  trouble 
and  pain  attendant  upon  the  preliminary  proceeding  of  finding  the  vein,  and 
the  large  amount  of  fluid  (3  pints  or  more  in  a  long  case)  which  it  is  sometimes 
necessary  to  inject;  this  may  give  rise  to  cardiac  dilatation,  increased  venous 
oozing,  and  other  troubles.  To  some  extent  the  amount  of  fluid  may  be 
diminished  by  the  addition  of  from  5  to  10  grains  of  hedonal  to  each  pint  of 
the  fluid.* 

This  method  is  particularly  indicated  for  patients  who  are  already  much 
collapsed  as  the  result  of  disease,  or  when  one  has  reason  to  anticipate  a  severe 
degree  of  collapse  as  the  result  of  the  operation.  It  has  also  been  used  with 
advantage  when  it  has  seemed  desirable  that  the  anaesthetist  and  his  para- 
phernalia should  be  removed  as  far  as  possible  from  the  operation  area. 

(2)  Intra-tracheal  Insufflation  of  Ether. — In  this  method  one  endeavours  to 
set  up  a  condition  of  artificial  respiration  similar  to  that  adopted  in  the 
physiological  laboratory,  anaesthesia  being  maintained  by  means  of  warm 
moist  ether  vapour  introduced  under  pressure.  The  patient  is  prepared  in 
the  ordinary  way,  and  a  preliminary  full  dose  of  morphia  and  atropine  ad- 
ministered. He  is  then  deeply  anaesthetized  by  means  of  chloroform,  and  the 
head  being  placed  in  a  proper  position,  the  vocal  cords  are  brought  into  the 
field  of  view  of  a  bronchoscope  (Fig.  432).  A  soft  catheter  is  then  passed 
through  the  glottis  and  as  far  down  as  the  bifurcation  of  the  bronchi,  care 
being  taken  that  the  catheter  does  not  entirely  fill  up  the  opening  of  the  glottis, 
but  allows  a  sufficient  interval  to  permit  of  the  escape  of  the  expired  air.  Air 
mixed  with  the  necessary  amount  of  ether  vapour  is  driven  through  the 
catheter  by  means  of  a  specalized  form  of  apparatus  worked  by  a  foot  bellows 
or  an  electric  force-pump.  The  air  is  supplied  at  a  pressure  of  from  15  to 
20  miUimetres  of  mercury,  and  to  avoid  over-distension  of  the  pulmonary 
tissues  the  pressure  is  allowed  to  fall  to  nil  two  or  three  times  per  minute. 
The  return  current  of  air  along  the  sides  of  the  catheter  sweeps  before  it  any 


*   In  cases  of  tetanus  this  addition  is  of  considerable  therapeutic  value. 


AN/ESTHESIA  i35^ 

blood  or  mucus  that  may  have  trickkul  into  the  trachea  or  accumulated  in  the 
mouth.* 

The  method  is  clearly  complicated  and  dil'licult,  and  except  in  a  few  isolated 
and  exceptional  cases  it  is  doubtL'ul  whether  the  results  are  so  very  superior 
to  those  obtained  by  the  administration  of  the  anaesthetic  in  a  simpler  fashion. 
It  is  chiefly  useful  in  intra-thoracic  cases,  when  it  is  desired  to  distend  the 
collapsed  air-vesicles,  and  in  extensive  tongue  and  mouth  cases,  to  sweep  out 
the  accumulations  of  blood  and  mucus.  The  plan  has  also  been  advocated 
for  abdominal  operations,  on  the  ground  that  the  diaphragmatic  action  is 
reduced  to  a  minimum,  and  the  manipulations  of  the  surgeon  facilitated ;  but 
it  is  very  doubtful  whether  this  reduction  is  really  more  than  could  be  obtained 
by  the  proper  administration  of  an  anaesthetic  in  the  ordinary  way,  and  it  is 
certainly  largely  due  to  the  prior  administration  of  alkaloids  by  which  the 
intra-tracheal  method  is  preceded. 

(3)  The  Rectal  Administration  of  Ether  has  advantages  which  are  suffi- 
ciently obvious  in  such  operations  as  those  on  the  mouth  or  pharynx.  It  has 
been  found,  however,  that  when  liquid  ether  alone  is  used  more  or  less  severe 
colitis  is  set  up,  while  if  the  vapour  be  employed,  the  period  of  induction  is 
unduly  prolonged  and  the  degree  of  anaesthesia  is  out  of  control.  More  re- 
cently Dr.  Gwathmey,  of  New  York,  has  suggested  the  injection  of  a  mixture 
of  oil  and  ether.  The  rectum  having  been  well  washed  out  with  warm  water, 
about  8  to  10  ounces  of  a  mixture  of  olive  oil  and  ether,  in  the  proportions  of 
3  of  oil  to  I  of  ether,  is  injected  very  slowly  into  the  bowel.  About  half  an 
hour  should  be  taken  in  the  process,  by  the  end  of  which  time  the  stage  of 
excitement  should  become  apparent,  and  a  little  chloroform  or  ether  given 
by  inhalation  will  assist  the  development  of  the  full  degree  of  anaesthesia.  It 
is  usual  to  use  a  double  tube  for  the  injection,  so  that  at  any  moment  the  rectal 
contents  can  be  withdrawn,  as  should  always  be  done  at  the  end  of  the  opera- 
tion. The  resulting  unconsciousness  is  not  very  deep,  but  it  forms  an  excellent 
basis  for  the  maintenance  of  inhalation  anaesthesia,  especially  in  the  neurotic, 
in  people  who  are  very  liable  to  sickness,  or  whenever  it  is  desirable  to  limit 
the  amount  of  vapour  given  by  inhalation. 

General  Remarks  as  to  the  Administration  o£  Ansesthetics. 

The  medical  practitioner  must  never  lose  sight  of  the  fact  that  a  certain  ele- 
ment of  risk  is  necessarily  attached  to  the  artificial  induction  of  a  condition  in 
which  the  activity  of  the  nervous  system  is  entirely  suspended,  except  for  the 
maintenance  of  tliose  phenomena  which  are  actually  essential  for  life.  Hence, 
an  anaesthetic  should  never  be  given,  unless  absolutely  necessary,  without 
careful  preparation  of  the  patient,  or  such  examination  as  shall  satisfy  the 
doctor  as  to  his  capability  of  safely  taking  it. 

The  Preparation  of  the  Patient  is  a  most  important  proceeding.  When  prac- 
ticable, the  general  habits  of  the  individual  should  be  carefully  regulated  for  a 
few  days  prior  to  the  operation,  and  on  the  preceding  day  a  suitable  purga- 
tive is  administered,  castor  oil  being,  perhaps,  the  most  efficacious.  Any  food 
given  on  the  morning  of  the  operation  should  be  light  and  easily  assimilable, 
whilst  nothing  should  be  taken  for  at  least  tliree  hours  previously,  so  as  to 
make  sure  that  the  stomach  is  empty.  In  casualty  cases,  it  may  be  advisable 
to  relieve  gastric  distension  with  an  emetic,  or  by  washing  out  the  organ  before 
commencing  the  administration.  The  anaesthetist  must  ascertain  that  no 
loose  artificial  teeth  are  present  in  the  mouth,  and  that  no  tight  clothes  or 
bands  encircle  the  neck  or  thorax.  In  very  nervous  patients,  or  where  much 
shock  is  anticipated,  a  preliminary  hypodermic  injection  of  strychnine  or  a 
nutrient  enema  may  be  administered. 

The  preliminary  hypodermic  administration  of  scopolamine  (gr.  i^)  and  mor- 
phine (gr.  \)  has  been  recommended  by  some  authorities  as  a  means  of  induc- 
ing ordinary  sleep,  and  thereby  diminishing  the  amount  of  anaesthetic  required . 

*  For  further  details  of  this  and  other  non  -  inhalation  methods,  see 
'  Modern  Anaesthetics,'  Silk,  1914. 


1352  A   MANUAL  OF  SURGERY 

A  dose  is  given  three  or  four  hours,  and  another  one  hour,  before  the  time  of 
operation.  There  is  a  good  deal  of  difference  of  opinion  as  to  the  value  of  this 
procedure;  sometimes  it  acts  perfectly,  and  the  patient  escapes  the  discomforts 
caused  b}^  the  larger  doses  of  anasthetic;  at  other  times  it  causes  great  mus- 
cular rigidity  and  increased  bleeding,  so  that  some  surgeons  condemn  it  most 
vigorously.  On  the  whole,  it  would  rather  appear  as  though  the  good  effects 
of  this  preliminary  medication  were  mainly  due  to  the  morphine,  and  that  the 
addition  of  the  scopolamine  is  unnecessary.  A  good  combination  is  morphine 
(gr.  I)  and  atropine  (gr.  ^i^),the  very  distinct  advantages  of  the  latter  drug 
being  that  it  diminishes  the  secretion  of  saliva  and  mucus,  and  probably 
counteracts  the  tendency  to  vagus  inhibition  of  the  heart's  action  which 
Embly*  has  shown  to  be  one  of  the  chief  dangers  of  chloroform  inhalation. 

The  anaesthetic  should  never  be  pushed  in  the  early  stages,  but  is  given 
slowh^  and  gradually,  especiall}'  in  nervous  individuals.  When  there  is  any 
struggling,  the  movements  of  the  limbs  should  be  restrained  with  as  little  force 
as  possible,  and  care  must  be  taken  during  the  deep  respirations  which  follow 
such  struggling  not  to  administer  an  overdose.  The  condition  which  the 
administrator  should  aim  at  maintaining  is  one  characterized  by  total  mus- 
cular relaxation,  insensitiveness  of  the  cornea,  and  a  contracted  state  of  the 
pupil,  whilst  the  pulse  and  breathing  continue  regular.  If  the  pupil  commences 
to  dilate,  and  the  corneal  reflex  is  present,  the  patient  is  apt  to  move  when 
the  knife  is  used,  indicating  that  more  anaesthetic  is  required.  Dilatation  of 
the  pupil  with  an  insensitive  cornea  is  always  an  indication  for  suspending 
the  administration  for  a  time.  If  the  anaesthesia  is  not  sufficiently  deep, 
vomiting  is  likely  to  occur,  being  ushered  in  by  weakness  and  rapidity  of  the 
pulse,  and  pallor  of  the  face;  this  may  often  be  averted  by  pushing  the  anaes- 
thetic. The  anaesthetist's  chief  attention  must  be  directed  to  observing  the 
state  of  the  respiration  and  pupil;  but  he  should  also  note  the  colour  of  the 
lips,  cheeks,  and  ears,  as  thereby  valuable  information  is  gained  as  to  the  con- 
dition of  the  circulation.  The  pulse  should  be  felt  occasionalh',  but  it  is  less 
important  to  attend  to  this  than  to  the  other  points  noted  above.  After  the 
deep  anaesthesia  required  in  division  of  the  skin,  most  operative  proceedings 
on  the  subcutaneous  tissues  are  comparatively  painless,  and  hence  the  anaes- 
thetic need  not  be  pushed  quite  so  far.  Whilst  the  wound  is  being  closed,  the 
patient  must  be  again  somewhat  more  completely  under  control.  In  opera 
tions  upon  the  mouth  associated  with  haemorrhage,  the  head  must  be  occasion- 
all}'  turned  to  one  side  to  allow  the  blood  to  gravitate  out  of  the  mouth,  and  the 
pharynx  well  sponged,  so  as  to  prevent  the  admission  of  clot  and  other  matters 
into  the  air-passages.  It  is  also  a  valuable  routine  plan  to  insist  upon  the  head 
always  being  turned  on  one  side,  especially  when  ether  is  being  given,  since 
mucus  tends  to  collect  about  the  pharynx. 

The  Af ter-Treatment  of  the  patient  is  always  a  matter  of  considerable  im- 
portance. He  is  carried  from  the  table  and  placed  on  his  back,  or  preferably, 
when  possible,  on  his  right  side,  in  bed  with  the  head  low.  When  there  is  any 
tendencj^to  shock,  the  patient  should  be  well  covered  with  hot  blankets,  and 
the  foot  of  the  bed  raised  by  some  lo  or  12  inches.  As  the  skin  of  an  anaes- 
thetized patient  is  particularly  insensitive,  it  is  perhaps  better  to  prohibit  the  use 
of  hot-water  bottles  for  at  least  twent3--four  hours  after  the  operation.  For  the 
further  treatment  of  shock,  see  p.  267.  Absolute  quiet  must  be  enjoined  for 
some  hours,  and  the  room  darkened,  so  that,  if  possible,  the  patient  may  fall 
asleep.  No  food  is  administered  for  at  least  three  or  four  hours,  and  then  only 
very  cautiously,  a  little  weak  tea,  soda-water,  or  beef -tea  being  given.  The 
patient  is  likely  to  vomit  on  returning  from  unconsciousness,  perhaps  bringing 
up  a  little  bile-stained  mucus,  but  if  the  anaesthetic  has  been  judiciously  given, 
this  soon  ceases.  Occasionally,  however,  the  vomiting  persists  for  some  time, 
becoming  ver}^  troublesome.  It  may  generally  be  checked  by  a  hypodermic 
injection  of  morphia,  and  by  washing  out  the  mouth  with  warm  water;  but  in 
more  severe  cases,  lasting  for  some  days,  the  patient's  nutrition  may  have  to  be 
maintained  by  enemata,  and  the  stomach  kept  absolutely  at  rest.     Benefit 

*  Brii.  Med.  Journ..  1914,  vol.  i.,  p.  1902. 


ANESTHESIA  1353 

may  sometimes  be  derived  by  giving  a  little  bismuth  and  hydrocyanic  acid  in 
an  effervescing  mixture,  or  perhaps  champagne;  but,  as  a  rule,  all  administra- 
tion of  food  by  the  mouth  should  be  stopped  until  the  vomiting  has  ceased. 

Three  chief  Dangers  are  encountered  during  the  administration  of  anaes- 
thetics: 

1 .  Obstructed  Respiration  usually  results  from  falling  backwards  of  the  root 
of  the  tongue,  which  blocks  the  entrance  of  air  into  the  larynx.  The  respira- 
tions gradually  become  more  and  more  stertorous,  the  face  and  ears  become 
dusky,  and,  if  the  condition  is  not  relieved,  the  chest  continues  to  heave  without 
any  air  entering  or  leaving  it,  and  finally  respiration  ceases  when  the  patient  is 
completely  asphyxiated.  The  early  stages  of  this  condition  are  of  common 
occurrence,  whatever  the  anaesthetic,  and  the  administrator  must  always  be  on 
the  look-out  and  endeavour  to  prevent  it  by  turning  the  head  or  the  patient  him- 
self so  that  the  tongue  falls  to  one  side.  If  it  occurs  in  spite  of  this  position  being 
adopted,  the  administration  is  at  once  suspended,  whilst  the  tongue  must  at  all 
hazards  be  drawn  forwards.  This  maybe  accomplished  in  the  early  stages  by 
pulling  on  the  beard  or  chin,  or  by  pressing  the  mandibleforwards  by  the  fingers 
placed  behind  the  angle  of  the  jaw,  In  the  later  stages  the  mouth  should  be 
forcibly  opened  by  a  gag,  and  the  tongue  grasped  by  forceps  and  pulled  well 
forwards,  or  a  finger  may  be  passed  back  into  the  pharynx  to  draw  the  root 
and  epiglottis  forwards,  and  at  the  same  time  ascertain  that  the  entrance  to 
the  glottis  is  free  from  obstruction.  Artificial  respiration  should  be  under- 
taken if  the  breathing  has  actually  stopped.  Death  ought  never  to  result 
from  this  cause,  and  if  it  occurs,  it  can  only  be  attributed  to  the  carelessness  of 
the  anaesthetist. 

Obstruction  to  the  respiration  may  occasionally  arise  from  the  entrance  of 
vomited  material  into  the  air-passages  or  lungs,  the  patient  becoming  cyanosed 
during  an  attack  of  vomiting,  and  passing  rapidly  into  a  state  of  asphyxia.  In 
such  a  case  the  finger  must  be  swept  round  the  pharynx,  if  the  mouth  can  be 
opened,  to  see  that  the  glottis  is  clear,  whilst  tracheotomy  or  laryngotomy  may 
be  necessary  should  the  teeth  be  firmly  clenched,  or  if  the  obstruction  is  below 
the  entrance  to  the  glottis.     Fortunately,  this  accident  is  of  rare  occurrence. 

2.  Complete  Cessation  of  Respiration  is  the  usual  primary  phenomenon  from 
an  overdose  of  chloroform ;  it  is  also  stated  to  happen  occasionally  during  ether 
narcosis.  The  pulse  continues  to  beat  distinctly  for  a  few  seconds,  although 
respiratory  movements  have  ceased.  Treatment  consists  in  at  once  stopping 
the  administration,  whilst  the  tongue  is  drawn  forwards,  and  the  fauces  cleared 
by  the  finger.  The  head  should  be  lowered  over  the  end  of  the  table,  and 
young  children  may  even  be  completely  inverted,  so  as  to  induce  a  flow  of  blood 
to  the  head.  Artificial  respiration  is  commenced  without  delay,  whilst  the 
thoracic  parietes  may  be  flicked  with  a  cold  wet  towel,  or  alternately  douched 
with  hot  and  cold  water.  Strychnine  or  ether  should  also  be  injected  h3rpo- 
dermically,  and  if  the  condition  persists  and  the  heart's  action  ceases,  a  Faradic 
current  may  be  passed  from  the  second  or  third  intercostal  space  in  front  to  an 
electrode  placed  over  the  spine.  Attempts  at  resuscitation  should  be  con- 
tinued for  half  to  three-quarters  of  an  hour.  At  the  same  time,  the;se  measures 
must  be  undertaken  with  discretion,  as  otherwise  it  is  quite  possible  to  ex- 
tinguish the  feeble  spark  of  life  by  the  very  means  which,  used  wisely,  would 
have  restored  it. 

3 .  Death  occasionally  results  from  primary  Cardiac  Failure,  which  may  ari  se 
(a)  from  f r i  ght  during  the  administration  of  the  anaesthetic ;  (6)  from  shock  with 
cardiac  inhibition,  by  commencing  the  operation  before  complete  anaesthesia 
has  been  obtained;  and  (c)  from  an  overdose  of  chloroform  or  ether  acting 
directly  on  the  nerve  centres  or  on  the  muscular  substance  of  the  heart.  On 
post-mortem  examination  in  such  cases,  the  heart  muscle  is  found  to  be  thin 
and  flabby,  and  perhaps  infiltrated  with  fat;  the  ventricular  walls  are  especi- 
ally affected.  Unfortunately,  this  condition  cannot  be  recognised  with  cer- 
tainty by  the  stethoscope.  Patients  with  simple  valvular  lesions,  where  the 
defect  has  been  more  or  less  compensated,  do  not  generally  run  any  extra  risk. 
The  treatment  to  be  adopted  in  cases  of  cardiac  failure  during  anaesthesia  is 
the  same  as  for  stoppage  of  the  respiration. 


1354  A   MANUAL  OF  SURGERY 

In  this  connection  it  is  important  to  note  the  association  of  sudden  death 
from  heart  failure  with  the  condition  known  as  Status  Lymphaticus.  It  usually 
occurs  in  children,  and  is  characterized  by  overgrowth  of  the  lyinphoitl  tissues 
of  the  body,  especially  in  the  pharynx,  and  of  the  tonsds,  abdominal  and 
mediastinal  glands.  The  thymus  also  remains  enlarged,  and  the  spleen  and 
bone  marrow  may  be  in  a  condition  of  hyperplasia.  The  administration  of  an 
anaesthetic  is  by  no  means  the  only  cause  of  sudden  death  in  this  condition, 
as  it  has  been  known  to  follow  the  hypodermic  injection  of  antidiphtheritic 
serum,  sudden  plunging  into  cold  water,  and  such  minor  ailments  as  bronchitis. 
It  is  usually  only  discovered  after  death,  but  if  it  is  suspected,  the  greatest 
care  must  be  exercised  in  administering  an  anaesthetic,  since  the  lethal  dose  is 
obviously  very  small  in  such  patients.  Ether  should  be  given,  and  for  choice 
by  the  open  method. 

The  Choice  of  an  Anaesthetic  in  any  particular  case  depends  mainly  on  the 
condition  of  the  circulatory  and  respiratory  apparatus  of  the  patient.  Ether 
is  perhaps,  on  the  whole,  the  safest  agent  to  employ,  especially  in  adults, 
although  it  is  less  pleasant  to  take ;  it  may  cause  a  good  deal  of  bronchial  irrita- 
tion and  congestion,  and  is  more  likely  to  give  rise  to  troublesome  after- 
vomiting,  although  such  does  not  usually  last  long.  It  is  sometimes  followed 
by  unpleasant  delirium.  Chloroform  is  easier  to  administer,  more  pleasant  to 
take,  and  less  likely  to  lead  to  objectionable  after-effects.  It  is  the  best  anaes- 
thetic for  young  children  and  old  people,  though  its  action  upon  the  heart 
contra-indicates  its  use  in  patients  whose  circulation  is  weak,  or  where  there 
is  any  suspicion  of  the  existence  of  the  status  lymphaticus.  The  A.C.E. 
mixture  may  also  be  safely  employed,  if  the  precautions  already  indicated  on 
an  earlier  page  are  attended  to. 

Ether  is  certainly  contra-indicated  in  patients  suffering  from  any  bronchitic 
or  pulmonary  trouble,  and  its  administration  for  operations  about  the  face  or 
mouth  is,  of  course,  impracticable.  Chloroform  should  not  be  given  in 
cases  of  cardiac  weakness  or  advanced  renal  disease;  for  abdominal  work  it 
is  usually  preferred  to  any  other  agent,  as  also  in  operations  on  the  brain,  but 
it  is  important  to  note  that  in  septic  conditions  in  the  abdomen — e.g., 
suppurative  appendicitis  in  children — the  results  of  chloroform  administra- 
tion seem  to  be  much  less  satisfactory  than  when  ether  is  given.  The 
mortality  over  an  extended  series  of  cases  is  much  greater  with  chloroform 
than  with  ether . 

Anoci-Association  is  the  term  used  by  Professor  Crile,  of  New  York,  to 
describe  a  systematic  method  of  operating  devised  by  him  in  order  to  give 
practical  effect  to  his  views  upon  the  causation  of  surgical  shock. 

According  to  Professor  Crile,*  '  the  essential  lesions  of  shock  are  in  the 
brain-cells,'  and  are  caused  partly  by  emotional  or  psychic  shocks  (e.g.. 
fear),  and  partly  and  mainly  by  afferent  impulses  from  the  site  of  the 
operation. 

Psychic  shocks  are  to  be  prevented  by  careful  preparation  of  the  patient, 
who  should,  as  far  as  possible,  be  kept  in  ignorance  of  the  exact  day  and  time 
of  the  operation.  In  the  emotional  [e.g..  thyroid  cases)  this  principle  is 
carried  to  the  extent  of  occasionally  anaesthetizing  the  patient  with  nitrous 
oxide,  under  the  guise  of  treatment. 

Afferent  impulses  are  prevented  by  temporarily  destroying  the  conduc- 
tivity of  the  nerves  in  the  immediate  vicinity  of  the  operation  area,  by  the 
infiltration  of  the  tissues  with  weak  solutions  of  local  anaesthetics  apphed 
systematically  to  each  layer.  In  an  abdominal  operation,  for  instance,  the 
procedure  would  be  as  follows: 

1.  A  dose  of  morphine  (gr.  ^)  and  scopolamine  (gr.  ^hi)  is  given  an  hour 
before  operation. 

2.  Just  sufficient  general  anaesthetic  is  given  to  render  the  patient  uncon- 
scious— ^nitrous  oxide  with  a  little  ether  by  preference. 


*  Lancet,   July  5,  191 3,  p.  7,   and   Seventeenth  International  Congress  of 
Medicine. 


ANESTHESIA  1355 

3.  The  skin  and  subcutaneous  tissues  over  the  point  of  the  incision  are 
infiltrated  witli  novocaine  (i  in  400).  Each  succeeding  layer  of  fascia,  muscle, 
aponeurosis,  etc.,  is  infiltrated  as  it  is  exposed. 

4.  As  needs  be,  the  meso-appendix,  the  base  of  the  gall-bladder,  the  uterus, 
the  broad  and  round  ligaments,  the  mesentery,  etc.,  are  treated  in  the  same 
way. 

5.  The  site  of  the  closing  stitches  is  infiltrated  with  quinine-urea  (J  per 
cent.),  which,  by  the  effusion  it  produces,  assists  in  sealing  the  wound, 

The  amount  of  the  anaesthetizing  fluid  used  is  immaterial,  as  in  the  strength 
employed  it  is  practically  innocuous. 

It  is  claimed  that  by  these  systematic  measures  the  whole  of  the  injurious 
impulses  to  the  brain-cells  are  blocked,  and  the  recovery  of  the  patient  much 
facilitated. 

Professor  Crile's  followers  have  for  the  most  part  been  much  less  systematic, 
and  the  term  '  anoci-association  '  is  now  applied  to  the  free  use  of  weak  solu- 
tions of  local  anaesthetics  applied  haphazard ;  but  even  in  this  limited  sense  a 
certain  amount  of  success  has  attended  the  procedure.  The  educational 
element  of  the  plan  hardly  seems  practicable  in  this  country. 


INDEX 


N.B. 


-The  more  important  references  are  always  placed  first,  the  less  important 
afterwards. 


Abbi^'s  string  saw,  871 
Abdominal  aorta,  compression  of,   292, 
326 
ligature  of,  326,  335 
aneurism,  325 
excision  of  rectum,  11 72 
exploration  of  kidney,  1175 
hysterectomy,  1305,  1310 
nephrectomy,  1213 
operations,  general  remarks  on,  959 
surgery     (Chapter     XXXV.),     959- 

1083 
walls,  injuries  of,  968,  106 1 
wounds,  mortality  of  gunshot,  248 
visceral  complications  of,  969 
Abdomino-perineal   excision   of  rectum, 

1173 
Abduction   frame   for  fractured   femur, 

534. 537.  541 
Abernethy's    operation    for    ligation    of 

external  iliac  artery,  336 
Abscess,  acute,  71,  68 

due  to  auto-infection,  72 
signs  and  symptoms  of,  76 
structure  of,  73 
treatment  of,  79 
alveolar,  795,  799 
anal,  1148,  1151 
antral,  800 

appendicitic,  1045,  1048,  1057 
atheromatous,  305 
axillary,  364 

cerebellar,  772,  883,  770,  773 
cerebral,  769,  741,  748,  758,  882,  883 
chronic,  181,  80,  312,  669,  771,  1094 
of  bone,  576,  563 
of  brain,  771 
of  breast,  939 
of  joints,  646 
of  spinal  disease,  708,  717 
cold,     80.     See     also    Tuberculous 

abscess 
dorsal,  710,  717  - 
embolic,  72,  96,  1061 
encysted,  of  breast,  939 

of  liver,  1061 
evacuation  of,  79 
extradural,  764,  772,  882 
extraperitoneal,  1046 


x\bscess,  frontal  lobe  of  brain,  742,  770 

frontal  sinus,  742,  770 

gas  in,  78,  984,  996,  1013,  1046 

gluteal,  673 

healing  of,  76 

in  appendicitis,  1045,  1048,  1057 

in  bone,  576,  563 

in  glands  of  neck,  364,  366 

in  groin,  364,  150 

in  hip  disease,  672 

in  kidney,  1199,  1201 

in  spinal  disease,  708,  717,  704 

intramammary,  936 

intrapelvic,  673,  678,  89, 1046, 1148, 
1224, 1313 

intraperitoneal,  979,  983,  996,  1013, 
1016,  1024,  1045,  1048 

ischio-rectal,  1149,  1267,  678 

lacunar,  146,  1270 

lumbar,  710,  717,  1109 

mastoid,  880 

of  brain.     See  Cerebellar  and  cere- 
bral abscess 

of  breast,  935 

of  labium,  1300 

of  liver,  1061 

of  lung,  903,  926 

of  scalp,  723 

of  spleen,  1082 

of  tongue,  834 

palmar,  253 

parotid,  844,  812 

pelvic,  89.     See  Intrapelvic  abscess 

pelvi-rectal,  1150 

peri-intestinal,  1025,  1030,  1045- 

perineal,  1258,  1268 

perinephric,  1200,  1047,  1192,  1204 

perirectal,  1148,  1147,  1151,  1167 

peritonsillar,  859 

peri-urethral,  1267,  1255,  1261 

prostatic,  1242 

psoas,  710,  182,  673,  1104 
treatment  of,  717 

pyaemic,  1191,  96,  97 

residual,  712,  183 

retroperitoneal,    983,     1013,     1046, 
1206 

retropharyngeal,  865,  709,  904 

secondary,  72,  97,  99 


1357 


1.358 


A   MANUAL  OF  SURGERY 


Abscess,  spinal,  708 

sterile,  1065,  71,  1062,  1312 
subaponeurotic,  723 
subcranial,  764,  730,  738,  772,  882 
sublingual,  89 
submammary,  937 
subpericranial,  723,  729 
subperiosteal,  561,  564,  576,  795,  799 
subphrenic,    983,    996,    1013,    1047, 

1074,  1079 
subpsoas,  673 
supra-mammary,  936 
tropical.  1062 

tuberculous,  181,  80,  365,  366,  576, 
646,  669,  708,  712,  771,  917, 
940,  1150,  1202,  1282 
treatment  of,  186,  646,  717,  865 
typhoid,  72,  569 
urethral.     See  Perineal  abscess 
wall,  structure  of,  73,  1982 
Accessory  auricles,  875,  884 

sinuses  of  nose,  affections  of,  821 
thyroids,  898 
Accommodative  shortening  of  muscles, 

666 
A.C.E.  anesthetic  mixture,  1349 
Acephalocyst,  233 
Acetabulum,  fracture  of,  527,  620 
travelling,  669 

triangular,  in  congenital  hip,  449 
Acetone  in  diabetes,  1181,  1346 
Achondroplasia,  586 
Achorion  Schonleinii,  10 
Acid-fast  bacilli,  8 
Acid-phosphate  of  lime  calculi,  1204 
Acinous  cancer,  222,  948,  803 

cysts,  940 
Acne,  815 

Acquired  hernia,  causes  of,  1085 
Acquired  immunity,  15 
inguinal  hernia,  1090 
vaginal  hydrocele,  1288 
Acro-arthritis,  662 
Acromegaly,  588,  441,  778 
Acromion,  dislocation  of,  606 

fracture  of,  502 
Actinomycosis,  191,  8,  10,  12,  809,  1059, 

1067 
Active  immunity,  15 

incontinence  of  urine,  1239 
Actual  cautery,  use  of,  50,  45,  288,  694, 

1 160 
Acupressure,  289 

Acupuncture  for  aneurism,  318,  320,  326 
for  neuritis,  377 
for  spina  bifida,  703 
Acute  arthritis,  633,  668,  600,  565,  811 
of  infants,  563,  565,  581 
bedsore,  121 
bursitis,  427 

cancer  of  breast,  952,  223 
cystitis,  1220 

dilatation  of  stomach,  1004 
emphysematous  gangrene,  121,  86 
enteritis,  1020,  1014,  1113,  1121 
epididymitis,  1279 
exanthemata,  94 
goitre,  898,  891 


Acute  hydrocele,  1287,  1279 

infective  arthritis    of    infants,  562. 

581 
inflammation  (Chapter  II.),  29-46 
intestinal  obstruction,  1126-1133 
intussusception,  11 38 
meningitis.  748,  768 
myositis,  418 
neuritis,  376 
orchitis,  1279 
osteo-arthritis,  657 
osteo-myelitis,  56c,  916 
pancreatitis,  1079 
parenchymatous  glossitis,  834 
peritonitis,  974-979 
poliomyelitis,  720 
prostatitis,  1242 
pyaemia,  97 
rhinitis,  818 
sapraemia,  92 
septicaemia,  92,  252 
spreading  oedema  of  brain,  755,  752 

gangrene,  121 
synovitis,  629 
teno-synovitis,  420 
tuberculosis,  184,  1200 
ulcer  of  stomach,  992 
Adam's  osteotomy,  667 

subcutaneous  operation  for  Dupuy- 
tren's  contraction,  447 
Adder's  bite,  251 
Adductor  longus,  injury  of,  417 
Adenocele  of  breast,  945 
Adenoids,  827,  852,  860,  876,  877 
Adenoma,  sebaceous,  410,  725 
Adenomata,  217 
congenital,  704 

intracanalicular  of  breast,  945 
malignant,  222 
of  adrenal  bodies,  121 1 
of  breast,  943,  954 
of  intestine,  1023 
of  kidney,  1210 
of  liver,  1066 
of  palatal  glands,  858 
of  pituitary  body,  778 
of  post-anal  gut,  704 
of  prostate,  1245 
of  sebaceous  glands,  410, 725 
of  testis,  1285,  230 
of  thyroid,  892 
Adeno-carcinoma  of  breast,  953 
Adeno-fibroma.     See  Fibro-adenoma 
Adhesions  after  fracture,  484,  487 
after  synovitis,  630,  662 
in  appendicitis,  1045,  1048 
in  cancer  of  stomach,  999 
in  hernial  sac,  1086,  iiii 
in  ovarian  cysts,  1318,  1321,  1322 
in  peritonitis,  974,  979,  980,  983,  996 
leading    to    intestinal    obstruction, 

1128, 980, 988, 1133,  1136 
leading  to  stricture  of  intestine,  973, 
1022 
Adiposis  dolorosa,  206 
Adolescent  genu  valgum,  453 
rickets,  585,  436,  450,  455 
scoliosis,  436,  453 


INDEX 


t359 


Adrenal  adenomata,  121 1 
Adrenalin  as  a  vaso-constrictor,  289,  298, 
795. 825,  830,  1343 
use  of,  in  shock,  267 
Adventitious  bursa;,  427,  232 
Atirial  tistula,  890 
Aerobes,  5 

After-treatment  of  abdominal  operations, 
.963 

of  general  anaesthesia,  1352 

of  operations,  280 
Agglutinins,  21 
Air  embolism,  344 
Air,  entrance  into  veins,  295,  761 
Air-hunger,  283,  970 
Air-passages,  examination  of,  900 

foreign  bodies,  in  900,  903 

operations  on,  907 

surgery  of  (Chapter  XXXIII.),  900- 
932 

wounds  of,  888 
Albuminoid  (amyloid)  disease,  83 
Albuminous  infiltration,  37 
Albuminuria,  1178,  in,  1202 

significance  of,  1179 
Alcohol-fast  bacilli,  8 
Alcohol  injections  in  tic-douloureux,  381 
Alexander's  operation  of  shortening  the 

round  ligaments,  1301 
Alexins,  17,  22,  32 
Alibert's  keloid,  263 
Alopecia  in  syphilis,  160 
Alveolar  abscess,  795,  799 

harelip,  784,  850 

processes,  affections  of,  795 
fracture  of,  495 

sarcoma,  202 
Amazia,  933 
Amboceptor,  22 

Ambulatory  treatment  of  fractures,  484 
Ammonium  urate  calculus,  1230 

deposits  in  tirine,  11S4 
Amceba  coli,  10,  1020,  1062 
Amorphous  phosphates  in  urine,  11S5 
Ampulla  of  Vater,  1068,  1074,  1079 
Amputation,  length  of  flaps,  1326 

methods  of,  1324 

circular,  1324 

elliptical,  1325 

flap,  1325 

modified  flap  and  circular,  1325 

of  breast,  968,  955-958 

of  penis,  1273,  1256 

of  stumps,  1328 

racquet,  1325 
Amputations    (Chapter    XLIV.),    1324- 
1341 

for  acute  arthritis,  636,  567 

for  aneurism.  319,  325 

for  chronic  ulcer  of  leg,  103 

for  compound  fractures,   244,   249, 
491 

for  dislocations,  604 

for  elephantiasis,  363 

for  gangrene,  114,  116,  118,  120,  319 

for  infantile  palsy,  721 

for  lacerated  wounds,  238,  243,  244 

for  necrosis  of  bone,  567,  568 


Amputations  for  pyaemia,  99,  567 

for    rupture    of   main    artery,   245, 

301 
for  sarcoma  of  bone,  595 
for  secondary  hemorrhage,  294 
for  senile  gangrene,  115 
for  spreading   traumatic  gangrene, 

123 
for  tuberculous  disease  of  joints,  647 

651.  677 
nerves  in  stumps  of,  372,  1328 
special,  1328-1341 
Amussat's  operation  of  colostomy,  1033 
Amygdaloid  glands,  157 
Amyloid  degeneration  of  arteries,  308 
disease,  83,  634,  644,  1179 
spleen,  1083 
Anaerobes,  5 
Anaerobiosis,  135 
xA.naemia  from  oral  sepsis,  85 
in  secondary  syphilis,  158 
pernicious,  85 

secondary,  blood  count  in,  66 
splenic,  1082 
Anemic  ulceration  in  gangrene,  no 
Anesthesia  (Chapter  XLV.),  1342-1355 
after-treatment  of,  1352 
dangers  of,  1353 
dolorosa,  712 

in  abdominal  operations,  1354,  960 
in  reduction  of  dislocations,  603 
in  th^Toid  operations,  897 
inhalational,  1345 
intratracheal,  1350,  925 
intravenous,  1350,  960 
local,  1342 
preparation  for,  1351 
rectal,  1351 
regional,  1343 
Schleich's  infiltration  method,  1343, 

895. 897, 1132, 1355 
spinal,  1344,  268,  118 
Anaesthetic,  choice  of,  1354 

leprosy,  189 
Anaesthetics,  administration  of  (general 

remarks),  135 1 
Anal  abscess,  1148 
Analgesia,  local,  1342 
regional,  1343 
spinal,  1344,  118 
Anaphylaxis,  28 
Anaplasia,  198,  219 
Anastomosis,  lateral,  of  intestine,  1038 

of  nerves,  376,  385 
Anatomical  neck  of  humerus,  fracture  of, 
503 
tubercle,  251 
Anel's  operation  for  aneurism,  316 
Aneurism     (Chapter    XIII.),     299-340, 
872 
causes  of,  30S 
cirsoid,  724 
diffuse  traumatic,  of  bone,  596 

of  scalp,  723 
gangrene  after,  312,  313 
treatment  of,  314 
varicose,  302 
varieties  of,  309 


1360 


A  MANUAL  OF  SURGERY 


Aneurism  V)y  anastomosis,  355,  596 
of^bone,  596 

rupture  of,  313,  299,  319 
Aneurismal  varix,  302,  324,  348,  763 
Aneurisms,  special.  319,  327 
Angina  of  Ludwig,  89,  845,  904 

Vincent's,  124 
Angioma,  352,  215 

of  liver,  1066,  354 
Angular  curvature  of  spine,  704,  441 
Ankle-joint: 

acute  arthritis  of,  637 

amputation  through,  1335 

ankylosis  of,  666 

dislocation  of,  624 

effusion  into,  628 

excision  of,  683 

fracture-dislocation  of,  550 

tuberculous  disease  of,  651 
Ankyloglossia,  833 

Ankylosis,  665,  634,  646,  662,  673,  679, 
706,  812, 190, 118 

fibrous,  665 

osseous,  665 

treatment  of,  666 
Annular  stricture  of  urethra,  1257 
Anoci-association,  1354,  268 
Anterior  gastro-enterostomy,  icio 

poliomyelitis,  720 

rhinoscopy,  817 

tibial  artery,  ligation  of,  339 
Anthracaemia,  141 
Anthrax,  140,  2,  12 

spores,  2 
Anti-anthrax  serum,  28,  141 
Anti-bodies,  21,  32 
Anti-diphtheritic  serum,  27,  134,  641 
Anti-pneumococcic  serum,  28 
Antiseptic  treatment  of  wounds,  271 
Antiseptics,  271 

in  abdominal  operations,  960 
Anti-sera,  15.  16 
Anti-streptococcic  serum,  27,  87,  95,  99, 

133 
in  cellulitis,  87 
in  erysipelas,  133 
in  pyaemia,  99 
in  septicaemia,  95 
Anti-tetanic  serum,  137,  138,  27,  16 
Anti-toxic  sera,  27 
Anti-toxin,  19,  20,  21,  32 

in  diphtheria,  134 
in  tetanus,  137,  138 
Anti-venene,  Calmette's,  251 
Antrum  of  jaw,  affections  of,  800-803 
hydrops  of,  802 
suppuration  in,  800,  795,  822 
transillumination  of,  801 
tumours  of,  .803 
Antyllus's  operation  for  aneurism,  316 
Anuria,  calculous,  1207 
Anus,  absence  of,  1145 

artificial,    1033,    969,    1023,    1027, 
1031, 1115.  1120,  1123,  1133,  1135 
closure  of  artificial,  1036 
condyloma  of,  1164,  1159 
epithelioma  of,  1167,  1159 
fissure  of,  11 54 


Anus,  imperforate,  1145 
malformations  of,  11 45 
mucous  tubercles  of,  1164,  1159 
prolapse  of,  1161 
pruritus  of,  1155,  1148,  1156 
stenosis  of,  1165 
varicose  veins  of,  11 55 
Aorta,  abdominal,  aneurism  of,  325 
compression  of,  292 
ligature  of,  335,  326 
thoracic,  aneurism  of,  319 
Aphasia,  756,  771 
Aphonia,  890,  870 
Aphthous  stomatitis,  832 
Aplasia  cranii  congenita,  725 
ApncBa.     See  Asphyxia 
Apparently  drowned,  treatment  of  the, 

930 
Appendicitis,  1040-1059,  1131,  1012 

abscess  in,   1046,  979,   1048,   1050, 

1131 
ffitiology  of,  1040-1043,  1030 
appendicular  colic,  1050 
complications  of,  1047 
diagnosis  of,  105 1,  11 31 
early  operation  in,  1056,  1057 
extraperitoneal  suppuration,  1046 
faecal  concretions  in,  1041 
faecal  fistula  after,  1058,  1045 
foreign  bodies  causing,  1041 
injury  a  cause  of,  1041 
intestinal  obstruction  in,  1045,  1131 
leucocvtosis  in,  value  of,  1049,  1057, 

62 
necrosis  in,  1044 

operations  in  fulminating  appendi- 
citis, 1054 
in  quiescent  period,  1053 
in      suppurative      appendicitis, 
1053, 1056, 1057 
pathological  anatomy  of,  1043 
peritoneal  phenomena  of,  1045,  979 
prognosis  of,  1052 
pylephlebitis  in,  1049,  1047 
quiescent  interval,  1049 
rectal  examination,  importance  of, 

1049 
recurrences  of,  1050,  1053 
recurrent,  1050 
relapsing,  1050 

septic  peritonitis  in,  1049,  1046 
subphrenic  abscess  in,  983,  1047 
symptoms  of,  1047 
thread -worms  in,  1148 
treatment  of,  1052-1058 
varieties  of,  1043 
Appendicostomy,  1021 
Appendicular  gastralgia,  1050 
Appendix  vermiformis,  actinomycosis  of 
192,  1059 
cancer  of,  1059 
in  hernial  sac,  1087,  1047 
stenosis  of,  1043 
strangulation   of   intestine   by, 

1128 
tuberculosis  of,  1058 
use  of,  in  treatment  of  colitis, 
1021 


INDEX 


1361 


Arachnoid  cyst,  763,  756,  237,  232,  731 
Aran's  theory  of  irradiation,  731 
Arc  lamp,  projection  of  light  from,  50 
Arm,  amputation  through,  1331 

deformities  of,  442 
Arrest  of  h;cmorrhage,  285 
Arterial  hemorrhage,  291,  282 
treatment  of,  291 

suture,  301 

thrombosis,  116,  119,  299,  308 
gangrene  from,  112,  116 

varix,  723 
Arteries,   affections  of  (Chapter  XIII.), 
299-340 

calcareous  degeneration,  307,  114 

cause  of  gangrene,  114 

degeneration  of,  307,  303 

digital  compression  of,  292,  288,  315 

diseases  of,  303 

injuries  of,  299 

ligature  of,  291,  293,  327-340 

secondary  haemorrhage  from,  treat- 
ment of,  294 

suture  of;  301 

wounds  of,  301 
Arterio-sclerosis,  304 
Arterio-venous  anastomosis,  115,  116 

aneurism,  302,  303 

wounds,  302,  352,  723 
Arteritis,  303 
Artery,  implication  of  main,  in  fractures, 

487 
Arthrectomy,  646,  649,  650,  651 
Arthritis,  acute,  633,  563,  565,  600,  668, 
811 

deformans,  653,  588 

following  nerve  injuries,  662,  376 

gonorrhcBal,  640,  148,  633,  811 

gouty,  639 

infective  (acute),  633,  562,  565 

neuropathic,  659,  662 

pneimiococcal,  639,  70 

pyemic,  97,  633,  639 

senilis,  653 

sicca,  653 

traumatic,  654,  487,  600 

tuberculous,  585,  641-651 

typhoid,  639 
Arthrodesis,  721,  465 
Arthroplasty,  667 
Artificial   anus,    1033,    969,  1023,  1113. 

1120.  1123,  1133.  1135 
Artificial  hyperemia,  41 

pneumothorax,  925 

respiration,  methods  of,  929,  930 
Arylarsonates  in  treatment  of  syphilis, 

166 
Ascending    pyelonephritis,    1196,    1222, 

1247,  1259 
Ascites,  985,  looi,  1081 
Ascitic  tuberculous  peritonitis,  980 
Aseptic  moist  gangrene,  109 

suppuration,  71 

traumatic  fever,  268,  478 

treatment  of  wounds,  242,  1331 

wounds,  273,  960 
Asphyxia,  928-932 
Aspiration  for  hydronephrosis,  1195 


Aspiration  of  bladder,  1250,  1266 

of  chronic  abscess,  187 

6f  cysts  of  kidney,  1213 

of  empyema,  923 

of  hydatid  cyst,  1066 

of  joints,  632,  661 

of  liver  abscess,  1063 

of  pericardium,  923 

of  pneumothorax,  919 

of  tuberculous  abscess,  187 

pneumonia,  85 
Asthenic  fever,  38,  269 
Asthma,  eosinophilia  in,  64 
Astragalus,  dislocation  of,  625 

excision  of,  683,  651,  463,  554,  575, 
626, 638 

fracture  of,  554 

in  talipes,  459,  460 

tuberculous  disease  of,  574,  575,  65 J 
Atheroma,  304,  308,  112,  114 
Atheromatous  abscess,  305 

ulcer,  305 
Atlas,  dislocation  of,  691 

and  axis,  tuberculous  disease  of,|7o6, 
712 
Atony  of  bladder,  1242,  1248,  1259 

of  stomach,  990,  998 
Atrophic  pharyngitis,  863 

rhinitis,  820 

scirrhus,  952,  223 
Atrophy  of  bone,  473,  529,  602 

of  breast,  938 

of  kidney,  1187,  1193 

of  muscle,  372,  696,  635,  661 

of  skull,  726 

of    testis,     1298,    1294,    844,    1099, 
1277, 1278, 1279, 1280, 1284 
Attenuation  of  virulence,  11 
Auditory  nerve,  injury  of,  386 
Auricles,  accessory,  875 

of  heart,  wounds  of,  927 
Autogenous  vaccine,  26 
Auto-infection,  7,  72,  633 
Auto-intoxication  in  osteo-arthritis,  653 
Autoplasty,  727 
Avenoliths,  1019 
Avulsion  of  scalp,  722 
Axillary  abscess,  364 

aneurism,  325 

artery,  ligature  of,  333 

cellulitis,  87 

Baccelli's  treatment  of  tetanus,  138 
Bacillary  cystitis,  1219 
Bacilli,  3 

acid-fast,  8 

alcohol-fast,  8 

asporogenous,  2 

culture  media  for,  8 

sporogenous,  2 
Bacilluria,  1186,  1198 

vaccine  treatment  for,  1223 
Bacillus  aerogenes  capsulatus,  122,  79 

anthracis,  140,  3,  8,  12 

coli  communis,  70.  4,  8,  93,  144,  '563, 

.     968,    973,    979.    981.   1046,   1113, 

1149.  1186,  1196,  1219,  1223, 1256 

influenzae,  8 

86 


1362 


A  MANUAL  OF  SURGERY 


Bacillus  leprae,  189,  8,  9 
mallei,  188,  8 

cedematis  maligni,  122,  3,  79,  80,  93 
of  diphtheria,  133,  8,  38 
of  soft  sore,  149,  8 
pyocyaneus,  71,  5,  8,  93 
smegmatis,  8 
tetani,  134,  .3,  8,  19 
tuberculosis,  176,  8,  10,  973,  1186 
typhosus,  70,  639,  3,  8,  21,  96,  568, 
1070 
Back-door  splint,  Gauvain's,  714 
Back-knee,  455 
Bacteria  (Chapter  I.),  i 
classification  of,  3 
conditions  of  life  of,  4 
cultures  of,  8 
distribution  of,  6 
effect  of  light  on,  5 
enzymes  of,  5 
flagella  of,  2,  3 
Gram-negative,  8 
Gram-positive,  8 
hanging-drop  preparation  of,  7 
in  blood,  66 

inoculation  of  animals  with,  8 
latent,  72 

methods  of  observation,  7 
of  reproduction,  2 
fission,  2 

spore-formation,  2 
pathogenic,  4 
pyogenic,  68 
staining  of,  7 
structure  of,  i 
toxins,  5 
vacuoles  in,  i 
virulence  of,  11 
Bacterial  inflammation,  34 
Bacteriological  examination  of  pus,  7 

of  urine,  1186 
Bacteriology  (Chapter  I.),  1-28 
Bacteriolysins,  21 
Bag-truss,  1107 
Baker's  cysts,  633,  232,  422 
Balanitis,  1272,  1270,  146,  150,  157 
Balano-posthitis,  1272 
'  Ballooning  '  of  bowel,  1024,  1165,  1169 
Ball's  operation  for  pruritus  ani,  1155 
Bands,  peritoneal,  1128,  1126 
Bank's    operation  for    inguinal    hernia. 

1 100 
Banti's  disease,  1083 
Barbadoes  leg,  361 
Bardenheuer's  modification  of  Kraske's 

operation,  11 72 
Barker's  operation  for  fractured  patella. 
545 
solution  for  local  anesthesia,  1343 
Barlow's  disease,  585 
Barrow,    Boyce,    operation    for    ectopia 

vesicae,  12 17  I 

Bartholin's  gland,  cyst  of,  1300  I 

Basal  meningitis,  822 
Base  of  skull,  fracture  of,  731,  748 
Basedow's  disease  (exophthalmic  goitre)     I 
896  '    j 

Basilar  artery,  aneurism  of,  323 


Bassini's  operation  for  inguinal  hernia, 

1098 
Baths,  electric,  53 
hot,  48 
hot-air,  49 

mercurial  vapour,  168 
radiant-heat,  49 
Russian,  48 
sun, 51 
Turkish,  48 
use  of,  in  cellulitis,  87 
use  of,  in  inflammation,  41,  48,  49 
Bavarian  splint,  483 
Bazin's  disease,  107 
Beatson's  operation  (oophorectomy)  for 

cancer  of  breast,  958 
Bedsores,  120,  488,  713 

in  spinal  injuries,  690 
Bee-stings,  250 
Bellocq's  sound,  830 
Bell's  palsy,  384 

'  Belly-ache  '  in  spinal  caries,  36,  707 
Benign  tumours,  197 
Bennett's  fracture  of  the  thumb,  525 
Berger's  amputation  of  upper  extremity, 

1332,  595 
Bezold's  perforation  of  mastoid,  880 
Biceps  cruris,  tenotomy  of,  425 
Biceps  cubiti,  injury  of,  416 
Bier's  treatment  by  induced  hyperaemia, 
41,  45,  79.  185,  253,  254,  492, 
560,  571,  646 
of  tuberculous  joints,  646 
of  un-united  fractures,  492 
Bigelow  on  dislocation  of  hip-joint,  616 
Bigelow's  method  of  reducing  dislocated 

hip-joint,  618 
Bilharzia  hsematobia,  1148,  1182 
Biliary  colic,  1073,  1051 
fistula,  972,  1075,  1080 
passages,  affections  of,  1067-1078 
gall-stones   impacted    in,   1073, 

1075 
treatment  of,  1074 
tumours  of,  1077 
Bilious    vomiting    after    gastro-entero- 

stomy,  ion 
Billington's  operation  for  moveable  kid- 
ney, iigi 
Bilocular  hydrocele,  1288,  1300 
Biniodide  of  mercury,  272 
Birth-paralysis,  388 

Bismuth  radiography  of  intestine,  1014, 
1028 
of  stomach,  989 
of  oesophagus,  866 
subnitrate    in    treatment  of  tuber- 
culous sinus,  187 
Bites,  snake,  251 
Bivalve,  tracheotomv-tube,  912 
Bladder,     affections   of   (Chapter    XL.), 
1215-1242 
atony  of,  1242,  1248,  1259 
cancer  of,  1227 
congenital  affections  of,  1216 
cystitis,  1219,  1221,  690 
distension,  signs  of,  1215 
extroversion  of,  12 16 


INDEX 


1363 


Bladder,  foreign  bodies  in,  1210 

functional  affections  of,  1239-1242 
hypertrophy  of,  1220,  1247,  1258 
in  paraplegia,  690,  696,  698 
in  sac  of  hernia,  1088 
methods  of  examining.  12 15 
papilloma  (villous  tumour)  of,  1225 
rupture  of,  12 17 
sarcoma  of,  1227 
simple  ulcer  of,  1225 
sounding,  the  method  of,  1232,  1215 
stone  in,  1230-1239,  1088,  1270 
tubercle  of,  1224 
tumours  of,  1225 
Blanket-suture,  239 
Blastomycetes,  10 
Blastomycetic  dermatitis,  10 
Blind  external  fistula,  1152 

internal  fistula,  1152 
Blisters,  45,  104 

Blood,    examination   of,    in    health    and 
disease  (Chapter  IV.),  58-67 
extravasation  of,  282 
in  septicaemia,  93 
in  suppuration,  67 
Blood-clot,  healing  by  organization  of, 

261, 287 
Blood  conditions  in  various  diseases,  66, 

67,  64 
Blood-counts,  differential,  59 
methods  of,  58,  59 
normal,  66 

in  acute  suppuration,  62 
in  anffimia  after  haemorrhage,  66 
in  appendicitis,  62,  1049 
in  chlorosis,  65 
in  chronic  suppuration,  63 
in  gastric  cancer,  1000 
in  Graves's  disease,  896 
in  infective  diseases,  63,  64 
in  lymphadenoma,  65,  369 
in    lymphatic    leucocythaemia, 

65.  67,  369 
in  malignant  cachexia,  67 
in  peritonitis,  63 
in  pernicious  ansemia,  64 
in  splenic  leucocythasmia,  65,  67 
in  tuberculosis,  64,  67 
Blood-cultures.  66 
Blood-cysts,  232,  887 
Blood-letting,  351,  41 
Blood-pressure  in  haemorrhage,  283 

test  for,  in  urine,  1183 
Boas-Oppler  bacillus,  990 
Bobbins,  decalcified  bone,  1038 
Boils,  399,  69,  112,  252,  878 
Bone,  affections  of  (Chanter  XXI.).  555- 
598 
atrophy  of,  473 
bending  of,  472 
carcinoma  of,  596,  473 
caries  of,  557 
cyst  of,  597 
expansion  of,  573,  590 
grafting,  597,  492,  591,  814,  816 
growth  of,  555 
hydatid  cysts  of,  597 
hypertrophy  of,  588 


Bone,  inflammation  of,  555-581 
injuries  of,  472-554 
necrosis  of,  556,  559,  562,  568,  569, 

571. 579 
sarcoma  of,  592,  473,  481,  588 
syphilis  of,  578-581,  557,  558.  569 
tubercle  of,  570,  558,  567,  571 
tumours  of,  590-598,  570 
Bones,  effects  of  rickets  on,  582,  583,  584 
Boric  (boracic)  acid,  272 
Bougies,  oesophageal,  866 
rectal,  1166 
urethral,  1263 
Bowel.     See  Intestine 
Bow-leg,  455,  456 
Bowles's  method  of  artificial  respiration, 

930 
/3-oxybutyric  acid  in  diabetes,  1181 
Brace,  Taylor's,  716 
Brachial  aneurism,  325 

artery,  compression  of,  292 

ligature  of,  334 
birth  palsy,  388 
plexus,  injury  of,  494,  387 
operations  on,  388 
pressure  on,  435 
Brain,  abscess  of,  769,  742,  748,  758,  883 
[   Brain    and    membranes,    affections    of 
j  (Chapter  XXVII. ),  744-782 

I  embolus  in,  345 

I  injury,  effects  of,  756 

I  laceration  of,  755 

softening,  yellow,  of,  756 
[  tumours  of,  775 

wounds  of,  755,  759 
'  See  also  Cerebral,  Cerebellar, 

cussion  and  Compression 
Branchial  carcinoma,  885 
clefts,  affections  of,  884 
cysts,  885 
fistula,  884 
Brasdor's  operation    for  aneurism, 

323 
Braun-Lossen's  operation  on  fifth  nerve, 

382 
Brawny  arm  in  cancer  of  breast,  951 
Breast,  diseases  of  (Chapter  XXXIV.), 
933-958 
abscess  of,  acute,  935 
areolar,  935 
chronic,  939 
adeno-carcinoma,  953 
adeno-fibroma,  943 
adenoma,  943,  953 
amputation  of,  955,  958 
cancer,  947 

acute,  952 

diagnosis  of,  953,  939,  941 

duct,  952 

en  ciiirasse,  951,  953,  958 

operations  for,  955 

scirrhus,  948 

atrophic,  952 
congenital  malformations,  933 
cysto-adenoma,  945,  954 
cysts,  940,  938 
diffuse  hypertrophy  of,  933 
duct  papilloma,  946 


Con- 


317. 


15^4 


A   MANUAL  OF  SURGRRY 


Breast,  fibro-adenoma.  943;  944        '      '  ; 

mastitis,  acute.  936  .  j 

chronic  lobar,  937  1 

chronic     lobular     (interstitial),  j 

(,37  ,;.:.-■  I 

nipples,  affections  of,  934 

sarcoma.  946,  954 

syphilitic  affections  of,  935,  940 

tuberculous  disease  of,  939 
Bridled  stricture  of  urethra,  1257  j 

Broad  ligament,  cysts  of,  1317, 1319. 1323    ; 
Broca's  convolution,  injury  of,  756,  776 
Brodie's  abscess,  563 
Bronchiectasis,  operation  for,  926 
Bronchocele.  890.     See  Goitre 
Bronchoscope,  Killian's,  900,  866,  13 
Bronchus,  foreign  bodies  in,  902,  910 
Brood  capsules,  233 

Brophy's  operation  for  cleft  palate,  852      I 
Brow-ague,  381  '    ; 

Brownian  movements.  2  : 

Bruise,  236,  237  ; 

Bryant's  test  for  dislocated  shoulder.  608    j 
line,  533 

treatment  of  fractured  femur,  541 
Bubo.  150,  146 
Bubonocele,  1089 
Buck's  method  of  extension,  535 
Bulbous  nerve-ends,  ^72.  1328 
Buller's  shield,  i47 

Bullet  wounds.     See  Gunshot  wounds 
Bullets  in  abdomen,  249 

in  brain,  760,  249 

in  limbs,  249 
Bunion,  469 

Burghard,  dilatation  of  congenital  hyper- 
trophy of  pylorus,  1003 
Burns,  125,  126,  112 

from  X  rays,  57 
Burrowing  epithelioma,  799,  803 
Bursas,  adventitious.  427,  232 

diseases  of,  427-431 

of  special,  429.  631 
Bursal  cysts  in  neck,  887 
Bursitis,  427.  428 
Butcher's  wart,  251 
Buttonhole  stitch,  239 

Cachexia  in  malignant  disease,  197.  64.  67 

strumipriva,  898 
Caical  colostomy,  1031,  1021 
Caecocele,  1087 

Cscum,  cancer  of,  1026,  1052,  ro39 
in  hernia,  1087 
thread -worms  in.  1148 
tuberculous  disease  of,  1022,  1052 
Calcaneum.     See  Os  calcis 
Calcar  femorale  (Merkel),  329 
Calcareous  degeneration  of  arteries,  307. 
114 
of  fibroids,  1304 
Calcification  of  arteries,  307,  114 

of  fibro-myomata,  1304 
Calcium  lactate  in  treatment  of  haemo- 
philia, 298 
in    treatment    of    haemorrhage. 
288,  lOII  _ 

Calculi,  cystine,  1230  ''•  " 


Calculi,  oxalate  of  lime,  1230,  1204 

phosphatic,  1230,  1204,  1088,  1218, 

1219 
urate  of  ammonium,  1230,  1204 
uric  acid,  1230,  1204 
xanthine.  1231 
Calculous  anuria,  1207 
Calculus,  biliary.     See  Gall-stones 
fusible,  1230 
intestinal.  1019 
mulberry,  1230 
nasal.  818 
pancreatic,  1079 
prostatic,  1244 
renal,  1203 
salivary,  845 
ureteral,  1206 
urethral,  1255 
vesical,  1 230-1 239 

diagnosis,  of  1232 
signs  of,  1232 
structure  of,  1231 
treatment  of,  1234-1239 
varieties  of.  1230 
in  boys.  1238 
in  females.  1238 
Caliper,  walking,  for  fractures,  534 
Callaway's  test  for  dislocated  shoulder, 

608 
Callosity.  401,  403,  470,  471 
Callus,  499 

compression  of  nerves  by,  488 
Calmette's  antivenene,  251 

reaction,  178 
Calvarium,  syphilis  of,  578 
Canal  of  Nuck,  231 

hernia  into,  1084.  1300 
hvdrocele  of,  1300 
Cancellous  osteomata,  208 
Cancer,  acute,  of  breast,  952 
Cancer  en  cuirasse,  951,  958 
Cancer,  curability  of,  226 
general  facts  of,  218 
of  antrum,  803,  799 
of  anus,  1 167 
of  appendix.  1059 
of  bile  ducts,  1077 
of  bladder,  1227  ' 

of  bone,  596,  473 
of  brain,  775 
of  branchial  clefts,  885 
of  breast,  947-958 
of  cajcum,  1026,  1052 
of  cranium,  730 
of  Fallopian  tubes.  131 7 
of  gall-bladder,  1077,  1072 
of  gum,  799 
'  of  intestine,  1024,  1133 

;  of  jaw, 799, 803.  809 

I  of  kidney,  121 1 

of  larynx. 907 
of  lip.  792 
of  liver.  1066,  1067 
of  nasal  fossje.  826 
of  oesophagus.  869 
of  omentum.  987 
I  of  ovary,  1323 

of  palate,  858 


INDEX 


1365 


Cancer  of  pancreas,  108 1 

of  parotid,  847 

of  jienis,  1273 

of  pharynx,  864 

of  prostate,  1252 

of  rectum,  1167 

of  scrotum,  1298 

of  sebaceous  glands,  411 

of  spine,  719,  44^ 

of  spleen,  1083 

of  stomach,  998,  1007,  t>4 

of  submaxillary  gland,  849 

of  testis,  1287 

of  thyroid,  897 

of  tongue,  838 

of  tonsil,  862 

of  umbilicus,  972,  1078 

of  urethra,  1256 

of  uterus,  1308 

parasites,  195 

treatment  of,  225,, 

See  also  Carcinoma 
Caacrum  oris,  123,  93-  "2,  812,  832 
Capillary  haemorrhage,  282 

lymphangioma,  358 

nasvus,  353 
Carbolic  acid,  271  . 

danger  of,  in  albuminuria,  04, 

1179 
gangrene  from,  117 
in  treatment  of  tetanus,  138 
Carboluria,  272 
Carbonic  acid  snow,  354 
Carbuncle,  400,  112,  69 
Carbuncular  boil,  399 
Carcinoma,  218 

acute,  223,  952 

branchial,  885 

colloid,  225,  218,  987,  1000,  1024 

columnar,  224,  803,  972,  998'  1024, 
1167 

duct,  952,  946 

encephaloid,  223 

epithelioma,  220 

glandular,  224 

malignant  papilloma,  220 

radium,  use  of,  in,  56,  226 

rodent  ulcer,  411 

scirrhous,  223,  948.  998,  1252 

spheroidal-celled,  222,  948 

treatment  of,  225 

X  rays,  use  of,  in,  56 
Carden's  supracondyloid  amputation  of 

thigh,  1338 
Cardiac  failure  under  anaesthetics,  1353. 

1343.  1346 
Cardiolysis,  928 
Caries,  557,  556,  571.  579 

fungosa,  558 

necrotica,  558,  568,  635 

of  palate,  858 

of  spine,  704 

of  temporal  bone,  878 

sicca,  557>  648 

suppurative,  557 

syphilitic,  578 

tuberculous,  557.  57i 
Carless's  operation  of  gastrostomy,  1006 


Carless's  operation    for  inguinal    hornia, 

Carotid    artery,    abnormal   arrangement 
of  the  branches  of,  323 
aneurism  of,  322,  323 
compression  of,  292 
hemorrhage  from,  290 
ligature  of,  33°,  320,  321-  32  3 
wounds  of,  775 
Carpal  bones,  dislocation  of,  014 
Carpus,  fractures  of,  524 
Carr's  splint,  522 

Carrying  angle,  510  .   .   .    ,■ 

Cartilage,  affections  of,  in  ]Oint  disease, 
635,  641,  652,  654.  662 
in  repair  of  fractures,  480 
semilunar,  displacement  of,  ()22,  004 
Cartilages,   laryngeal,   necrosis   ot,  905, 

906,     907  Jo 

Cartilaginous  tumours.     See  Chondroma 
Caruncle,  urethral,  1256 
Caseation,  180,  163,  365 
Castration,  operation  of,  i29() 
for  haematocele,  1278 
for  hernia  testis,  1285 
for  tuberculosis  of  testis,  1283 
for  tumours  of  testis,  1286,  1287 
for  undescended  testis,  1276 
Cataphoresis,  54 

Catarrhal  appendicitis,  1043,  1040 
cholangitis,  1069 
inflammation,  38 
jaundice,  1069 
stomatitis,  832 
Catgut,  277.  290 
Catheter-a-boule,  1260 
Catheter  bicoude,  1249 
coude,  1249 
Eustachian,  875 
fever,  1250,  1261 
Catheterism,  asepsis  in,  1259,  1249.  1219, 
690,  718 
dangers  of,  1261 
difficulties  in,  1260 
of  ureters,  1176 
.   lor  atony  of  bladder,  1242 
for  enlarged  prostate,  1249 
for  rupture  of  urethra,  1255 
for  stricture  of  urethra.  1263 
in  spinal  injuries,  690 
shock  in,  1261 
Catheterization  of  ureters,  1176 
Catheters,  method  of  introducing,  12O0 
sterilization  of,  1259 
varieties  of,  1259 
Caustics,  gangrene  from,  121 
Cauterization  for  hjemorrhage,  2»» 
Cautery  for  haemorrhoids,  11 60 
uses  of,  45.  50,  288,  694 
varieties  of*  50  o      oq 

Cavernous  lymphangioma,  350,  9»» 
naevus,  354 

sinus,  injury  of,  760,  734 
thrombosis  of,  769.  742,  822 
Cell-nests,  222,  412 
]    Cellular  theory  of  immunity.  17 
[    Cellulitis,  85-89,  69,  252 
'  bacteriology  of,  85 


1366 


A   MANUAL  OF  SURGERY 


Cellulitis,   gangrenous,    after    extravasa- 
tion of  urine,  1269 
of  axilla,  87 
of  neck,  88. 913 
of  orbit.  88,  379 
of  scalp,  88,  722 
of  scrotum,  1297 
pelvic,    89,    85,    1023.    1 165.    i2i8, 

1220.    1224 

peri-rectal,  1151 

submaxillary.  89 

treatment  of,  86 
Cellulo-cutaneous  erysipelas.  131,  129 
Cellulo-humoral  theory  of  immuaitv.  19 
Central  dislocation  of  femur.  52S 

necrosis,  568 

sarcoma  of  bone,  592 
Cephal-ha?matoma.  723.  237 
Cephal-hydrocele,  traumatic,  731 
Cephalo-tetanus,  136 
Cerebello-pontine  angle,  tumour  of,  776 
Cerebellum,  abscess  of,  772,  773,  883 

tumour  of,  776 

wounds  of.  758 
Cerebral  abscess,  769.  742,  748.  758,  883 

compression.  752 

concussion,  749,  267,  747.  756 

diplegia,  operation  for.  398 

haemorrhage,  763 

irritation,  751 

laceration,  755 

tumours,  775,  749 

operations  on.  yyy 
Cerebro-spinal  fluid,  escape  in  fractures 
of  base  of  skull,  734 
in  various  states,  characters  of, 
748 
Cerebrum,  wounds  of.  755-760 
Cerumen  in  ear,  875 
Cervical  caries,  706,  709,  712,  865 
Cervical  fibroid  of  uterus.  1304 

fistula,  median,  886 

glands,  tuberculosis  of,  366,  828 

plexus,  injury  to,  387 

rib,  435.  324,'  117 

sympathetic  ganglia,  excision  of.  395 

yertebra\  dislocation  of.  691 
Cervico-facial  actinomycosis,  192 
Cervix  femoris,  fracture  of.  529.  330 
Chance's  spinal  splint.  441,  434 
Chancre,  digital.  156 

extragenital,  154.  156 

hard.  155,  157 

Hunterian,  155 

of  anus,  1 164 

of  lip,  791 

of  nipple,  935 

of  tongue,  837 

of  tonsil,  861 

of  urethra.  156,  1257 

relapsing,  158 

satellite,  150 

soft,   149 

syphilitic,  155 

treatment  of,  166 
Chancroid.     See  Soft  chancre 
Chapped  lips,  791 
Charcot's  disease,  659.  456,  633 


Chassaignac's  tubercle,  292 

Chauffeur's  fracture,  518 

Cheiragra,  639 

Chemosis,  147 

Chemotaxis,  18 

Chest,  deformity  of,  in  scoliosis,  438 

Cheyne-Stokes  respiration,  752.  758,  772 

Chigoe  (jigger),  250 

Chilblains,  403 

Chimney-sweep's  cancer,  129H 

Chinosol,  273 

Chloroform,  delayed  poisoning  l)y,  1346 

method  of  administering.  1346 

for  reduction  of  dislocations.  603 
Chlorosis.  65 
Cholangitis,  catarrhal,  1069 

suppurative,  1061,  1069 
Cholecystectomy,  1074,  1077,  1078 
Cholecystendysis,  1077,  1075 
Cholecystenterostomy,  1077,  1069,  1078 
Cholecystitis,  1070 
Cholecystostomy.  1077,  1070,  1075 

for  pancreatitis,  1080 
Choledocho-duodenostomy,  1076 
Choledochotomy.  1075 
Cholelithiasis,  1071-1077 
Cholesteatoma.  S80 
Cholesterin.  1071,  182,  305.  409,  885 
Chondro-arthritis  syphilitic,  652 
Chondrodystrophia  foetalis,  586 
Chondroma,    207,    719,    803,    808.    917, 

1285 
Chopart's  amputation,  1334 

modifications  of,  1334 
Chordee,  147 

Chorion -epithelioma,  131 1 
Chronic  abscess.     See  Abscess 

cholangitis,  1069 

cystitis,  1221 

epididymitis,  1280 

gonorrhoea.  143 

inflammation,  43-46.  33 

intestinal  obstruction.  1133-1136 

intussusception,  1139 

ischio-rectal  abscess,  11 50 

mastitis,  937 

meningitis,  768 

neuritis,  377 

orchitis,  1280 

osteo-arthritis,  655 

osteo-periostitis,  569 

otorrhcea.  877,  770 

pancreatitis,  1080 

peritonitis,  980 

pharyngitis,  863 

prostatitis,  1243 

pyaemia,  97,  98 

rhinitis,  819 

superficial  glossitis.  835 

synovitis,  631,  428 

tetanus,  136 

ulcer  of  stomach,  993 
Chylous  ascites.  985 

hydrocele,  1292,  359 
Chyluria,  1183 
Cicatrices.     See  Scar 
Cicatrix  after  amputation,  1327 

tuberculous,  366 


IXDEX 


1367 


Cinder-sifting   ino\ciuciits   of   mo\-eable 

kidney, 1188 
Circular  amputation,  1324 

modified.  1325 
Circumcision,  127 1,  1097 
Circumtiex  nerve,  injury  of,  388,  505 
Circumscribed  aneurism,  311 
Cirsoid  aneurism,  724,  355 
Civiale's  urethrotome,  1264 
Clamp  and  cautery  operation  for  hajmor- 

rhoids,  1160 
Clamps,  intestinal.  1137 
Clavicle,  dislocation  of,  606 

fracture  of,  499 
Clavus,  401 
Claw-foot,  468 

-hands  in  leprosy,  190 

in  ulnar  paralysis,  393 
Cleft  palate,  849-857 

operations  for,  852 

tongue,  833 
Clefts,  branchial,  affections  of,  884 
Clicking  jaw,  813 
Cline's  splint,  549,  553 
Cloacae,  559,  564 
Closure  of  colostomy,  1036 

of  jaw,  causes  of,  812 

of  vessels,  286 
Cloudy  swelling,  37 
Clover's  inhaler  for  administering  ether, 

1348 
Club-foot,  457 

-hand,  443 
Coagulation  necrosis,  33 

of  blood,  341 

in  haemorrhage,  286 
Coagulum,  internal  and  external,  286 
Cocaine,  uses  of,  as  an  anesthetic,  1342, 

817,  866,  900,  913 
Cocci,  3 

CoccydjTiia,  529 
Coccygeal  tumours,  763 
Coccyx,  excision  of,  529 

fracture  of,  528 
Cochlea,  disease  of,  879 
Cock's    operation    of    perineal    section, 
1266 

peculiar  tmnour,  410 
Cold  abscess,  63.     See  also  Tuberculous 

abscess 
Cold,  effects  of,  on  tissues,  124,  14 

in  treatment  of  hemorrhage,  288 
of  inflammation,  40 
Colectomj',  1038,  1030 
Coley's  fluid,  203 
Colic,  appendicular,  1050 

biliary,  1073,  1051 

gall-bladder,  1067 

intestinal,  1025,  1125 

intussusception,  1137 

renal,  1192,  1202,  1205,  1051 
Colitis,  1020,  1041,  1051,  1030 
Collagen,  257 
Collapse,  264 

in  intestinal  obstruction,  1141 

in  intussusception,  1138 

in  peritonitis,  975 

in  strangulated  hernia,  11 15 


Collargal  for  X-ray  examination  of  renal 

pelvis,  1 187 
Collateral  circulation,  291 
CoUes's  fascia,  1268 
fracture,  520 
law.  171 
Colliquative  necrosis,  33 
Colloid  cancer.  225,  218,  987,  1000.  1024 
Colon,  cancer  of,  1024 

idiopathic  dilatation  of,  1027 
mobilization  of,  1026,  1034 
transverse,  colostomy  of.  1032 
Colopexy,  1163 

Colostomy  (colotomy),  1031,  1133,  1170, 
1174 
comparison  of  methods,  1035 
for  cancer    of    rectum,   11 70,   11 73, 

1174 
iliac,  1034,  1133,  1170,  1174 
lumbar,  1033 
preliminary,  1170,  1171 
spur  in,  1032 
uses  of,  1033 
Colour-index,  58 
Columnar  carcinoma,  224 
of  bladder,  1227 
of  intestine,  1024 
of  rectum,  1167 
of  stomach,  998 
of  umbilicus,  972 
of  upper  jaw,  803 
of  uterus,  1308 
Coma,  diabetic,  1181,  118 
diagnosis  of,  753 
in  cerebral  abscess,  772 
in  cerebral  tumour,  777 
in  head  injuries,  752,  753,  761,  763- 

765,  766 
in  renal  disease,  1207,  754 
Comminuted  fracture,  475,  480,  489 
Common  bile-duct,  anatomy  of,  1067 
stone  impacted  in,  1073,  1075 
carotid  artery,  aneurism  of,  322 
compression  of,  292 
ligature  of,  329,  320,  323,  763 
iliac  artery,  ligature  of,  336,  326 
Compensatory  talipes,  458 
Complement,  22,  32 
Complete  fistula,  1151 

fracture,  475 
Complicated  fracture,  487 
dislocations,  601,  614 
Composite  odontome,  215 
Compound  dislocations,  601,  604 

fractures,  489,  474,  732,  74°,  759 
amputations  for,  244 
septic  osteo-myelitis  after,  567 
palmar  ganglion,  423 
Compression,  cerebral,  752,  738,  761,  777 
digital,  of  arteries  for  cure  of  aneur- 
ism, 325,  288,  289 
to    control    hemorrhage,    292, 
1327 
fractures,  473,  554.  686 
of  nerves,  371 
theory  of  fracture  of  base  of  skull, 

731 
Concentric  hypertrophy  of  skull,  728 


1368 


A   MANUAL  OF  SURGERY 


Concussion  of  brain,  749,  267,  733,  756, 
761 
of  spine,  692 
Condyles,  fracture  of  femur,  541 
of  humerus,  512 
of  jaw,  495 
Condylomata,  160,  217 
of  anus,  1 164,  1 1 59 
of  tongue,  837 
Congenital  abnormalities  of  testis,  1275 
of  tongue,  833 
absence  of  patella,  451 
of  radius,  443 
of  tibia,  457 
adenoma,  704 
affections  of  bladder,  1216 
of  cranium,  725 
of  kidney,  1187 
of  knee,  451 
atrophy  of  bone,  726 
cysts,  229,  885 
deformities  of  fingers,  444 
dislocation  of  hip,  447 

of  patella,  451 
dislocations,  600 
elevation  of  shoulder,  442 
epilepsy,  779 
fissures  of  lips,  783-790 
fractures,  474 
hernia,  1084,  1090,  iioo,  1106,  mo, 

1216, 1276, 1300 
hydrocele,  1287,  1291 
hydronephrosis,  1193 
hypertrophy  of  pylorus,  1003 
induration  of  muscle,  433,  885 
malformation  of  breast,  933 
of  foot,  457 
of  intestine,  1014 
of  oesophagus,  866 
of  rectum,  1145,  1033 
of  urethra,  1253 
phimosis,  1270 
sacral  tumour,  703 
sarcoma  of  kidney,  12 11 
stenosis  of  duodenum,  1014 
syphilis,  171,  791,  1082 
talipes,  457,  458,  461 
torticollis,  432 
umbilical  fistula.',  972 
hernia,  1106 
Congestive  stricture  of  urethra,  1256,  143 
Conical  stump,  1328 
Conjugate  deviation  of  eyes,  758 
Conjunctivitis,  gonorrhceal,  147 
Connective  tissue  tumours,  199-215 
Constipation  as  a  cause  of  hernia,  1085 
in  appendicitis,  1042,  1047 
in  cerebral  tumours,  776 
in  cholecystitis,  1070 
in  faecal  impaction,  1134 
in  fibroids  of  uterus,  1304 
in  intestinal  obstruction,  1124,  1142 
in  obstructed  hernia,  iiii 
in  peritonitis,  975,  1131 
in  stricture  of  rectum,  1165,  1168 
in  volvulus,  1129 
Continuous    dilatation    of    stricture    of 
urethra,  1263 


Contraction,  Dupuytren's,  446,  445 

of  fingers,  445 

of  palmar  fascia,  446 

of  scars,  262 

of  sterno-mastoid,  432 

Volkmann's  isch;cmic,  489 
Contrecoup  laceration  of  brain,  755 
Contused  wounds,  242 
Contusions,  236 

of  abdominal  walls,  968 

of  arteries,  291 

of  bone,  472 

of  brachial  plexus,  387 

of  cranium,  730 

of  hip,  533 

of  intestine,  1014 

of  lung,  917 

of  kidney,  1191 

of  muscles,  414 

of  nerves,  371 

of  scalp,  722 

of  testis,  1277 
Cooper-Hewitt  lamp.  51 
Cooper's,  Astley,  operation  for  ligaturing, 

external  iliac  artery,  336 
Copaiba  rash,  145 
Coprostasis,  1124 
Coracoid  process  of  scapula,  fracture  of, 

502 
Corded  veins,  188.     See  Glanders 
Corns,  401 

in  hammer-toe,  470 

in  perforating  ulcer,  402 
Corona  radiata,  injury  of,  758 

Veneris,  159 
Coronoid   process   of  jaw,    fracture   of, 

495 

of  ulna,  fracture  of,  517 
Corpus  luteum  cysts,  1318,  1311 
Corradi's  method  of  treating  aneurisms, 

318 
Corrosive  sublimate,  272 
Corrosives,  gangrene  from,  121 
Costal  cartilage,  separation  of,  499 
Counter-irritation,  45 
Courvoisier's  law,  1074 
Coverings  of  femoral  hernia,  1103 

of  inguinal  hernia,  1089,  1092 
Cowper's  glands,  inflammation  of,   147, 

1267 
Coxa  valga,  451 
Coxa  vara,  450 
Coxalgia,  668 
Coxitis,  tuberculous,  668 
Cracked  lips,  791 

nipples,  934 

tongue,  836 
Cranial  complications  of  otorrhcea,  878 

lesions  of  seventh  nerve,  383 
Cranial  nerves,  affections  of,  379-387 
Craniectomy,  linear,  728, 
Cranio-cerebral  topography,  744 
Craniotabes,  581,  726 
Cranium,  affections  of,  725-743 

injuries  of,  730 

methods  of  opening,  746.     See  also 
under  Skull 
Crede's  preventive  treatment.  148 


INDEX 


1369 


Creeping  epithelioma,  799 
Crepitus,  477 

in  affections  of  joints,  630,  632,  656 
Cretinism,  890,  898 
Cricotomy,  910 
Crile,  pathology  of  shock,  264,  266 

treatment  of  shock,  267,  1354 
Croft's  splint,  483 

Cross-bow  incision  (Cushing's)  for  cere- 
bellar tumours,  778 
Crossed  paralysis,  758 
Croupous  inflammation,  38 
Crucial  ligaments,  rupture  of,  624 
Crural  canal,  1103 
Crus  cerebri,  wound  of,  758 
Crutch  palsy,  488,  389 
Cubitus  valgus,  510 

varus,  510,  514 
Cuboid,  tuberculosis  of,  575 
Cultural  methods  of  bacteriology,  8 
Cultures,  attenuation  of,  11 

from  blood,  66 

media  for,  8 
Cuneiform  osteotomy,  457,  667 
Cupping,  in  treatment  of  inflammation, 

39.  42. 
Curvature  of  legs.     See  Genu  varum 
Curvature  of  spine,  angular,  704,  441 

in  hip  disease,  442 

in  torticollis,  433 

lateral,  435 

rachitic,  435,  583 
Cushing's  suture,  967 
Cutaneous  appendages,  affections  of,  407 

gummata,  163 

leprosy,  189 

syphilides,  159 
Cut  throat,  887-890 
Cyclical  albuminuria,  11 79 
Cylindroma,  228 
Cystectomy,  1229 
Cystic  degeneration  of  fibroids,  1304 

disease  of  breast,  938 
of  kidney,  12 10 

duct,  anatomy  of,  1067 

impaction  of,  gall-stone  in,  1073, 
1075 

hygroma,  898,  899,  359,  231,  704 

sarcocele,  of  testis,  1285 
Cystine  calculus,  1230 
Cystitis,  acute,  1220 

urine  in,  12 19 

causes  of,  1219 

chronic,  1221 

in  prostatic  enlargement,  1247,  1248 

in  spinal  affections,  690,  697,  713 

in  stricture  of  urethra,  1258 
Cysto-adenoma  of  breast,  945,  954 

of  ovary,  1317 

of  thyroid,  893,  896 
Cysto-sarcoma  of  breast,  945 
Cystoscope,  12 15 

Cystoscopy     in     diagnosis     of     bladder 
disease,  1222,  1225,  1228 
of  tuberculous  kidney,  1202 
Cystotomy,  exploratory,  121 5 

perineal,  1223,  1237 

complications  of,  1224 


Cystotomy,    supra-pubic,    for    enlarged 
prostate,  1251 
for  tuberculous  disease  of  blad 

der,  1225 
for  tumours  of  the  bladder,  1229 
Cysts  (Chapter  IX.),  194-235 

arachnoid,  237,  232,  756.  763 

Baker's,  633,  232,  422 

blood,  232,  887,  988 

branchial,  885 

broad  ligament,  1317,  1319 

corpus  luteum,  1318,  1311 

degeneration,  235,  941 

dental,  797,  802 

dentigerous,  808,  802,  215,  230 

dermoid,  229,  232,  410,  704,  725,  815, 
838,  885,  886,  898,  941, 1213     . 

distension,  228,  231 

extravasation,  232 

exudation,  231 

foreign  bodies,  232 

hydatid,    233,    597.    719.    887,    926, 
941,  1065,  1212 

implantation,  232 

in  connection  with  teeth,  230,  215 

in  floor  of  mouth,  845,  838 

involution,  937,  940 

irritation,  941 

malignant,  885,  887,  839 

mucous,  792,  845 

of  bone,  597 

of  breast,  940,  938,  945,  953 

of  broad  ligament,  1319 

of  canal  of  Nuck,  231 

of  embryonic  origin,  229 

of  epididymis,  1290 

of  funicular  process,  231,  1291 

of  Gartner's  duct,  231 

of  jaw, 797, 808,  215,  230 

of  kidney,  12 12  ■ 

of  Kobelt's  tubes,  231,  1319.  1291 

of  labia,  1300 

of  lip,  792 

of  liver,  1065 

of  mamma,  940,  938,  945 

of  mesentery,  988 

of  neck,  887 

of  new  formation,  232 

of  ovary,  1317,  228,  1051 

of  pancreas,  1080,  989 

of  round  ligament,  231 

of  scalp,  725 

of  sebaceous  glands,  409,  725,  887 

of  spermatic  cord,  231,  1291 

of  spleen,  1083 

of  thyroid,  893,  898 

of  thyro-glossal  duct,  886,  83.8,  230 

of  tunical  vaginalis,  231 

of  Wolffian  body,  230,  1285,  1291, 

1319 
parasitic,  233 
paroophoritic,  1318,  230 
parovarian,  1319.  230,  1323 
retention,  232,  940 
sebaceous,  409,  725 
serous,   232,   887,  941,   1083,   1087. 

1213 
traumatic  dermoid,  232 


I370 


A   MANUAL  OF  SURGERY 


Cytolysins.  21,  22 
Czerny-Lembert  suture,  966 

Dactylitis,  tuberculous,  572 
Dangerous  area  of  scalp,  722 

region  of  neck,  296 
Dean's  operation  for  abscess  of  brain.  775 
Death,  signs  of,  in  tissues,  108 
Deciduoma  malignuin.  1311 
Decompression    operations    for    cerebral 

tumour.  778,  781.  739 
Decortication,  pulmonary.  925 

of     kidney     for     chronic     Bright's 
disease,  1195 
Deep  sensation,  373 
Definitive  callus.  479 
Deformities  (Chapter  XIX.).  432-471 

in  rickets,  582 

in  spine,  435-442,  707,  582 

of  hand. 445 

of  lower  extremity.  447 

of  nose,  814 

of  upper  extremity,  442 
Degeneration  cysts,  235,  941,  228 

in  arteries,  307 

in  muscles,  51,  372 

in  nerves,  Wallerian,  372 

in  sarcoma,  200 

reaction  of,  372 
Delirium,  traumatic.  269 

tremens,  270.  478 
Deltoid  bursa,  inflammation  of,  431.  627 

muscle,  paralysis  of,  389 
Demarcation,  line  of,  in  gangrene,  no 
Dental  cysts,  797.  802 

splints.  496 

ulcers  of  tongue,  837 
Dentigerous  cysts,  808,  802,  215,  230 
Depressed  fracture  of  skull,  735,  780.  473 

treatment  of.  739,  740 
Derangement  of  knee-joint,  internal,  622 
Dercum's  disease,  206 
Dermatitis  maligna,  934 

traumatic,  278 
Dermoid  cysts,  229,  232,  410 

acquired,  232 

of  breast,  941 

of  kidney, 1213 

of  neck, '886 

of  ovary,  228,  1319,  1051 

of  scalp,  725 

of  tongue,  838 

sacral.  704 

traumatic.  232 
Descending  pyelonephritis,  1196 
Descent,  incomplete,  of  testis,  1275 
Development  of  lips  and  palate,  785 
Diabetes,  1180,  loi,  400,  402,  662 

relation    to    pancreatic    affections, 
1080, 1181 

operations  in,  1181,  1345 
Diabetic  coma,  1181,  754 

gangrene,  112,  117,  1181 

spinal  analgesia  in,  118,  1345 
Diapedesis,  32 
Diaphragm,  congenital  defects  in,  11 10, 

1085 
Diaphragmatic  hernia,  11 10,  1085 


Diaphysitis,  acute,  560 
Diarrhoea  after  strangulated  hernia,  1 1 2 1 , 
1118 

in  appendicitis,  1047 

of  amyloid  disease,  84 

of  colitis.  1020 

of  constipation,  1124,  1022,  1025 
Diathermy,  49,  638 
Dietl's  crises,  1189,  1051 
Diffuse  aneurism,  treatment  of,  319 

arteiio-sclerosis,  303 

hydrocele  of  cord,  1292 

lipoma,  205 
Diffusion  of  aneurisms,  313 
Digital  arrest  of  hiemorrhage,  288,  927 

chancre,  156 

compression    of   arteries,    292,    288, 
289 
Dilatation,  acute,  of  stomach.  1004 

of  cardiac  orifice,  868,  871 

of  colon,  idiopathic,  1027 

of  oesophagus,  for  stricture.  871 

of  pylorus,  1003 

of  rectum,  1165 

of  stomach,   989,   996.    looi,    1003, 
1004, 1029 

of  stricture  of  urethra,  1263 

of  urethra  in  females,  1239,  1219 
Diphtheria,   133,  38,  63,  859,  904,  910, 

916 
Diphtheritic  antitoxin,  19,  27.  134.  641 

inflammation,  38 
Diplococci,  3 
Diplococcus  intracellularis,  764 

of  rheumatism,  638 

ureaj  liquefaciens,  1219 
Direct  inguinal  hernia,  1091.  1102 
Diseases  of  scars.  262 
Dislocation  of  humerus,  with  fracture  of 

surgical  neck,  507 
Dislocations  (Chapter  XXII.),  600-626 

accompanying    fracture,    487,    601, 
507-  527-  550. 614 

complete,  60  r 

complicated,  601,  614 

compound,  604,  601 

congenital,  600,  447 

of  spine,  691 

pathological,  600 

special,  604-626 

traumatic,  600 

treatment  of,  603 

unreduced,  602,  603 
Displacement  of  kidney,  11 88 

of  liver,  1059 

of  tendons,  414 

of  uterus,  1301 
Dissecting  aneurism.  311,  305 
Dissection  wounds.  252 
Dissemination  of  sarcoma,  199 
Distal  ligature  for  aneurisms,  317,  320, 

321,  323.  325 
Distended  bladder,  1215 
Distension  cysts,  228 
Distension  of  bladder  with  overflow,  1240 
Disunited  fracture,  493 
j    Diverticula  of  appendix,  1044 
I  of  oesophagus,  866 


INDEX 


r37» 


l^iverticulum  of  Meckel,  1014,  1128,  072 
Division  of  nerves,  effects  of.  372 
Dorsal  abscess  in  spinal  caries,  710.  717 

dislocation  of  hip,  617.  615 
Dorsalis  pedis  artery,  ligature  of.  340 
Drainage  in  abdominal  operations,  962, 
'■)77 

in  acute  inflammation.  41 

i>f  empyema.  923 

of  wounds.  241.  270 
Dressings  for  operations,  280 
Dribbling  of  urine  from  distension.  1241, 
1240.  1242.  1248,  1253 

from  paralysis,  1240.  696,  697.  712 
Drowning,  930 

Drugs  in  treatment  of  inflaniniation.  42 
Dry  gangrene.  109,  307 

heat,  uses  of,  48 
Duchenne's  ape-hand.  391 
Ducrey's  bacillus,  149 
Duct  cancer  of  breast.  952.  946 

papilloma  of  breast,  946,  941 
Dugas'  test  for  dislocated  shoulder.  607 
Duodeno-jejunal  fossa.  1129 
Duodenum,  dilatation  of.  1029 

mobilization  of,  1076 

perforation  of ,  1012,  1051,  126 

stenosis  of,  1013,  1014 

ulcer  of,  1012,  983,  126 
Dupuytren's  classification  of  burns,  125 

contraction,  446,  445 

fracture.  550 

splint,  552 
Dura  mater,  inflammation  of,  738.  764 
injuries  of.  738 
sarcoma  of,  730 

thickening  of,  causing  epilepsy, 
780 
Duret's  theory  of  concussion  of  brain,  749 
Dynamic  ileus,  11 26 
Dysentery,   21,   1022,   1041,   1062.   1063, 

1147.  1165 
Dyspeptic  ulcer  of  tongue,  837 
Dysphagia.  871 
Dyspnoea,  928 

Ear.  affections  of  (Chapter  XXXI.).  873- 
883 
examination  of,  &ji, 
middle,  affections  of,  876 
otitis  media,  876 

complications  of,  896.  878- 
883 
Eburnation  of  joint  cartilages,  655,  652 
Eccentric  hypertrophy  of  skull,  728 
Ecchondroses.  208,  663,  655,  662 
Ecchymosis  in  fracture  of  base  of  skull, 

733 
Echinococcus,  taenia.  233.  1065,  344 
Ecthyma,  161 
Ectocyst,  233,  1066 
Ectopia  testis,  1276 

vesicse,  1216.  1253 
Ectopic  gestation,  1314 
Ectrodactylism.  444 

Eczema    of    external    auditorv  meatus, 
878,  875 
of  nipple.  934,  947 


Eczema  of  scrotum.  1298 

of  umbilicus.  971 

varicose,  349,  103 
Eczematous  ulcer,  102,  105 
Edebohl's       operation      for      nephritis, 

1195 
Eflieurage,  46 
Effusion  in  peritonitis,  974 

into  joints,  627 

into  pericardium,  928 
Eggshell  crackling,   59c,   730,   742,   797, 

801,  802,  808 
Ehrlich-Hata's  salvarsan  ('  606  '),  i65 
Ehrlich's  side-chain  theory  of  immunity, 

20 
Elbow,  pulled,  614 
Elbow-joint,  acute  arthritis  of,  636 

amputation  through,  1331 

ankylosis  of,  665 

dislocation  of,  611 

effusion  into,  628 

excision  of,  680,  649,  667 

tuberculous  disease  of,  648 
Electric  baths,  53 
Electricity  for  atony  of  bladder,  1242 

for  divided  nerves,  376 

for  enteroptosis,  1028 

for  neuritis,  377 

uses  of,  in  surgery,  51-55 
Electrolysis,  53 

for  aneurism.  318.  320,  324 

for  angiomata,  354,  355,  792 

for  cirsoid  aneurism,  724 

for  hydatid  cyst,  1066 
Elephantiasis,  359,  357,  103,  131 

Graecorum  (leprosy).  189 

scroti,  363 
Elevated  fracture,  737 
Elliptical  (oval)  method  of  amputating, 

1325 
Emboli,  34.4,  112,  308 

infective,  344,  96,  112,  308,  562,  633, 
1047 

malignant,  344,  199,  1211 

parasitic,  344 
Embolic  abscess,  72 

arteritis,  303,  987 

gangrene,  112 
Embolus,  344,  345,  753.  898 

effects  of  an,  344 

fat,  478 

pulmonary',  345 
Embryonic  origin,  cysts  of,  229 

tumours  of,  196 
Emphysema  of  abdominal  wall  in  rup- 
ture of  bowel,  1017 

interstitial,  919 

surgical,  918,  493,  741,  889 
Emphysematous  gangrene,  121,  86 
Emprosthotonos,  136 
Empyema,  921,  70,  710,  903,  919,  984, 
996,  1063 

of  antrum,  800 

of  appendix,  1043 

of  frontal  sinuses,  742 

of  gall-bladder,  1073 

pulsating,  922 

scoliosis  from,  436 


1372 


A   MANUAL  OF  SURGERY 


En  bee  dc  /lute  fracture,  475 
Encephalitis,  766,  767 
Encephalocele,  725,  781 
Encephaloid  cancer,  223 
Encysted  abscess  (chronic),  of  bone,  576 
of  breast,  939 
of  liver,  1063 

ascites,  985 

calculus,  1231,  1234 

hernia,  1091 

hydrocele  of  cord,  1295,  231,  1097 
of  epididymis,  1294,  230 
of  round  ligament,  1300,  231 
of  testis,  1291 
Endarteritis,  acute,  303 

chronic,  304 

obliterans,  306,  116 

syphilitic,  306,  163,  578 

tuberculous,  306,  180,  572 
Endocarditis,  infective,  96,  344 

ulcerative,  66,  93 
Endocyst,  1068,  233 
Endogenous  spore  formation,  i 
Endometritis,  149 
Endoscope,  144,  146 
Endosteal  sarcoma,  593,  730,  809 
Endothelioma,   226-228,    198,   202,    380, 
720,  775.  827,  847,  849 

of  parotid,  847,  227 
End-to-end  anastomosis  of  bowel,  1037 
Enemata   in    treatment   of   chronic   ob- 
struction, 1 135 

in  treatment  of  intussusception,  1139 

turpentine,  964 

use    of,    in    diagnosis    of    intestinal 
obstruction,  1143 
Enlargement  of  spleen,  causes  of,  1082 
Ensheathing  callus,  479 
Enterectomy,  1036,  1026,  1028,  1139 

for  strangulated  hernia.  1120,  1123 
Enteric  intussusception,  1137 
Enteritis,  1020 

after  injury  to  bowel,  1014 

after  strangulated  hernia,  1121 

intestinal  obstruction  in,  1130 
Entero-anastomosis,  1037 
Enterocele,  1087 
Entero-epiplocele,  1087 
Enteroliths,  1019,  1130 
Enteroplasty,  1036,  1023 
Enteroptosis,  1028,  1003,  1059,  1189 
Enterospasm,  1131,  1126 
Enterostomy,  1030,  978,  988,  1132 

for  acute  obstruction,  11 32 
Enterotomy,  1030 
Entrance  of  air  into  veins,  295 
Enucleation  of  prostate,  1251,  1252 

of  thyroid  adenomata,  896 

of  tonsil,  861 
Enuresis,  nocturnal,  1239 
Enzymes,  5,  78 
Eosinophils,  60 
Eosinophilia,  64,  61 
Epicratic  sensation,  373 
Epidemic  parotitis,  844 
Epididymectomy,  1282 
Epididymis,  cysts  of,  1290 

encvsted  hydrocele  of,  1290,  230 


Epididymitis,  acute,  1279.  1261 

chronic,  1280 

gonorrhoeal,  1283,  147 

syphilitic,  1283,  162 

tuberculous,  1281 
Epiglottis,   affections  of,   in   diseases  of 
larynx,  904, 905, 906 

wounds  of,  888 
Epilepsy,  congenital.  779 

hystero-,  779 

idiopathic,  779 

Jacksonian,  776,  779 

reflex,  779 

surgical  treatment  of,  779 

traumatic,  779,  731,  759 
Epileptiform  tic,  380 
Epiphora,  801,  804 
Epiphyses  in  rickets,  584,  585 

separation  of,  475,  562,  576,  581,  586 

suppuration  in  connection  with,  476, 

563 
Epiphysitis,  559 

syphilitic,  581,  47,'i 

tuberculous,  575,  475,  641,  669 
Epiplocele,  1087 

strangulation  of,  11 16 
Epiploitis,  987 

Epiplopexy  operation  of,  for  ascites,  986 
Epispadias,  1253,  1216 
Epistaxis,  830,  282,  493.  586,  733.  769. 

826 
Epithelial  odontome,  215,  808 

tumours,  215-226 
Epithelioma,  220,  198 

after  lupus,  405,  407 

'  burrowing,'  799,  803 

branchial,  885 

columnar,  224 

of  anus,  1167,  1159 

of  bladder,  1227 

of  cervix  uteri,  1308 

of  glands  in  neck,  885 

of  gum,  799 

of  larynx, 907 

of  lower  jaw,  809,  799 

of  lip,  792,  791 

of  nipple,  935 

of  nose,  826 

of  oesophagus,  869 

of  palate,  858 

of  penis,  1273 

of  pharynx,  864 

of  scalp,  724 

of  scars,  263 

of  scrotum,  1298 

of  stomach,  999 

of  tongue,  838,  837 

of  tonsil,  862 

of  umbilicus,  972 

of  upper  jaw,  803 

of  urethra,  1256 

value  of  radium  treatment,  56 
Epithelium,  tumours  derived  from,  198, 

215  ... 

Epityphlitis.     See  Appendicitis 
Epulis,  798,  858,  207 

myeloid,  799.  59^ 
Erasion  of  joints,  operation  of,  646 


INDEX 


1373 


Erb-Duchcnne  paralysis,  388 
Erethitic  shock,  265 
Ergot,  gangrene  from,  112,  118 
Erysipelas,  129,  69,  972,  63 
curative  action  of,  132 
of  fauces,  859 
of  scalp,  131,  723 
of  scrotum,  1297,  131 
Erythema  ab  igne,  125 

induratmn,  107 
Esmarch's  operation  for  closure  of  jaw, 

812 
Estlander's   operation    for    chronic    em- 
pyema, 924 
Ether,  method  of  administering,  1348 
Ethmoid,  diseases  of  the,  822,  770,  824 
Ethyl  chloride  as  a  general  anaesthetic, 
1350 
as  a  local  anaesthetic,  1343 
Eucaine  as  an  ansesthetic,  uses  of,  1343 
Eustachian  catheter,  875 
Evacuator  for  removal  of  stones  from 
bladder,  1235 
use  of,  in  diagnosis  of  vesical  disease, 
1234,  1215 
Eve's  operation  for  gastroptosis,  1004 
Evisceration  in  treatment  of  peritonitis, 

977 
Examination  of  air-passages,  900 
Exanthemata,  acute,  94 

necrosis  of  jaw  after,  799 
Excision  of  astragalus,  683,  463,  554,  575, 
626,  638, 651 
of  condyle  of  jaw,  812,  659 
of  coccyx,  528 
of  Gasserian  ganglion,  383 
of  gastric  ulcer,  997 
of  head  of  metatarsal,  471 
of  head  of  radius,  518,  613,  681 
of  joints,  678-683,  647 

for  acute  arthritis,  636 
for  ankylosis,  667,  679 
'  for  dislocation,  604,  679 
for  fractures,  679,  487 
for    osteo-arthritis,    658,     659, 

811,  679 
for  tuberculous  disease,  647 
of  larynx,  908 
of  lower  jaw,  810,  800 
of  maxilla,  806 
of  naevi,  355 
of  OS  calcis,  575 
of  parotid  gland,  849 
of  piles,  1 160 

of  pylorus  (hemi-gastrectomy),  1007 
of  rectum,  1169 
of  rib  for  empyema,  924 
of  rib  for  hepatis  abscess,  1064 
of  rib  for  subphrenic  abscess,  985 
of  stomach,  1007,  1002 
of  stricture  of  urethra,  1264 
of  tongue,  840-844 
of  tuberculous  foci  in  kidney,  1203 
of  varicocele,  1293 
Exclusion  of  intestine,  operation  of,  1027 
Exercises  in  scoliosis,  440 
Exogenous    multiplication    of    hydatid 
C3'sts,  235 


Exomphalos,  1106 
Exophthalmic  goitre,  896,  891 
Exophthalmos,  896,  323,  380,  769,  801 
Exostoses,  209,  729 
Exostosis  bursata,  209 
cancellous,  208 
ivory,  210 
of  ear,  876 
of  rib,  324 
subungual,  209 
Expansile  impulse  in  aneurisms,  311 
Expansion  of  bone,  573,  590,  797,  802, 
808 
of  bridge  of  nose,  814 
Extension   of   leg   in   hip-joint    disease, 
674 
in  fractures  of  femur,  534 
in  reduction  of  dislocations,  603,  611. 

618,  620 
in  spinal  caries,  713,  718 
External  ear,  defoimities  of,  875 
External  carotid,  aneurism  of,  323 

ligature    of,    330,    297,     849,    865, 

889 
coagulum  in  haemorrhage,  286 
direct  hernia,  1092 
fistula  of  anus,  1152 
iliac  artery,  aneurism  of,  326 

ligature  of,  336,  326 
piles,  1 156 

popliteal  nerve,  affection  of,  394 
urethrotomy,  1265 
Extirpation  of  aneurism,  315,  324 
of  thyroid,  895,  898 
of  tuberculous  glands,  366 
Extracapsular  fracture  of  femur,  530 

of  humerus,  505 
Extracellular  toxins,  6 
Extracranial  complications  of  otorrhcea. 
878 
lesions  of  seventh  nerve,  384 
neurectomy  for  trigeminal  neuralgia, 
381 
Extraction  of  teeth,  794 
,  Extradural  abscess,  764,  772 
'  Extragenital  chancres,  156 
Extramedullar y  haemorrhage,  spinal,  693 
Extraparietal  hernia,  1093 
Extraperitoneal  rupture  of  bladder,  1218 

of  tubal  gestation,  13 15 
Extravasation  cysts,  232 
of  blood,  282 

of   urine,    1268,    1192,    1218,    1224, 
1241, 1254,  527 
treatment  of,  1269,  1255 
Extrinsic  cancer  of  larynx,  908 
i    Extroversion  of  bladder,  1216.  1253 
j:   Exudation  cysts,  231 
f  of  leucocytes,  30,  255 

I 

Facial  artery,  compression  of,  292 
I  ligation  of,  332 

j  cleft,  oblique,  789 

j  nerve,  affections  of,  383,  878 

I  operations  on,  385 

Facial  paralysis,  383,  137,  735,  847,  878 
I  tic,  385 

i    Facies  hippocratica,  975,  1115,  ri27 


1374 


A   MANUAL  OF  SUJiGEJiV 


Faecal  concretions  in  appendicitis,  1041 
fistula,  972,  -979,  981,   1016,   1018, 
1019,  1021,  1022,  1026,  1045, 
1058, 1120,  1123 
umbilical,  972,  981 
iiupaction,  1134 
vomiting,  1 125.  1 142 
Fasces,  retention  of,  1124 
Facultative  aerobes,  5 
anaerobes,  5 
parasites,  4 
Facultative  saprophytes,  4.  134 
Fallopian  tubes,  affecti<jns  of,  1311-1317 
strangulation  by,  1128 
in  sac  of  hernia,  1088 
False  ankylosis,  665 

incontinence  of  urine,  1240 
joints,  491,  602 
membrane,  38 
neuromata,  212 
passages,  1261 
Faraboeuf's  amputation  of  big  toe,  1332 
of  lingers,  1329 
of  leg,  1341,  1337,  104 
Faradic  current  in  diagnosis,  51 

in  treatment,  53 
Farcy-buds,  188.     See  Glanders 
Fat  embolism,  478,  344 

necrosis,  1079 
Fatty  hernia,  1108,  205 

tumours,  204.     See  also  Lipoma 
Fauces,  erysipelas  of,  859 
Favus,  10 
Female     genital     organs,     surgery     of 

(Chapter  XLIII.),  1299-1323 
Femoral  artery,  aneurism  of,  326 
compression  of,  292 
ligature  of,  337,  326,  327 
Femoral  hernia,  1103 

diagnosis  of,  1104 
operations  for  radical  cure,  1105 
strangulated,  1122 
thrombosis,  343,  1047 
truss,  1 105 
Femur,  abscess  of  neck  of,  673,  668 
central  dislocation  of,  528 
incurvation  of  neck  of,  450 
fractures  of,  529-543 
periostitis  of  lower  end,  561 
rachitic  deformity  of,  457,  455.  584 
separation  of  lower  epiphysis.  542 

upper  epiphysis,  530 
shaft,  fracture  of,  538 
Fever,  36 

catheter,  1250,  1262 
hectic,  82,  92 
traumatic,  268,  91,  478 
Fibrin  ferment,  31 
Fibro-adenoma  of  breast,  943 

of  thyroid,  892 
Fibroblasts,  256 
Fibro-cicatricial  tissue,  257 
Fibro-cystic  disease  of  jaw,  808,  215 
of  testis,  1285,  230 
of  uterus,  1304 
Fibroid  bursitis,  428 
myositis,  418 
polypus,  1303 


Fibroid,  recurrent,  202,  947 
Fibroids,  uterine,  1303-1308 

degenerations  in,  1304 

lordosis  from,  442 

operations  for,  1305 
Fibrolysin,  263 

Fibroma  of  naso-pharynx,  825,  207 
Fibromata,  206,  213,  720.  724,  798,  803, 

808,  1221,  1290 
Fibro-myoma.  212,  1303 

cysts  in,  235,  1304 
Fibro-sarcoma.  1290,  202.  212,  947 
Fibrosis,  44 

in  tuberculous  nodules,  :8o 

of  appendix,  1043 
Fibrositis,  418,  48,  49,  53 

gonorrhoeal,  148 
Fibrous  ankylosis,  665 

goitre,  892 

odontome,  215 

polypus  of  nose,  824,  823.  207 

stricture  of  oesophagus,  869 
of  rectum,  1165 

union  of  fracture,  491 
Fibula,  absence  of,  462 

fracture  of,  548 

rachitic,  457 

syphilitic  deformity  of,  457 
Fifth  nerve,  affections  of.  380 

operations  on,  382-383 
Filaria  sanguinis  hominis.  361,  344,  1183 
Filariasis,  65.  361 
Filiform  bougies.  1260 
Filigree,  silver,  in  treatment   of  herraa, 

1109 
Fingers,  adhesions  of  tendons  of,  417,  421 

amputation  of,  1328 

chancre  of,  156 

deformities  of,  444 

division  of  tendons  of,  417 

sloughing  of  tendons  of,  418 

webbed,  445 
Finney's    operation    (gastro-duodeno- 

stomy),  1012 
Finsen-iight  cure  of  lupus,  406,  51 
First  intention,  healing  by,  258 
Fish-hook  wounds,  245 
Fission,  2,  i 
Fission  fungi,  i 
Fissure  of  anus,  11 54 

of  lip,  congenital,  783.  789 

of  Rolando.  744 

of  Sylvius,  745 
Fissured  fracture  of  skull,  731,  475 

fractures.  475 
Fissures  of  lips,  791 

of  nipple,  934 

of  tongue,  836 
Fistula,  80 

aerial,  890 

biliary,  972,  1075-  loSo 

bimucosa,  981 

branchial,  884 

cervical,  886 

f;ecal,  972,  979,  981,  1016,"  1018 
1019,1021,  1022,1026,1045,1058 
1120,  1123 

gastric,  996 


INDEX 


1375 


Fistula,  horse-shoe,  1151,  1153 
-in-ano,  1151 
median  cervical,  886 
oesophageal,  890 
penile,  14C 

perineal,  1270,  1258,  1267 
pharyngeal,  890,  909 
recto-vesical,  1164,  1167,  1224,  1228, 

1297 
salivary,  846 
scrotal,  1270,  1298 
umbilical,  972 

urinary,  1270,  972,  1204,  1210,  1228, 
1252, 1255 
Fixation  of  fractures,  482 
Flagella,  2,  i 
Flap  method  of  amputation,  1325 

modified,  1325 
Flaps  in  amputation,  1326 
Flat-foot,  465,  453,  458,  554 

gonorrhoeal,  148 
Flexible  bougies,  1260 

catheters,  1259 
Floating  kidney,  1188 

spleen,  1082 
Fluctuation,  jy 
Foetal  goitre,  893 

residues,  196,  663 

origin  of  tumours  in,  196 
Follicular  odontome,  215,  808 
pharyngitis,  863 
tonsillitis,  859 
Folliculitis,  suppurative,  252 
Fomentations,  40,  47 
Fontanelles,  in  rickets,  582 

in  syphilis,  5S0 
Foot,  amputation  of,  1335 
deformities  of,  457-471 
laceration  of,  245 
painful  lipoma  of,  205 
Forcible  correction  in  talipes,  464 

dilatation   of  stricture   of   urethra, 
1263 
Forcipressure  treatment  of  heemorrhage, 

289 
Forearm,  amputation  through,  1330 
Foreign  bodies,  cysts  in  connection  with, 
232 
in  air-passages,  900 
in  appendix,  1041 
in  bladder,  1219 
in  brain,  treatment  of,  760 
in  bronchus,  902,  910 
in  cure  of  aneurisms,  318 
in  ear,  875 
in  hernial  sac,  1088 
in  intestine,  1019,  1130,  1133 
in  larynx,  910 
in  nose,  818 
in  oesophagus,  867 
in  rectum,  1147 
in  stomach,  992 
in  trachea,  902 
in  urethra,  1255 
Formalin,  273 

Forster's  operation  on  nerve-roots,  398 
Fossa  duodeno-jejunalis,  1128 
Fossa  retro-cjecal,  1128 


Fourth  nerve,  paralysis  of,  380 
Fowler's  position  in  peritonitis,  976,  963 
Fracture-dislocation  of  ankle,  550 

of  femur,  528 

of  humerus,  507 

of  spine,  688 
Fracture-dislocations,  601,  487,  507,  528, 

550,  614 
Fracture  en  bec-de-flute,  475 
Fracture  fever,  478 

green-stick,  474 
Fractures  (Chapter  XX.),  472-554 

comminution  of,  475,  480 

complications  of,  478,  487 
during  treatment,  488 

compound,  489,  474,  732,  760 

compression,  473,  554,  686 

congenital,  474 

disunited,  493 

early  operative  treatment  of,  484 

effects  of,  478 

impacted,  475,  520,  530,  536 

implication  of  joints  in,  487 
of  main  artery  in,  487 

intra-uterine,  474 

massage  in  treatment  of,  484 

nerves,  involvement  of,  488 

obstetric,  474 

signs  of,  476 

spontaneous,  473,  586,  591 

treatment  of,  481 

union  of,  451,  490 

ununited,  491 

varieties  of,  474 

veins,  laceration  of,  488 

vicious,  union  of,  493,  553 

See  also  special  fractures 
Fragilitas  ossium,  473,  586 
Framboesia  (yaws),  175 
Frank's  operation  of  gastrostomy,  1005 
Freezing  for  anaesthesia,  1343 
Fremitus,  hydatid,  1065 
French  olive-headed  catheter,  1260 

operation  of  rhinoplasty,  816 
Fringes,  synovial,  632 
'  Frog-nose,'  814 
Frontal  bone,  fracture  of,  741 

bosses,  582 
Frontal  lobes  of  brain,  abscess  in,  742 

lobes,  injuries  of,  756,  751,  755,  742 

sinuses,  affections  of,  741,  822 

suppuration  in,  742,  770,  822 
Fronto-nasal  process,  785 
Frost-bite,  124 
Functional     derangement     of     bladder, 

1239-1242 
Fungi,  filamentous,  10 
Fungus  hasmatodes,  197,  224 
Funicular  hernia,  1091 

process  in  hernia,  1084 
Furuncle,  399 
Fusible  calculus,  1230 
Fusiform  aneurism,  309 

Galatocele,  940 

Gall-bladder,  affections  of,  1067-1078 

anatomy  of,  1067 

colic,  1067 


1376 


A   MANUAL  OF  SURGERY 


Gall-bladder,  empyema  of,  1073 

hydrops  of,  1073 

rupture  of,  1068,  973 

suppuration  in,  1070 

tumours  of,  1077 
Gall-stones,  1071 

impaction  of,  1073-  io75 

in  intestine,  1019,  1130 

operations  for,  1075,  1076 

pancreatitis,  due  to,  1079 
Galvanic  electricity  in  diagnosis,  51 

in  treatment,  53 
Galvano-cautery,  50 
Ganglion,  422 

compound  palmar,  423 

Gasserian,  removal  of,  381,  383 
Gangrene  (Chapter  VII.),  108-128,  34 

acute   emphysematous,    1273,    121, 
86,  93 

after  aneurism,  312,  313,  327 

amputation  for,  114,  116 

diabetic,  112,  117 

dry, 109 

embolic,  112,  344,  987 

from  arterial  thrombosis,  116,   119, 

345. 987 
from  carbolic  acid,  117 
from  cervical  rib,  117,  435 
from  corrosives  (chemicals).  121 
from  ergot,  112,  118 
from    fractures    during    treatment. 

487, 489. 539'  543 
from  ligature  of  arteries,  329,  119 
from   obstruction   of   main   vessels, 

119 

from  rupture  of  arteries,  30c 

from  splint-pressure,  120 

from  thermal  causes,  122 

in  intestinal  obstruction,  1125 

in  intussusception,  1137,  1138 

moist,  109 

of  appendix,  1044 

of  intestine  in  hernia,   1113,   1115. 
1117,  1120,  1121,  1123 

of  lung, 921,  926 

senile,  114,  112,  307 

spontaneous,  118 

symptomatic,  112 

traumatic,  119,  109,  112 

varieties  of,  112 
Gangrenous  cholecystitis,  1071 

periproctitis,  1151 

stomatitis,  837 
Garre  and  Bockhardt,  observations  of,  71 
Gartner's  duct,  cyst  of,  231 
Gas    in    abscesses,    78,   984-    996.   1013, 

1046 
Gasserian  ganglion,  removal  of,  381,  383 
Gastralgia  appendicular,  1050 
Gastrectomy,  1007,  1002 
Gastric  fistula,  996 

juice  in  cancer  of  stomach,  1000,  990 

ulcer  and  its  effects,  992-998,  983, 
990 
Gastritis  phlegmonous,  992 
Gastrocnemius,  rupture  of,  416 
Gastro-duodenostomy    (Finney's    opera- 
tion), 1012 


Gastro-enterostomv.  operation  of,  1008, 

85 
for  cancer  of  stomach,  1002 
for     haemorrhage     from     duodenal 
ulcer,  1013 
from  stomach  ulcer,  994 
for  hour-glass  stomach,  997 
for  pyloric  stenosis,  1003 
for  stenosis  of  duodenum,  10 13 
for  ulcer  of  stomach,  994.  995,  997 
httmorrhage  after,  ion 
in  gastrectomy,  1008 
recurrence  of  symptoms  after,  998 
vicious  circle,  vomiting  after,  loio, 
ion 
Gastroplication,  1004 
Gastroptosis,  1003 
Gastroscopy,  989 
Gastrostomy,  1005,  871,  909 
Gastrotomy,  1004,  871,  992 
Gauvain's  back-door  splint,  714 
Gauze  for  dressings,  280 
Gelatin,  B.  tetani  in,  135 
'  Gelenkmaus,'  664 
Genital  organs  of  female,   affections  of 

(Chapter  XLIII.),  I299-I3i23 
Genu  recurvatum,  455,  650 
valgum,  452,  436.  584 
varum,  455,  585 
Gerlach's  valve,  1041 
Giant  cells,  179,  287 

in  sarcoma,  201 
in  tubercle,  179 
Gigantism.  194,  589 
Gigli's  saw,  747,  483 
Giraldcs,  organ  of,  230.  1286 
Girdle  pain,  392,  36 
Glanders.  188 

Glands,  lymphatic,  affections  of,  363 
malignant,  370,  220,  221,  225,  199. 
mesenteric.  988 
syphilitic,  364,  157,  160 
tuberculous,  365,  369,  988,  184 
Glandular  cancer,  222 
Glass  wounds,  302 
Gleet,  143,  1243,  1258 
treatment  of,  146 
Glenard's     disease,    1028,     1003,     io59' 

1189 
Gliomata.  214 

of  brain,  775 
Globus  hystericus,  869 
Glossitis.  834.  835,  837 
Glosso-phar\-ngeal   nerve,    affections   of, 

386 
Glossy  skin,  374 
Glottis,  acute  oedema  of.  904.     See  also 

(Edematous  laryngitis 
Glover's  stitch,  239 
Gloves,  use  of,  for  operating.  276 
Gluteal  abscess,  673 

artery,  aneurism  of,  326 

haemorrhage  from,  298 
bursa,  disease  of,  430 
Glycogen  in  diagnosis  of  suppuration,  63 
Glycosuria,  1180,  758 
.    Goadby,  on  pyorrhoea  alveolaris.  797 
I   Goitre,  890-898,  322,  872 


INDEX 


1377 


Golding  Bird's  sling  for  flat-foot,  467 
Gonococcajmia,  142,  148 
Gonococcus,  142,  8,  71,  93,  96,  973 
Gonorrhcea,  142,  64,  148,  1256 

affections  oi  fasciae  in,  148 

arthritis  in,  640,  14S,  633,  719,  811 

stricture  in,  1256 

%'accine  treatment  of,  144 
Gonorrhavxl  conjunctivitis,  147 

epiLlidyniitis,  1279 

fibrositis,  148 

flat-foot,  466,  148 

peritonitis,  982,  149 

proctitis,  147,  1147 

prostatitis,  1242 

pyasmia,  148 

rlieumatism  of  spine,  719 

rhinitis,  147,  819 

sclerotitis,  148 

urethritis,  143,  640 

vaginitis,  149,  1300 

vulvitis,  149,  1300 

warts,  146,  1273 
Gordon's  splint  for  Colles's  fracture,  520, 

523 
Gottstein's  curette,  829 
Gouty  arthritis,  639 

depositis  in  bursae,  429 

fibrositis,  418 
Gradual  dilatation  of  stricture  of  urethra, 

1263 
Graefe's,  von,  sign,  896 
Grafting  of  nerves,  376 
Gram's  method  of  staining  organisms,  8, 

142 
Gram-negative  bacteria,  8 
-positive  bacteria,  8 
Granular  degeneration,  37 

urethritis,  143 
Granulation  tissue,  257,  74,  109,  479 
Granulomata,  44 
Graves'  disease,  896 
Gravitation  paraplegia,  693 
Green-stick  fracture,  474 
Gritti's  supracondylar  amputation,  1338 
Groin,  abscess  in  glands  of,  364 

tuberculous  glands  in,  368 
'  Growing-out  hip,'  438 
'  Growing-out  shoulder,'  438 
'  Growing  pain,'  565 

Growth  of  bone,  555,  476,  566,  585,  586 
Gubernaculum  testis,  anatomy  of,  1275 
Gumboil,  795 

Gum-elastic  catheters,  1260 
Gumma,  162 

of  bone,  578,  570 

of  brain,  775 

of  larynx,  905 

of  lip,  791 

of  liver,  1066 

of  muscles,  419,  433 

of  pharynx,  864 

of  rectum,  1164 

of  ribs,  917 

of  spine,  718,  441 

of  sternum,  916 

of  testis,  1284 

of  tongue,  837 


Gumma  of  tonsil,  862 
perisynovial,  652 
subcutaneous,  164 
subperiosteal,  578 
Guniniata,  cutaneous,  163 
Gummatous  osteo-myelitis,  580 
synovitis,  652 
ulcer,  163 
Gums,  affections  of,  795-800 
Gunshot  wounds,  246-250 

of  abdomen,  248,  249 
of  lung,  920 
of  skull,  737,  759,  247 
tetanus  in,  135 
treatment  of,  249 
Gutter  fracture,  737 
Gynecomastia,  933 

Hajmatemesis,  282,  733,  86g,  971,  990, 

993,  1000,  1003,  1013,  1083 
Hasmatocele,  diagnosis  of,  1295 

of  cord,  1278,  1095 

of  tunica  vaginalis,  1277,  231 

pelvic,  1315 
Haematoma,  237 

of  abdominal  walls,  968 

of  ear,  875 

of  scalp,  722 

of  vulva,  1299 

scroti,  1297 
Hajmatomyelia,  693 
Hzematorachis,  693 
Hsematuria,  1182,  283 

constitutional,  11 82 

diagnosis  of  source  of,  1183 

from  injuries,  1192,  1218 

in  appendicitis,  1047 

in  calculus  of  bladder,  1232 
of  kidney,  1205 

in  prostatic  affections,  1244,  1252 

in  tubercle  of  bladder,  1225 
of  kidney, 1202 

in  tumours  of  bladder,  1226,  1228, 
of  kidney,  12 11 

in  urethral  affections,  1254 
Haemocytometer,  58 
Ha9mogiobinometer,  58 
Hsemoglobinuria,  paroxysmal,  1183,  118 
Haemolysins,  19,  21,  22 
Hemophilia,  298,  1182 

joints  in,  662 
Haemoptysis,  283,  918 
Haemorrhage  (Chapter  XII.),  282-298 

after  gastro-enterostomy,  ion 

after  removal  of  teeth,  795 

blood  examination  after,  58 

cerebral,  763 

during    amputations    at    hip-joint, 

1339 
effects  of,  283,  505 
from  catheterism,  i26r 
from  duodenal  ulcer,  1013 
from  gastric  ulcer,  993 
from  nipple,  946,  953 
from  pancreas,  1078,  1079 
from  varicose  vein  or  ulcer,  350,  351, 


103 
intermediate,  293 


87 


1378 


A   MANUAL  OF  SURGERY 


Haemorrhage,  intraperitoneal,  970,  986, 
987,  1060,  1081,  1191, 1315 
in  fibroids  of  uterus,  1304 
in  fracture  of  skull,  733,  756 
in  fractures,  478,  489 
in  ruptured  ectopic  gestation,  1315 
kidney, 1191 
urethra,  1254 
in  scurvy-  rickets,  585 
in  villous  (papillomatous)  tumour  of 

bladder,  1226 
leucocytosis  after,  64 
meningeal,  760 
natural  arrest  of,  283 
primary,  291 
pulmonary,  921 
recurrent,  293 
secondary,  293,  328 
special  sources  of,  296 
spinal,  693 
subperiosteal,     in    scurvv    rickets, 

586 
treatment  of,  general,  284 

surgical,  288 
venous,  295,  282 
Hajmorrhagic  infarct,  345,  97 
pancreatitis,  1079 
rickets,  585 
Haemorrhoids,  1155-1161 
complications  of,  1158 
diagnosis  of,  1158 
external,  1156 
internal,  1157 

treatment  of,  1159 
Haemostasis,  279,  289 
Hemostatics,  289 
Haemothorax,  918,  498 
Hahn's  tracheotomy-tube,  912 
Hallux  rigidus  (Hallux  flexus),  468,  466 

valgus,  469 
Halstead's  intradermic  stitch,  240,  367 
operation  for  hernia,  iioi 

for     removal     of     tuberculous 
glands,  367 
suture,  intestinal,  967 
Hamilton's  splint,  541 

test  for  dislocated  shoulder,  608 
Hammer-nose,  815 
Hammer-toe,  470 
Hammond's  wire  splint  for  fracture  of 

lower  jaw,  497 
Hand,  amputation  of,  1330 

deformities  of,  445 
Hands,  sterilization  of,  275 
'  Hanging-drop  '  preparation,  7 
Haptophore,  20 
Hard-bake  spleen,  368 
Hard  fibroma,  206 

sore,  155 
Hare-lip,  783-789 

operations  for,  786 
Hartley-Krause    operation    for    the    re- 
moval of  Gasserian  ganglion,  383 
Head  injuries.     See   Fractures  of  skull 

and  injuries  of  brain 
Head  of  radius,  fracture  of,  518 
Healing  of  wounds,  258 
by  granulation,  259 


Healing  by  organization  of   blood-clot, 
261, 1066 
by  primary  union,  258 
by  secondary  union,  259 
under  a  scab,  261 
Hearing,  investigation  of,  873 
Heart,  wounds  of,  927 
Heat  as  a  sterilizing  agent,  273,  276,  277 
in  inflammation,  35 
in  treatment  of  acute  inflammation, 
40,  47 
of  chronic  inflammation,  43,  48 
of  shock, 49,  267 
Heat-stroke,  734 
Heberden's  nodosities,  656 
Hectic  fever,  82,  92,  634,  644,  673,  711 
Hemianaesthesia  in  head  injuries,  758 
Hemianopsia,  758,  776,  779 
Hemiatrophy  of  tongue,  833 
Hemiplegia  after  head  injuries,  753 
Henoch's  purpura,  11 38 
Hepatic  abscess,  1061.     See  Abscess  of 
liver 
duct,  anatomy  of,  1067 

stone  impacted  in,  1073 
Hepatoptosis,  1059 
Heredity  as  a  cause  of  tumours,  194 
Hernia  (Chapter  XXXVI.).  1084-1123 
aetiology  of,  1084 
bladder  in,  1088 
cascum  in,  1087 
coverings  of,  1087,  1089,  1103 
enterocele,  1087 
epiplocele,  1087 
Fallopian  tube  in,  1088 
inflammation  of,  11 11,  1086 
irreducibility  of,  mo,  1086,  1098 
obstructed,  mo,  1107 
ovary  in,  1088 
sac  of,  1086 

adhesions  in,  1086,  1098 
foreign  bodies  in,  1088 
hydrocele  of,  1086 
signs  of,  1088, 
strangulated  1112-1123 

complications   after   operation, 

1121 

after  taxis  for,  1117 

grangrene    of   bowel    in,   1113, 

1115,  1117,  1120,  1121,  1123 

operative   treatment   of,    1118, 

1122 
pathological  effects  of,  11 12 
prognosis  of ,  1116 
sequela;  of,  11 23 
signs  and  symptoms  of,  11 14 
taxis  in,  1116 
structure  of,  1086 
treatment  of,  1095 
vermiform  ajipendix  in,  1087 
volvulus  in,  1 1 17 
Hernia,  acquired,  1083,  1090 
bubonocele,  1089 
cerebri,  781,  738,  739,  778 
congenital,  1084,  1090,  iioo,  1106 
diaphragmatic,  mo 
direct,  1091,  1102 
en  bissac,  1092 


INDEX 


1379 


Hernia,  encysted,  109 1 
fatty,  1 108,  205 
femoral,  1103 
funicular,  109 1 
infantile,  109 1 
inguinal,  1089-1103 
inguinalis  ante-vesicalis,  1092 
inguinalis  intra-iliaca,  1092 
internal,  1129 
interstitial,  1092,  11 18 
Littre's,  1112 
lumbar,  1109 
obturator,  mo 
of  lung,  921 
post-operative,     1085,     963,     1058, 

1109 
Richter's,  1112,  1115 
testis,  1284 
traumatic,  1085 
umbilical,  1106 
vaginal,  mo 
ventral,  1108,  1058,  965 
Herpes  labialis,  792 
in  neuralgia,  377 
preputialis,  1272 
zoster,  378,  393 
Hesselbach's  triangle,  1091 
Heteroplasty,  727 
Hey's  amputation,  1334 
Hey's  saw,  739 

Hilton's  method  of  opening  abscesses,  79 
Hinged-cup  truss,  mi 
Hip  disease,  668,  678 

-joint,  acute  arthritis  of,  637,  668 
amputation  at,  1339,  677 
ankylosis  of,  665 
contusion  of,  533 
dislocation  of,  congenital,  447 

traumatic,  615-621,  533 
effusion  into,  628 
excision  of,  682,  676 
osteo-arthritis  of,  658,  533 
scissor-like  deformity  of,  666 
tuberculous  disease  of,  668 
Hirschsprung's  disease,  1027 
Histrionic  spasm,  385 
Hodgen's  splint,  537 
Hodgkin's  disease,  368,  64 

blood  in,  65 
Hoffmann's  bone  rongeur,  739 
Hollow-foot,  468 
Hooklets,  233,  1065 
Horn,  sebaceous,  409,  1273 
Horse-shoe  fistula,  1151,  1153 

kidney, 1188 
Horsley's  classification  of  epilepsy,  779 
knife,  778 
wax,  747 
Hospital  gangrene,  123 
Hot-air  baths,  49 
Hour-glass  stomach,  997 
Housemaid's  knee,  429 
Howship's  lacunas,  557 
Hot  water  in  treatment  of  hsemorrhage, 

288 
Humerus,  fractures  of,  503-516 

fracture,  with  dislocation  of  head, 
507 


Humerus,  separation  of  lower  epiphysis, 
514 
of  upper  epiphysis,  506 
'  Huinmy,'  427 

Humoral  theory  of  immunity,  17 
Hvmch-  or  hump-back,  439,  708 
Hunterian  chancre,  155 
Hunter's  canal,  ligature  of  femoral  artery 
in,  338 

operation  for  aneurism,  316 
Hutchinson's  teeth,  174 

wart,  160,  836 
Hyaline  cells,  61 
Hydatid  cysts,  233 

eosinophilia  in,  64 

of  bone,  597 

of  brain,  775 

of  breast,  941 

of  kidney,  12 12 

of  liver,  1065,  1062,  234 

of  lung,  926 

of  neck,  887 

of  spine,  719 

of  spleen,  1083 
Hydatid  of  Morgagni,  230 
cysts  of,  1291 
fremitus,  1065 
Hydrarthrosis,  633,  631 
Hydrencephalocele,  726 
Hydrocele,  acute,  1287,  1279 

bilocular,  1288,  1300 

chronic,  1288,  1283 

chylous,  1292,  359 

congenital,  1287,  1291 

encysted,  1290 

infantile,  1287 

of  breast,  941 

of  cord,  1291,  231,  1094 

of  epididymis,  1290,  230 

of  hernial  sac,  1086 

of  neck,  887 

of  round  ligament,  1291,  1300,  230 

of  tunica  albuginea,  1291 

of  tunica  vaginalis,  1287,  1295 

ovarian,  13 19 

radical  cure  of,  1289 

tapping,  method  of,  1289 

vaginal,  1287 
Hydrocephalus,  727,  702 
Hydrogen,  peroxide  of,  273 
Hydronephrosis,  1193,  1205,  1190 

from  disease  of  bladder,  1220 

from  stricture  of  urethra,  1259 

in  enlarged  prostate,  1247 

in  moveable  kidney,  1190 

in  renal  calculus,  1204 

in  uterine  fibroids,  1304 
cancer,  1309 
Hydrophobia,  138,  137 
H^'drops  antri,  802 

articuli,  633,  631 

of  appendix,  1043 

of  frontal  sinus,  742 

of  gall-bladder,  1073 

tuberculous,  642,  644 
Hydrosalpinx,  1313 
Hygroma,  cystic,  887,  359,  704,  231 

of  neck,  887,  886 


i38o 


A   MANUAL  OF  SURGERY 


Hyoid  bone,  fracture  of,  497 
Hyperajmia,  induced  (Bier),  41,  45 

in  infiannuation,  30,  43 
Hyperciilorhydria,  990,  996,  998,   1002, 

1012 
Hypernephroma,  12 11 
Hyperostoses,  210,  803 
Hyperpituitarism,  779,  589 
Hyperplasia,  due  to  lymphatic  obstruc- 
tion, 360 
Hyperpyiexia,  43 

in  tetanus,  136 
Hypertrophic  cancer  of  intestine,  1024 

osteo-arthropathy,  590,  441 

rhinitis,  819 

tonsillitis,  860 
Hypertrophy,  194 

of  bladder,  1220,  1234,  1247,  1258 

of  bone,  590 

of  breasts,  933 

of  gums,  797 

of  lips,  790 

of  prostate,  1245 

of  pylorus,  1003 

of  scars,  263 

of  skull,  728 

of  spleen,  1083 

of  tonsils,  860 
Hyphomycetes,  10 
Hypochlorhydria,  990 
Hypodermic  injections  in  shock,  267 
Hypodermoclysis,  285,  978 
Hypoglossal  nerve,  injury  of,  387 
Hy]>ophysis  cerebri,  tumours  of,  778,  389 
Hypopituitarism,  779,  206 
Hypopyon,  79 
Hypospadias,  1253 
Hypostatic  pneumonia  in  fractures,  488, 

530 
Hypothyroidism,  206,  898 
Hysterectomy,  abdominal,  1305 

for  cancer  of  uterus,  1310 

for  deciduoma  maligna,  1311 

vaginal,  1303,  1310 

Wertheim's,  13 10 
Hysteria  in  spinal  injuries,  695 
Hysterical  joints,  664 

stricture  of  oesophagus,  869 

wry -neck,  435 
Hystero-epilepsy,  779,  780 
Hysteropexy,  1301 

Ichthyosis  linguae,  835 
Icterus.  See  Jaundice 
Idiopathic  dilatation  of  colon,  1027 

erysipelas,  131,  129 

psathyrosis,  586 
Ileo-csecal  intussusception,  1137 
Ileo-colic  intussusception,  1137 
Ileo-colostomy,  1023,  1027,  1030,  1039 
Ileo-sigmoidostomy,  1026,  1030 
Ileus,  1 1 24 

dynamic,  11 26 

mechanical,  11 26 
Iliac,  aneurism  326 

colostomy,  1034,  1033 

vessels,  ligature  of,  335,  336 
Immunity,  13-28,  74,  974 


Immunity,  theories  r)f,  17,  18,  19 

to  cancer.  196 
Impacted  calculus  in  ureter,  1206,  1209 

fa;ces,  1 134 

fracture,  475,  529,  530 

gall-stones,  effects  of,  1073 

urethral  calculus,  1255 
Impaction   of  foreign   bodies  in  bowel, 

1019,  1030,  1130,  1133 
Impassable  stricture   of  urethra,    1257, 

1265 
Imperforate  anus,  1145 
Impermeable  stricture  of  urethra,  1257 
Impetigo  contagiosa,  69 
Implantation  cysts,  232 

lateral,  of  intestine,  1039,  1027 
Impulse,  expansible  in  aneurism.  311 

in  hernia,  1088,  1104 
Incised  wounds,  238 

Incision,   parietal,  in   abdominal  opera- 
tions, 961 

in  gall-bladder  operations,  1076 
Incisions  in  treatment  of  inflammation, 

42 
Incomplete  descent  of  testis,  1275 

dislocations,  601 

fracture,  474 
Incontinence  of  faeces,  696,  697 

of  urine,  1239,  697,  712,  1248,  1258 
Incurv-ation  of  neck  of  femur,  450 
Indian    ink    method    of    demonstrating 

spirochoetae,  153 
Indian  operation  of  rhinoplasty,  861 
Induced  hypera^mia,  41 
Induration  of  sterno-mastoid,  congenital, 

433 
Infantile  hernia,  1091 

hydrocele,  1287 

palsy,  720.  458 

scurvy,  585 

umbilical  hernia,  1106 
Infarct.     See  also  Emboli 

haemorrhagic,  345,  97 

pyemic,  345 
Infection  (Chapter  I.),  11-13 

mixed,  71,  80 

secondary,  182 
Infections,  non-specific  pyogenic  (Chap- 
ter V.),  68-99 
Infectious  diseases,  non-specific,  12 

specific,  12 
Infective  arteritis,  303 

disease,    specific    (Chapter    VIII.), 
129-193 

emboli,  344,  96,  308 

endocarditis,  96,  97 

gangrene,  121. 112 

osteo-myelitis,  acute,  560,  558 

phenomena    of    intestinal    obstruc- 
tion, 1 125 

phlebitis,  346,  96,  769 

processes,  13 

thrombosis  of  cerebral  sinuses,  768 
Inferior  dental  nerve,  operations  on,  382 

maxilla,  fracture  of,  494 
Infiltration  in  carcinoma,  219 
Inflamed  aneurism.,  313 

treatment  of,  319 


INDEX 


1381 


Iiiilamed  gums,  795 

luoiiiorrhoids,  1x56,  115S 

hernia,  rm 

lymphatic  gland  simulating  hernia, 
1122, 1104,  1094 

undescended    testis,    simulating 
hernia,  1122,  1277 
Intlammation  (Chapter  II.),  29-46 

resolution  in,  34 

signs  of,  35 

tissue  changes  in,  32 

varieties  of,  38 
Inflammatory  fever,  126 

leucocytosis,  62 

lymph,  32 

senile  gangrene,  115 
Inflation    of    bowel    in    intussusception, 

1139 
of  stomach,  989 
of  tympanic  cavities,  873 
Infra-orbital  nerve,  operations  on,  381 
Infusion  of  salt  solution,  284,  92 

for  abdominal  operations,  960,  971 
for  hjemorrhage,  284 
for  peritonitis,  978 
for  sepsis,  92,  95 
for  shock, 267 

into  subcutaneous  tissues,  285,  978 
with  ether,  1350,  960 
Ingrowing  toe-nail,  408 
Inguinal  aneurism,  326 
bubo, 146 

(iliac),  colostomy,  1034 
hernia,  1089-1103 
acquired,  1090 
congenital,  varieties    of,    1090, 

1 100 
diagnosis  of,  1094,  1104 
direct,  1091,  1102 
infantile  (encysted),  1091 
interstitial,  1092 
oblique,  1089 
strangulated,  1122 
treatment  of,  1095-1103 
varieties  of,  1089 
Inherited  syphilis,  171,  791 

bone  affections  in,  580,  457 
Injections  for  cure  of  hydrocele,  1289 

in  gonorrhoea,  145 
Injuries  a  cause  of  tumours,  194 

of  arteries,  299 
Innominate  artery,  aneurism  of,  321 

ligature  of,  329,  324 
Inoperable  malignant  disease,  treatment 
of— 

[a)  by  Coley's  fluid,  203 

[b)  by    double    oophorectomy, 

958 

[c)  by  X  rays,  226 
Insanity,  traumatic,  781 
Insect  stings,  250 

Instruments,  preparations  of,  for  opera- 
tions, 276 
Interacinous  cysts  of  breasts,  941 
Intercostal  artery,  haemorrhage  from,  297 

neuralgia,  392 
Intermaxilla  in  hare-lip,  785 
treatment  of,  788. 


Intermediate  h;umorrhage,  293 
Internal  callus,  479 

carotid  artery,  aneurism  of,  323 
ligature  of,  330,  323,  324 
wounds  of,  763 
coagulum  in  the  arrest  of    ha3mor- 

rhage,  286 
derangement  of  jaw,  813 

of  knee-joint,  622 
ear,  disease  of,  879 
fistula  of  anus,  1152 
hasmorrhoids,  1157 
hernia,  1128 

iliac  artery,  ligature  of,  336 
malleolus,  fracture  of,  548,  55c 
mammary  artery,  haemorrhage  from, 
297 
ligature  of,  332 
popliteal  nerve,  affections  of,  394 
strangulation     of    intestine,     1128, 

113I'  1133 
urethrotomy,  1264 
Interparietal  hernia,  1092 
Interscapulo-thoracic  amputation,  1332, 

595 
Interstitial  emphysema  of  lungs,  919 
fibroids,  1303 
hernia,  1092,  1118 
inflammation,  38 
keratitis,  174 
mastitis,  937 

nephritis  (suppurative),  1197 
Intestinal  adhesions,  974,  979,  980,  1128 
anastomosis,  1037 
bobbins,  1038 
calculi,  1020 

obstruction     (Chapter     XXXVII.), 
1124-1143 
acute,  1126-1133 
chronic,  1133-1136 
paralysis,  1125,  11 13,  974 
sutures,  965 
Intestines,  affections  of,  1014-1030 
bismuth  radiography  of,  1014 
carcinoma  of,  1024 
colitis,  1020 

congenital  malformations  of,  1014 
embolus  in,  345 
enteritis.  1020,  1121 
enteroptosis,  1028 
foreign  bodies,  in  1019,  1130,  1133 
idiopathic  dilatation  of  colon,  1027 
injuries  of,  1014 
operations  on,  1030-1039 
perforation  of,  1018 
sarcoma  of,  1024 
stasis,  1029 
stenosis  of,  1022,  1038,  1123,  1126, 

1014 
tuberculous  ulcers  of.    1021,    1022, 
1018 
Intracanalicular  adenoma  of  breast,  945 
Intracapsular  fracture  of  femur,  529 

of  humerus,  503 
Intracellular  toxins,  6 
Intracoracoid    dislocation    of    humerus, 

609 
Intracranial  aneurism,  323 


1382 


A  MANUAL  OF  SURGERY 


Intracranial    bloodvessels,    injuries    of, 
760-763 
complications  of  otorrhoea,  881 
inflammation,  764 
lesion  of  seventh  nerve,  383 
Intradermic  suture,  240 
Intramammary  abscess,  936 
Intramedullary  haemorrhage  of  spine,  693 
Intrameningeal  hajmorrhage,  763 
Intramuscular  injections  of  mercury,  169 
Intraparietal  hernia,  1092,  11 18 
Intraperitoneal  abscess,  979,  983,  996, 
1045 
hasmorrhage,  970,  987,  1060,  1082, 

1191,  1315 
rupture  of  bladder,  1218 
ectopic  gestation,  1314 
Intrathoracic  aneurism,  319 
goitre,  8gi 
surgery,  925 
Intratracheal  insufflation  of  ether,  1350, 

925 
Intravenous  infusion,  284.     See  Infusion 
of  salt  solution 
of  ether,  1350,  960 
Intra-uterine  fractures,  474 
Intrinsic  cancer  of  larynx,  907 
Intubation  of  larynx,  916,  904,  929 
Intussusception,  acute,  1138 
anatomy  of,  11 36 
treatment  of,  1139 
varieties  of,  1137 
chronic,  1139 

treatment  of,  1140 
Inunction  of  mercury  for  syphilis,  168 
Inversion  of  testis,  1276 
Involucrum,  559,  564,  565 
Involution  cysts,  937,  940 
Iodides  in  syphilis,  169 
Iodine,  sterilization  of  skin  by,  272,  279, 
281 
paint,  45 
Iodoform,  272 

and  glycerine,  273,  187,  646,  717 
lodolysin,  263,  632,  768 
Ionic  medication,  54,  413,  632 
Ions,  zinc,  treatment  by,  413 
Ipecacuanha  in  treatment  of  hepatitis, 

1063 
Iritis,  syphilitic,  160 
Irradiation,  Aran's  theory  of,  731 
Irreducible  hernia,  11 10 
Irrigation  of  abdomen,  977 
of  bowel  for  colitis,  102 1 
of  chronic  abscess,  187 
of  urinary  bladder,  1222 
Irritable  ulcer,  105 
Irritation,  cerebral,  751 
cysts  of  breast,  940 
Irving's  apparatus  for  suprapubic  cysto- 
tomy, 1252 
Ischemic  contraction  of  muscles,  489 
Ischio-rectal  abscess,  1149,  1150 
Italian  operation  of  rhinoplasty,  816 
Ivory  exostosis,  210 

Jacques'  catheter,  1260 
Jacksonian  epilepsy,  776,  779 


Jackson's  membrane,  1029 
Jaundice,  catarrhal,  1069 

in  cancer  of  bile-ducts,  1078 
in  cancer  of  pancreas,  1081 

of  stomach,  looi 
in  gall-stones,  1073 
in  rupture  of  gall-bladder,  1068 
Jaw,  locking  or  clicking,  813 
lower,  closure  of,  812 
dislocation  of,  604 
excision  of,  810,  800 

of  condyle  of,  812 
fracture  of,  494 
necrosis  of,  799 
tumours  of,  808-811 
upper,  excision  of,  806 
fracture  of,  494 
necrosis  of,  799 
tumours  of,  803 
Jaws,  affections  of,  795-813 
Jejunostomy,  1030,  1002 
Jenner's  stain,  59 
Jerk  -finger,  445 
Jigger  (chigoe),  250 
Joints,  ankylosis  of,  665 

diseases  of  (Chapter  XX I II.), 627-683 
dislocation  of,  600-626 
effusion  into,  evidences  of,  627 
excision  of,  678 
false,  491,  602 

gonorrhoeal,  affections,  640,  633,  148 
gouty  affections  of,  639 
haemophilic  disease  of,  662 
hysterical,  664 

implication  of,  in  fractures,  487 
injuries  of  (Chapter  XXII.),  599-626 
loose  bodies  in,  662 
neuralgic,  664 
operations  on,  629,  678 
pneumococcal,  639 
pysemic,  639 

rheumatic  affections  of,  638 
sprains  of,  599 
syphilitic  affections  of,  652 
tuberculous  disease  of,  641,  576,  633 
typhoid  disease  of,  639 
wounds  of,  599 
Jordan's  (Furneaux)  amputation  at  hip- 
joint,  1340 
Jugular  vein,  haemorrhage  from,  295 

ligature  of,  883,  347 
Junker's  inhaler,  1347 
Juxta-epiphyseal  strain,  476 

Kader-Senn's  gastrostomy,  1007 

Kangri  cancer,  194 

Keith's  glass  tubes,  962,  977 

Keloid,  263,  56 

Keratitis,  interstitial,  174 

Keratomycosis,  10 

Kidneys,        affections       of       (Chapter 
XXXIX.),  1175-1214 
abscess  of,  1199,  1202 
adenoma  of,  1210 
amyloid  disease  of,  11 79.  84 
atrophy  of,  1187,  1193 
congenital  affections  of,  1187 
displacement  of,  1188 


INDEX 


1383 


Kidneys,  calculus  in,  1203 

carcinoma  of,  12 11 

cystic  disease  of,  12 10 

embolus  in,  345 

enlarged,  signs  of,  11 76 

estimation    of    functional    activity, 
methods  of,  1177 

examination  of,  11 76,  11 77 

(loafing,  1 188 

hydatid  of,  1212 

hydronephrosis,  1193 

hypernephroma  of,  12 11 

injuries  of,  1191 

methods  of  exposure,  1175 

moveable,  1188 

nephritis,  1195 

pyelitis,  iig6 

pyelonephritis,  1197 

sarcoma  of,  12 11 

surgical,  1196 

tuberculous  disease  of,  1200 

tumours  of,  1210 
Killian's  tubes  for  air-passages,  900, 902, 
1350 

oesophagoscope,  use  of,  866 
Kingsley's  splint  for  fracture   of  man- 
dible, 497 
Kinking  of  intestine,  1126,  1130 

of  ureter,  1189,  1193 
Klapp's  suction  balls,  42,  252,  400,  401 
Klebs-Loffler  bacillus,  133 
Knee-joint,  acute  arthritis  of,  637 

amputation  through,  1337 

ankylosis  of,  666 

congenital  affections  of,  451 

dislocation  of,  622 

effusion  into,  628 

excision  of,  682,  650,  658 

internal  derangement  of,  622,  664 

subluxation  of,  622 

tuberculous  disease  of,  649 
Knock-knee,  452 

Kobelt's  tubes,  cysts  of,  1291,  1319,  231 
Koch's  postulates,  9 

tuberculin,  15,  178 

views  on  tuberculosis,  176 
Kocher's  method  of  treating  dislocation 
of  the  humerus,  609 
of    operating    for    removal    of 
tongue,  842 

operation     on     contracted     palmar 
fascia,  447 

pertrochanteric  fracture,  537 
'  Kopf- tetanus,'  136 

Kraske's  method  of  excision  of  rectum, 
1171 

treatment  for  erysipelas,  132 
Kronlein's  cerebral  topography,  746 
Kyphosis,  440,  582,  587,  589,"  590,  719, 
828 

Labium,  abscess  of,  1300 

cysts  of,  1300 
Laboratory  diagnosis  of  gonorrhcea,  142 
of  syphilis,  153 
of  tuberculosis,  177- 
Labyrinthitis,  879 
Lacerated  wounds,  242 


Laccraticjn  of  arteries,  299 
of  brain,  755,  751 
of  lung,  918 

of  recto-vaginal  se|)tum,  1299 
of  urethra,  1254 
Lachrymal  bone,  fracture  of,  494 
Lactic  acid  in  gastric  affections,  989,  990, 
1000 
in  mollities  ossium,  587 
in  tuberculous  disease  of  larynx, 
906 
Lacunar  abscess,  146,  1270 
Lambkin's  cream,  169 
Laminic,  fractures  of,  687 
Laminectomy,  698 

for  division  of  posterior  nerve-roots, 

398 
in  spinal  caries,  718 
in  spinal  diseases,  720 
Lane's  ileal  kink,  1029 

operation  for  cleft  palate,  852 
plates  for  fractures,  485 
theory  of  intestinal  stasis,  1029 
Langenbeck's  operation  for  excision  of 
rectum,  1170 
uranoplasty,  854 
Laparotomy  for  abdominal  wounds,  971 
for  appendicitis  in  quiescent  period, 

1053 
for  ascites,  986 
for  cancer  of  intestine,  1026 
for  cancer  of  stomach,  1002 
for  fulminating  appendicitis,  1054 
for  intestinal  injuries,  1017,971 
for    intestinal    obstruction,     1131', 

1135,  1139 
for  intestinal  stenosis,  1023 
for  intussusception,  1139 
for  kidney  tumours,  12 13 
for  pancreatitis,  1079 
for  perforation   of  duodenal   ulcer 
1013 
of  stomach  ulcer,  995 
of  typhoid  ulcer,  10 19 
for  perigastritis,  996,  1003 
for  peritonitic  adhesions,  980 
for  peritonitis,  acute,  977,  979,  982, 
983 
chronic,  980 
tuberculous,  981 
for  rupture  of  bladder,  12 18 
of  ectopic  gestation, 1316 
of  gall-bladder,  1069 
of  intestine,  1017 
of  liver,  1060 
of  spleen,  1082 
of  stomach,  990 
for  strangulated  hernia,  1123 
for  suppurative  appendicitis,  1057 
for  tuberculous  peritonitis,  gSi 
for  ulcer  of  duodenum,  1013 
for  ulcer  of  stomach,  994,  997 
for  wound  of  stomach,  990 
for  wounds  of  intestine,  10 17 
for  wounds  of  mesentery,  987 
for  wounds  of  rectum,  11 47 
Lardaceous  disease,  83,  1179,  1082.     See 
also  Amyloid  disease 


1384 


A   MAX  UAL  OF  SURGERY 


Larrey's   anputation   at   shouldfi'-joiiit, 

1 33 1 
Laryngeal  cartilages,  necrosis  of,  907 
dysphagia,  871 
paralysis,  906,  916,  386 

from  aneurisn.   320,   321.   322, 

386 
in  cancer  of  a'sophagus,  870 
in  cut  tliroat,  888 
in  thyroid  tumours,  892 
stenosis,  890,  905,  910,  916 
Laryngectomy,  90S,  907 
Laryngitis,  acute  and  chronic,  904,  910 
cedematous,  904,  910,   88,  89,  498, 
834.  859,  865,  888 
Laryngoscope,  use  of,  900 
Laryngotomy,  910,  901,  902,  905 
Laryngo-tracheotomy,  910 
Larynx,  diseases  of,  904-907 

acute    oedema    of,    904.     See    also 

OEdematous  laryngitis 
epithelioma  of,  907 
foreign  bodies  in,  901,  902,  910 
injuries  of,  904,  888 
intubation  of,  916 
papilloma  of,  906 

paralysis  of,  910.     See  also  Laryn- 
geal paralysis 
syphilis  of,  905 
tuberculous  disease  of,  906 
Lateral  anastomosis  of  intestine. 
1027 
curvature  of  spine,  435,  453 

in  hip  disease,  670 
implantation  of  intestine,  1039, 
lithotomy,  1237 
sinus,    thrombosis  of.    882,   96,   99, 
748, 768,  772 
pyaemia,  882,  347 
Lavage  of  stomach,  1004 

in  intestinal  obstruction,  11 32 
in  stenosis  of  pylorus,  1003 
Leaking  aneurism,  313 
Leather-bottle  stomach,  999 
Leather  splints,  482 
Leg,  amputation  of,  methods  of,  1337 

fractures  of,  547 
Leiomyoma,  212 
Leiter's  tubes,  40 
Lembert's  intestinal  stitch,  965 
Lengthening  a  tendon,  method  of,  425 
Lennander's    method    of    opening    the 

abdomen,  g6i 
Leontiasis  ossea,  803,  210,  728 
Leprosy,  189, 662 

Lepto-meningitis,  766,  768,  694,  772 
Leptothrix,  3 
Leucocytes,  enumeration  of,  59 

migration  of,  in  inflammation,  30 
phagocytic  action  of,  17,  31 
varieties  of,  60 
Leucocythajmia,  369,  65,  67 

splenectomy  for,  1083 
Leucocytosis,  62,  61 
Leucopenia,  61,  63 
Leucoplakia,  835 

Ligament,  round,  affections  of,  1300 
Ligamentum  patella-,  bursa  beneath,  429 


1038, 


1027 


Ligamentum  patelke,  rupture  of,  416 
Ligation  in  continuity  of  vessels,  327 
Ligature  of  vessels,  327-340 

for  aneurism,  316,  320,  321,  323,  324 

for  ha-morrhage,  290,  296 

for  piles,  1162 

gangrene  following,  119,  328 

secondary  ha^morrhageafter,  293,328 
Ligatures,  materials  for,  290,  277 

changes  in,  290 

effects  of,  290 

preparation  of,  277,  290 
Light,  use  of,  in  surgerv  (Chapter  IIL), 
50,51 

arc,  50 

Finsen,  51,  406,  407 

of  mercury  vapour  lamp,  51 

sun. 51, 5' 
Linea  alba,  fattj'  hernia  of,   1108,  205, 

1085 
Linear  craniectomy,  728 
Lingual  artery,  ligature  of,  331,  842,  844 
Lipoma,  204 

arborescens,  632,  654 

diffuse,  205 

nasi,  815 

of  femoral  canal,  1104 

of  inguinal  canal,  1094 

of  intestine.  1023 

painful,  of  the  foot,  205 

parosteal.  205 

pericranial,  205,  724 

retroperitoneal,  989 

subserous,  205 
'  Lipping  '  of  joints,  655.-  638,  652 
Lips,  affections  of  (Chapter  XXVIIL), 

783-794 
Lisfranc's  amputation,  1337 
Lister,  operation   for  fractured   patella, 

546 
Lister's  antiseptic  treatment  of  wounds, 
271 

bougies,  1260,  1263 

dressings,  280 

excision  of  wrist,  681 

modified  flap  and  circular  amputa- 
tion, 1323 

strong  mixture.  271 

supracondj'lar  amputation  of  thigh, 
1338 
Liston's  long  splint,  535 
Lithiasis  (lithffimia).  1184.  1231 
Litholapaxy,  1234 
Lithotomy,  lateral.  1237 

perineal.  1237 

indications  for,  1238 

suprapubic,  1236 

indications  for.  1238 
Lithotrites,  1235 
Lithotrity,  contra-indications  to,  1238 

in  boys,  1238 

operation  of.  1234 
Littre's  hernia,  1112 

operation  of  colostomy,  1034 
Liver,  abscess  of,  tropical,  1061,  71 

actinomycosis  of,  1067 

affections  of,  1059-1078 

amyloid  disease  of,  84 


INDEX 


1385 


I.iver,  displacements  of,  1059 

eiuboUis  in,  345 

foaming,  122 

gummata  of,  1066 

hydatid  cysts  of,  1065 

in  delayedchloroform  poisoning,  1 346 

rupture  of,  1060 

tumours  of,  1066 
Local  aniPsthesia,  methods  of  inducing, 

1342 
Localization  in  cerebral  injuries,  756-758 
Locking  jaw,  813 
Locomotor  ataxy,  joints  in,  659 
Longitudinal  fractures,  475 

sinus,  affections  of,  760,  769 
Loose  bodies  in  joints,  662 
Lordosis,  442 

in  hip  disease,  671 
Lorenz's   bloodless  method   of  treating 

congenital  dislocation  of  hip,  449 
Loreta's  operation  on  pylorus,  1003 
Lowenberg's  forceps,  829 
Lower  jaw.     See  Jaw  and  Mandible 
Ludwig's  angina,  89,  845,  904 
Lumbago,  418,  49 
Lumbar  abscess,  710,  717,  1109 

colostomy,  1033 

hernia,  1109 

incision  for  exposing  kidney,  1175 

nephrectomy,  1214 

puncture  for  diagnostic  purposes,  748 

puncture  for  spinal  analgesia,  1344 

puncture   for   treatment,    748,    138, 
751,  754.  767.  768 
Lung,  actinomycosis  of,  192 

embolus  in,  345 

wounds  of,  917,  921 
Lupoid  ulcers,  405 
Lupus  action  of  erysipelas  on,  132 

erythematosus,  407 

of  palate,  857 

of  tongue,  837 

treatment  of,  by  Finsen  light,  407 
by  X  rays,  407 

vulgaris,  404 
Luschka's  tonsil,  827,  863 
Luxatio  erecta,  608 
Luxation  of  joints,  601 
Luys'  segregator,  11 76 
Lymph,  characters  of,  32 
Lymphadenitis,  acute,  363 

chronic,  364 

special  forms  of,  364 

syphilitic,  364,  150 

tuberculous,  365 
Lymphadenoma,  368,  215,  1085 
Lymphangeioplasty,  363,  958 
Lymphangiectasis,  358,  790,  834 
Lymphangioma,  358,  215,  988 

of  round  ligament,  1301 
Lymphangitis,    356,    86,    157.    357-    399. 
401, 834 

syphilitic,  157 

tuberculous,  357 
Lymphatic  glands,  affections  of,  363-370 
involvement  in  soft  sores,  150 
secondary  growths  in,  370,  950 
tumours  of,  368-370 


Lymphatic  Icucjcythiumia,  64,65,67,369 

n;cvus,  358 

oedema,  360,  951,  958 

vessels,  diseases  of,  356 
Lymphatics,    diseases    of    the    (Chapter 
XV.),  356-370 

Lymphocytes,  60,  33,  44,  178 
in  chronic  inflammation,  44 
in  tuberculousinflammation,  178,179 

Lymphocytosis,  64,  61 

LymphorrhcBa,  361,  359 

Lympho-sarcoma,  369,  201, 
of  testis,  1286 
of  tonsil,  862 

Lysol,  273 

McBurney's  hook,  508 

method   of   opening   the    abdomen, 
961,  1034,  1053 

spot,  1047 
McCarrison  on  goitre,  890 
MacEwen   on   symptoms   of   abscess   of 

brain,  776 
MacEwen's  operation  for  hernia,  iioo 

for  knock-knee  (osteotomy),  454 
treatment    of    aneurism,    318, 
320, 322, 324,  326 
Macintyre's  splint,  540,  547,  553 
Mackenzie's  guillotine,  861 
Macrocheilia,  790,  359 
Macrodactyly,  444 
Macroglossia,  833,  359 
Macrostoma,  789 
Madelung's  deformity,  523 
Madura  foot,  193 
Magnesium    sulphate    in    treatment    of 

tetanus,  138 
Main-en-griffe,  392 
Malar,  fracture  of,  494 
Malaria,  diagnosis  of,  65,  64 
Malarial  spleen,  1082 
Malignancy,  characteristics  of,  197 
Malignant  adenoma,  222 

cysts  of  neck,  886,  887 

disease,  blood  in,  67 

diseases  of  scars,  263 

embolus,  199,  344 

endocarditis,  96.     See  also  Infective 
endocarditis 

goitre,  897,  891 

cedema,  122 

papilloma,  220 

pustule,  140,  141 

syphilis,  166 

tumours,  197 

ulcers,  838 

warts,  220 
Mallein  in  diagnosis  of  glanders,  188 
Mallet-finger,  417,  446 
Malposition  of  testis,  1276 

inflammation      of,      simulating 
strangulated  hernia,  1122 
Mamma.     See  Breast 
Mandible,  dislocation  of,  604 

excision  of,  810,  800 

injuries  of,  494,  604,  794 

tumours  of,  808 
Mandibular  clefts,  790 


1386 


A  MANUAL  OF  SURGERY 


Marjoliii's  ulcer,  264 
Martin's  bandage,  41,  104,  632 

proctoscope,  1144 
Massage,  45 

abdominal,  1028,  1030 
in  treatment  of  embolic  gangrene, 
113 
of  embolism,  345 
of  fractures,  484 
of  phlebitis,  347 
of  synovitis,  630 
Mast-cells,  60 
Mastitis,  acute,  935 
chronic,  937 
interstitial,  937 
Mastoid  antrum,  suppuration  in,  879 

operations  on,  880 
Mastoiditis,  879 

Matas'  operation  for  aneurism.  314 
Mattress  suture,  967 

Maxilla,  affections  of,  800-808.     See  also 
Upper  jaw 
excision  of,  806 
fracture  of,  494 
Maxillary  sinus,  empyema  of,  800 
Mechanical  treatment  of  cleft  palate,  857 
Meckel's  diverticulum,  1014,  1128,  972 
Median  cervical  fistula,  886 
hare-lip,  789 
nerve,  affections  of,  390 
Mediastinitis,  septic,  888,  867 
Medulla  oblongata,  injury  of,  758 

of    bone,    inflammation    of.       See 
Osteo-myelitis 
Medullary  cancer,  223 

plug,  479 
Megaloblasts,  64 
Megalocytes,  64 
Melffina,  283,  1013,  1159 
Melanin,  202 
Melanosis,  202 

Melanotic  sarcoma,  202,  1066 
Melon-seed  bodies,  662,  421,  423,  428, 

642 
Membrana  tympani,  appearances  of,  872, 
874 
rupture  of,  876,  734 
Meningeal  hemorrhage,  cerebral,  761 
spinal,  693 
tuberculosis     in     association     with 
tuberculous  testis,  128 
Meningitis,  basal,  766,  822 

cerebral  acute,  766,  738,  748,  759, 

769,  772,  882 
chronic,  768 
spinal,  694,  713 
syphilitic,  768 
tuberculous,  768,  748,  1281 
Meningocele,  700,  725,  815 
Meningococcus,  8 

Meningo-encephalitis,  766,  767,  759 
Meningo-encephalocele,  726 
Meningo-myelocele,  700 
Meniscitis,  623 
Menorrhagia,  1304 
Mercurialism,  169,  838 
Mercury  in  treatment  of  syphilis,   167, 
168,  170,  174 


Mesenteric    glands,    affections    uf,    988, 
1128 

vessels,   thrombosis  of,   987,    10 16, 
1126 
Mesentery,  affections  of,  987 
Meso-appendix,  thrombosis  of  vessels  in, 

1044 
Metacarpal  bones,  diseases  of,  572 
dislocations  of,  614 
fractures  of,  525 
Metacarpo-phalangeal  joint,  aminitation 

at,  1328 
Metastases  in  mumps,  844 
Metastasis,  39 

Metatarsal,  first,  tubercle  of,  574 
Metatarsalgia  (Morton's  disease),  471 
Metchnikoff's  theory  of  immunity,  17 
Meteorism,  1124,  697,  975,  1141 
Methylene-blue   test   of  renal   function, 

1177 
Metrorrhagia,  1304 
Michel's  clips,  240 
Microcephaly,  728 
Micrococci,  3 
Micrococcus  epidermidis  albus,  70 

melitensis,  8 

neoformans,  219 

prodigiosus,  203 

tetragenus,  71,  8 

ureae,  1214,  70 
Microcytes,  64 
Microsporon  Audouini,  10 

furfur,  10 
Microstoma,  790 
Middeldorpf's  triangle,  508,  505 
Middle-ear  disease.     See  Otitis  media 
Middle  lobe  of  prostate,  1246 
Middle  meningeal  artery,  wounds  of,  761 
Middle  turbinate  bone,  diseases  of,  822 
Mid-tarsal  joint,  amputation  at,  1334 
Miliary  tubercle,  178 

tuberculosis,  1285,  644,  713 
Miner's  elbow,  431 
Mirault's  operation  for  hare-lip,  787 
Mitosis  in  tumours,  219 
Mixed  infection,  71,  80 

parotid  tumour,  227 

thrombus,  345 
Mobilization  of  colon.  1026,  1034 

of  duodenum.  1076 
Modified    flap    and   circular   method    of 

amputation,  1325 
Moist  gangrene,  109 
Mollities  ossium,  586 
Molluscum  contagiosum,  410 

fibrosum,  207 
Monarticular  osteo-arthritis.  655 
Mononuclear  cells.  61 
Monoplegia  after  head  injuries,  757,  759 
Moore's  method  of  treating  aneurism,  318 
Morbus  coxa2,  668 
Morgagni,  hydatid  of,  cysts  from,  1295, 

230 
de  Morgan  spots,  353 
Morris's  bitrochanteric  line,  533 
Morton's    disease.       See    Metatarsalgia 

fluid,  703 
Motor  aphasia,  756,  771 


INDEX 


1387 


Motor  area,  paralysis  of,  in  cerebral  com- 
pression, 753 
wounds  of,  757 
oculi  nerve,  affections  of,  379 
Moure's  operation   (lateral  rhinotomy), 

805.  827 
Mouse  cancer,  196 
Mouth,   affections  of  (Chapter   XXX.), 

S32-858 
Moveable  kidney,  1188 

spleen,  1082 
Moxa,  45 
Muco-pus,  78 
Mucous  colitis,  1020,  105 1 

cysts  of  frontal  sinus,  743 
of  lips,  792 
of  mouth,  845 
polypi  of  antrum  of  jaw,  803 
polypus  of  nose,  824 
tubercles,    159,   160,  217,  791,  837 
905,  1159,  1164 
treatment  of,  170 
Mulberry  calculus,  1230 
Multiple  abscess  of  liver,  106 1 

fractures,  473 
Mummification,  109 
Mumps,  844 
Murexide  test,  11 84 
Muscle,  congenital,  induration  of,  433 

of  Treitz,  1086 
Muscles,  affections  of  (Chapter  XVIII.), 
414-420 
changes  in,  after  injury  to  nerves, 

372 
inflammation  of,  418 
rupture  of,  415,  136 
tumours  of,  420 
Muscle-splitting,     method     of     opening 
abdomen    (McBurney's),    961,     1034, 
1053 
Muscular  torticollis,  432 
Musculo-spiral  nerve,  injury  of,  389,  960 

operation  on,  390 
Mycetoma  (Madura  foot),  193 
Mydriasis,  380 
Myelitis,  spinal,  694,  711 
Myelocele,  700 
Myelocytes,  65 

Myeloma,  211,  590,  730,  799,  809 
Myelomatosis,  212 
Myelopathic  albumosuria,  212 
Myeloplaxes,  211,  179 
Myoma,  1028,  212 

Myomectomy  for  fibroids  of  uterus,  1305 
Myosarcoma,  202 
Myosis,  758 
Myositis,  418 

fibrosa,  418,  433,  489 
ossificans,  419,  489,  665,  812 
parasitic,  419 
rheumatic,  418 
suppurative,  419 
syphilitic,  419 
traumatic,  418 
tuberculous,  419 
Myxoedema,  898,  890,  897,  589 
Myxo-fibro-neuroma,  214 
Myxoma,  204,  720 


Najvo-lipoma,  355 
Nrevus,  352,  312,  53 

cavernous,  354 

electrolysis  for,  53 

lymphatic,  358 

of  lip,  792 

of  scalp,  723 

of  umbilicus,  972 

spider  (N.  araneus),  353 

unius  lateris,  353 
Nails,  affections  of,  407 
Napkin  rash,  173 
Nasal  bones,  fracture  of,  493,  814 

obstruction,  804,  818,  824,  826,  828 

polypi,  824,  814 

septum,  deviations  of,  818 
fracture  of,  494 

spurs,  818 
Naso-orbital  fissure,  785,  789 
Naso-pharyngeal  polypus,  825,  864 
Naso-pharynx,  examination  of,  817 

operations  on,  827 
Nastin  in  treatment  of  leprosy,  191 
Navel,  starting  of,  1106 
Neck,  abscess  in  glands  of,  364 

affections    of    (Chapter    XXXII.), 
884-899 

cellulitis  of,  88 

malignant  glands  of,  operations  on, 

843 
of  femur,  abscess  in,  673 

fractures  of,  529 
of  humerus,  fractures  of,  503 
of  radius,  fractures  of,  518 
of  scapula,  fracture  of,  502 
tuberculous  glands  of,  366 
Necrosis,  acute,  560,  34 

after  amputation,  1328,  567 
after  compound  fracture,  567 
central,  568,  569 
fat,  1079 
quiet,  557 
superficial,  559 
syphilitic,  578,  163 
tuberculous,   of  cranial  bones, 

729 
tubular,  568 
typhoid,  569 
of  bone,  560,  556,  558,  562, 565 
of  jaw,  799 
of  ossicles  of  ear,  878 
of  palate,  858 
of  skull,  728 
of  temporal  bone,  878 
Needles,  wounds  by,  245 
Negri  bodies  in  hydrophobia,  139 
Nelaton's  line,  532,  450,  617 

operation  on  naso-pharynx,  827 
Neo-salvarsan,  167 

Nephrectomy,  for  abscess  of  kidney,  1200 
for  calculus  pyonephrosis,  1209 
for  hydronephrosis,  1195 
for  injury  of  kidney,  1192 

of  ureter,  1192 
for  tuberculous  disease,  1203 
for  tumours,  1211,  1212 
indications  for,  12 13 
methods  of,  1213 


1388 


A   MANUAL  OF  SURGERY 


Nephritis,  1195,  1179 

surgical  treatment  of,  1195 
Nephrolithotomy,  1208 
Nephropexy,  1190 
Nephrorrhaphy,  1190 
Nephrostomy,    1197,    1199,    1194,    1200, 

1230,  1263 
Nephrotomy,  1195,  1199 
Nerve  anastomosis,  376,  385 

extraction,  378 

grafting,  376 

roots,  affections  of,  395 

division    of    (Forster's    opera- 
tion), 398 
P     stretching,  378,  381,  394,  135 
''>     suture,  375 

Nerves,    affections   of    (Chapter    XVI.), 
371-398 
of  special,  379-398 

bulbous  ends  of,  372,  1328,  214,  263 

degeneration  of,  372 

division  of,  372 

inflammation  of,  376 

injuries  of,  370,  735 
^     involvement  in  fractures,  488 

regeneration  of,  375 

rupture  of,  371 

suture  of,  375 

tumours  of,  212-214 

See  also  the  special  nerves 
Nervous    phenomena    in    intestinal    ob- 
struction, 1125 

traumatic  delirium,  269 
Neuralgia,  377,  313 

of  joints,  664 

of  scalp,  780 

of  testis,  1294 

sciatic,  393 

spinal,  operation  for,  398 

trigeminal,  380 
Neurasthenia,  695,  750 
Neurectomy,  378,  381 
Neurenteric    canal,    origin    of    tumours 

from,  703 
Neuritis,  acute  and  chronic,  376,  377 

optic,  379.  776,  775.  771.  772.  88 

peripheral,  joint  changes  in,  662 
Neuro-fibromatosis,  213,  720 
Neuroma,  212 
»^     traumatic,  214,  372 
Neuropathic  arthritis,  659,  662 
Neurotomy,  378,  381 
Nicoll's    operation    for    radical    cure    of 

femoral  hernia,  1106 
Night  pains  in  bone  disease,  578,  570 
in  joint  disease,  634,  644,  672 

sweats,  ?^ 
Nipple,  affections  of,  934 

retraction  of,  949,  938,  940 
Nitrous  oxide  gas,  method  of  using,  1345 
Nocturnal  incontinence  of  urine,  1239 
Node,  periosteal,  569,  578,  729 

from  chronic  ulceration,  102 

syphilitic,  578,  580,  160 

tuberculous,  571 
Nodes,  Parrot's,  580 
Nodular  arterio-sclerosis,  305 
Noma,  124,  112 


Non-specific  pyogenic  infections,  68-99, 12 
Non-tuberculated  leprosy,  189 
Non-union  of  fractures,  491 
Normal  blood,  66 

Nose,   affections   of   (Chapter    XXIX.), 
814-831 

depression  of  bridge,  814 

examination  of,  817 

expansion  of  bridge,  814 

foreign  bodies  in,  818 

malignant  disease  of,  826 

operations  for  dealing  with  disease 
of,  827 

ozaena,  820 

polypi  of,  824 

rhinitis,  818 

septum  of,  deformities  of,  818 
Novocaine,  1043,  1055 
Nystagmus,  879,  776 

Oat-shaped  sarcoma,  201 
Oblique  facial  cleft,  789 

inguinal  hernia,  1089 
Obliterated  hypogastric  artery,  relation 

to  hernia,  1092 
Obliteration  of  appendix,  1043 

of  arteries,  308 
Obstetric  fracture,  474 
Obstructed  hernia,  11 11 
Obstruction,  intestinal  (Chapter 

XXXVII.),  1124-1143 
acute,  1126-1133 
causes  of,  1126 
diagnosis  of,  1140,  1131 
method  of  examining  a  case  of, 

1141 
phenomena  of,  1127,  1129 
treatment,  1131-1133 
chronic,  1133-1136 
causes  of,  1133 
diagnosis  of,  1135 
symptoms  of,  11 36 
treatment  of,  1135 
nasal,  824,  826,  828 
of  vessels,  gangrene  from,  119 
to  flow  of  saliva,  845 
Obturator    artery,    relation    to    femoral 
hernia,  1103,  1122 
dislocation  of  hip,  619,  616 
hernia,  11 10 
Obturators  for  cleft  palate,  857 
Occipital  artery,  compression  of,  292 
ligature  of,  332 
lobe,  abscess  of,  771 
injuries  of,  758 
Occiput,  dislocation  of,  691,  712 
Oculomotor  palsy,  758 
Odontoid  process,  fracture  of,  691 
Odontomata,  215,  803,  804,  808 
O'Dwvcr's  intubation  tubes,  916 
CEdenia,  acute  spreading,  755,  752,  77t 
anthrax,  141 
lymphatic,  360,  951,  958 
malignant,  122 
of  brain,  752,  755 
of  glottis,  904.  910,  88,  89,  498,  834, 

859,  867,  888,  902,  916 
of  scrotum,  1297 


INDEX 


1389 


CEsophageal  bougies,  866 

dj'sphagia,  872 

fistula,  890 
CEsophagocele,  866,  869 
Qisophagoscope,  866 
G£sophagotoniy,  868 
(Esophagus,  affections  of,  866-871 

anatomy  of,  866 

diverticula  of,  866 

fistula  of,  866 

foreign  bodies  in,  867 

inflammation  of,  868 

spasm  of,  869 

stricture  of  fibrous,  869 
malignant,  869 

varix  of,  869 
Ogston's  operation  for  flat-foot,  46S 
Oidium  albicans,  10,  837 
Oil  of  turpentine  in  frost-bite,  125 
Olecranon  bursa,  431,  628 

fracture  of,  516 
Oleo-balsams  in  treatment  of  gonorrhosa, 

145 
Olfactory  nerve,  affections  of,  379 
Omental  cords,  986,  1128 

cysts,  1087 

grafts,  986 

hernia,  1087,  1088,  1116 
Omentum,  affections  of,  986 

cancer  of,  987 

strangulation  of,  in  hernia,  1114,1116 

torsion  of,  987,  973,  1126 
Onychia,  408 
Onychogryphosis,  409 
Oophorectomy  for  uterine  fibroids,  1308 

for  osteo-malacia,  587 

in  cancer  of  breast,  958 

in  hystero-epilepsy,  780 
Open  method  for  chloroform,  1346 
for  ether,  1349 
for  gas,  1345 
Open  treatment  of  wounds,  281 
Operating  theatre,  essentials  of,  274 
Operations,  abdominal,  remarks  on,  959 

during  shock,  268 

technique  of,  959-967 
Operative  surgerv,  technique  of  (Chap- 
ter XI.),  271-281 

treatment  of  fractures,  484 
Ophthalmia  neonatorum,  147 
Ophthalmoplegia  externa,  380 
Opisthotonos,  136 
Opium  in  intestinal  obstruction,   1132, 

1135,  1139,  1140 
Oppler-Boas  bacillus,  990 
Opsonic  index  24,  178,  645,  982 
diagnostic  value  of,  24 
Opsonins,  23.  24 
Optic  atrophy,  379,  88,  777 

nerve  aft'ections  of,  379 

neuritis,  379,  776,  765,  771,  772,  88 
Oral  sepsis,  importance  of,  796,  84,  73, 

1012,  1041, 1042 
Orbit,  penetrating  wounds  of,  88 
Orbital  aneurism,  323,  379,  763 

cellulitis,  88,  379 
Orchitis,  acute,  1279,  844 

chronic,  1280,  1295 


Orchitis,  syphilitic,  1283,  1295 

tuberculous,  1281,  1295 
Organ  of  Giraldes,  230,  1286 

of  Kosenmiillcr,  230,  1319 
cysts  of,  1 3 19 
Organic  stricture  of  urethra,  1257 
Organization  of  blood-clot,  healing  by, 

261, 570, 1066 
Orthopncea,  929 
Os  calcis,  fracture  of,  553 

tuberculosis  of,  574,  575 
Os  incisivum,  785,  788 
Os  magnum,  dislocation  of,  614 
Osseous  ankylosis,  665 
Ossicles  of  ear,  necrosis  of,  878 
Osteitis,  558,  556 

deformans,  5S7,  441 

fibrosa,  597 

syphilitic,  578 

tuberculous,  571 

typhoid,  568 
Osteo-aneurism,  596 
Osteo-arthritis,  653,  661,  638 

of  hip,  65S,  533 

of  spine,  719.  44i 

of  temporo-maxillary  joint,  811,  659 

varieties  of,  655 
Osteo-arthropathy,    hypertrophic.     590, 

441.  85 
Osteoblasts,  479,  556,  584 
Osteochondritis,  syphilitic,  581 
Osteoclasia,  493 
Osteoclasts,  557 
Osteocopic  pains,  160,  578 
Osteogenesis  imperfecta,  586,  474 
Osteoma,  208,  743 

of  antrum,  803 

of  lower  jaw,  808 

of  skull,  729,  743 

of  spine,  719 

of  upper  jaw, 803 
Osteo-malacia,  586,  441,  473-  492 
Osteo-myelitis,  556,  558,  560,  567 

acute,  infective,  560,  567,  916 

in  compound  fractures,  490,  567 
of  cranium,  728,  730,  742 
of  spine,  704 

syphilitic,  580,  569 

tuberculous,  577,  571 
Osteo-periostitis,  chronic,  569,  577 
Osteophytes,  635,  642,  655,  661 
Osteo-porosis,  557,  556 
Osteo-psathjTOsis,  473,  586 
Osteo-sarcoma,  592 
Osteo-sclerosis,  558,  570 
Osteotome,  454 
Osteotomy,  Adams's,  667 

cuneiform,  457 

for  knock-knee,  454 

for  rachitic  deformities,  5S5,  457 

]\IacE wen's,  454 

subtrochanteric  (Gant),  667,  451 
Otitis  media,  876,  70,  S28 

abscess  of  brain  in,  770 
thrombosis  of  lateral  sinus  in, 
882,768 
Otomvcosis,  10 
Otorrhcea,  chronic,  877,  768,  770 


1390 


A   MANUAL  OF  SURGERY 


Otorrhoea,  complications  of,  878-883 
Ovarian  cysts,  131 7 

complications  of,  1321 
malignant,  1323 
torsion  of,  1321,  973,  1051,  1131 
dermoids,  228,  1319 
hydrocele,  13 19 
Ovaries,  removal  of,   in   hvsterectomv, 

1308 
Ovaritis,  complicating  appendicitis,  1047 
Ovariotomy,  1322 
Ovary  in  sac  of  hernia,  1088 

tumours  of,  1323 
Oxalate  of  lime  calculi,  1230,  1204 

deposits  in  urine,  11 85 
Oxaluria,  1185,  1231 
Oxyuris  vermicularis,  1148 
Ozaena,  820 

Pachydermatocele,  214,  724 
Pachymeningitis,  764,  694,  696 
Paget's  disease  of  nipple,  934,  947 

'  quiet  necrosis,'  673,  557 

recurrent  fibroid,  202,  947 
Pain  in  burns,  124 

in  cholelithiasis,  1073 

in  gangrene,  108,  iii,  113,  115 

in  inflammation,  35 

in  intestinal  obstruction,  1142 

in  Pott's  disease,  706 

in  vesical  calculi,  1232 

referred,  36,  673,  707,  1047,   1205, 
1232 
Painful  lipoma  of  foot,  205 

scars,  263 

stump,  1328 

subcutaneous  nodule,  213 
Painless  haematuria,  1228 
Palate,  affections  of,  849-858 

cleft,  849 

diseases  of,  857,  579 
Palatine  route  for  operations  on  nasal 

growths,  827 
Palmar  abscess,  253 

arch,  haemorrhage  from,  297 

fascia,  contraction  of,  446 

ganglion,  compound,  423 
Palsy,  crutch,  488 

infantile,  458,  720 
Panaritium.     See  Paronychia 
Pancreas,  affections  of,  1078 

carcinoma  of,  108 1 

cysts  of,  1080 

in  diabetes,  11 80 

risks  of  wounds  of,  and  operations 
on,  1078 
Pancreatic  calculi,  1079,  1080 
Pancreatitis,  acute,  1079 

chronic,  1080 
Panhysterectomy,  1307,  1310 
Panophthalmitis  after  orbital  cellulitis, 

88, 147 
Panostitis,  acute,  560 
Pan -sinusitis,  821 
Papillary  synovitis,  632 
Papilloedenia,  776.     See  Optic  neuritis 
Papillomata,  216 

malignant,  220 


Papillomata  of  bladder,  1225 

of  breast,  946,  953 

of  intestine,  1023 

of  kidney,  12 10 

of  larynx,  906 

of  lip,  792 

of  nipple,  935 

of  rectum,  1166 

of  scalp,  724 

of  tongue,  838 
Papular  syphilides,  159,  173 
Paquelin  cautery,  50 
Paracentesis  abdominis,  985 
Paradidymis,  230,  1286 
Paraffin  cancer,  1298 

injection  of,  for  deformed  nose,  814 
Paralysis  after  injury  to  brain,  756,  753 

after  injury  to  spine,  696 

crossed,  758 

Erb-Duchenne,  388 

infantile,  720,  458 

of  bladder,  1240,  690,  697 

of  face,  383,  735.  847.  878 

of  intestine,  1126,  1125,  974,  1113 

of  larynx,  906,  320,  321,  322,  386, 
870,  888, 910, 916 

of  serratus  magnus,  388,  443 

of  sphincter  vesicae,  1240,  697 

post-diphtheritic,  133 
Paralytic  talipes.     See  varieties  of  talipes 
Paraphimosis,  1271 
Paraplegia,  bedsores  in,  690,  120 

gravitation,  693 

in  spinal  caries,  711,  71S 

in  spinal  injuries,  695 
Parasites,  4 

cancer,  195 

examination  of  blood  for,  65 
Parasitic,  organisms,  4 

cysts,  233 

emboli,  344 

myositis,  419 

theory  of  tumours,  195 
Parathyroids,  898 
Parenchymatous  glossitis,  acute,  834 

goitre,  892 

inflammation,  38 

injections  in  joints,  646 
Parieto-occipital  fissure,  745,  757 
Parker's  tracheotomy-tube,  912 
Paronychia,  252,  407 
Paroophoron  cysts,  230,  1318 
Parosteal  lipoma,  205 
Parotid  tumours,  847 

mixed,  227,  847 
Parotitis,  epidemic,  844,  1279 
simple,  844 
suppurative,  844 
Parovarian  cysts,  1319,  230 
treatment  of,  1328 
Paroxysmal  haemoglobinuria,  1231,  1183, 

118 
Parrot's  nodes,  580 
Passable  stricture  of  urethra,  treatment 

of,  1263 
Passive  hyperiemia,  41 
immunity.  16 

incontinence  of  urine,  1240 


INDEX 


1391 


Paste,  Unna's,  104 

Pasteur's  treatment  of  hytlrophobia,  140 

vaccine  for  anthrax,  140 
Patella,  congenital  absence  of,  451 
dislocations  of,  621,  451,  454 
fractures  of,  543 
operations  on,  545,  546 
Patellar,  bursa,  enlargement  of,  429,  628, 

tap,  628 
Patheticus  nerve,  affections  of,  380 
Pathogenic  bacteria,  4,  11 
Pathological  contractions  of  scars,  262 

dislocations,  600 
Paul's  tube,  1031,  1034,  1120,  1132,  1135 
Peau  d' orange  in  cancer  of  breast,  95  ij 
Pelvic  cellulitis,  89,  85,  1023,  1165,  1218, 

1220, 1224 
Pelvirectal  abscess,  1150 
Pelvis,  fractures  of,  526-529 

injury  to  bladder  in,  1217,  527 
to  urethra  in,  1254,  527 
rachitic,  584 
triradiate,  584,  587 
Pemphigus,  173 
Penetrating  wounds,  245 

of  abdominal  walls,  968,  978, 

987 
of  arteries,  301 
of  brain,  759 
of  joints,  599 
of  liver,  1063 
of  lung,  919 
of  spine,  685 
of  testis,  1277 
Penile,  fistula,  146,  1270 
Penis,  affections  of,  1270-1274 
amputation  of,  1274 
balanitis,  1272 
chancre  of,  155 
epithelioma  of,  1273 
fistulae  of,  1270 
herpes,  1272 
paraphimosis,  1271 
phimosis,  1270 

plastic  operations  on,  1254,  1270,147 
warts  of,  1273 
Peptic  ulcer    after    gastro-enterostomy, 

1012,  998 
Perforating  ulcer  of  duodenum,  10 12, 127, 

of  foot,  402,  661 
Perforation  of  appendix,  1044 
of  bowel,  1018,  975 
of  colon,  in  chronic  obstruction,  1019 
of  duodenal  ulcer,  1012,  1051 
of  intestine,  1018 
of  palate,  857 
of  stomach,  994,  105 1 
of  typhoid  ulcer  of  intestine,  1018 
Peri-adenitis  in  soft  sore,  150 

in  tuberculous  glands,  369 
Peri-arteritis,  303 
Pericardial  effusions,  928 
Pericarditis,  suppurative,  928 
Perichondritis  of  larynx,  acute,  907,  904, 
902 
chronic,  907 
Pericranial  gumma,  579,  729 
lipoma,  205,  724 


l^ericranitis,  728 
Perigastritis,  993,  996 
Perineal  abscess,  1258,  1267 
cystotomy,  1223 
fistula,  1267,  1270,  1258 
lithotomy,  1237 

(jperation  for  malformation  of  rec- 
tum, 1 146 
prostatectomy,  1252 
section,  1266 
Perinephric  abscess,    1200,    1047,    1192, 
1204 
haemorrhage,  iigi 
Perinephritis,  1200 

Perineum,  operation  for  ruptured,  1303 
Perineuritis,  377 
Peri-onychia,  407 
Periosteal  bridge,  478 
nodes,  569,  578 
sarcoma,  593 
sleeve,  476 
Periostitis,  559,  728 
acute,  559 
albuminosa,  563 
chronic,  569 
suppurative,  559,  561 
syphilitic,  569,  578,  917 
tuberculous,  570,  705,  917 
typhoid,  569 
Peripheral  neuritis,  117 
Periphlebitis,  346,  130 
Periproctitis,  gangrenous,  1151 
Perirectal  suppuration,  1148,  1147 
Peristalsis  in  intestinal  obstruction,  1125, 

1134, 1141 
Perisynovial  gummata,  652 
Perithelial  sarcoma,  227 
Perithelioma,  227 

Peritoneal  adhesions,  strangulation  by, 
1128 
pouches  and  slits,  1128 
Peritonism,  964 
Peritonitis,  972-983,  971,  69 

acute  diffuse,  974,  1016,  1046,  1054, 

1079, 1218 
acute  localized,  979 
ante-natal,  1029 
aseptic,  1078,  1126 
chronic  simple,  980,  987,  1136 
following  appendicitis,  1045,  1049 
gonorrhcsal,  982,  149,  1312 
pneumococcal,  982 
tuberculous,  980,  973,  987,  988 
Peritonsillar  abscess,  859 
Perityphlitis,  1040 
Peri-urethral  abscess,  1267,  1255 
Permanent  callus,  479 
Permanganate  of  potash,  273 
Permeation  (infiltration)  of  cancer  cells, 

219, 1024 
Pernicious  anaemia,  64,  85 
Pernio,  403 

Peroneal  artery,  ligature  of,  340 
Peronei  tendons,  tenotomy  of,  425,  465, 

467 
Peroxide  of  hydrogen,  273 
Perrin's    (Maurice)    subastragaloid    am- 
putation, 1335 


1392 


A   MANUAL  OF  SURG  BUY 


Perthes'  incision  for  gall-bladder,  1076 
Pertrochanteric  fracture,  537 
Pes  cavus,  459,  468 
Petechias,  282 

in  septic  conditions,  92,  93 
Petrissage,  46 
Petticoated  tube,  1224 
Pfeiffer's  reaction,  22 
Phagedena,  157,  123,  112 
Phagocytosis,  18 

Metchnikoff's  theory  of,  18 
Phalanges,  amputation  of,  1328 

dislocation  of,  614 

fracture  of,  525 
Phantom  tumour,  971 
Pharyngeal  dysphagia,  871 

fistula,  890 

stenosis,  864 

tonsil,  827,  863 
Pharyngitis,  varieties  of,  863 
Pharyngocoele,  867 
Pharyngotomy,  subhyoid,  907 

transhyoid,  907,  865 
Pharynx,  affections  of,  863 
Phelps's  box,  714,  676 

operation  for  talipes,  465 
Phimosis,  1239,  1270 

as  a  cause  of  hernia,  1085 

in  association  with  cancer  of  penis, 
1270,  1273 

retention  of  urine  from,  1241 
Phlebitis,  345,  351 

infective,  346,  96 

septic,  346 
Phleboliths,  342,  350 
Phlebotomy,  351 
Phlegmasia  alba  dolens,  343 
Phlegmonous  gastritis,  992 

inflammation,  38 
Phloridzin  test  for  estimation  of  renal 

function,  1178 
Phosphates  in  urine,  1185 
Phosphatic  calculi,  1230,  1247,  1186 
Phosphaturia,  1186 
Phosphorus  necrosis  of  jaw,  799 
Phrenic  nerve,  injury  of,  387 
Picric  acid  in  treatment  of  burns,  127 

test  for  sugar,  1180 
Pigeon-breast,  583 
•  Pig-skin  '  in  cancer  of  breast,  951 
Piles,  1 155.     See  also  Hasmorrhoids 
Pin  in  urethra,  1255 
Pipe-stem  motions,  1170,  1165,  1168 
Pirogoff' s  amputation,  1336,  575 
Pituitary  body,  tumours  of,  778,  588 
Pityriasis  rubra,  10 
Plantar  arch,  haemorrhage  from,  298 

fascia,  division  of,  463 
Plantaris  tendon,  rupture  of,  417 
Plaques  muqueuses,  862 
Plasma-cells,  44 
Plaster  of  Paris  jackets,  714 

splints,  483 
Plastic  arteritis,  303 

inflammation,  38 
Plates  (Lane's)  for  fractures,  486 
Pleura,  affections  of,  917,  g  18 

drainage  of,  923 


Pleurosthotonos,  136 
Plexiform  angioma,  355 

neuroma,  212 
Pneumatocele  capitis,  741 
Pneumertomy,  926 
Pncuinocole,  921 
Pneumococcal  arthiitis,  639 
empyema,  922,  923 
peritonitis,  982 
Pneumococcus,  70,  8,  93,  96,  563,  633, 
764,  922,  923,  973,  982 
capsules  of,  2 
Pneumogastric  nerve,  affections  of,  386 
Pneumomycosis,  10 

Pneumonia,  diagnosis  from  appendicitis, 
103 1 
hypostatic,  488 
leucocytosis  in,  62 
septic,  in  fracture  of  jaw,  496 

after  excision  of  tongue,  843 
after  injury  to  lung,  919 
after  tracheotomy,  915 
from  foreign  body  in  bronchus, 

903 
in  cut  throat,  889 
in  wound  of  lung,  919 
Pneumothorax,  918,  925,  927 
Pneumotomy,  926 
Podagra,  639 
Poikilocytosis,  64 
Points  douloureux,  377,  380 
Poisoned  wounds,  250 
Polio-myelitis,  anterior,  720 
Politzer's  method  of  inflating  middle  ear, 

874 
Polyarticular  osteo-arthritis,  656 
Polydactylism,  444 
Polymastia,  933 

Polymorphism  of  syphilides,  158 
Polymorphonuclear  leucocytes,  6c 
Polynuclear  leucocytes,  60,  33,  73 
Polyorchism,  1275 
Polypus,  mucous,  824 

of  antrum,  800,  803,  822 

of  ear,  878 

of  frontal  sinus,  743 

of  naso-phar\Tix,  825,  864 

of  nose,  824 

of  rectum,  1166,  1147,  1154,  1158 

of  umbilicus,  972 

of  urethra,  1256 

of  uterus,  1303 
Polyvalent  sera,  27 
Pond  fracture  of  skull.  737,  739 
Pons  Varolii,  injury  of,  758 
Popliteal  aneurism,  326 

artery,  ligature  of,  338 

bursa?,  affections  of,  430 

nerves,  injury  of,  394 
Poroplastic  splints,  482 
Port-wine  stain,  353 
Post-anal  dimple,  704 
Posterior  cervical  nerves,  operation  on. 

434 
gastro-enterostomy,  loio 
nerve-roots,  division  of,  398 
rhinoscopy,  817 
tibial  artery,  ligature  of,  339 


INDEX 


1393 


Post-mortem  wounds,  252 
Post-nasal  plug,  830 
Pott's  disease,  704,  441 
fracture,  550 
puffy  tumour,  765,  728 
Pouches  of  peritoneum,  strangulation  of 

intestines  by,  1128 
Poultices,  41,  47 
Power  (D'Arcy),  treatment  of  aneurism, 

318 
Precipitins,  21 

Pregnancy,  extra-uterine,  1314 
lordosis  in,  442 
piles  in,  1156 

varicose  veins  in,  1300,  348 
Preliminary  colostomy,  1170,  1171 

tracheotomy,  842,  910,  912 
Preparation    of    patient    for    abdominal 

operations,  959 
Prepuce,  deformities  of,  1253 
Pressure  diverticula  of  oesophagus,  866 
Pressure   in    treatment    of    disease     of 
joints,  630,  632 
of  hcemorrhage,  288 
of  inflammation,  45 
of  ulcers,  104 
Priapism,  697,  1249,  1297 
Prickle  cells  in  epitheliomata,  222 
Primary  arterial  hasmorrhage,  291 
nerve  suture,  375 
sore,  155 

of  anus,  1 1 64 
of  finger,  156 
of  lips,  791 
of  nipple,  935 
of  tongue,  837 
of  tonsil,  861 
of  urethra,  156 
tuberculosis  of  kidney,  1200 
union  of  wounds,  258 
Probang,  867 
Proctectomy,  1169-1174 
Proctitis,  1 147 

gonorrhoeal,  147,  1165 
Proctoclysis,  92,  285,  978,  963 
Proctodeal tags,  1154 
Proctoscope,  1145 
Profeta's  law,  172 
Prolapse  of  anus,  1161 
of  colon,  1030,  1028 
of  lung,  921 
of  rectum,  ii6i,  1158 
of  uterus,  1302 
Properitoneal  hernia,  1092 
Proptosis.     See  Exophthalmos 
Prostate,  affections  of,  1242-1252 
abscess  of,  1242,  1268,  1270 
calculi  of,  1244 
cancer  of,  1252 
haemorrhage  from,  1183 
inflammation  of,  1245 
senile  enlargement  of,   1216,   1245- 

1252, 1221 
tuberculosis  of,  1244 
Prostatectomy,  perineal,  r252 

suprapubic,  1251 
Prostatic  pouch,  1247 

urethra,  forcible  dilatation  of,  1244 


Prostatic  urethra  in  enlargedprostate,  1 246 
Prostatitis,  138,  1242 

chronic,  1243 
Prostatorrhoea,  1243 
Protopathic  sensation,  373 
Protozoa,  10 
Provisional  callus,  479 
Pruritus  ani,  1148,  1155,  1156 
Psammomata,  228,  720,  775 
Psathyrosis,  idiopathic,  586 
Pseud-arthrosis,  602,  491,  427 

after  excision  of  joints,  679 
Pseud-elephantiasis,  103 
Pseudo-hypertrophic  paralysis,  442 
Pseudo-neuroma,  212 
Pseudo-paralysis,  syphilitic,  581 
Psoas  abscess,  710,  7'i7'  182,  673.  1104 
treatment  of,  717 

bursa,  affections  of,  430 
Psoriasis  linguse,  836 

syphilitic,  161 
Psorosperms,  11 
Ptomains,  5 
Ptosis,  379,  769 

Pubic  dislocation  of  hip,  620,  616 
Pudic  artery,  haemorrhage  from,  298 
Puerperal  peritonitis,  973 
Pulled  elbow,  614 
Pulmonary  abscess,  926 

decortication,  925 

embolus,  343,  345 

hemorrhage,  918,  921 
Pulpy   degeneration   of  synovial  mem- 
brane, 641 
Pulsating  empyema,  922 

exophthalmos,  323 

goitre,  896,  322 

sarcoma  of  bone,  596,  312 

tumours  of  bone,  596 
Pulse  in  aneurisms,  311,  321,  322 

in  cerebral  compression,  753 
concussion,  750 

in  haemorrhage,  283 

in  peritonitis,  975 

in  shock, 265 
Punctured  fracture  of  skull,   735.   738. 

741 
wounds,  245 

of  chest,  919 
of  heart,  927 
of  intestine,  1017 
of  lung,  919 
of  testis,  1277 
Pupils  in  anaesthesia,  1347,  1352 
in  cerebral  compression,  753 

concussion,  750 
in  spinal  injuries  (cervical),  693,  697 
Purpura,  Henoch's,  1138 
Pus  corpuscles,  31 

in  acid  urine  in  pyelitis,  1197 
in  acute  abscess,  78,  76 
in  chronic  abscess,  181 
laudable,  76 
sterile,  71,  1062,  1313 
tuberculous,  181 
varieties  of,  78 
Pustular  acne,  69 
syphilide,  159 

88 


1394 


A  MANUAL  OF  SURGERY 


Pustule,  malignant,  141 
Pysemia,  123,  95,  69.  131,  343,  562,  769, 
882, 1061, 1082 

in  diseases  of  bones,  562,  565,  568 

in  joint  diseases,  811 

lateral  sinus,  882,  343 
PyEemic  abscess,  97,  1061,  1082,  1199 

synovitis,  639 
Pyelitis,  1196,  1197 
Pyelo-nephritis,  1196,  1197,  1204,  1222, 

1224,  1236,  1248,  1259,  1262 
Pylephlebitis,  97,  345,  1047,  1049,  1061 
Pyloroplasty,  1008,  1003 
Pylorus,  cancer  of,  looi 

congenital  hypertrophy  of,  1003 

stenosis  of,  1002,  looi 
Pyogenic  bacteria,  68 

infections  (Chapter  V.),  68-gg 
of  kidney  and  ureters,  1195 

membrane,  76 
Pyonephrosis,    1194,    1196.    1199,    1221, 

1247, 1259 
Pyo-pneumothorax,  subphrenic,  9S4 
Pyorrhoea  alveolaris,  796,  84,  1012,  1041 
Pyosalpinx,  1311,  980,  982,  71 
Pyosepticamia,  97 
Pyrexia,  36 
Pyuria,  1183,  1199,  1258 

in  tuberculous  kidney,  1202 

in  tuberculous  prostate,  1244 

Quiescent  interval  in  appendicitis,  1049 

operation  in,  1053 
'  Quiet  necrosis,'  673,  557 
Quinine  in  liver  abscess,  1064 
Quinine-urea,  as  aucesthetic,  1343,  1355 
Quinsy,  859 

Rabies,  139 

Rachitic  tibia  and  fibula,  457 

Racquet  method  of  amputation,  1325 

at  hip-joint,  1341 
Radial  artery,  compression  of,  290 

ligature  of,  335 
Radiant  heat,  49,  419,  658 
Radical  cure  of  haemorrhoids,  11 59 

of  hernia,  1097,  1105,  1107,  1108 
contra-indications,  1097 
recurrence  after,  1102 
of  hydrocele,  1289 
of  varicocele,  1293 
Radicular  odontome,  215 
Radi(-)graphic  screen,  52 
Radiography.     See  X  rays 
Radium,  55-57 
uses  of,  56 

in  cancer,  56 

in  mammary  cancer,  56,  956 
in  myeloma,  57,  591 
in  oesophageal  cancer,  871 
in  rodent  ulcer,  56,  413 
in  sarcoma,  57,  595 
in  uterine  cancer,  57,  13 11 
Radius,  congenital  absence  of,  443 
dislocations  of,  613 
excision  of  head  of,  518,  613,  681 
fractures  of,  518 
separation  of  lower  epiphysis,  523 


Radius,  subluxation  of  head  of,  614 
Radius  and  ulna,  dislocation  of,  611,  613 

fractures  of,  524 
Railway  spine,  694 
Ranula,  845 
Rapid  dilatation  of  stricture  of  urethra, 

1263 
Rarefaction  of  bone,  556,  557 
Rashes  of  syphilis,  158 
Ray  fungus,  191 
Raynaud's  disease,  118,  112 

haemoglobinuria  in,  1183 
Reaction  from  concussion,  750 
from  shock,  265 
of  degeneration,  51,  373 
Reactionary  fe\er,  268 
haemorrhage,  292 
Recklinghausen's  disease,  2J4 
Rectal  administration  of  ether,  1351 

examination  in   appendicitis,    1049, 
1052 
in  diseases  of  bladder,  1215. 1226 

of  prostate,  1249 
in  tuberculous  disease  of  ureter, 
1202 
feeding,  962 
suppuration,  1148 
Rectopexy,  1163 

Rectovaginal  septum,  laceration  of,  1299 
Rectovesical   fistulje,    1167,   1164,   1224, 
1033 
in  cancer  of  bladder,  1228 
of  rectum,  1169 
Rectum,        affections        of        (Chapter 
XXXVIII.),  1144-1174 
cancer  of,  1167-1174 
colostomy  in  cancer  of,  11 70,  1173, 

1174,  1033 
congenital  malformations  of,  1145 
excision  of,  1169-1174 
foreign  bodies  in,  1147 
inflammation  of,  1147 
injuries  of,  526,  1147,  1224 
methods  of  examining,  1144 
polypus  of,  217,  1148,  1158 
prolapse,  1161,  1158 
stricture  of,  1165,  1147 
suppuration  in  connection  with,  1 148 
syphilis  of,  1164 

treatment  of  cancer  of,  1169-1174 
tuberculous  disease  of,  1163 
tumours  of,  1166 
Rectus   abdominis   muscle,    injuries    of, 

968, 971 
Recurrence  after  radical  cure  of  hernia , 

1102 
Recurrent  appendicitis,  1050 
dislocations,  621 
fibroid,  202,  947 
hicmorrhagc,  293 

laryngeal  nerve,   paralvsis  of,   888, 
386 
Red  corpuscles  in  inflammation,  32 

thrombus.  342 
Redness  in  inflammation,  35 
Reduction  en  masse  of  a  hernia,   11 16, 
1118 
of  a  dislocation,  602,  603 


INDEX 


1395 


Reduction  of  a  fracture,  481 
Reef-knot,  327 

Referred  pain  in  hip  disease,  670,  673,  36 
in  renal  calculus,  1205,  36 
in  spinal  caries,  707,  36 
Regeneration  of  nerves,  375 
Reid's  base-line,  744 

line  of  fissure  of  Sylvius,  745 
Relapsing  appendicitis,  1050 

fever,  65 
Renal   artery,   ligature   of,    for   urinary 
fistula,  1 2 10 

calculus,  1203-1210 

colic,  1205,  1051,  1192,  1204,  1207 

functional   activity,    estimation    of, 
1177 

ha3maturia,  1182 
Rendle's  mask  for  A.C.E.,  1349 
Repair  after  fractures,  478-481,  490 

after  inflammation,  34 
Resection.     See  Excision 
Residual  abscess,  183,  712 

urine,  1240,  1247,  1258 
Resilient  stricture  of  urethra,  1257 
Respiration,  artificial,  929,  1353 

cessation  of,  in  general  aucesthesia, 

1353 
obstruction  of,  in  general  anaesthesia, 

1353 
Rest  in  treatment  of  inflammation,  39, 

40,  45 
Retained  testis,  1275,  1094 

malignant  disease  of,  1276 
removal  of,  1276 
Retention  cysts,  940,  232 

of  testis,  1275,  1094 

of   urine,    1241,    1240,    1242,    1249, 
1258,  1266 
Retina,  embolus  in,  345 
Retraction  of  head,  766,  772,  882 
Retrograde     dilatation     of     oesophageal 

stricture,  871 
Retroperitoneal  abscess,  983,  1016,  1206 

lipoma,  989 

sarcoma,  989 

uretero-lithotomy,  1209 
Retropharyngeal  abscess,  865,  709,  904 
Retro-sternal  goitre,  891,  895 
Reverdin's  method  of  skin-grafting,  106 
Revolver  wounds,  248 
Rhabdomyoma,  212 
Rhagades,  173 
Rhexmiatic  arthritis,  638,  634 

fibrositis,  418 

gout,  653 

myositis,  418 

nodules,  638 

spondylitis,  718,  433 

synovitis,  638 

torticollis,  432 
Rheumatism,  diagnosis  from  aneurism, 

313 
gonorrhoeal,  of  spine,  719 
Rhemnatoid    arthritis,    653.     See    also 

Osteo-arthritis 
Rhinitis,  818 

atrophic,  820 
gonorrhoeal,  819,  147 


Rhinitis,  sicca,  820,  863 

syphilitic,  173 
Rhinolith,  818 
Rhinophyma,  815 
Rhinoplasty,  816 
Rhinoscopy,  817 
Rhinotomy,  lateral,  805,  827 
Rhomboid  muscles,  paralysis  of,  433,  388 
Rib,  cervical,  435 
Ribbert's  theory  of  tumour  formation, 

196 
Ribs,  beaded  in  rickets,  583 
fracture  of,  498 
osteo-mj'elitis  of,  916 
syphilitic  disease  of,  916 
tuberculous  disease  of,  917,  710 
tumours  of,  917 
Richter's  hernia,  1112,  1115,  1123 
Rickets,  581-585,  1082 

adolescent,  585,  436,  450,  455 
coxa  vara  from,  450 
femur  in,  457,  584 
genu  valgum  from,  452 
genu  varum  from,  455 
green-stick  fractures  in,  474 
haemorrhagic,  585 
of  spine,  582,  435,  440 
of  tibia  and  fibula,  584,  456 
Rickety  rosary,  583 
Rider's  bone,  210,  420 
Riedel's  lobe  of  liver,  1060 
Rifle  wounds,  246 

Rigg's  disease  (pyorrhoea  alveolaris),  796 
Rigors,  77 

in  infective  thrombosis  of  cerebral 

sinuses,  769 
in  lateral  sinus  pyaemia,  883 
in  urethral  fever,  1262 
Ring^vorm,  10 

Rinne's  tuning-fork  test,  873 
Risus  sardonicus,  136 
Rodent  ulcer,  411 
Rogers  on  liver  abscess,  1064 
Rolando,  fissure  of,  744,  757 
Rontgen  rays.     See  X  rays 
Rose's  operation  for  hare-lip,  786,  788 

for  removal  of  Gasserian  gan- 
glion, 383 
Rouge's  operation  for  nasal  diseases,  827 
Roughton's  splint,  630 
Round-cell  sarcoma,  200 
of  breast,  946 
of  tonsils,  862 
Round  ligaments,  affections  of,  1300 
fibro-myoma  of,  1301 
hydrocele  of,  1300 
tumours  of,  1301 
shoulders,  441 
Roux's  operation  for  femoral  hernia,  1106 

of  gastro-enterostomy,  loii 
Rubber  gloves,  use  of,  276 
Run-around,  407 
Rupia,  161 

Rupture.     See  Hernia 
Rupture  of  aneiurism,  313 

of  appendix  abscess,  1049 
of  arteries,  299,  308 
of  bladder,  1217.  527 


1396 


A  MANUAL  OF  SURGERY 


Rupture  of  crucial  ligaments,  624 

of  gall-bladder,  1068,  973 

of  hj-datid  cyst,  235 

of  hydrocele,  1288 

of  intestine,  1016,  973 

of  kidney, 1191 

of  liver,  1060 

of  lung,  919 

of  nierabrana  tynipani,  876 

of  muscles,  415,  135 

of  nerves,  371 

of  ovarian  cyst,  1321 

of  recto- vaginal  septum,  1299 

of  rectus  abdominis,  968 

of  sheath  of  muscle,  414 

of  spleen,  108 1 

of  stomach,  990,  973 

of  tendons,  415 

of  thoracic  duct,  356 

of  tubal  gestation,  1314 

of  ureter,  1192 

of  urethra,  1254,  527 

of  vas  deferens,  1278 
Russian  baths,  48 

Saccharomyces,  10 
Sacculated  aneurism,  310 
Sacculi  of  bladder,  1220,  1258 

rupture  of,  1218,  1258 
Sac  of  a  hernia,  description  of,  1086 

in  strangulation,  11 14 
Sacral  anus,  1172 

tumours,  congenital,  703 
Sacro-iliac  disease,  677 
Sacrmn,  fractures  of,  528 
Saline  infusion  in  abdominal  operations, 
960, 962 
in  haemorrhage,  284 
in  peritonitis,  978 
in  septicemia,  92,  95 
in  shock,  267 
Salivary  calculus,  845 

fistula,  846 

glands,  affections  of,  844 
cysts  of,  845 
Salivation,  169,  833,  839 
Salmon  patches  of  cornea,  174 
Salpingitis,  149 

Salpingo-oophorectomy,  double,  1308 
Salter's  swing,  270,  478 
Salvarsan  ('  606  '),  166,  164,  167 
Sanitas,  273 

Saphena,  varix  of,  348,  1104 
Saprffimia,  92 
Saprophytes,  4 
Sarcinse,  3,  1002 
Sarcocele,  cystic,  of  testis,  1285 

syphilitic,  1283 

tuberculous,  128 1 
Sarcoma,  199 

after  fibroids  of  uterus,  1304 

after  fractures,  481 

alveolar,  202 

congenital,  of  kidney,  1211,  202, 1188 

curative  action  of  erysipelas  on,  203 

endosteal,  592 

melanotic,  202,  1066 

of  antrum,  803 


Sarcoma,  of  appendix,  1059 

of  bladder,  1227 

of  bone, 592,  473,  481,  588,  597 

of  brain,  775 

of  breast,  946,  954 

of  cranium,  730 

of  dura  mater,  730 

of  gum,  799 

of  intestine,  1024 

of  jaws,  803,  809 

of  kidney, 121 1,  11 88 

of  liver,  1066 

of  lymphatic  glands,  369,  201 

of  muscles,  420 

of  naso-pharynx,  826 

of  nerves,  213 

of  nose,  826 

of  orbit,  324 

of  ovary,  1323 

of  palate,  858 

of  pancreas,  1081 

of  parotid,  847 

of  rectum,  1166 

of  ribs,  917 

of  sacrum,  704 

of  scalp,  724 

of  skull,  730 

of  spine,  719 

of  sternum,  917 

of  submaxillary  gland,  849 

of  testis,  1286 

of  thyroid,  897 

of  tonsil,  862 

of  uterus,  1308 

periosteal,  593 

pulsating,  199,  312 

retroperitoneal,  989 

secondary,  of  bone,  596 

treatment  of,  203 
Satellite  chancre,  150 
Saucer  fracture  of  skull,  737,  739 
Sauerbruch's  chamber,  925 
Sayre's  apparatus  for  talipes,  463 

treatment  of  fracture  of  clavicle,  501 
Scab,  healing  under  a,  261 
'  Scabbard  '  trachea  in  goitre,  891 
Scalds,  125 
Scalp,  affections  of,  722 

avulsion  of,  722 

cellulitis  of,  88 

injuries  of,  722 

tumours  of,  723 
Scaphoid,  fracture  of,  524 

tuberculosis  of,  574 
Scapula,  congenital  elevation  of,  443 

dislocation  of  angle,  443 

fractures  of,  502 

winged, 443, 388 
Scars,  262 

keloid,  263 

malignant  disease  of,  263 

painful,  263 

pathological  conditions  of,  262 

ulceration  of,  263 
Schede's  operation  of  thoracoplasty,  924 
Schimmelbusch's  low-pressure  sterilizer, 

274 
mask  for  ancesthetics,  I347'  i349 


INDEX 


1397 


Schizomycetes,  i 

Schlatter's  disease,  548 

Schleich's    method    of    inducing    local 

anaesthesia,  1343,  1132,  895,  897 
Schlosser's  treatment  for  tic-douloureux, 

381 
Schwartze's  operation  for  mastoid  dis- 
ease, 880 
Sciatic  artery,  aneurism  of,  326 
haMuorrhage  from.  298 

dislocation  of  hip,  617,  616 

nerve,  operation  on,  394 
Sciatica,  393,  678 
Scirrhous  ulcer,  950 
Scirrhus,  223.  948 

of  breast,  948,  952 

of  pancreas,  1081 

of  prostate,  1232 

of  pylorus,  998 
'  Scissor  '  deformity  of  hip-joint.  666 
Sclavo's  serum,  141 

Sclerosis  of  bone,  558,  556,  569,  576,  578 
Sclerotitis,  gonorrhceal,  148 
Scolices,  233,  1065 
Scoliosis,  435.  443'  447 
Scott's  dressing,  45 
Scrofuloderma,  107 
Scrotal  tumours,    general   diagnosis   of, 

1295 
Scrotum,  cellulitis  of,  1297 

eczema  of,  1298 

epithelioma  of,  1298 

erysipelas  of,  1297,  131 

fistulas  of,  1270,  1298 

oedema  of,  1297 
Scurvy,  haematuria  in,  1182 

infantile,  585,  492 

rickets,  585 
Sebaceous  adenoma,  410,  725 

cysts,  409,  725,  887 
of  neck, 887 
of  nipple,  935 
of  scalp,  725 

glands,  cancer  of  (rodent  ulcer),  411 

horn,  409,  1273 
Second  intention,  healing  by,  259 
Secondary  anaemia,  66 

growths  in  glands,  370 

hjeniorrhage,  293,  295 

nerve  suture,  376 

sarcoma  of  bone,  596 

syphilis,  158 

union  of  %vounds,  259 
Sedillot's  amputation  of  foot,  1336 
Segregation  of  urine,  11 76 
Semicircular  canals,  disease  of,  879 
Semilunar    cartilage,    displacement    of, 

622,  664 
Semimembranous  bursa,  enlargement  of, 
430 

tendon,  tenotomy'  of,  425 
Senile  atrophy  of  bone,  726 

enlargement  of  prostate,  1245 -1252 

gangrene,  114,  112, 307 
Sensation,  varieties  of,  373 
Sensory  nerve,  results  of  section  of,  373 
'  Sentinel '  pile.  1154 
Separation,  line  of,  in  gangrene,  iii 


Sepsis,  90 

oral,  797,  84 
Septic  arthritis,  633 

gangrene,  109 

intoxication,  82 

meningitis,  766 

osteo-myelitis.     See  Osteo-myelitis 

phlebitis,  346 

pneumonia,  496,  843,  889,  903,  915. 
919 

thrombosis  of  lateral  sinus,  882,  96, 
748,  772 

traumatic  fever,  91 

wounds,  242 
Septicaemia,  92-95,  68,  69,  252  . 

blood  in,  92 
Septum  nasi,  fracture  of,  494 

lateral  deviation  of.  818 
ulcer  of,  830 
Sequestration  dermoids,  229 
Sequestrectomy,  567 
Sequestrum,  557,  109,  799 

separation  of,  559 
Sera,  antitoxic,  27 

polyvalent,  27 

use  of,  27,  28 
Serotherapy,  39 

Serous  cysts,  232,  887,  941,  1083.  1087, 
1213 

synovitis,  631 
Serratus  magnus,  paralysis  of,  388,  443 
Serum,  antistreptococcic,  27 

antitetanic,  138 

disease,  28 

in  inflammation,  40 
Setons,  45 

Seventh  nerve,  affections  of,  383,  878 
Sheath  of  muscle,  rupture  of,  414 
Sheaths  of  tendons,  disease  of,  420 
Sheffield-Tallerman  bath,  49 
Shock,  264-268 

adrenalin  in,  267 

anaesthesia  during,  268 

from  amputation,  1327 

in  abdominal  injuries,  970,  1016 

in  burns,  126 

in  catheterism,  1261 

in  contusion  of  testis,  1277 

in  intestinal  obstruction,  1125,  1127 

in  perforated  gastric  ulcer,  994 

operations  during,  268 

patholog}^  of,  266 

prevention  of,  268 

use  of  saline  solution  in,  267 
Short-circuiting  operations  on  intestine, 

1027 
Shortening  a  tendon,  method  of,  425 

of  round  ligaments  of  uterus,  1301 
Shoulder-joint,  acute  arthritis  of,  636 

amputation  through,  1331 

ankylosis  of,  665 

congenital  elevation  of  (Sprengel's), 
442 

dislocations  of,  607 

effusion  into,  627 

excision  of,  679,  636,  648 

tuberculosis  of,  648 
Shoulders,  round,  441 


1398 


A   MANUAL  OF  SURGERY 


Side-chain  theory  of  Ehrlich,  20 

Sigmoid  colostomy,  1033 

Sigmoidoscope,  1145 

Sigiie  de  Dance,  11 38 

Silli,  277 

Silver  filigree  in  treatment  of  hernia,  1 109 

Simple  fractures,  474 

na?vus,  353 

tinnours,  197 
Sinus,  80,  187 
Sinuses  of  nose,  affections  of,  821 

of    skull,    infective    thrombosis    of, 
768,  748,  742,  770,  822, 882 
Site  of  election  for  amputation  of   leg, 

1337 
'  606,'  166 

Sixth  nerve,  injuries  of,  383 
Skiagraphy.  See  X  rays  and  radiography 
Skin,  preparation  of,  for  operations,  278 

surgical  diseases  of,  399-413 
Skin-grafting,  106 
Skull,  affections  of,  725-743 

fractures  of,  731-741 
base  of,  731 

compound,  731,  732,  738,  739 
depressed,  735 
fissured,  731 
punctured,  735 
treatment,  735 

gunshot  injuries  of,  737 

in  inherited  syphilis,  580 

in  osteitis  deformans,  587 

in  rickets,  582 

methods  of  opening,  746 
Slough,  108 
Sloughing  of  amputation  flaps,  1328 

of  appendix,  1044 

of  tendons  of  fingers,  417 
Smith's  fracture  (radius),  523 

method      of     reducing      dislocated 
shoulder,  611 

(Henry)  operation  for  piles,  1160 

(Stephen),  amputation,  1337 
Smoker's  patch,  836 
'  Snail-track  '  ulcers  of  tonsil,  159,  862 
Snake-bites,  251 
Snap-finger,  445 
Snuffles  in  syphilis,  173 
Sobenheim's  serum  in  anthrax,  142 
Soft  chancre,  149 

fibromata,  207 
Softening,  yellow,  of  brain,  756 
Sordes,  270 
Sore,  primary,  155,  791 

soft,  149 
Sounding  the   urinary  bladder,   method 

of,  1233,  1215 
Southey's  trocars,  986 
Spasm  of  intestine,  1131,  1126 

of  oesophagus,  869 

of  sphincter  vesicaj,  1241 
Spasmodic  stricture  of  urethra,  1256 

stump,  1328 

torticollis,  434 
Spastic  talipes,  458,  462 
Specific      infective      diseases      (Chapter 

VIII.),  129-193,  12 
Speculum,  nasal,  817 


Spence's  amputation   at  shoulder-joint, 

1331 
Spermatic  cord,  hjematocele  of,  1278 
hydrocele  of,  1291 
torsion  of,  1276 
Spermatocele,  1291 
Sphacelus,  108 

Sphenoidal  sinus,  disease  of,  822,  769,  770 
Spheroidal-celled  cancer,  222,  858 
Sphincter  vesicae,  paralysis  of,  1240 
Spina  bifida, 700, 458, 662, 784 
occulta,  703 

ventosa.    See  Tuberculous  dactylitis 
Spinal  abscess,  708.  717,  865 
Spinal  accessory  nerve,  affections,  386 
operations  on,  386,  435 
anassthesia,  1347,  118,  268 
caries,  704 
concussion,  692 
cord,  diseases  of,  692,  719 
h;rmorrhages  into,  693 
injuries  of,  692 
pressure  on,  in  Pott's  disease, 

711,  718 
total  transverse  lesion  of,  696 
tumours  of,  719 
ha>morrhage,  693 
membranes,  tumours  of,  719 
meningitis,  694,  713 
myelitis,  694,  711 
nerves,  affections  of,  387 
neurasthenia,  695 
splints,  440,  441,  442,  366 
Spindle-celled  sarcomata,  201 
Spine,  deformities  of,  435-442 

diseases  of  (Chapter  XXV.),  700-721 
congenital    malformations     of, 

700 
gonorrhoeal  rheumatism  of,  719 
osteitis  deformans,  587 
osteo-arthritis,  719,  441 
osteo-myelitis,  704 
rheumatic  spondylitis,  718 
rickets  of,  582,  435.  44° 
spinal   caries    (Pott's   disease). 

704 
syphilitic  disease  of,  718 
tuberculous  disease  of,  704,  435. 

441, 865 
tumours  of,  719.  7^3 
injuries  of  (Chapter  XXIV.),  684-699 
bladder,  effects  on,  1220 
dislocations,  691 
fracture-dislocation,  688 
fractures,  686 
sprains,  684 
wounds,  685 
Spiral  fractures,  475 
Spirilla,  3 
Spirillum  Obermeyeri,  65 

of  relapsing  fever,  8,  4 
Spirochaita,  151,  8 
Splay-foot.     See  Flat-foot 
Spleen,  affections  of,  1 081 -1083 
amyloid  disease  of,  84,  1082 
embolus  in,  345 
torsion  of,  973,  1126 
Splenectomy,  1083 


INDEX 


1399 


Splenic  an;v!mia,  1082 

fever,  140 

flexure,  cancer  of,  1026 
kink  of,  1028 
Spleno-medullary  leucocvthaMuia,  65,  67, 

1082 
Splenomegaly,  1083 
Splenopexy,  1082 

Splint-pressure,  causing  gangrene,  120 
Splints,  uses  of,  482 
S;3ondylitis  deformans,  719,  441 

rheumatic,  718,  433 
Spondylolisthesis,  442 
Spongy  gums,  795 

in  mercurialism,  169 
Spontaneous  cure  of  aneurism,  313 

fracture,  473,  586,  591 
Spores,  characters  of,  2,  i,  3 
Sprains  of  joints,  599 

of  muscles,  414 

of  spine,  684 

of  wrist,  524 
Spreading  gangrene,  acute,  121 

cedema  of  brain,  755,  752,  771 
Sprengel's  shoulder,  442 
Spring-finger,  445 
Springing  the  fibula,  548 
Spur  in  colostomy,  1032,  1036,  1123 

of  nose,  818 
Spurious  valgus.     See  Flat-foot 
Squamous  epithelioma,  220 
Squint,  in  paralysis  of  sixth  nerve,  383 

in  paralysis  of  third  nerve,  380 

in   thrombosis   of   cavernous   sinus, 
769 
Stabs,  245,  1017 
Stacke's  operation  for  mastoid  disease, 

881 
Stains  for  bacteria,  8 
Staphylococcus  pyogenes,   68,  4,   5,   71, 

85.  93.  96.  400,  563,  764,  1196,  1219 
Staphyloma,  anterior,  174 
Staphylorrhaphy,  856 
Starch  bandages,  483 
Starting  pains  in  joint  disease,  644,  672 
Stasis,  30,  32 
Static  electricity,  54 

genu  valgum,  453 
Status  lymphaticus,  1354,  899 
Stave  of  thumb  fracture,  525 
Stay-knot,  291,  328 
Stenosis  after  duodenal  ulcer,  10 13 

after  ulcer  of  stomach,  996 

of  intestine,  1022,  1038,  1123,  1126 

of  larynx,  890,  910,  916 

of  pylorus,  1002 

of  trachea,  890 
Stenson's  duct,  wounds  of,  846 
Stercoraceous     vomiting,     1114,     1125, 

1127,  1142 
Stercoral  ulcers,  1024,  1027,  11 13,  1169 
Sterile  abscess,  71,  1062,  1312 
Sterilization  of  wounds,  238 
Sterilizers,  274 

Sternal  end  of  clavicle,  dislocation  of,  606 
Sterno-mastoid  in  torticollis,  432 

congenital  induration  of,  433,  885 

tenotomy  of,  433 


Sternum,  diseases  of,  916,  579 

fractures  of,  499 
Stewart's  treatment   of  aneurism,   318, 

320,  322,  324 
Sthenic  fever,  37 
Still's  disease  of  joints,  653,  657 
Stings  of  insects,  250 
Stitch  suppuration,  965,  90 
Stitches,  deep,  239 

of  coaptation,  239 
Stokes-Gritti     amputation     of     thighs, 

1338 
Stomach,  affections  of,  989-1012 
anatomy  of,  989 
bismuth  radiography  of,  989 
cancer  of,  998,  1007 
dilatation  of,  989,  1002,  1029 

acute,  1004 
hour-glass,  997 
operations  on,  1004 
rupture  of,  990 
ulcer  of,  992,  990,  1030 
haemorrhage  in,  993 
perforation  of,  994,  105 1 
Stomatitis,  832 

mercurial,  833,  169 
Stone.     See  Calculus 
Stools  in  pancreatitis,  1080 
Stovaine,  uses  of,  1344 
Strabismus,  380,  383 
Strains.     See  Sprains 

juxta-epiphyseal,  476 
Strangulated  external  hernia,  1112-1123 
complications  after  opera- 

tion  for,  1121 
complications    after    taxis 

for,  1 1 17 
gangrene  of  bowel  in,  1113, 
•1115,   1117,1120,   1121, 
1123 
operative     treatment     of, 

1118-1123 
pathological  effects  of,  11 12 
prognosis  of,  11 16 
sequelje  of,  1123 
signs  and  symptoms  of ,  1 1 1 4 
taxis  in,  1116 
treatment    of   intestine    in 

operations  for,  11 19 
umbilical  hernia,  971 
Strangulation,  acute,  of  testis,  1276 
internal,  1126 

of  intestine  by  bands,  1128,  1126 
of  piles,  1158 
Strangury,  1205,  1221 
Strepto-bacillus,  3 
Streptococci,  3 

Streptococcus  pyogenes,  69,  3,  8,  11,  85, 
93,  96,  123,  129,  203,  563.  633,  764, 
922, 973, 1043, 1196 
Streptothrix,  10,  8 

Stricture  of  appendix  vermiformis,  1043 
of  bile-duct,  1077 
of  intestine,  1022,  1036,  1133 
of  oesophagus,  869 
of  pylorus,  1002 
of  rectum,  1165,  1151,  1164 
of  urethra,  1256-1270 


I400 


A   MANUAL    OF  SURGERY 


'  Strong  mixture,'  272 

Strongylus  gigas,  1196 

'  Strumous  lip,'  790 

Strumpell-.Marie's  spondylitis  deformans, 

719 
Strychnine-poisoning,  137 
Stumps,  amputation  of,  1328 

affections  of,  1328 
Styloid  process  of  ulna,  fracture  of,  518 
Styptics,  288 
Subaponeurotic  abscess,  723 

hajmatoma,  723 
Subarachnoid    space,    drainage    of,    in 

meningitis,  767 
Subastragaloid  amputation,  1335 

dislocation,  626 
Subclayian  artery,  aneurism  of,  324 

compression  of,  292,  325,  1331 

ligature  of,  325,  332,  320,  321 

Subclayicular  dislocation  of  shoulder,  609 

Subcoracoid  dislocation  of  shoulder,  608 

Subcranial  abscess,   764,   728,   730,   738, 

741,  772,  882 

haemorrhage,  760,  761 

inflammation,  764 
Subcutaneous  gumma.  164 

infusion,  978 

tenotomy,  423 

whitlow,  252 
Subcuticular  stitch,  240 

whitlow,  252 
Subdeltoid  bursa,  enlargement  of.  627, 

431 
Subdiaphragmatic  abscess,  983 
Subglenoid  dislocation  of  shoulder,  608 
Subhepatic  abscess,  983 
Subhyoid  pharyngotomy,  907 
Sublingual  abscess,  835 

gland,  affections  of,  845 
Subluxation  of  head  of  radius,  614 

of  joints,  601 

of  knee,  622 
Submammary  abscess,  936 
Submaxillary  cellulitis,  89,  845,  904 

gland,  affections  of,  845,  849 
Submucous  abscess  of  rectum,  1148 

fibroid,  1303 

resection  of  septum  of  nose,  818 
Subpericranial  abscess,  723 

haematoma,  723,  236 
Subperiosteal  abscess,  561,  564,  576,  795, 

799 

gummata,  578 

haemorrhages  in  scuryy  rickets,  586 

whitlow,  254 
Subphrenic  abscess,  983,  996,  1013,  1047, 
1074-  1079 

pj'opneumothorax,  984 
Subpsoas  abscess,  673 
Subserous  fibroids,  1303 

lipoma,  205 
Subspinous  dislocation  of  shoulder,  609 
'  Substance  sensibilatrice,'  22 
Subtrochanteric  fracture.  537 

osteotomy,  451,  667 
Subungual  exostosis,  209 
Sugar  in  urine,  tests  for,  1180 
Suicidal  wounds,  248,  887 


Superior   longitudinal   sinus,   injury  of, 
760 
thrombosis  of,  769 
Superior  maxilla,  affections  of,  800,  803 
excision  of,  806 
fracture  of,  494 
tumours  of,  803 
Suppression  of  urine,  1262,  1198 
Suppuration,  71,  33,  34,  68 
in  pericardium,  928 
leucocytosis  in,  67 
of  aneurisms,  314 
of  frontal  sinus,  742 
of  maxillary  antrum,  800 
of  parotid  gland,  844 
of  tuberculous  glands,  365 
results  of,  82 
without  organisms,  71 
Suppurative  nephritis,  1193 
Supraclavicular   gland,   enlargement   of, 
in  cancer  of  stomach,  looi 
glands  in  sclrrhus,  949,  957 
Supracondyloid    amputation    of    thigh, 
1338 
fracture  of  humerus,  510 
Supracoracoid  dislocation  of  humerus,  609 
Supramalleolar  amputation,  1337 
Supramammary  abscess,  936 
Supra-orbital  nerve,  operations  on,  381 
Suprapubic  aspiration  of  bladder,  1250, 
1266 
cystotomy,  1225,  1229 
lithotomy,  1236 
prostatectomy,  1250 
puncture  for  enlarged  prostate,  1250 
Supravaginal  hysterectomy,  1305 
Surgical  emphysema,  918,  493,  889 
kidney, 1196 

neck  of  humerus,  fracture  of,  505 
of  scapula,  fracture  of,  503 
Susceptibility,  13 
Sutures,  239 

of  arteries,  301 
of  bladder.  1218 
of  gall-bladder,  1077,  1076 
of  kidney,  1208 
of  nerv^es,  375 
of  tendons,  416 
of  ureter,  1209 
intestinal,  965-967 
preparation  of,  277 
Swabs,  277 
Sweep's  cancer,  1298 
Sylvester's  methjd  of  artificial  respira- 
tion, 929 
Sylvian  point,  743 
Sylvius,  fissure  of,  745 
Syme's  amputation,  1335.  575-  72i 
horseshoe  splint,  552 
operation  for  epithelioma  of  lip,  794 
for  epithelioma  of  tongue,  842 
for  external  urethrotomy,  1265 
staff,  1265 

treatment  of  chronic  ulcers.  104 
Symond's  tube  for  oesophageal  stricture, 

871 
Sympathetic  nerve,  affections  of,  395,  213 
excision  of  cervical,  395 


INDEX 


1401 


Svmpathetic  nerve  in  shock,  action  of, 
266 
irritation     <>f,     in     innominate 
aneurism,  321 
Symptomatic  gangrene,  112 

traumatic  fever,  269 
Syncope  in  shock,  265 
Syncytioma  maligna,  131 1 
Syndactylism,  445 
Syndesmotomy,  464 
Synechia,  160 
Ssmostosis,  665 

S^Tiovial  membrane,  pulpy  degeneration 
of,  641 
sheaths,  suppuration  in,  421,  253 
villi  (fringes),  632,  654 
Synovitis,  acute,  629,  627 
chronic,  631 
gonorrhoeal,  640 
papillary,  632 
pyemic,  639 
rheumatic,  638 
serous,  631 
syphilitic,  652,  633 
tuberculous.     See  Joints 
typhoid,  639 
Syphilides,  159 
Syphilis,  151-175 

arylarsonates  in,  166 

congenital     (inherited),     171.     791, 

1082 
insontium,  154 
intermediate,  161 
laboratory,  diagnosis  of,  153 
malignant,  i56 
prevention  of,  166 
primary,  155 
prognosis  of,  164 
secondary,  158 
spirochaete  of,  151 
tertiary,  162 
treatment  of,  166,  174 
Syphilitic  affections  of  anus,  1164 
of  arteries,  306,  161 
of  bone, 578, 457, 569 
of  breast,  940 
of  bursse,  429 
of  calvarium,  579,  729 
of  cornea,  174 
of  cranium,  579,  729 
of  epididymis,  1283,  161 
of  epiphyses,  581 
of  eye,  160,  161,  174 
of  hair,  160 
of  intestine,  1022 
of  jaw,  799 
of  joints,  652,  633 
of  lar^Tix,  905 
of  lips,  791 
of  liver,  1066 
of  Ivmphatic  glands,  157,  160, 

36 
of  meninges,  768 
of  mucous  membranes,  159 
of  muscles,  419 
of  nipple,  935 
of  nose,  173,  579,  814,  823 
of  optic  sheath,  379 


Syphilitic  affections  of  palate,  857,  579 

of  pharynx,  864 

of  periosteum,  578 

of  rectum,  1164 

of  ribs,  917 

of  skin,  158 

of  skull,  579 

of  spine,  718 

of  sternum,  gi6 

of  teeth,  174 

of  testis,  1283 

of  tibia  and  fibula,  457 

of  tongue,  837,  839 

of  tonsil,  861 
alopecia,  160 
chondro-arthritis,  652 
endarteritis,  306,  163 
epiphysitis,  581 
iritis,  160 
keratitis,  174 
pseudo-paralysis,  581 
psoriasis,  161 
sarcocele,  1283 
stomatitis,  159 
stricture  of  rectum,  1164 
synovitis,  633,  652 
ulcers,  164,  107,  161,  838 
Syringo-mj'elia,  joint  affections  in,  661 
Syringo-myelocele,  700,  231 

Tabes  dorsalis,  spontaneous  fracture  in, 

473 
joint  affections  in,  659 

mesenterica,  988,  365 
Tabetic   lightning   pains,  operation  for, 

398 
Tffinia  echinococcus,  233,  344 
Tagliacozzian  operation,  816 
Talipes,  457,  784 

calcaneus,  458,  461 

decubitus,  458,  459 

equino-varus,  459,  460 

equinus,  458,  459,  419 

paralytic,  702 

tenoplasty  in  paralytic,  426 

treatment  of,  463 

valgus,  458,  462 

varieties  of,  458 

varus,  458,  460 
Talma-Morison,  operation  of  epiplopexy 

for  ascites,  986 
Tapotement,  46 

Tapping  a  hydrocele,  method  of,  1289 
Tarsectomy,  464 
Tarso-metatarsal  joints,  amputation  at, 

1333 
Tarsus,  amputation  through,  1334 

tuberculous  disease  of,  573 
Taxis,  II r6,  mi 
Taylor's  brace,  716 
Teale's  amputation  of  leg,  1326,  1337 
Technique  of  operative  surgery  (Chap- 
ter XL),  271-281 
Teeth,  extraction  of,  794 

in  congenital  syphilis,  174 

in  rickets,  582 

tumours  in  connection  with,  215,  808 

See  also  Odontomata 


t402 


A   MANUAL  OF  SURGERY 


Tegmen  tympani,  disease  of,  878,  764, 

765.  770 
Telangiectases,  353 

Temporal  artery,  compression  of,  292, 
ligature  of,  332 
bone,  necrosis  of,  878 
Temporo-maxillary    joint,    diseases    of, 
811 
dislocation  at,  604 
osteo-arthritis  of,  811,  659 
subluxation  of,  605,  813 
Temporo-sphenoidal    lobe,    abscess    of, 
770,  773 
injuries  of,  758 
Tendo   Achillis,  affections  of  bursa  be- 
neath, 430,  628 
operation    on,    in    talipes    cal- 
caneus, 465 
right  angle  contraction  of,  468 
rupture  of,  416 

tenotomy  of,  424,  463,  468,  625.  626 
Tendon  sheaths,  diseases  of,  420 
ganglion,  422 
implantation,  426 
suppurative,  421,  253 
tenosynovitis,  420 
transplantation,  426 
tuberculous,  421,  423,  572,  573 
Tendons,  adhesion  of,  417 
displacement  of,  414 
of  fingers,  division  of,  417 
operations  on,  424,  416 
rupture  of,  415 
sloughing  of,  of  fingers,  418 
suture  of,  416 
Tenesmus,  1147,  1148,  1166 
in  cancer  of  rectum,  1168 
in  cystitis,  1221 
in  fissure-in-ano,  11 54 
in  intussusception,  1138 
in  tumours  of  rectum,  11 66 
in  vesical  calculus,  1232 
in  volvulus,  1 1 30 
in  uterine  fibroids,  1304 
Tenoplasty,  426,  465,  721 
Teno-synovitis,  420,  253 
Tenotomy,  423,  645,  721 

of  adductors,  449,  659,  667 
of  biceps  cruris,  425 
of  peronei,  425,  465,  467 
of  semimembranosus,  425 
of  semitendinosus,  425 
of  sterno-mastoid,  433 
of  tendo  Achillis,  424,  463,  625,  626 
of  tibialis  anticus,  424,  464 
of  tibialis  posticus,  424,  464 
Teratoma,  228,  704 
Tertiary  syphilis,  162.    See  also  Gumma 

ulcers,  107 
Testicular  sensation,  loss  of,  1286 
Testis,    affections    of    (Chapter    XLII.), 
1275-1298 
atrophy  of,  1294 
carcinoma  of,  1287 
congenital  affections  of,  1275,  1276 
epididymitis,  1279,  1281.  1283 
fibro-cystic  disease,  1285,  230 
hernia,  1284 


Testis,  injuries  of,  1277 

innocent  tumours  of,  1285 

malp(;sition  of,  1276 

neuralgia  of,  1294 

orchitis,  1279,  1281,  1283 

retention  of,  1275,  1094,  1122 

sarcoma  of,  1286 

syphilis  of,  1283,  1295 

torsion  of,  1276,  1122 

tuberculous  disease  of,  1281,  1296 

wounds  of,  1277 
Test-meal  for  gastric  juice,  989,  1000 
Tetanus,  134 

bacillus  of,  134 

hydrophobicus,  137 

neonatorum,  971-972 

paralyticus,  136 

toxins  of,  138 
Tetracocci,  3 
Theatre,  operating,  274 
Thecal  whitlow,  253 
Thermo-cautery,  50 
Thermo-penetration,  49 
Thermo-therapy,  47-50 
Thiersch's  method  of  nerve  extraction, 
378 
of  skin-grafting,  128 
Thigh,  amputation  of,  1339 

Stokes-Gritti  amputation  of,  1338 

supracondylar  amputation  of,  1338 
Thiosinamin,  263 
Third  nerve,  affections  of,  379 
Thomas's  hip-splint,  674.  533-  534-  7i4 

knee-splint,  650,  534,  541,  659 

operation  on  breast,  944 

wrench,  468,  467,  464 
Thoma-Zeiss  haemocytometer,  58 
Thompson's  lithotrite,  1235 
Thoracic  aorta,  aneurism  of,  319 

duct,  rupture  of,  356 

pressure  on,  looi 
Thorax,  in  scoliosis,  438 

punctured  wounds  of,  92c 
Thread -worms,  1148 
Thrombo-angiitis  obliterans,  116 
Thrombosis,  341,  30 

arterial,  299,  308,  116 

gangrene  from,  116,  119 

of  cavernous  sinus,  769,  822 

of  cerebral  sinuses,  768,  760 

of  femoral  vein,  343,  1047 

of  haemorrhoids,  1156 

of  lateral  sinus,  882,  768,  772,  347. 

99 

of  mesenteric  vessels,  987, 1016, 1126 

of  superior  longitudinal  sinus,  768 

of  vena  cava,  342 

of  vessels  in  meso-appendix,  1044 

venous,  341,  345,  35o 
Thrombus,  96 

changes  in,  287 

characters  of,  342 
Thrash,  10,  832 
Thudichum's  speculum,  817 
Thumb,  amputation  of,  1326 

dislocation  of,  614 

stave  fracture  of,  525 
Thymus,  affections  of,  899,  1354 


INDEX 


1403 


Thyro-glossal  cyst.  886.  838.  898 

duct,  anatomy  of,  886 
Thyroid,  accessory,  898 

body,  affections  of.  890 

cancer  of  bone.  894.  730 

cartilage,  injuries  of,  904 

cysts  of,  887,  898 

dislocation  of  hip,  619 

extract,  in  cancer  of  breast.  958 

goitre,  890 

dissemination  of,  894 
operations  on,  895 

inflammation  of,  898 

tumours  of,  892,  897.  910 

vessels,  ligature  of,  333 
Thyroidectom3%  partial.  895,  897 
Th^TToiditis,  acute,  898 
Thwotomy,  908,  907,  902 
Tibia,  fracture  of,  547 

and  fibula,  fracture  of,  548 

lower  epiphysis,  separation  of,  552 

rachitic,  457,  584 

syphilitic  affections  of,  457 
Tibial  arteries,  ligature  of,  339 

nerves,  affections  of,  394 
Tibialis  anticus,  tenotomy  of,  424 

posticus,  tenotomy  of,  424 
Tic-douloureux,  380 

facial.  385 
Tinnitus,  879 

Tissue  tension,  Ribbert's  theory  of,  196 
Toenail,  ingrowing,  408 
Toes,  amputation  of,  1332 

deformities  of,  468 
Tongue,  affections  of,  833-844 

cancer  of,  838 

operations  on,  841 
Tongue-tie,  833 
Tonsil,  abdominal,  1040 
Tonsillitis,  858,  827,  1040 
Tonsillotomy,  861 
Tonsils,  affections  of,  858 
Tophi,  639 

Topography,  cranio-cerebral,  744 
Torsion  in  treatment  of  hemorrhage,  290 

of  omentum,  987,  1126 

of  ovarian   cyst,    1321,    973,    1051, 
1126,  1131 

of  testicle,  1276 

of  spleen,  1082,  1126 
Torticollis,  432 

Tour-de-maitre  in  passing  bougies,  1260 
Tourniquets  in  amputating,  1327,  1339 

in  arresting  hjemorrhage,  292 
Toxaemia,  13,  68,  91,  974,  1221,  1115 
Toxins,  5,  6 
Toxophore,  20 
Trachea,  foreign  bodies  in,  902 

scabbard,  891 

stenosis  of,  890,  916 

wounds  of,  888 
'  Tracheal  tug '   in  aneurisms  of  aorta, 

320,  322 
Tracheotomy,  910,  899.  902,  903.  905, 
906,  907, 908, 929,  134 
preliminary,  910,  912,  806,  842,  908 
tubes,  912 
Traction  diverticula  of  oesophagus,  867 


Transfixion  method  of  amputating,  1325 
Transfusion  for  hccmorrhage,  284 
Transhyoid  pharyngotomy,  907,  865 
Transillumination  of  antrum,  801,  805 
Transperitoneal  uretero-lithotomy,  1209 
Transplantation  of  joints,  667 

of  tendons,  426 
Trans-sacral  proctectomy,  1170 

uretero-lithotomy,  1209 
Transverse  colon,  cancer  of,  1026 
colostomy  of,  1032 
incision  of  abdominal  wall,  961 
Traumatic  aneurism,  299,  302,  324 
arteritis,  303 
arthritis,  654 
cephalhydrocele,  731 
delirium,  269 
dermatitis,  278 
dermoid  cysts,  232 
dislocations,  600 
epilepsy,  780,  731,  739 
fever,  268,  478 
flat-foot,  465,  553,  554 
gangrene,  119,  109,  112 
genu  valgum,  453 
insanity,  781 
myositis,  418 

ossificans,  419 
neurasthenia,  695 
neuroma,  372,  214 
osteomyelitis,  567 
periostitis,  559 
ulcers,  837 
Travelling  acetabulum,  669 
Trendelenburg's    operation    for    ectopia 
vesica,  1217 
for  varicose  veins,  351,  105 
position,  960 
trachea  tampon,  912 
Trephining,  operation  of,  746 
for  abscess  of  brain,  773 
for  fracture  of  skull,  739,  741 
for  intrameningeal  hemorrhage,  763 
for  lateral  sinus  thrombosis,  883 
for  middle  meningeal  haemorrhage, 

762 
for  tuberculous  meningitis,  768 
for  tumours  of  brain,  747,  777 
Treponema  pallidum,  151 
Trichina  spiralis,  233,  419 
Trichophyton,  10 
Trigeminal  neuralgia,  380 
Triple  displacement  of  knee-joint.  650. 
666 
phosphate  calculi,  1230 
phosphates  in  urine,  11 83 
Triradiate  pelvis,  584,  587 
Trismus,  812,  136,  137,  193 
Trochanter,  fracture  of,  537 
Trophic  changes  after  division  of  sen, 

sory  nerves,  373 
Tropical  abscess  of  liver,  1062 
Trunk  neuroma,  213 
Trusses,  femoral,  1105 
hinged-cup,  iiri 
inguinal,  1095 
umbilical,  1107 
wool,  1096 


M04 


A   MANUAL  OF  SURGERY 


Trypanosomes,  ii 
T-shaped  fractures,  512,  541 
Tubal  gestation,  1313 

rupture  of,  1314 
treatment  of,  13 16 
Tubby's  painful  lipoma,  205 
Tubercle    bacillus.     See    under    Bacillus 

miliary,  178 
Tuberculated  leprosy,  i8g 
Tuberculin,  82,  178,  184,  366,  405,  982, 
1203 
in  diagnosis,  178 
in  treatment,  184 
in   tuberculous  disease   of   bladder, 

1225 
in  tuberculous  disease  of  prostate. 
1244 
Tuberculomyces,  10 
Tuberculosis,  175-187 

acute  miliary,  184,  644.  1082,  1200 
bovine,  176,  177 
pathological  diagnosis  of,  177 
treatment  of,  184 
Tuberculous  abscess,  181,  365,  646,  669, 
708,  712, 771, 1150 
treatment  of,  186,  717 
caecal  tumour,  1022 
coxitis,  668 
dactylitis,  572 

disease    of    appendix    vermiformis, 
1058 
of  arteries,  306 
of  astragalus,  574,  575 
of  atlas  and  axis,  706,  712 
of  bladder,  1224 
of  bone,  570 
of  brain,  768,  775 
of  breast,  939 
of  bursae,  428 
of  caecum,  1021,  1052 
of  cranium,  729 
of  elbow,  648 
of  epididymis,  1281 
of  epiphyses,  575,  475 
of  Fallopian  tube,  1312 
of  hip-joint,  668 
of  intestine,  1021 
of  jaw,  800 

of  joints,  641,  633,  577 
of  kidney,  1200 
of  larynx,  906 
of  lung,  926,  922 
of  lymphatic  glands,  368,  828 
of  lymphatic  vessels,  357 
of  mastoid,  880 
of  meninges  of  brain,  768,  748, 

1281 
of  mesenteric  glands,  988 
of  muscles,  419 
of  oscalcis,  574,  575 
of  palate,  857 

of  peritoneum,  980,  972,  987 
of  phalanges,  572 
of  prostate,  1244,  1281 
of  rectum,  1163,  1150 
of  ribs,  710,  917 
of  sacro-iliac  joint,  677 
of  shoulder,  648 


Tuberculous  disease  of  skin,  404 

of  spine,  704,  441,  865 

of  sternum,  917 

of  tarsus,  573 

of  temporo-maxillary  joint,  811 

of  testis,  1 281 

of  tongue,  837 

of  vas  deferens,  1281,  1283 

of    vesicula;    seminales,     1297, 
1281 

of  wrist,  649 
endarteritis,  306,  180,  572 
epiphysitis,  575.  641 
ischio-rectal  abscess,  11 50 
lupus,  404 

meningitis,  768,  748,  1281 
osteitis,  571 
periostitis,  570 
peritonitis,  980 
sarcocele,  128 1 
sequestra,  571,  557 
tenosynovitis,  421,  423 
tumour  of  caecum,  102 1,  1052 
ulcers,  182,  407,  1021,  1022 
Tuber  ischii,  fracture  of.  528 
Tuberosity  of  humerus,  fracture  of,  507 
Tubes,  Fallopian,  diseases  of,  131 1 
Tubular  necrosis.  568 
Tubulo-dermoids.  230 
Tumours  (Chapter  IX.),  194-228 
benign,  197 
congenital  sacral,  703 
fatty.     See  Lipoma 
malignant.  197 
of  adrenals,  121 1 
of  antrum,  803 
of  anus,  1 167 
of  appendix,  1059 
of  bile  duct.  1077 
of  bladder,  1225 
of  bone,  590-597.  473'  4^1 
of  brain,  775,  772 
of  breast,  942 

of  connective-tissue  origin,  199-215 
of  cranium,  729 
of  endothelial  origin,  226 
of  epithelial  origin,  215-226 
of  frontal  sinus,  743 
of  gall-bladder.  1077 
of  gums,  798 
of  intestine,  1023 
of  kidney,  1210 
of  larynx,  906 
of  lip,  792 
of  liver,  1066 
of  lymphatic  glands.  368 
of  mandible,  808 
of  maxilla,  803 
of  mesentery,  989 
of  muscle,  420 
of  nerves,  212 
of  nipple,  935 
of  nose,  824 
of  oesophagus,  869 
of  omentum,  987 
of  ovary,  1317,  1323 
of  palate,  858 
of  pancreas,  108 1 


INDEX 


I405 


Tumours  of  parutid,  1347 

of  penis,  1273 

of  pharynx,  864 

of  pituitary  body,  778,  775,  588 

of  prostate,  1245,  1252 

of  pylorus,  999 

of  rectiun,  1166 

of  ribs,  917 

of  round  ligament,  1301 

of  scalp,  723 

of  scrotum,  1298 

of  sebaceous  glands,  410 

of  spinal  cord,  719 

of  spine,  719,  713 

of  spleen,  1083 

of  sternum,  917 

of  stomach,  998 

of  submaxillary  gland,  S49 

of  testis,  1285 

of  thymus,  899 

of  thyroid,  892,  897 

of  tongue,  838 

of  tonsil,  862 

of  umbilicus,  972 

of  upper  jaw,  803 

of  urethra,  1256 

of  uterus,  1303 

of  vulva,  1300 

pathogenesis  of,  195 

phantom,  971 

Pott's  pufiy,  765 

theories  of  origin  of,  195 
Tunica  albuginea,  hj'drocele  of,  1291 

vaginalis,  hematocele  of,  1277 
hydrocele  of,  1287 
Tuning-fork  ear  tests,  873 
Tiurkish  baths,  48 
Twelfth  dorsal  nerve,  injuries  of,  393, 

1191 
Tympanic  cavity,  inflation  of,  874 

membrane,  appearances  of,  873,  874 
rupture  of,  876 
Typhoid  bacillus.     See  under  Bacilli 

carriers,  71,  1070 

cholecystitis,  1070 

disease  of  joints,  639 

osteitis,  568,  916 

state,  38 

ulcer,  perforation  of,  10 18 

,  Ulcer,  rodent,  411 
Ulceration  (Chapter  VI.),  100-107,  34 

anaemic,  no 

duodenal,  in  burns,  126,  1012 

dysenteric,  1022,  1147 

of  bladder,  1220,  1225 

of  rectum,  1147,  1163,  1164,  1169 

of  scars,  263 

of  tongue,  837 

of  umbilicus,  971 
Ulcerative  colitis,  102 1,  103 1 

endocarditis,  69,  93 
Ulcers,  callous,  102 

due  to  bacterial  infection,  100,  loi 

dyspeptic,  837 

eczematous,  102,  105 

epitheliomatous,  220 

gummatous,  163 


Ulcers,  healing,  105 

indolent,  102 

irritable,  103,  105 

lupoid,  405,  107 

malignant,  107,  100,  839 

Marjolin's,  264 

of  bladder,  1220,  1225 

of  duodenum,  1012, 983,  1030 

of  intestine  (stercoral),  1024,   1027, 
1113,  1169 
(tuberculous),  1021,  1022,  1018 

of  palate,  857 

of  pharynx,  863,  864 

of  stomach,  992-998,  983,  990,  1030 

of  tongue,  837 

perforating,  of  foot,  402 

phagedenic,  157 

scirrhous,  950 

snail-track,  159 

stercoral,  1024,  1137,  1167 

syphilitic,  107 

traumatic,  100,  loi 

tuberculous,  182,  407,  837,  1021 

typhoid,  1019,  1022 

varicose,  103 

varieties  of,  921,  107 
Ulcus  moUe,  149 
Ulcus  serpens,  28 
Ulna,  dislocation  of,  612 

fracture  of,  516 
Ulnar  artery,  ligature  of,  334 

nerve,  injury  of,  391 
operation  on,  392 
paralysis  of,  391 
Ultramicroscope,  153 
Umbilical  faecal  fistula,  972,  981,  1106 

hernia,  1106 

urinary  fistula,  972,  1217,  1253 
Umbilicus,  affections  of,  971 
Undescended  testis,  1275,  1094 
inflammation  of,  1222 
malignant  disease  of,  1276 
Ungual  whitlow,  408 
Union  of  fractures,  478,  490 
Unna's  treatment  of  ulcers,  104 
Unreduced  dislocations,  602,  603 
Ununited  fractures,  491 
Upper  extremity,  deformities  of,  442 
fractures  of,  499 

jaw.     See  Maxilla 
Ursmia,  1178,  754,  1210,  1248,  1263 
Uranoplasty,  865 
Urate  of  ammonimn  calculus,  1230 

of  soda  in  gout,  639 
Urates,  amorphous,  11 84 

ascending   inflammation    in,    1196, 
1220,  1222 
Ureter,  catheterization  of,  11 76,  1187 

exposure  of,  1209 

impaction  of  calculus  in,  1206 
treatment  of,  1209 

kinking  of,  1189,  1193 

removal  of,  in  nephrectomy,  1203, 
1214 

rupture  of,  1192 

transplantation  into  rectmn,  1217, 
1229 

tuberculous,  1201,  1241 


I406 


A  MANUAL  OF  SURGERY 


Ureteral  orifice,   in   tuberculous  kidnev, 

1202 
Uretero-lithotoiny,  1209 
Ureteroplasty,  1195 

Urethra,   affections  of  (Chapter  XLI.), 
1253-1270 

calculus  impacted  in.  1255 

changes  of,  in  enlarged  prostate,  1 246 

congenital  malformations  of,  1253 

dilatation  of,  in  females,  1239,  1219 

epithelioma  of,  1256 

false  passages  of,  1261 

foreign  bodies  in,  1255 

h;craorrhage  from,  1254,  1261 

polypoid  tumours  of,  1256 

rupture  of,  1254 

stricture  of,  1256,  1220,  1254 
complications  of,  1267 
pathological  effects  of,  1258 
_  treatment  of,  1263-1270 

'^^         varieties  of,  1257 
Urethral  chancre,  156,  1257 

fever,  1261 

ha-maturia,  1231 

irrigation,  145 
Urethritis,  135,  1256,  143 

granular,  143 

posterior,  143  ..•;. 

Urethroscope,  144,  146    '■.: 
Urethrotome,  1264  0 

Urethrotomy,  external,  1265 

internal,  1264 
Uric  acid  and  urates,  1183 

calculus,  1203,  1207,  1230 
Urinary  fever,  1261 

I  fistula,  1270,  972,  1204,  1210,  1228, 
I         1252,  1255 

segregator,  Luys',  1177 
Urine,  abnormal  conditions  of,  11 78 

extravasation  of,  1268,  1192,  1218, 
1224,  1254,  527 
treatment  of,  1269,  1255 

incontinence  of,  1239 

in  cystitis,  1219,  1220 

in  gonorrhoea,  144 

pus  in,  1183 

residual,  1240,  1247,  1258 

retention  of,  1241 

segregation  of,  11 76 

suppression  of,  1262,  1198 
Uterus,  carcinoma  of,  1308 

deciduoma  malignum,  1311 

displacements  of,  1301 

fibroids  of,  1303 

prolapse  of,  1302 

sacroma  of,  1308 

syncytioma  maligna,  1311 

tumours  of,  1303 
Uvula,  elongation  of,  858 

Vaccination,  15 
Vaccines,  26,  15,  25 

treatment  by,  26,  46,  81,  87,  95,  99, 
146,  400 
Vaginal  hysterectomy,  1310,  1303 
Vaginitis,  1300 

in  gonorrhoea,  1300,  149 
Vagus,  nerve  affections  of,  386 


Valsalva's   method    of   inflating   middle 

ear,  874 
Vapour-baths,  mercurial,  168 
Varicocele,  1292,  1095 

in  carcinoma  of  kidney,  121 1 
Varicose  aneurism,  302 

eczema,  349 

ulcer,  349,  103 

veins,  347 
Varix,  347, 869, 1155, 1292, 1299 

aneurismal,  302,  324,  763 

arterial,  723 

of  oesophagus,  869 

of  saphena  vein, 349,  1104 

of  vulva.  1299 
Vas  deferens,  rupture  of,  1278 

tuberculous    disease    of,    1281, 
1282 
Vater,   ampulla  of,  stone  impacted   at, 

1074,  1079 
Vein  stones,  342,  350,  1187 
Veins,  entrance  of  air  into,  295 

laceration  of,  in  fractures,  488 

surgery  of  {Chapter  XIV.),  341-352 

varicose,  347 
Vena  cava,  thrombosis  of,  342 
Venereal  warts,  146,  217,  1273 
Venesection,  351,  42 
Venous  haemorrhage,  282,  295 
secondary,  295 

sinuses,  thrombosis  of,  768,  882 
wounds  of,  760 

thrombosis,  341,  351,  1047 
Ventral  hernia.  1108,  1058, 965 
Vermiform     appendix.     See     Appendix 

vermiformis 
Verruca.     See  warts,  403 

necrogenica,  251,  177 
Vertebral  arterv,  haemorrhage  from,  297, 
685' 
ligature  of,  333 
Vertigo,  758,  776,  772,  879 
Vesical  calculus,  1230-1239 

choice  of  operation  for,  1237 

haematuria,  1182 
Vesiculae  seminales,  affections  of,  1297 
Vesicular  mole,  1311 
Vesiculitis,  1297 
Vibrio  cholerae  Asiatics,  3,  8,  22 
Vibrion  septique,  122 
Vibrios,  3 
Vibro-massage,  46 

Vicious  circle  after  gastro-enterostomy , 
loio,  ion 

union  of  fractures,  493 
Villi,  synovial,  627,  632,  654 
Villous  tumour  of  bladder.  1225 
Virchow's  theory  of  origin  of  tumours, 

196 
Visceral  crises,  operation  for,  398 
Volkmann's  ischa-mic  contraction,  489 

sliding  rest  for  extension,  535 
Volvulus,  1129,  1117 

treatment  of,  1133,  1033 
Vomiting    after    abdominal    operations, 
964 

after  concussion,  750 

anesthetic,  1353 


INDEX 


1407 


Vomiting,  biliary,  alter    gastro-enteros- 
toiny.ioii 
cerebral,  776 
t;ecal,  11 25,  1142 

ill  intestinal  obstruction,  11 25,  1142 
in  moveable  kidney,  1189 
in  peritonitis,  975  " 
in  strangulated  hernia,  11 14 
after  operation  for,  1121 
after  taxis,  ni8 
Von  Bechterew's  spondylitis  deformans, 

719 
Von  Hacker's  method  of  gastro-enter- 

ostomy,  loio 
Von  Pirquet's  skhi  reaction,  178 
Vulva,  injuries  of,  1299 

varix  of,  1299 
Vulvitis,  1300,  149,  1219 

cystitis  in,  1219 
Vulvo- vaginitis,  12 19 

Wagner's  osteoplastic  craniotomy,  747 
Wagstaffe's  fracture,  548 
Wallerian  degeneration,  372 
Wardrop's  operation  for  aneurism,  317 
Warts,  403.     See  also  Papillonia 

anatomical,  251,  177 

gonorrhoeal,  146,  217,  1273 

Hutchinson's,  837 

laryngeal,  906 

malignant,  220 

on  lip,  792 

mnbilical,  972 

venereal,  146,  217,  1273 
Warty  growths  on  tongue,  malignant, 

839 
Wassermann's  reaction,   153,   167,    172, 

174 
Water-glass  bandage,  483 
Wax,  Horsley's,  747 

in  ear,  875 
Webbed  fingers,  445 
Weber's  test,  873 
Weight  extension  in  fractures,  534 

in  spinal  caries,  713 
Weir  Mitchell  treatment,  1028 
Whalebone  bougie,  1260 
Wheelhouse's  operation  for   impassable 
stricture,  1266 

staff,  1266 
Whip-lash  bougie,  1260 
Whitehead's    operation    for    cancer    of 
tongue,  841 
for  piles,  1160 

varnish,  843 
White  swelling,  641,  642,  644 

thrombus,  342 
Whitlow,  252,  421 
Widal's  reaction,  21,  26,  1051 
Winged  scapula,  443,  388 
Wirsung,  duct  of,  1078 
Witzel's  method  for  gastrostomy,  1005 
Wolfe's  method  of  skin-grafting,  107 
Wolffian    bod^^    origin    of    tumours    o* 

testis  in,  1285,  230 
Wolfler's  intestinal  suture,  967 
Woody  angina,  88 
Woolsorter's  disease,  141 


Wool  truss,  1096 
Word-deafness,  776,  758 
Wound  phagedena,  123 
Wounds  (Chapter  X.),  236-270 

abdominal,  968 

antiseptic  treatment  of,  271 

arterio-venous,  302,  324,  763 

aseptic  treatment  of,  273 

by  needles,  245 

contused,  242 

fish-hook,  245 

gunshot,  246-250 

healing  of,  255 

incised,  238 

lacerated,  242 

of  abdominal  walls,  968 

of  air -passages,  888 

of  arteries,  299 

of  bladder,  1217,  1088 

of  brachial  plexus,  387 

of  brain,  755,  759 

of  bursffi,  427 

of  gall-bladder,  1068 

of  heart,  927 

of  internal  carotid  artery,  763 

of  intestine,  1016 

of  joints,  599 

of  kidney,  1191 

of  larynx,  888 

of  liver,  1060 

of  lung,  917 

of  mesentery,  987 

of  middle  meningeal  artery,  761 

of  nerves,  371 

of  omentum,  986,  969 

of  pancreas,  1079 

of  recto-vaginal  septum,  1299 

of  rectum,  1147 

of  scalp,  722 

of  scrotum,  1297 

of  spine,  685 

of  spleen,  1081 

of  Stenson's  duct,  846 

of  stomach,  990 

of  testis,  1277 

of  throat,  887 

of  tongue,  834 

of  trachea,  888 

of  ureter,  1192 

of  urethra,  1254 

of  veins,  295,  302 

of  venous  sinuses  of  head,  760 

of  vulva,  1299 

open,  238 

open  treatment  of,  281 

poisoned,  250 

post-mortem,  252 

punctured,  245 

repair  of,  255 

revolver,  248 

suicidal,  248,  887 

treatment  of  abdominal,  969 
of  contused,  243 
of  gunshot,  249 
of  incised,  238 

of     lacerated.     See     Contused 
wounds 
Wrist-drop,  389 


1408 


A   MANUAL  OF  SURGERY 


Wrist-joint,  acute  arthritis  of,  637 

amputation  at,  1330 

ankylosis  of,  665 

dislocation  of,  614 

effusion  into,  628 

excision  of,  681,  649 

sprain  of,  524 

tuberculous  disease  of,  649 
Wry-neck.     See  Torticollis 
Wyeth's  method  of  controlling  hii'uior- 
rhage  in  amputation  at  hip-joint,  1339 

Xanthine,  1231 
X  rays,  52 

burns,  57 

cancer,  57 

dermatitis,  57 

interpretation  of  pictures,  52 
X  rays  in  diagnosis  of  aneurism,  320 

of  bone  diseases,  570,  572,  591, 

595.  597 
of  disease  of  joints,  645,  657, 

674 
of  fractures,  477 
of  gastric  affections,  989 
of  intestinal  lesions,  1014 


X  rays  of  joints,  645,  657,  674 

of  renal  calculus,  n86,  1207 

of  renal  pelvis,  11 87 

of  sarcoma  of  bone,  595,  597 

of  subphrenic  abscess,  984 

of    tuberculous    kidney,    1187, 

1202 
of  vesical  calculus,  1232 
of  ureteral  calculus,  1187,  1207 
in  treatment  of  cancer,  55,  56 
of  leucocythajmia,  369 
of  lupus,  406 
of  lymphadenoma,  369 
of  rodent  ulcer,  413 
results  of  prolonged  exposures,  57 

Yaws  (framboesia),  175 

Y-ligament  of  hip-joint,  importance  of, 

616 
Yellow  softening  of  brain,  756 

Z-operation  on  tendons,  425 
Ziehl-Nielsen  method  of  staining  bacilli,  8 
Zinc  ions,  treatment  by,  54,  413 
Zooglcea,  2,  96,  344 
Zygoma,  fracture  of,  494 


THE    END 


Bailliere,  Tindall  &"  Cox,  8  Henrietta  Street,  Covent  Garaen 


'^"Sfi;indC,iilj..sssin,i(,nalo(siirger 
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